Musculoskeletal services in Ealing 2013: Care closer to home

Abstract

Community musculoskeletal services in Ealing are organized with an integrated care approach, with most patients being managed in primary care and community settings, while, at the same time, providing 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. Ealing Clinical Commissioning Group (CCG) 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 general practitioner (GP) education programme enabled GPs to triage in their practices and manage patients without referral. The integrated care approach was implemented incrementally in three phases between 2005 and 2013, with a fourth phase planned for 2015. In Phase 3, only patients triaged by GPs to hospital outpatients are triaged by a referral management service, serviced by senior clinicians from the community musculoskeletal service. This secondary triage accounts for 15% of total GP referrals. The remainder being booked directly with no further triage beyond the initial GP triage unless marked ‘urgent’.

Keywords:

• Commissioning
• Musculoskeletal disorders
• National Health Service
• Service redesign

Background

Demographics

Ealing is an urban borough situated in West London. It is the third largest London borough¹ with a population of 347 000.² The population's black and minority ethnic (BME) communities constitute 38% of Ealing's total population.³ This compares with approximately 30% of London's population.² The age–sex distribution of the population in Ealing is slightly younger than the national average.² Ealing is a relatively prosperous borough. Nevertheless, the level of deprivation in the east and west of the borough means that overall, Ealing is in the top quintile in England.² The population of Ealing is served by nine surrounding hospitals within a 7 mile radius in West London,⁴ with the largest provider having a share of 46% of outpatient activity.⁵

Healthcare and societal burden

Providing musculoskeletal care is set in the context that 20% of the general practitioner (GP) registered population present each year with a musculoskeletal disorder^6,7 and about 50% of these patients are managed by GPs without referral.⁸ Musculoskeletal disorders are the third highest cause of disability life adjusted years in the UK (after cancer and cardiovascular disease).⁹ Musculoskeletal disorders account for 30% of all causes of years lived with a disability⁹ and one-third of the population over 65 suffer with a chronic musculoskeletal disorder.¹⁰ About 8.5% of the adult population have severe chronic musculoskeletal or neurological pain.¹¹ There is major co-morbidity with cardiovascular disease, diabetes, hypertension, and depression.¹² About 11.2 million working days per year are lost through musculoskeletal problems.¹³

Care closer to home and integrated care

Providing care closer to home has been national policy in successive white papers since the National Health Service (NHS) Plan 2000.¹⁴ It is an implied and embedded method of achieving the outcome indicators in ‘Everyone Counts – planning’ published by the new NHS Commissioning Board in 2012.¹⁵ The Department of Health piloted a number of models for delivering care closer to home, including practitioners with special interest (GPs, extended scope physiotherapists, and nurses), specialist outreach clinics, interface clinics, and admission avoidance schemes.¹⁶

However, a recent systematic review of outcomes of care closer to home schemes showed that although patients appreciate the schemes, care was not shown to be consistently better or worse than in the hospital.¹⁶ The schemes reviewed were not conclusively shown to be cost-effective and the report cautioned those wishing to replicate or roll out similar services that one model ‘doesn't fit all’.¹⁶

The King's Fund and the Nuffield Trust reviewed models of providing integrated care.¹⁷ They concluded that integrated care services could fill the gaps in traditional care models or could be used where there is poor coordination of care, which might lead to an adverse impact on care experiences and outcomes.¹⁷ The review concluded that integrated care models should be centred around the needs of patients and are best suited to those people with chronic long-term conditions or medically complex needs.¹⁷ The report cautioned that disease-based approaches rather than patient-centred service delivery could lead to new silos of care.¹⁷

Musculoskeletal services in Ealing

Community and secondary care

In addition to the 50% of patients presenting with musculoskeletal disorders managed by GPs without referrals, care is provided in community and hospital settings. Phase 2 of the musculoskeletal service redesign brought in a community based ‘See and Treat’ interface service and a GP direct access physiotherapy service in 2007. The description¹⁸ and performance¹⁹ of this service have been reported elsewhere.

