1

Joint Strategic Needs Assessment: Musculoskeletal Disorders

Contents Contents .................................................................................................................................................. 1

1 Introduction .................................................................................................................................... 2

1.1 Purpose of Chapter ................................................................................................................. 2

1.2 Aims and Objectives ................................................................................................................ 2

1.2.1 Aims: ............................................................................................................................... 2

1.2.2 Objectives:....................................................................................................................... 2

2 Musculoskeletal conditions ............................................................................................................ 3

2.1 Introduction ............................................................................................................................ 3

2.2 Risk factors .............................................................................................................................. 3

3 The conditions ................................................................................................................................. 4

3.1 Osteoporosis, falls and fractures ............................................................................................ 4

3.2 Osteoarthritis and joint degeneration .................................................................................... 5

3.3 Inflammatory musculoskeletal conditions .............................................................................. 5

4 Epidemiology in Hertfordshire and Nationally ............................................................................... 7

4.1 Epidemiology of musculoskeletal conditions .......................................................................... 7

4.2 Epidemiology of risk factors .................................................................................................. 11

4.3 Health impact of musculoskeletal conditions ....................................................................... 11

5 Healthcare spending on musculoskeletal conditions ................................................................... 14

6 Social and economic impact of musculoskeletal conditions......................................................... 19

7 Future needs ................................................................................................................................. 21

8 Current services ............................................................................................................................ 22

9 Users views ................................................................................................................................... 23

10 Evaluation and Recommendations ........................................................................................... 25

10.1 Evaluation ............................................................................................................................. 25

10.2 Gaps in evidence ................................................................................................................... 25

10.3 Recommendations ................................................................................................................ 26

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1 Introduction

1.1 Purpose of Chapter

Musculoskeletal conditions are an often overlooked and undervalued cause of morbidity. Having

healthy joint, bones and muscles are essential to our daily activities. Conditions such as arthritis,

osteoporosis and fragility fractures are increasing in prevalence as our population ages. A

comprehensive public health approach to increasing awareness of the impact of musculoskeletal

conditions, primary prevention through controlling risk factors and reducing pain and mortality for

those who suffer from these conditions is needed. Our needs assessment aims to briefly review the

current literature regarding musculoskeletal conditions, demonstrate the impact of musculoskeletal

conditions in Hertfordshire and review the services available in Hertfordshire alongside policy

recommendations.

1.2 Aims and Objectives

1.2.1 Aims:

1. Provide an evidence base to inform future commissioning and decision-making

around MSK conditions in Hertfordshire.

2. Highlight areas for particular focus in future efforts to improve outcomes and reduce

inequalities around MSK conditions in Hertfordshire.

1.2.2 Objectives:

1. Summarise evidence and guidelines relating to prevention and treatment of MSK

conditions.

2. Summarise population level data on MSK conditions in Hertfordshire.

3. Summarise evidence and data on risk factors for MSK conditions in Hertfordshire.

4. Summarise evidence and data on health impact of MSK conditions in Hertfordshire.

5. Summarise data on healthcare spending for MSK conditions in Hertfordshire.

6. Summarise evidence on wider social and economic impact of MSK conditions in

Hertfordshire.

7. Model future needs in relation to the above.

8. Summarise current service provision and data on healthcare spending for MSK

conditions in Hertfordshire.

9. Summarise evidence on Hertfordshire service users’ views for MSK conditions.

10. Identify gaps in current evidence and data on MSK conditions.

11. Identify gaps in current service provision in Hertfordshire for MSK conditions

including local inequalities in provision and gaps between best practice and current

local practice.

12. Provide recommendations of priorities and next steps for local decision-makers and

commissioners.

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2 Musculoskeletal conditions

2.1 Introduction

Musculoskeletal conditions include a broad range of conditions including disorders of the bone,

joints, muscles and spine. They can be as a result of acute trauma, acute conditions or long-term

chronic conditions. Many are progressive causing a range of symptoms that impact on quality of life

and activities of daily living. Broadly speaking the three major burdens of disease within

musculoskeletal conditions are: osteoarthritis, osteoporosis and resulting fragility fractures, and

inflammatory conditions such as rheumatoid arthritis.

In the UK, 10 million people live with long-term painful condition of their joints, spine, bones or

muscles. [1] Musculoskeletal conditions are the largest single cause of years lived with disability

(YLDs) and third largest cause of disability adjusted life years (DALYs). [2] 20% of the general

population sees a GP about a musculoskeletal problem [1], the majority due to back pain and

osteoarthritis.

