Musculoskeletal conditions

Summary

Arthritis and back pain constitute the majority of musculoskeletal (MSK) conditions

which are self-reported as causing long-standing illness or disability in the UK (ONS,

2013).

The annual national cost of musculoskeletal disorders on the economy is around

£5.7billion (Health and Safety Executive, 2008) and 6.9% of NHS costs go on

musculoskeletal conditions (DH, 2013), in 2012/13 the total NHS expenditure on

direct, indirect and overhead costs for musculoskeletal care was £3.8billion.

The UK figures for Years Living with Disability (YLDs) are increasing with

musculoskeletal problems being the biggest contributor at 30.5%; the top

musculoskeletal causes were low back pain, neck pain, other musculoskeletal

disorders and osteoarthritis (Murray et al, 2012).

Facts and Figures

In Greenwich, the total NHS expenditure on musculoskeletal conditions in 2012/13

was £11,638,587.

Greenwich spent £7.5m, or £33,633 per 1,000 population on inpatient activity. When

compared to London and other boroughs of similar deprivation (IMD comparators),

Greenwich was the highest spender, although this was lower than England’s spend

per 1,000 population at £40,192.2.

Nearly half of hospital admissions in Greenwich were for anthropathies (diseases of

the joint), mostly arthritis.

Inequalities

Women report more chronic illness due to musculoskeletal disorders than men - the

main cause of this difference is arthritis; women reported nearly twice as many

chronic illnesses due to arthritis than men.

White British had the highest rate of inpatient treatment for a musculoskeletal

condition, followed by those from the “other black background” (i.e. who do not

identify themselves as Caribbean or African).

Prevention and treatment

Risk factors for various MSK conditions include excess body weight, certain manual

occupations, smoking and stress and anxiety.

Prevention strategies focus on early identification of symptoms and implementation

of interventions.

Local assets

Oxleas NHS Foundation Trust offer a Musculoskeletal integrated clinical assessment

and treatment (ICAT) service at 5 venues within the Greenwich community.

There are a number of community weight management and exercise programmes for

Greenwich residents of all ages and abilities.

Planned Improvements

Greenwich CCG is proposing to commission a redesigned local MSK pathway that

will include community MSK services for rheumatology, elective orthopaedic care,

podiatry, low back pain and chronic pain. This pathway aims to reduce the steps

through the pathway so that patients can be treated more efficiently, without

duplication of diagnostic tests and treatment

Musculoskeletal conditions

What do we know about it?

Introduction

Musculoskeletal (MSK) is an umbrella term referring to a range of conditions that affect the

muscles, bones and joints. It includes pain syndromes and autoimmune conditions such as

lupus (Arthritis Research UK, 2013b). These conditions can cause pain, physical disability,

anxiety and sleeplessness and lead to loss of personal and economic independence (Murray

et al, 2012). Musculoskeletal conditions are extremely common and are the most common

cause of severe long-term pain and physical disability (Woolf et al, 2003). The risk of

suffering from a musculoskeletal condition increases with age and the burden on society is

likely to grow as aging populations increase, particularly with age-related disorders such as

osteoarthritis and osteoporosis (Murray et al, 2012).

There are over 200 musculoskeletal disorders that can affect people of all ages (Dziedzic &

Dawes, 2010). The disability-adjusted life year (DALY) calculation shows that

musculoskeletal disorders are the 2nd biggest contributor to disease burden after cancers

and cardiovascular diseases combined, accounting for 13% of years lost due to ill-health,

disability or early death (Murray et al, 2012). The UK figures for Years Living with Disability

(YLDs) are increasing with musculoskeletal problems being the biggest contributor at 30.5%,

the top musculoskeletal causes were low back pain, neck pain, other musculoskeletal

disorders and osteoarthritis (Murray et al, 2012).

Musculoskeletal conditions are a major cause of morbidity that inflict enormous costs on

health and social care systems and this increasing burden impacts greatly on the economy.