Local healthcare expenditure and activity

Historically, health expenditure on musculoskeletal disorders in Ealing has been low, more than two standard deviations below the mean. In 2009, programme budgeting data for musculoskeletal problems showed funding at 49% of the national average²⁰ and yet the service was providing activity at 86% of the national average.^21,22 However, Ealing has a slightly higher average programme budget on ‘miscellaneous’ items, which might include some musculoskeletal expenditure.²³ Nevertheless, out of a total £1413 expenditure per head of population in Ealing, only £45 per head is spent on musculoskeletal disorders.²⁴

In April 2011, Ealing Primary Care Trust (PCT) divested itself of its provider services, including community physiotherapy. Previously, since the demise of fundholding in 1988, the PCT had been providing both community physiotherapy services and the Ealing hospital outpatient physiotherapy service. From April 2011, the community services of Ealing, Brent, and Harrow were hosted by Ealing Hospital NHS Trust, which formed an ‘integrated care organisation’. This merger was instrumental in achieving service redesign because it overcame a significant obstacle to moving away from the status quo caused by the Department of Health's ‘payment by results’ policy.

Fig. 1 shows how all musculoskeletal activity was divided across community and secondary care prior to Phase 3 of the service redesign. Programme budgeting data show that the 12% of elective surgical activity accounted for 55% of the budget.²³ The total secondary care activity accounted for 82% of the budget.²³

Figure 1. Musculoskeletal healthcare utilization Ealing 2012. Number of referrals, percentages and annual rates per 100 000 population, NHS Ealing CCG, 2012.

Sources: CSE Servelec RiO^® Data Warehouse Reports Manager, Dr Foster Intelligence Practice and Provider Monitor Tool (PPM)^®.

Performance of local musculoskeletal services

The corollary of both historical underfunding and below average activity was long waiting lists for physiotherapy and elective orthopaedic admissions for Ealing residents. Although the latter was largely addressed by the 18 weeks initiative,²⁵ physiotherapy waits have varied between a median of 22 and 26 weeks since the demise of fundholding in 1998.²⁶ However, with the introduction of Phase 3 of the MSk service redesign in October 2013, median physiotherapy waiting times are down to 8 weeks and interface clinic waiting times are down to 7 weeks.²⁶

External audit of efficiency

In late 2011, the Delivery Support Unit (DSU) for the eight north west (NW) London PCTs reported on the efficiency of different models of musculoskeletal service provision across the cluster.^27,28 The DSU tracked patients by NHS number across community musculoskeletal services, GP access to magnetic resonance imaging (MRI) scanning, hospital rheumatology and orthopaedic outpatients, orthopaedic day case and inpatient activity. They commented that the ‘See and Treat’ service in Ealing had outcomes that ‘appear to be exceptionally strong, with 96% of patients discharged not subsequently receiving treatment in other settings of care. This represents a 10–12% higher performance than other, similar scope services in NW London’²⁷ (see Fig. 2 below).

Figure 2. Analysis of health care utilisation following treatment in community services

Source: Delivery Support Unit NHS NW London 2011

Secondary care activity

Secondary uses statistics data supplied by the NWL Commissioning Support Unit for Ealing Clinical Commissioning Group (CCG) showed a 5% fall in the number of first appointments in orthopaedic outpatients, from all sources, comparing the year to August 2013 with the year to August 2012.²⁹ This was fuelled principally by a drop in GP referrals to outpatients and mirrored by an increase in referrals to the interface service. Over the same period there was a 9.2% drop in elective orthopaedic admissions and a 2.3% drop in day case activity.²⁹ The cause of these drops is multifactorial, including the effectiveness of the Ealing interface service, changes in the acute contracts negotiated by the NW London CCG cluster, and the enforcement of the NW London Planned Procedures with Thresholds (PPwT) policy.³⁰