The impact of musculoskeletal conditions can also be seen to the NHS. The NHS in England spends

£5 billion per year on treating musculoskeletal conditions, which includes the cost of 150,000 joint

replacements for osteoarthritis of the hip and knee. [3] £2 billion a year is spent on clinical and social

care for treatment of hip fractures. [4] There is also a cost to the wider economy; in the UK 8.3

million working days are lost due to MSK conditions. [5]

2.2 Risk factors

The risk factors for most conditions can be split up into two main categories: modifiable and non-

modifiable. Non-modifiable risk factors such as genetics, age, sex and previous history of

musculoskeletal disorders have a clear impact on musculoskeletal conditions. For instance, over 80

gene mutations may be involved in the pathogenesis of osteoarthritis. [6]The prevalence of some

musculoskeletal disorders also tends to increase with age as normal wear and tear takes its toll on

the body. Having a previous fragility fracture also increases the risk of having a future fracture.

Women have a higher risk of osteoarthritis in the hand, foot and knee than men. [7]

There are however plenty of modifiable factors which can be targeted to greatly reduce the impact

of musculoskeletal conditions on the population. Risk factors for some musculoskeletal disorders are

similar to risk factors for common metabolic conditions such as diabetes. In fact Type 2 Diabetes can

itself increase the risk of osteoarthritis and worsen its progression. [8] Obesity is also associated with

an increased risk for developing osteoarthritis. This is partly due to increased burden on weight

bearing joints but also by causing generalised inflammation and oxidative stress. [9] Having low

levels of Vitamin C increases the risk of knee osteoarthritis highlighting the importance of healthy

eating. [10] Low levels of physical activity can also predispose people to musculoskeletal conditions.

Moderate exercise helps prevent weakening of the joints and alterations in articular cartilage

reducing the incidence of musculoskeletal conditions. [11]

It is not merely osteoarthritis that has modifiable risk factors. Osteoporosis risk factors include

excessive alcohol intake, smoking, nutrition and physical activity all of which are potentially

modifiable. [12] There is a clear multi-faceted link between rheumatoid arthritis and smoking. [13]

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Modifiable risk factors for musculoskeletal disorders throughout the lifecourse. [14]

3 The conditions

3.1 Osteoporosis, falls and fractures

Osteoporosis is the decrease of bone density resulting in increased risk of bone fractures especially

following a fall. Osteoporosis is currently identified opportunistically in the community or

alternatively following a fragility fracture and admission to hospital. Treatment of osteoporosis has

two main facets; primary and secondary prevention. Primary prevention is aimed to prevent a

fragility fracture whereas with secondary prevention the aim is to prevent further fragility fractures

once one has occurred. Osteoporosis is predominantly a disease of the elderly and affects post-

menopausal females more so than males in general. [15] The risk of falls in the elderly also increases

which heightens the risk of fragility fractures due to decreased bone density and strength.

Diagnosing individuals with osteoporosis prior to them having a fragility fracture would decrease the

health implications to the individual of having osteoporosis and potentially reduce hospital

admissions. Using GP practice lists to identify people at higher risk of osteoporosis (age, prescription

record, major diagnoses and previous fractures) could result in a more efficient method to prevent

osteoporosis rather than the current opportunistic approach. [16]

Vitamin D supplementation reduces the risk of falls by over 20% [17] and reduces the incidence of

fractures at a dose of 700-800 IU per day. [18] Mortality is reduced in the elderly but only by Vitamin

D supplementation with calcium, either alone does not significantly alter mortality rates. [19] [20]

Meta-analysis of RCTs into the efficacy of bisphosphonates demonstrate a role for them in primary

prevention based on age, risk factors and bone mineral density. [21] Alendronate may also be used

as an initiation therapy for secondary prevention of osteoporosis. [22]

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The main resulting cause of morbidity from osteoporosis is a fragility fracture often due to falls. A

falls history should be routinely taken by healthcare professionals when seeing an older person. A

multifactorial risk assessment should be performed on any older person who has presented due to a

fall or reports recurrent falls in the past year. During a hospital stay anyone over 50 deemed to be at

risk of falling and everyone aged 65 or older should have a multifactorial assessment. A successful

multifactorial intervention may include: strength and balance training, home hazard assessment and

intervention, vision assessment and referral, and medication review. There is insufficient evidence to

support low intensity exercise, cognitive/behavioural interventions, Vitamin D and hip protectors as

tools to reduce falls. [23] Multifactorial interventions including individual risk assessment and

tailored interventions appear to reduce the risk of falling to a statistically significant degree. The use

of exercise or vitamin D supplementation alone does not appear to reduce the incidence of falls. [24]

3.2 Osteoarthritis and joint degeneration

Osteoarthritis is the degeneration of joints causing pain and stiffness. It can be identified through

symptoms alone though there often characteristic radiological changes. These degenerative changes

build up and mainly present as symptoms in the middle-aged and elderly populations. Having a

healthy lifestyle including exercise and maintaining a healthy weight are key factors in reducing

incidence of osteoarthritis and must be encouraged as part of an overall public health approach to

musculoskeletal disorders.

