How can GP consortia lead the development of integrated musculoskeletal services?
Musculoskeletal conditions are common in primary care and are associated with significant comorbidity and impairment of quality of life.An integrated care approach, with most patients being managed in primary care and community settings, whilst providing clear and fast routes to secondary care, provides an effective and cost-effective solution compared with traditional models.GP consortia, in conjunction with strong clinical leadership, inbuilt organisational and professional learning, and a GP champion, are well placed to deliver service redesign by co-ordinating primary care development, local commissioning of community services, and the acute commissioning vehicles responsible for secondary care.
Why this matters to me
I authored the first review of musculoskeletal services available for GPs in Ealing in 1994. Three reviews and 16 years later, progress has been frustratingly slow. GP consortia put clinicians in the driving seat, leading service design and steering a path to improved services for patients. Back pain is the leading single presentation of musculoskeletal problems in General Practice. The National Institute for Health and Clinical Excellence (NICE) estimates that about 50% of back pain patients, accounting for 30% of the cost of back pain treatments, seek private therapy (physiotherapy, osteopathy, chiropractic) because of inadequate NHS service provision. Musculoskeletal disorders are the second highest cause of time lost from work and have worse quality of life scores than cancer, mental health, cardiovascular and respiratory diseases, visual and hearing impairment, and renal disease, which makes this a priority that needs championing.1 The government chose not to create a national clinical director for musculoskeletal services and community services were disconnected from acute services by the creation of acute commissioning vehicles. Only by creating an integrated service, led by GP consortia, can cohesive services and coherent pathways be developed. In a time of financial constraint, such service redesign will create extra capacity by the virement of funds from secondary to primary and community care. This will enable the patient to be seen in the right place at the right time by the right clinician.
Background Musculoskeletal conditions are common in primary care and are associated with significant co-morbidity and impairment of quality of life. Traditional care pathways combined community-based physiotherapy with GP referral to hospital for a consultant opinion. Locally, this model led to only 30% of hospital consultant orthopaedic referrals being listed for surgery, with the majority being referred for physiotherapy. The NHS musculoskeletal framework proposed the use of interface services to provide expertise in diagnosis, triage and management of musculoskeletal problems not requiring surgery. The White Paper Equity and Excellence: Liberating the NHS has replaced PCT commissioning with GP consortia, who will lead future service development.
Setting Primary and community care, integrated with secondary care, in the NHS in England.
Question How can GP consortia lead the development of integrated musculoskeletal services?
Review: The Ealing experience We explore here how Ealing implemented a ‘See and Treat’ interface clinic model to improve surgical conversion rates, reduce unnecessary hospital referrals and provide community treatment more efficiently than a triage model. A high-profile GP education programme enabled GPs to triage in their practices and manage patients without referral.
Conclusion In Ealing, we demonstrated that most patients with musculoskeletal conditions can be managed in primary care and community settings. The integrated musculoskeletal service provides clear and fast routes to secondary care. This is both clinically effective and cost-effective, reserving hospital referral for patients most likely to need surgery. GP consortia, in conjunction with strong clinical leadership, inbuilt organisational and professional learning, and a GP champion, are well placed to deliver service redesign by co-ordinating primary care development, local commissioning of community services and the acute commissioning vehicles responsible for secondary care. The immediate priority for GP consortia is to develop a truly integrated service by facilitating consultant opinions within a community setting.