In 2010 musculoskeletal disorders were the most prevalent work-related illnesses reported

by specialist doctors (Health and Safety Commission Executive, 2012). 33% of Disability

Living Allowance is awarded to people who are suffering from MSK conditions (Department

of Work and Pensions, 2008) and almost half of work-related ill health is due to

musculoskeletal disorders (Health and Safety Commission Executive, 2012). The annual

national cost of musculoskeletal disorders on the economy is around £5.7billion (Health and

Safety Executive, 2008) and 6.9% of NHS costs go on musculoskeletal conditions (DH,

2013), in 2012/13 the total NHS expenditure on direct, indirect and overhead costs for

musculoskeletal care was £3.8billion.

This chapter will review the impact of musculoskeletal disorders on Greenwich and its

residents through relevant national strategies, local facts and figures and what works in

reducing the impact of musculoskeletal conditions. Particular attention will be paid to

arthritis and back pain as they constitute the majority of musculoskeletal conditions which

are self-reported as causing long-standing illness or disability in the UK (ONS, 2013).

What is arthritis?

Arthritis is a term used to describe a group of diseases that result in inflammation of joints

and share the common symptom of leading to pain and sometimes disability. The World

Health Organisation and the Health and Social Care Information Centre classify this

condition as an Anthropathy (ICD 2010). There are many different types of arthritis and the

symptoms can vary from condition to condition. Some of the most common symptoms are:

joint pain, tenderness and stiffness

inflammation in and around the joints

restricted movement of the joints

warmth and redness of the skin over the affected joint

weakness and muscle wasting

Arthritis is the leading cause for pain and disability affecting one in every six people in the

UK (Arthritis research UK, 2008). The most common form of arthritis is osteoarthritis, which

affects an estimated 8.5 million in the UK (NHS Choices, 2012).

What is back pain?

Back pain can be triggered by a number of things, for example bad posture when sitting or

standing, bending awkwardly or lifting incorrectly. Back pain is usually resolved within 12

weeks but can last for longer (NHS Choices, 2013).

90% of the UK population experience back problems at some point of their life (NHS Inform,

2014) and the Global Burden of Disease findings rate low back pain as the biggest

contributor to Years Living with Disability figures in the UK (Murray et al, 2010). There are

many different causes of back problems including sciatica, prolapsed disc, ankylosing

spondylitis, arthritis, frozen shoulder and whiplash. However in 85% of cases it is not

possible to determine what the cause of the problem is (Nachemson et al, 2000), in which

case the condition is defined as non-specific back pain (Ramond-Roquin et al, 2014). The

World Health Organisation and the Health and Social Care Information Centre classify back

pain as Dorsalgia (ICD, 2010).

National Strategies

The Department of Health (2006) published a Musculoskeletal Services Framework to

address the fragmented and poor access to musculoskeletal care and long waiting lists. As a

result of this framework, musculoskeletal services in the UK are shifting from secondary care

to multidisciplinary Clinical Assessment and Treatment Services (CATS) shared by primary

and secondary care. CATS are intended to act as a one-stop shop for rapid assessment and

treatment while providing holistic care addressing psychological, social and physical needs.

The framework reviewed examples of best practice and promoted the following aims:

- To redesign services to fully exploit the skills and roles of all healthcare

professionals.

- To more actively manage patient care pathways, with explicit sharing of information

and responsibility thus improving the overall outcome for the patient.

- To highlight the importance of a holistic in approach in management, addressing

psychological and social needs of the patient.

It aimed to achieve these outcomes by:

1. Improving information and education for healthcare professionals and people

suffering with musculoskeletal problems.

2. Improving access to high quality front line care so that patients can choose who to

consult for first-line assessment and treatment, and experience a seamless service

between disciplines.

3. Ensuring appropriate access to a range of specialist opinions within a locally agreed

referral processes.

4. First-line specialist opinion in musculoskeletal Clinical Assessment and Treatment

Services (CATS) providing specialist assessment, advice, investigation and

appropriate onward referral where necessary.