Assessment of patients with osteoarthritis should take a holistic approach covering social effects of

having the condition, occupational effects, co-morbidities, the effect on mood, sleep, exercise and

pain. [25] Activity, exercise [26] and reducing weight [27] have been shown to improve pain and

symptoms for people suffering with osteoarthritis. Ultimately joint replacement therapy may be

necessary when symptoms and impact on quality of life are refractory to non-surgical interventions

though functional outcomes may be poor and the lifespan of prostheses is limited. [28]

3.3 Inflammatory musculoskeletal conditions

Rheumatoid arthritis is an inflammatory disorder which causes progressive joint pain and swelling.

It most frequently affects the joints in the hands and feet symmetrically, but can affect any synovial

joint. However, the disease does not limit itself to the joints, and inflammation can affect the lining

of the heart, lungs and blood vessels. Those affected by rheumatoid arthritis can suffer from other

systemic symptoms such as fatigue, flu-like symptoms and weight loss. This condition can cause life

threatening problems when the neck joints are involved, causing dislocation, or inflammation causes

pressure on the spinal cord results in bladder or bowel dysfunction or problems moving the limbs.

This can also affect the nerves controlling respiration, which may be fatal.

Aside from pharmacological treatment a number of important management interventions are key.

Specialist physiotherapy helps enhance joint flexibility and reduce functional impairments. [29]

Specialist occupational therapy input can also preserve function, especially in the hands. [30]

Psychological interventions mainly aimed at stress management, relaxation and cognitive coping

skills can also improve the morbidity of a person suffering from rheumatoid arthritis. [31] NICE

guidelines also suggest involving a podiatrist with therapeutic footwear. [32] Working in a multi-

disciplinary team has been shown to produce long term benefits to outcomes [33] but there is

limited evidence supporting patient education programmes. Other physical therapies such as the use

of cooling and heating, transcutaneous electrical nerve stimulation, and laser therapy have

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insufficient evidence to support their routine use. There is limited evidence to support the use of

splinting though the use of orthosis has a much clearer evidence base. [34]

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4 Epidemiology in Hertfordshire and Nationally

4.1 Epidemiology of musculoskeletal conditions

The prevalence of the major musculoskeletal disorders in Hertfordshire can be found using various

different sources. QOF data from every GP practice in Hertfordshire can be used to calculate the

prevalence of both osteoporosis and rheumatoid arthritis. Arthritis UK has also estimated prevalence

for hip and knee osteoarthritis in Hertfordshire.

These graphs below provide an estimate of the prevalence of osteoporosis and rheumatoid arthritis

in Hertfordshire using QOF data. QOF data is dependent on GPs using specific codes to input

diagnoses into patient data. As a result some patients with either condition may not be counted. The

actual prevalence of these conditions may therefore be higher.

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

Pre

va

len

ce (

%)

QOF prevalence of osteoporosis by CCG Locality, 2013/14 and

2014/15, Hertfordshire

2013/14 2014/15PH.Intelligence@hertfordshire.gov.uk

8

Prevalence rates of knee and hip osteoarthritis can also be calculated using the Arthritis UK

musculoskeletal calculator. This tool uses data on risk factors for osteoarthritis such as age of

population, obesity rates, smoking prevalence etc. to estimate the prevalence of the condition.

Below are the estimates for the various districts of Hertfordshire broken down into knee and hip

osteoarthritis and the severity of the condition.

