What is the role of MSK Medicine in the modern NHS?
Evolution or revolution?
Dr Giles Hazan GPwSI MSK Medicine
I currently work as a GPwSI in MSK Medicine – more specifically in spine and chronic pain clinics in Brighton and Eastbourne NHS MSK Services.
You’re doing what?
I have to be honest and tell you that my mother was less than impressed when I announced that after twenty years of medical training and practice I was going to be a Gypsy, at least that's what she heard. So what the heck is a GPwSI and what is musculoskeletal medicine for that matter? This always throws a curve ball for my patients when they see the title so what do I tell them and how did this evolve?
Superficially, MSK medicine is described as the non-surgical management of problems affecting the bones, muscles and joints but this really only skims the surface of what we do.
As our understanding of modern pain science has evolved so the ‘biopsychosocial’ model of practice has changed requiring the identification of the combination of biomedical factors at play alongside an understanding of the context of the presentation, the individual’s social circumstances, health beliefs, fears and expectations and the behavioural change required to overcome some of these barriers.
There is a huge need for this with over half of working age people experiencing musculoskeletal conditions[i] at any point in time and one in five people attending their GP for them[ii], the cost to the wider economy runs into the billions and the impact on the individual is devastating, identified as the leading cause of years lived with disability[iii]
Traditional models of primary and secondary care were established at the inception of the NHS to handle what was a very different health landscape with an emphasis on managing acute health problems in specialist settings. The UK population is growing (to over 75million by 2039) and ageing (nearly 20% are above the age of 65[iv]) and this requires a shift in our approach.
Our local challenges with the existing provision of MSK care matched those seen nationally with fragmented services from a multitude of providers offering a significant variation in out patient treatment & surgical interventions at a cost greater than expected for population.
It was not unusual for a single patient to be bounced between orthopedic, rheumatology, pain and physiotherapy services with each offering their individual opinion but no-one providing oversight into the individual.
Large scale change with the commissioning of Community based models have emerged that place an emphasis on a multidisciplinary team holding the care of the patient within a single organisation and identifying the right care for the patient at the right time.
These models have been shown to improve patient reported outcomes, reduce surgical interventions all within community settings[v]
But with changing models come a need for changing clinicians….
Probably the most obvious change has been the explosion of ‘Advanced Practitioners’ (previously known as Extended Scope Practitioners or ESPs, these are clinicians drawn predominantly from the world of physiotherapy (but also osteopaths, OTs, Podiatrists and GPs) who have attained a range of advanced skills to be able to assess the patient, diagnose and guide management.
But does this meet the need and has the provision of specialist trained doctors lagged behind the development of our colleagues in physiotherapy?
Whilst MSK medicine is now an established term it remains to have a clearly defined speciality or pathway of training. The Faculty of Sports and Exercise Medicine has made a strong case for the increased role of SEM physicians working within the MDT delivering care for patients with MSK complaints. In addition to having some MSK training the knowledge and use of exercise as an intervention for a range of problems has been clearly identified in both primary and secondary care[vi].
There are over 120 doctors on the SEM specialist register (GMC 2017) however only a minority of these work within NHS settings. Not unreasonably those undertaking training specialising in sports medicine will predominantly end up working in sports settings and it may seem the patients in these settings are a long way from those we might expect to see within a typical NHS MSK clinic however this may not be the case.
The similarities in practice become more apparent when talking to colleagues working with elite athletes as well as those in standard NHS MSK settings. Our approach in assessing and understanding the problem and the broader psychosocial factors contributing to their presentation are a good example; an athlete under pressure to perform who sustains a functionally limiting problem has the potential to catastrophise over the potential consequences of their problem in the same way a parent presenting with an acute sciatica that stops them being able to work, play with their children and put their job at risk will be at risk of maladaptive behavioural changes and catastrophic thinking that can markedly set back their recovery.
In Sport, rehabilitation approaches are well established that identify strategies identifying role-specific needs to be met with tailored exercise and rehabilitation programmes enabling return to play (RTP). Is this any different to the approach one could take for a plumber to be able to manage the physical demands of her job and enable a return to work (RTW)?
Metabolic drivers are another evolving landscape of relevance to sport and the wider msk community, Dr Nicky Keay’s brilliant presentations[vii] amongst others at the BASEM Spring conference showcased the latest developments in Relative Energy Deficiency in Sport (RED-S) and the potentially devastating impacts of nutritional deficiencies on the athletes physiology and performance. There is a growing body of evidence of the potential impacts at the other end of the spectrum, with nutritional excesses driving an increase in obesity and diabetes as well as a metabolic phenotype of osteoarthritis[viii]. This Relative Energy Surplus in Life (RESL), as we could consider it, demands that we have a far better understanding of the role of nutrition in disease and dysfunction across the spectrum of MSK presentations, not just in sport, and equally demands that we become more able to give the relevant nutritional advice to our patients.
So what next?
There is good news on the horizon, organisations such as The Arthritis and Musculoskeletal Alliance (ARMA) work to encourage collaboration amongst organisations and the likes of Arthritis Research UK continue to support and educate both patients and clinicians alike.
Further workforce development is forging ahead with the provision of First Contact Practitioners – specialist physiotherapists to work in primary care alongside GP’s to support their practice and support a depleted workforce. A nationally recognised framework has emerged (New Musculoskeletal Core Capabilities Framework[ix]) as the first part of a plan to provide consistency in skills of those clinicians working in MSK clinics. Looking into the near future, the faculty is in constructive conversations with the Primary Care Rheumatology Society about developing further training for doctors to fill the void.
So what does this mean for us MSK physicians and those wanting to work in an MSK setting?
- Further definition of the role of MSK clinicians and how they can work effectively within an MDT will create further opportunities.
- Support of clinician’s development is overdue, with nationally recognised qualifications and networks of clinicians supporting each other.
- The world of Sports and Exercise Medicine is not distinct from Musculoskeletal Medicine and we have a lot to learn from each other.
- Opportunities abound in the growing number of multidisciplinary community MSK services and the time is right to capitalise on them.
[i] Department for Work and Pensions and Department of Health. Work, Health and Disability Green Paper Data Pack, Supplementary Tables; 2016. Source: Table 1m. Labour Force Survey April to June 2016.
[ii] Arthritis Research UK National Primary Care Centre, Keele University (2009), Musculoskeletal Matters.
[iii] Global, regional, and national incidence, prevalence, and years lived with disability for 310 disease and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. (2016)
[v] Intermediate Care pathways for musculoskeletal conditions – Are they working? A systematic review.
Hussenbux et al. Physiotherapy. 2015 Mar
[vi] Sport & Exercise Medicine A Fresh Approach in Practice – NHS Information Document examples of MSK Models of Care Primary and Secondary
[viii] The role of metabolism in the pathogenesis of osteoarthritis. Mobasheri et al. Nature. May 2017, Vol 13, 302-311