5. Pre-listing clinical assessment – i.e. only medically fit patients willing to undergo

surgery be listed for surgery.

6. Listing for surgery – where appropriate, patients are listed for surgery by CATS

service, without the need to see a consultant.

7. Pre-surgical assessment - to ensure patients are medically fit for surgery, ensuring

optimal discharge planning and educating the patient on post-operative rehabilitation.

8. Outpatient follow-up after surgery shared between physiotherapist, nurse and

consultant-led clinics as locally agreed.

Facts and Figures

It is difficult to obtain accurate data on the prevalence of certain musculoskeletal conditions

as the NHS does not routinely collect data about patient conditions treated via outpatient

appointments. This is particularly difficult with conditions such as back pain, which is

generally treated in primary care or community services, or not treated at all. However, it is

possible to examine local programme budget spend, rates of admissions for local secondary

and emergency care, patient reported outcomes, national survey results and public health

mortality statistics. These are considered below.

Programme budgeting

One way of measuring the impact of musculoskeletal conditions is to review NHS

expenditure on MSK conditions locally. In Greenwich, the total cost of expenditure on

musculoskeletal conditions shown in Figure 1 below in 2012/13 was £11,638,587, with 57%

of this spend on elective inpatient and day cases and 25% on outpatient appointments.

Figure 1: Total expenditure on musculoskeletal system,

Source: NHS Comparators, extracted September 2014

No less than 65% of Greenwich’s total spend in 2012/13 was on inpatient activity (elective

and non-elective/emergency) and it is possible to analyse this area of spend alongside

comparators.

The total spend on inpatient activity (elective and non-elective/emergency) was £7.5m, or

£33,633 per 1000 population (see figure 2). When compared to London and other boroughs

of similar deprivation (IMD comparators), Greenwich was the highest spender, although this

was lower than England’s spend per 1,000 population at £40,192.2. The rate of admissions

in Greenwich is also relatively high in comparison to London and most IMD comparators with

the exception of Brent (see figure 2).

Figure 2: Cost of admissions and rate of admissions per 1000 population for problems

with the musculoskeletal system, Greenwich PCT, IMD Comparators, London SHA

and England, 2012/13.

Source: NHS comparators, programme budgeting, accessed April 2014.

Conversely, Greenwich spent less than its comparators other than England for emergency

and non-elective procedures in 2012/13. Its rate of admissions was also lower than all

comparators at 1.4 per 1000 population (see Figure 3).

Figure 3: Cost of emergency and non-elective care admissions and rate of admissions

per 1000 population for problems with the musculoskeletal system, Greenwich PCT,

IMD Comparators, London SHA and England, 2012/13.

Source: NHS comparators, programme budgeting, accessed April 2014.

It is notable that emergency and non-elective admissions for MSK are a relatively small

proportion of the total number of admissions. This means that compared with the IMD group,

Greenwich spent over £6000 more per 1000 population on all MSK admissions, but spent

only £471 less on emergency admissions.

An alternative tracking of spend on MSK comes from the Department of Health Programme

Budgeting Toolkit which includes additional areas such as A&E as well as community care.

This suggests a total spend of £21.8m in 12/13, however there is variation in the way that

costs are allocated between different areas, so these figures should be treated with some

caution.

Patients outcomes

Patient-reported outcomes allow us to examine the quality of life of patients after a treatment

using a standard questionnaire (known as the EQ-5D health questionnaire). This is a self-

report measurement tool given to patients for a number of health procedures including hip

and knee replacement surgeries. The quality of life measurement encompasses mobility,

ability to self-care, ability to carry out usual activities, pain/discomfort and anxiety/depression

(Oemar & Oppe, 2013).

Public Health England’s Spend and Outcomes Tool was employed to assess spend against

patient reported outcomes for hip and knee replacements in Greenwich Primary Care Trust

(PCT) and other PCTs. The results of these are displayed in figures 4 and 5. These results

show that Greenwich PCT had low expenditure for both hip and knee replacements (sample

of 85 and 109 respectively), particularly hip replacements, and that worse procedure

outcomes are a reflection of this. In addition, both hip and knee replacement outcome scores

fell from the previous year, particularly the hip replacement outcomes, displayed in figure 5,

which are among the lowest in the country.