GP direct access MRI scans

GP access to MRI scanning was purchased from 2007 as part of the 18-week referral to treatment standard by NHS London from a private provider (InHealth, High Wycombe, UK). The Department of Health set milestones for maximum diagnostic waiting times of 6 weeks by 2008.²⁵ The DSU analysis of GP-access to MRI scanning showed that GP-access MRI usage was not associated with treatment in musculoskeletal or orthopaedic clinics or surgery in 60% of patients, and no further NHS treatment in 50% of patients.²⁷ The DSU also demonstrated that where patients had a MRI scan organized by the GP, multiple and complex pathways occurred in 20% of patients and suggested that patients ‘may not be treated in the most appropriate setting’.²⁷

Local guidelines for MRI scanning from primary care³¹ formed the backbone of high-profile GP education sessions in 2010 and 2012. Monthly returns from the MRI provider (InHealth Ltd) demonstrated a 42% drop in MRI scanning in 2011. Nevertheless, the InHealth data showed that 20% of GP practices continued to request about 80% of the GP-access MRI scans, and MRI rates per 1000 population varied more than 5-fold between practices.³² MRI scanning rates started to rise again and exceeded previous levels by early 2013.³³

The GP-access MRI usage data suggested no correlation between MRI scanning, subsequent reduction in healthcare utilization, or scanning as per local clinical guidelines. Therefore, the CCG board accepted a proposal to decommission the GP-access MRI service and re-provision MRI scanning via the interface service as part of the Phase 3 MSk service redesign.³⁴ The quality, innovation, productivity, and prevention (QIPP) improvements and savings resulting from the Phase 3 MSk service redesign have subsequently resulted in quicker access to MRI scanning for those patients where it is clinically necessary, as well as providing earlier access to a clinical opinion, definitive treatment, and increased physiotherapy capacity.

Delivering service change in Ealing

Ealing is in a densely populated area of West London,¹ surrounded by nine hospitals providing orthopaedic services.⁴ Since the inception of CCGs in 2012, each hospital relates to a single CCG that negotiates the acute commissioning contracts on behalf of the other CCGs served by that hospital. However, each CCG has its own Joint Strategic Needs Assessment (JSNA), Commissioning Intentions, and Out of Hospital Strategy and is responsible for commissioning local community services. Ealing PCT considered commissioning a prime vendor model for musculoskeletal service delivery for its residents in 2008 and 2011. However, it was not possible to reach agreement on a prime vendor or other unified model for musculoskeletal service delivery across multiple commissioners and providers in NW London, leaving each CCG (and former PCT) to develop its musculoskeletal service strategy in a piecemeal fashion. Ealing has redesigned musculoskeletal services in a series of three stages to date, and a fourth stage planned for 2015. The effect of this staged approach is shown in Fig. 3 below, which shows how the proportion of patients seen in hospital orthopaedic clinics has decreased as patients have transferred to a community interface setting.

Figure 3. Phased MSk service redesign: Ealing – proportion of first attendances: Hospital Orthopaedics and Community Musculoskeletal Interface (% per financial year, all referral sources) (figures are predictions for 2013–2016).

Sources: CSE Servelec RiO^® Data Warehouse Reports Manager, Dr Foster Intelligence Practice and Provider Monitor Tool (PPM)^®.

Phase 3 MSk service redesign, 2013

Aims and objectives

The overarching aims of the musculoskeletal service redesign are: to commission high quality and efficient musculoskeletal services that meet the needs of the population, to make best and evidence-based use of scarce healthcare resources, to provide patient choice with services closer to home, to decommission services that are less efficient, and to recycle savings in accordance with the QIPP programme for Ealing CCG.

The specific objectives for the musculoskeletal service redesign are: to commission an enhanced musculoskeletal interface service with consultant input, to expand physiotherapy services, to improve the conversion rates of trauma and orthopaedic outpatient referrals, to reduce unnecessary MRI scanning activity, and to use savings from activity reductions and tariff changes to invest in the expanded community musculoskeletal service.

Costs of service redesign

The full business case for Phase 3 was approved by the CCG Board in March 2013.³⁴ The business case³⁵ allowed for a 5% annual increase in baseline elective inpatient orthopaedic activity due to population growth, ageing, and obesity; factors which were shown in the Musculoskeletal Framework to be drivers for increasing joint replacement surgery.³⁶ Moving 40% of GP referrals from orthopaedic outpatients to community interface service disinvests £1.17 million per year. Decommissioning GP-access MRI saves £395k per year. Reinvestment in community services costs £1.06 million per year. This includes a small increase in both MRI scanning and onward referrals from the interface service. A one-off waiting physiotherapy waiting list initiative of £200k was granted prior to the start of the new service delivery. The net annual net saving after year 1 is £507k per year.³⁵

Referral pathways

GPs are encouraged to refer patients, whom they would previously have sent for GP-access MRI scanning or orthopaedic outpatients, to the musculoskeletal interface service. This pathway reflects the concept that GP triage patients in their practice. The other triage options for GPs are to refer to physiotherapy or to orthopaedic outpatients. Fig. 4 below, shows the referral pathways from a GP perspective, following the Phase 3 MSk service redesign.

Figure 4. Community musculoskeletal referral pathways.

Orthopaedic referrals

In accordance with the NW London CCG Cluster PPwT policy, 13 orthopaedic procedures (e.g. hip and knee arthroplasty or revision surgery, arthroscopy, carpal tunnel release) are subject to clinical criteria and thresholds before funding is agreed.³⁰ In NW London, referrals for these procedures have to be made on bespoke ‘Choose and Book’ referral forms and the criteria are checked by each CCG's referral management service. Assuming the GP ticks all the boxes (e.g. to confirm conservative treatment has been tried), the commissioner will pay the provider for the PPwT procedure.

For non-PPwT orthopaedic outpatient referrals from GPs, there is an online triage carried out by senior clinicians from the musculoskeletal service. They can divert patients to the interface or physiotherapy service where it is clinically appropriate to do so (e.g. where conservative options have not been tried, to allow assessment for surgery or where appropriate investigations need to be completed if on a surgical pathway). Alternatively, they can allow the referral to be passed to the hospital. To reduce the administrative burden and delays for the patient, GPs are encouraged to send patients directly to the interface service, in which case no further triage occurs. The business case assumed that at least 55% of GP referrals to orthopaedic outpatients could be seen and treated in the community. This figure is expected to rise to 70% once consultants are in place in the community interface clinics. These figures are predicated upon the low surgical conversion rates (20–30%) for GP referrals direct to hospital compared with 80% from the interface clinic.^19,27,37,38 The reason that a diversion figure of only 55% was used for Phase 3 is that following Phases 1 and 2 of the MSk service redesign, GPs are already using the interface service for 37% of their referral activity (see Fig. 1 above).

Community staffing, capacity, and outcomes

The interface service is led by a consultant physiotherapist and staffed by 10.7 whole time equivalent (WTE) extended scope physiotherapists and 1.3 WTE musculoskeletal physicians. The interface service has been funded to ‘See and Treat’ 7730 patients per year. The physiotherapy service is staffed by 12 WTE band 7 and 3 WTE band 6 physiotherapists. The physiotherapy service has been funded to treat 10 230 patients per year.

The interface service has three clinics seeing the following proportions of referrals: spinal (44%), lower limb (38%), and upper limb (18%). Seven per cent of patients are cross-referred for further physiotherapy or classes. The onward referral rate to secondary care is 19%, and is expected to rise a little with the recent service redesign. The MRI rate is 17% and is also expected to rise a little.^26,34 The surgical conversion rates are spinal 60%, lower limb 84%, and upper limb 90%.³⁸

As part of the Phase 3 MSk service redesign, recruitment is under way for consultant input: two sessions per week of spinal consultant input, one session per week of upper limb orthopaedic input, one session per week of lower limb orthopaedic input, and one session per week of clinical radiology support. The consultants will be drawn from several secondary care providers to support transparency of patient choice of the surgical provider.