Figure 4: Spend & outcome for Greenwich PCT and other English PCTs for knee

replacements, 2010/11 and 2011/12

Source: PHE, Spend and Outcomes Tool, accessed April 2014

Figure 5: Spend & outcome for Greenwich PCT and other English PCTs for hip

replacements, 2010/11 and 2011/12

Source: PHE, Spend and Outcomes Tool, accessed April 2014

National survey results

It is possible to ascertain what musculoskeletal problems most commonly affect the

population using non-medical statistics. Using the General Lifestyle Survey (ONS, 2013),

information can be gleaned on the leading causes of chronic sickness and who is most

affected. This is particularly useful in determining conditions that may not necessarily be

treated by the medical profession, e.g. back pain, for which only 20% of sufferers will consult

with a GP (NICE, 2009).

According to the General Lifestyle Survey (ONS, 2013) problems with the musculoskeletal

system is the leading cause of chronic sickness in the UK. 798 of 1000 people reported

chronic sickness (long-standing illness or disability) of the musculoskeletal system in 2011.

The musculoskeletal conditions that have the biggest impact on morbidity according to this

survey are arthritis and rheumatism, and back problems. Rheumatism is a term that is no

longer used medically, but is often used informally to describe medical problems that affect

the joints and connective tissue, similar to arthritis.

When assessed by age groups, problems with the musculoskeletal system are higher than

the other leading causes of chronic sickness in all age groups in Great Britain, except for

people over 75 (see figure 6).

Figure 6: Leading chronic sickness rates per 1,000 by age in Great Britain, 2011

Source: General Lifestyle Survey, Office for National Statistics, 2013

Hospital Episode Statistics

A good way to measure the impact of MSK locally is by use of Hospital Episode Statistics.

Hospital episode statistics are collated by the Health and Social Care Information Centre

(HSCIC) from English NHS trusts. These statistics allow for review of trends and patterns in

local hospital activity and to assess the effectiveness of delivery of care. For this chapter

inpatient hospital episode statistics on musculoskeletal conditions were extracted for both

Greenwich residents and patients who were registered with a Greenwich GP. Altogether

there were 4,921 hospital episodes in 2012/13.

Figure 7 illustrates the most common musculoskeletal disorder diagnoses that were

presented in 2012/13 by Greenwich residents and patients registered with Greenwich GPs. It

shows that 42% of hospital episodes were for anthropathies (diseases of the joint), mostly

arthritis.

The most common musculoskeletal problems fall under the classifications shown in the

following tables 7, 8 & 9, with an explanation of some of the less commonly used terms

below:

Anthropathy is a general term referring to diseases of the joint (Arthritis is a form of

arthropathy that involves inflammation of one or more joints

Chondropathy is a nonspecific term for any disease or disorder of cartilage.

Coxarthrosis is arthrosis of the hip joint.

Derangement of meniscus is commonly known as torn cartilage.

Dorsalgia is pain felt in the back that usually originates from the muscles, nerves, bones,

joints or other structures in the spine.

Dorsopathies are diseases of the back or spine impairing the backbone

Gonarthrosis is arthrosis of the knee joint

Osteopathy is a nonspecific term for any disease or disorder of bone (but the term can be

confusing as Osteopathy is also a complementary therapy based on moving, stretching and

massaging muscles and joints)

Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain,

numbness, tingling, or weakness along the course of the nerve usually affecting the lower

back or the neck.

Soft tissue disorders are disorders that affect soft connective tissues, fascia, joints,

muscles and tendons.

Spinal stenosis is an abnormal narrowing of the spinal canal (the space in vertebrae

through which the spinal cord passes), with symptoms including pain, numbness,

paraesthesia (commonly known as "pins and needles" or a limb "falling asleep"), and loss of

motor control, depending on which regions of the spine are affected.