Orthopaedic outpatient activity

The full business case for Phase 3 of the MSk service redesign predicts that activity will shift from outpatients for 3400 patients, who will either be referred directly by GPs to the interface service or diverted by the online triage.³⁵ Consultant-to-consultant and A&E referrals to orthopaedic outpatients are assumed to remain unchanged at 7000 referrals per year. This activity is a potential target for Phase 4 of the MSk service redesign.

Booking and triage services

About 23 000 referrals per year are expected to be handled by the booking and referral management services across physiotherapy, interface, and orthopaedic referrals. About 10–15% of these referrals will be triaged online by the musculoskeletal clinicians supporting the GP Referral Management Service; the remainder will be booked directly by GPs into community clinics. Phase 3 of the MSk service redesign sees a genuine 50% increase in physiotherapy service provision. There is also a 42% increase in interface capacity, but this is dedicated to patients diverted from hospital outpatients.

Waiting times

Phase 3 of the service redesign has brought shorter waiting times for definitive treatment and investigations for the majority of patients. Median physiotherapy waiting times are down to 8 weeks and interface clinic waiting times are down to 7 weeks, both with a target of 4 weeks by April 2014.²⁶ Urgent referrals are currently seen within 2 weeks, and MRI scans can be arranged within 1–4 weeks depending on clinical priority.

Evaluation

Assessing whether integrated service redesign has delivered improvements in care and quality is complex. The King's Fund advises that the appraisal of such schemes should include the impact on outcomes (e.g. NHS Outcomes Framework), patient experience, use of upstream and downstream services, and costs in different parts of the system.¹⁷ The King's Fund imply that integrated care redesigns under the current NHS market arrangements reduce patient choice initially through the focus on producing tightly integrated and seamless care with a limited number of providers.^39,40 The King's Fund believes that the NHS will need to seek ways of providing choice both within and between integrated care models to drive forward innovations in care.³⁹ In addition, the King's Fund advises that the NHS should support the role of integration in improving patient outcomes.³⁹ However, they warn that focusing on disease-specific models will lead to ‘silos of care’⁴¹ rather than holistic care. With these warnings in mind, the Ealing musculoskeletal service will be offering a choice of consultants from different secondary care trusts, and linking up with the education programmes supporting local integrated care pilots for diabetes and frail elderly patients.

Developing primary care

Empowering primary care

A key feature of moving care closer to home is empowering and resourcing primary care.⁴² Primary care clinicians are well placed to carry out primary triage, signposting, and gatekeeping functions. Primary care clinicians are also pivotal in coordinating care for patients with complex pathways of care.⁴² GPs are trained to manage patients with multiple morbidities, and are doing so in other settings, e.g. frail elderly and diabetic patients. Primary care nurses deliver core treatments for musculoskeletal disorders including education, advice on losing weight and exercise advice for osteoarthritis, and cardiovascular and osteoporosis screening for patients with inflammatory arthritis. Primary care nurses also share management of disease monitoring for patients on disease modifying drugs for inflammatory arthritides.

However, much of the movement of this work from secondary to primary care has occurred with little support. A high quality and on-going ‘hands-on’ education programme is needed to support GPs, practice nurses, and community nurses to deliver care closer to home for patients with long-term musculoskeletal disorders, particularly in the presence of co-morbidities.

The current model of commissioning in the NHS is clinically led, principally by GPs. GPs are therefore key stakeholders and drivers for change. They need to ensure that as care moves from secondary to primary care, this is achieved with adequate clinical resources, educational support, and with full assessment and mitigation of the clinical risks associated with a new service delivery model.