Spondylosis is degeneration of the vertebrae and discs in the neck, which may cause pain.

Figure 7: Most common MSK diagnoses for hospital admissions in Greenwich

residents and GP registered, by ICD-10 blocks, 2012/13

Source: HSCIC, Hospital Episodes Statistics, extracted April 2014

The most commonly treated conditions treated in Greenwich are displayed in figure 8.

Figure 8: Most common individual diagnoses for hospital admissions for Greenwich

resident and GP registered due to Musculoskeletal Disorder, 2013

Source: HSCIC, Hospital Episodes Statistics, extracted April 2014

The most common anthropathies treated were internal derangement of the knee,

gonarthrosis (arthrosis of knee) and rheumatoid arthritis (see figure 9).

Figure 9: Admissions for Greenwich residents and GP registered due to

anthropathies, 2012/13

Source: HSCIC, Hospital Episodes Statistics, extracted April 2014

Public health mortality statistics (data on deaths)

Public health mortality data can provide statistics on the main causes of death at the local

level. Locally, 1.4% of deaths in Greenwich between 2002 and 2012 were attributed to

musculoskeletal problems, most of which were caused by osteoporosis or were a result of a

fall. Osteoporosis and injuries from falls that can accompany it are most prevalent among

women over 65 years of age (HSCIC, 2007).

Health inequalities

A number of demographic factors were assessed to ascertain if and where inequalities lie

with regards to musculoskeletal disorders in Greenwich. These were age and gender,

ethnicity, occupation and ward residency which are discussed below.

Age and Gender

According to the ONS General Lifestyle Survey (2013), women report more chronic illness

due to musculoskeletal disorders than men with age-standardised rates of 164 and 112 per

1,000 population respectively. The main cause of this difference is arthritis; women reported

nearly twice as much arthritis and rheumatism compared to men (see Figure 10).

Figure 10: Leading chronic sickness rates by musculoskeletal cause per 1,000 by age

and gender in Great Britain, 2011

Source: General Lifestyle Survey, Office for National Statistics, 2013

A review of local hospital episode statistics show that in Greenwich the rate of inpatient

treatment for all musculoskeletal disorders and chronic pain due to backache increases with

age. The highest rate of such treatment lies with women over the age of 65 years of age,

over 4 times the rates for women in the 24-49 group (see figure 11). This is consistent with

national general lifestyle survey findings on arthritis.

Figure 11: Hospital episodes for Greenwich residents and GP registered due to

Musculoskeletal Disorder and chronic pain due to backache, crude rates per 1000

population by age and gender, 2012/13

Source: HSCIC, Hospital Episodes Statistics, extracted April 2014

Ethnicity

Local hospital episode statistics show that there are some marked differences between

ethnicities with regards to who presented for treatment in Greenwich as an inpatient between

2008/9 and 2012/13 (see figure 12). “White British” had the highest rate of inpatient

treatment for a musculoskeletal condition, followed by the “other black background” (ie.

those who do not identify themselves as Caribbean or African). The difference between

“White British” and “other black background” does not appear to be statistically significant.

Figure 12: Hospital episodes for Greenwich residents and GP registered due to

Musculoskeletal Disorder, crude rates per 1,000 population by ethnicity, 2008/09-

2012/13

Source: HSCIC, Hospital Episodes Statistics, extracted April 2014

The reasons for the differences between ethnicities are unknown, although the fact that

ethnic groups are self-identified may bias the ethnic classifications and their results. For

example, 8 out of 10 who record themselves in the ‘Other Black’ category are born in the UK

and may have African, Caribbean or mixed heritage (Gardener & Connelly, 2005).

Additionally they may relate to cultural, socioeconomic and occupational differences that

may lie in these groups.

Occupation

According to national statistics it is routine and manual workers who are most vulnerable to

chronic illness due to musculoskeletal problems. Managerial and professional workers were

consistently least likely to be chronically ill due to a musculoskeletal problem in all age

groups except 16-44 (see figure 13).