Primary care workforce training

Ealing PCT took a conscious decision in 2008 that the redesign of the musculoskeletal service provided an opportunity to supplement the meagre undergraduate training⁴³ for GPs in musculoskeletal medicine. Ealing PCT abandoned plans for a ‘hub and spoke’ model proposed in 2004. That proposal placed a musculoskeletal triage service at the hub and required GPs to refer all musculoskeletal problems for detailed needs assessment. Instead the PCT funded an ambitious education programme to facilitate GPs triaging patients in their practices into one of four streams: direct access physiotherapy, and spinal, upper, and lower limb interface clinics. The Ealing Action Line was developed for active management in primary care without referral, along with a referral flowchart and local referral advice.⁴⁴ Key elements of the education programme were to help GPs deliver core musculoskeletal treatments, improve examination skills, and develop confidence with diagnosing and managing musculoskeletal problems. To date, about 50% of Ealing GPs have been through the education programme, and many have refreshed their skills on more than one occasion.

The recent Phase 3 MSk service redesign built on earlier changes and continues to empower GPs to actively manage about 50% of all musculoskeletal disorders presenting in primary care without referral. Individual GP triage in their practices remains central. Secondary triage is targeted at orthopaedic referrals (PPwT and non-PPwT) and accounts for 15% of total GP referrals; the remainder being booked directly with no further triage beyond the initial GP triage. In addition, any urgent requests directly to the interface or physiotherapy service may be triaged where this challenges short-term capacity. Referral advice⁴⁴ has remained consistent over the past 5 years and is distributed regularly to GPs, other community staff, and hospital staff. The musculoskeletal education programme continues to be available to GPs, practice nurses, nurse practitioners, community matrons, and other community staff including podiatry and mental health workers. The programme will be offered to A&E and hospital staff to raise awareness of community options, patient pathways, and ensure patients are given consistent messages, for instance, about the indications for MRI scanning or the role of exercise and physiotherapy. The educational programme therefore remains aligned with service development needs and moving care closer to home.

Drivers and obstacles to change

Drivers for change

The main driver for change in Ealing was the long waiting lists for physiotherapy (median 22 weeks (2012–2013)).²⁶ MRI scans from the interface clinic were available in 3–5 weeks. If a scan was deemed more urgent than this, the only recourse was to request an opinion from the on-call orthopaedic team at one of the local hospitals. Phase 3 of the service redesign has addressed both of these issues.

The JSNA for the London Borough of Ealing³ has included a substantial musculoskeletal chapter since 2010, which in turn has informed the Ealing Commissioning Intentions,⁴⁵ Joint Prevention Strategy,⁴⁶ Out of Hospital Strategy,⁴⁷ and the Health and Wellbeing Strategy.⁴⁸ Having good access to musculoskeletal assessment and treatment, as well as empowering general practice to deliver core treatments is instrumental in delivering these plans locally.

Future JSNAs can be strengthened in the light of recent data from the Global Burden of Disease (GBD) study with UK data analysis,⁹ supported by Public Health England and pioneering work by Arthritis Research UK.⁴⁹ The GBD study provided a composite index of normative health (disability-adjusted life years), which means that commissioners and providers will be now able to focus on long-term conditions with high morbidity in addition to those conditions with significant mortality. Musculoskeletal services in Ealing historically incurred relatively low expenditure (£45/head out of a total CCG spend of £1413/head),²⁴ although the number of people requiring assessment, advice, and treatment is high (20% of the population).^6,10 As there are public health interventions that can improve musculoskeletal health (exercise, weight loss),⁹ this can be reflected in the local Health and Well Being strategy, which aims to translate the JSNA into local action points.

The QIPP challenge aims to save the NHS £15–20 billion by 2014 while keeping quality as an organizing principle.^50,51 Underlying both the commissioners’ and providers’ plans for the current service redesign is the financial requirement to produce savings while improving the service and maintaining quality.

Overcoming obstacles – the context of change

The main obstacle to Phase 3 of the service redesign has been the frequent reorganization of the NHS. Payment by results provided a significant disincentive for local hospitals to engage in moving services ‘off tariff’ into the community. However, the formation of the Ealing Hospital NHS Trust Integrated Care Organisation in April 2011 was a game-changer in facilitating progress with service redesign. In moving hospital services to the community, one of the hospitals serving the Ealing population could mitigate its financial losses caused by outpatient work moving off tariff by recouping work under a block community contract and also becoming an MRI provider to the interface service.

The move to divest community services from PCTs to provider trusts in 2010–2011 produced additional delay in the MSk service redesign as the merger of the community services with the new host (Ealing Hospital NHS Trust) diverted project management resources away from the MSk service redesign. A number of changes to commissioning arrangements also meant that continuity and consistency of approach was impeded over the period from 2010 to present. In particular, the QIPP challenge meant that commissioning acute services was split away from commissioning community services. The former was dealt with at a cluster level with eight PCTs, the latter at local level for one PCT. Developing an integrated plan across primary community and secondary care was difficult as commissioners at local and cluster level had differing priorities. In fact, the evolution of CCGs following the Health and Social Care Act 2012 has finally driven through the service redesign as priority setting now resided with local clinicians. The new CCG board was focused on addressing a long-standing health inequality, informed by the local JSNA, and were prepared to overcome the obfuscation produced by previous commissioning arrangements.

The challenging economic position meant that CCG finance officers were risk averse and it was difficult to push a case for ‘invest to save’ pump-priming funds. The local provider advised that the service redesign could not proceed until the physiotherapy waiting lists had been cleared. A risk sharing scheme was therefore devised between the commissioner and the provider to achieve the reduction in waiting times before the Phase 3 of the service redesign went live in October 2013.

GPs make up the majority of the CCG executive board, which drives innovation. However, at grass roots, primary care colleagues are weary of change, which may lead to inertia during the implementation phases of a service redesign. There is no doubt that moving care closer to home has pushed work towards general practice, for instance: musculoskeletal assessments, core treatments, and active management without referral. The Royal College of General Practitioners press release highlighted that investment in general practice has fallen by £400 million in real terms in the past 3 years, resulting in a 7% cut in spending per patient.⁵² In addition, GP spending is 9% of total NHS budget whereas GPs have 90% of contacts with patients.⁵² It has been an interesting challenge to motivate colleagues through the MSk service redesign's communications stage.

Conclusion

The success of the MSk service redesign is founded on keeping the patient's perspective at the centre of all decision-making. The MSk Core Strategy Group has demonstrated strong leadership and persistence over a number of years to design and steer the service redesign. They have been strongly supported by the new CCG executive. Engaging and maintaining good communications with the main stakeholders facilitated the provider to move away from a hospital-based ‘payment by results’ tariff model and secured support from GPs for a model ‘closer to home’. The education programme has improved confidence in musculoskeletal diagnosis, empowered primary care to deliver core treatments, and improved the quality and appropriateness of referrals. Until we have better outcome data, we cannot be sure that patients who might previously have had hospital inpatient and day case surgery will enjoy similar outcomes with conservative treatment closer to home. However, we believe that this is making the best use of scarce resources and is of overall benefit to the vast majority of patients. Reassuringly, GPs, commissioners, and providers are sharing accountability for delivering clinical, organization, and financial outcomes.

Declaration of interests

Funding none.

Ethical approval not required.

I.B. is a clinical advisor to NHS Ealing CCG and the Arthritis and Musculoskeletal Alliance. He is also a musculoskeletal physician with Ealing Hospital NHS Trust Community Musculoskeletal Service.

Note on references

A supplementary file is available online, in which the URLs below are repeated in a more easily to copy format.

Acknowledgements

I wish to acknowledge the help of the MSk Core Strategy Group in preparing this paper and for permission to use audit data: Rochelle Bloch, Justine Currie, Stephanie Griffiths, Kate Laverty, Robert McLaren, and Neha Unadkat.