Figure 13: Leading chronic sickness rates by musculoskeletal cause by age and

profession per 1,000 by age and gender in Great Britain, 2011

Source: General Lifestyle Survey, Office for National Statistics, 2013

The work-based activities that are most associated with musculoskeletal problems are

manual handling (for example: lifting, carrying, pushing, pulling), awkward or tiring positions

and workplace accidents (Health and Safety Executive, 2013).

Ward analysis

Age standardised rates of hospital episodes for musculoskeletal conditions were analysed at

Ward level (see figure 14). There were significant differences between Wards with

particularly high levels of admissions in Kidbrooke with Hornfair and Shooter’s Hill and low

rates in Blackheath Westcombe and Peninsula. The variation did not correlate strongly with

deprivation.

.

Figure 14: Total admissions for Greenwich residents and registered due to

musculoskeletal conditions, crude rates per 1,000 population by ward, 2013.

Source: HSCIC, Hospital Episodes Statistics, extracted April 2014

This was broken down even further to review anthropathies and dorsalgia. It was found that

Kidbrooke with Hornfair, Eltham North and Shooters Hill wards had the highest rates of

inpatient treated anthropathies. Kidbrooke with Hornfair, at 9.65 episodes per 1,000

population, had more than twice the rates of Glyndon at 4.46 per 1000, and nearly a third

higher than the overall Greenwich rate of 6.65 per 1,000 population.

For dorsalgia, the overall Greenwich inpatient rate was 2.16 per 1000 population. This was

nearly half the rate of Eltham West, the Greenwich ward with the highest rate at 3.94 per

1,000 population. The ward with the lowest treatment rate was Woolwich riverside at 0.73

episodes per 1,000 population.

Deprivation

An analysis of inpatient admissions for all musculoskeletal disorders by quintile of

deprivation shows that there was not a strong deprivation gradient to admissions, as shown

in Figure 15 below.

Figure 15: Number of admissions of Greenwich residents for MSK conditions by

quintile of deprivation, 2012/13

Source: HSCIC, Hospital Episodes Statistics, extracted April 2014

What works?

Prevention

There are a number of preventable risk factors associated with musculoskeletal problems:

Maintaining a healthy weight: taking osteoarthritis of the knee as an example, the risk

increases by 2.96 if overweight or obese (Blagojevic et al, 2010)

Certain occupational activities, particularly manual handling and awkward or tiring

positions can increase the risk of osteoarthritis and dorsalgia (Felson et al, 1991 &

HSE, 2013a)

Smoking has been shown to be a major preventable risk factor for rheumatoid

arthritis (Kallberg et al, 2011).

Psychological factors such as stress, anxiety and pain behaviour are associated with

the onset of back pain and acute and chronic back pain (Linton, 2000).

In addition, the UK Arthritis and Musculoskeletal Alliance (ARMA) recommend that frontline

services promote physical activity, general (aerobic) fitness, weight reduction programmes

and injury prevention strategies to reduce the risk of developing joint pain and osteoarthritis

(ARMA, 2004).

There are a number of evidence reviews that address prevention of musculoskeletal

conditions in various settings:

Working for a healthier tomorrow is a review of the consequences of ill health in

people of working age on families, workplaces and communities. It identifies factors

that prevent good health and interventions to help overcome them. For

musculoskeletal conditions, this is promoting recognition of the early warning signs

and implementation of early interventions (Black, 2008).

The Health and Safety Executive reviews the costs and benefits of active case

management and rehabilitation for musculoskeletal disorders, a goal-orientated

approach to keeping employees at work and facilitate an early return to work (Hu-

Tech Associates, 2006). It lists a set of recommendations for strategists

implementing a case-management approach. They have also produced a number of

guidelines for employers on preventing workplace musculoskeletal problems, these

include:

Working with display screen equipment

Managing upper limb disorders in the workplace

Manual Handling

The NHS Health and wellbeing review emphasises the need for early tailored

interventions for NHS staff who have illnesses and injuries including musculoskeletal

disorders (DH, 2009). Included in its recommendations are appointing a Health &

Wellbeing Board executive champion for each NHS Trust and development of

training and educational programmes on health and wellbeing for staff.

Treatment

ARTHRITIS

To enable early diagnosis and management ARMA recommend that individuals should have

access to primary and community care to enable early identification. Patients should be

offered individualised care plans and access to multidisciplinary support in cases where self-

care or independence is hindered. People with joint pain or arthritis should, where possible,

remain active and in employment or education. Where conditions are worsening or not

responding to treatment they should be referred to specialised care. Where surgery is

needed, individuals should be provided with a pre-surgery assessment that includes

informed consent, individualised discharge plan and an informed choice of provider. Ongoing

treatment plans should include access to self-management programmes, regular review of

treatment and prompt access to care if symptoms worsen (ARMA, 2004).

BACKACHE

The Royal College of General Practitioners produced a set of guidelines for the early

treatment and management of persistent or recurrent lower back pain, i.e. pain that has

lasted more than 6 weeks but less than 12 months (RCGP, 2009). Their recommendations

for primary care are:

- Keep diagnosis under review at all times

- Promote self-management, i.e. advise people with low back pain to exercise, to be

physically active and to carry on with normal activities as far as possible

- Offer drug treatments as appropriate to manage pain and to help people keep active

- Offer one of either an exercise programme, course of manual therapy or a course of

acupuncture, taking patient preference into account (and consider offering another if

the first chosen treatment does not result in satisfactory improvement).

For those who do not seek medical advice, the National Institute for Health and Care

Excellence have produced a set of guidelines for people with lower back pain who may not

seek medical advice (NICE, 2009). Their recommendations include:

- stay active

- take regular pain medication to allow the body to remain active

- take regular exercise and physical activity

- Change lifestyle factors that may be aggravating the back such as uncomfortable

postures, long periods of sitting or stress (NICE, 2009).

Local assets

Musculoskeletal Community Services

Oxleas NHS Foundation Trust offer a Musculoskeletal (MSK) integrated clinical assessment

and treatment (ICAT) service at 5 venues within the Greenwich community. This service is

delivered by a multidisciplinary team of a GP with MSK specialist interest, podiatry and

physiotherapy and is accessed through referral from a GP. Its aim is to provide faster access

to appropriate assessment, treatment by appropriate specialist and shorter waiting times for

hospital treatment. At the time of writing the service is in the pilot phase.

Health and Wellbeing

There are a number of community weight management and exercise programmes for

Greenwich residents of all ages and abilities. They include Greenwich Get Active and

various cooking clubs. A list of the available programmes can be found in the Greenwich

Healthy Living website.

Greenwich Time to Talk is a short term psychological therapies treatment service that offers

cognitive behavioural therapy and counselling to Greenwich residents who need it. This

service is currently working with Oxleas NHS Foundation Trust to develop a long term

conditions service for patients with a comorbid diagnosis of mental health and a long term

condition, including musculoskeletal disorders.

The Expert Patients Programme is a free self-referral, self-management programme for

people with long term conditions, including musculoskeletal problems.

Greenwich Stop Smoking works with local medical and community services to provide

advice and support to Greenwich residents who wish to stop smoking.

There are also a number of national charities such as Arthritis Research UK and Arthritis

Care who offer support, information and advice for people living with arthritis and their

carers.

Planned Improvements

NHS Greenwich CCG is proposing to commission a redesigned local MSK pathway that will

include community MSK services for rheumatology, elective orthopaedic care, podiatry, low

back pain and chronic pain. This pathway aims to reduce the steps through the pathway so

that patients can be treated more efficiently, without duplication of diagnostic tests and

treatment (see figure 16). The proposed pathway is designed on analysis of patient needs

and experiences and best practice throughout the country.

Figure 16: Proposed Greenwich musculoskeletal treatment pathway.

Source: NHS Greenwich Clinical Commissioning Group

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