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00P

reva

len

ce (

%)

2013/14 2014/15PH.Intelligence@hertfordshire.gov.uk

QOF prevalence of rheumatoid arthritis by CCG Locality, 2013/14 and 2014/15,

Hertfordshire

9

0

2

4

6

8

10

12

Pe

rce

nta

ge

(%

)

Arthritis UK estimated percentage of people with hip osteoarthritis in Hertfordshire districts,

2015

Hip osteoarthritis Total Hip osteoarthritis Severe

10

0

2

4

6

8

10

12

14

16

18

20

Pe

rce

nta

ge

(%

)

Arthritis UK estimated percentage of people with knee osteoarthritis in Hertfordshire districts,

2015

Knee osteoarthritis Total Knee osteoarthritis Severe

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According to the Arthritis UK data, the estimated prevalence of knee osteoarthritis in Hertfordshire

is below the national average. The estimated prevalence of total hip osteoarthritis is over 10% within

Hertfordshire and nationally. There is not much variation in the estimated figures across

Hertfordshire although St. Albans has the lowest estimated prevalence and Stevenage the highest

for both knee and hip osteoarthritis tallying with what we know about the prevalence of the major

risk factors for osteoarthritis in Hertfordshire.

4.2 Epidemiology of risk factors

Modifiable Hertfordshire Wider Geographic Area

Physical activity [35] 54% adults are not physically active.

Those over 55 years are less likely to

be active than younger adults.

In East of England and England,

58% not physically active.

Smoking [36] 19% adults are smokers Nationally, 21% of adults

smoke.

Nutrition [35] Just over one third of the adult

population are eating healthily

(recommended amount of fruit and

vegetables)

One third of adults’ diets are

healthy in England.

Obesity [35] 21% adults are obese. Currently 67% adults and 33%

children are classed as

overweight or obese

By 2050, nearly 90% adults and

67% of children will be

overweight or obese

Non modifiable

Ageing population [37] Currently around 21% of people in

Hertfordshire are ≥60 years.

In the East of England now, 24%

are ≥60 years and in England,

22%.

Over next 20 years, there is an

estimated 70% increase in people

aged ≥65 years.

Hertfordshire County Council has JSNAs on ‘Increasing Physical Activity and Promoting a Healthy

Weight’, ‘Tobacco Harm’ and ‘Ageing Well’.

4.3 Health impact of musculoskeletal conditions

The Global Burden of Disease Study found that in the UK, the second major cause of years lived with

disability (YLDs) were musculoskeletal disorders, after mental health and behavioural problems [38].

The study believed that this burden was worsening as there are more people are living longer. This is

a cause for concern, and policies should move to reflect this trend.

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This burden has been supported by research by Arthritis Research UK, who estimated that

musculoskeletal problems are the second most common complaint to GPs by adult patients in the

UK [39].

Musculoskeletal problems also affect secondary care. Each year, at least 70,000 people fracture their

hip in the UK, costing an estimated £2 billion a year in medical and social care [40].

Local data for the districts in Hertfordshire regarding hospital admissions for fractured neck of femur

and injuries due to falls is demonstrated below. This is compared to the rest of the East of England

and nationally.

[41] Data sources\NOF admissions.xlsx

In 2013/14 Watford had the highest rate of emergency admissions for fractured neck of femur.

Welwyn Hatfield had the least, which was much less than the Hertfordshire and England average.

Overall, the district total was slightly better than the rest of the East of England and England.

[41] Data sources\NOF admissions.xlsx

In general, the average rate for emergency admissions for neck of femur fractures in the

Hertfordshire districts have been falling.

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[41] Data sources\NOF admissions.xlsx

The rates of emergency hospital admissions for falls injuries in the districts are quite variable.

Watford had the highest proportion compared to the rest of the Hertfordshire districts, and

Broxbourne the least. The average for the districts was slightly higher than the rest of the East of

England average, but similar to the England average.

[41]

The rates of emergency admissions for falls injuries have been rising over the last few years in

Hertfordshire. Data sources\NOF admissions.xlsx

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5 Healthcare spending on musculoskeletal conditions

Spending on musculoskeletal conditions in Hertfordshire is available for both of the two main CCGs

covering Hertfordshire. This can be compared with the average spend across England. The figures

below are for total spend for each of the categories per 1,000 weighted population.

Data sources\CCG Tools spreadsheet.xlsx

The average spend for elective and emergency admissions to hospital and primary care prescribing

for musculoskeletal disorders is lower in both main Hertfordshire CCGs compared with nationally.

Using programme budgeting data from NHS England we can examine the various spending

categories within musculoskeletal disorders. The greatest proportion of spending is from elective

and day case surgery followed by outpatient care. This highlights the progress in reducing the need

for emergency care which can be more costly and lead to worse outcomes for the patients. The total

cost for musculoskeletal disorders to CCGs in Hertfordshire is over £16,000,000 highlighting the

significance of musculoskeletal disorders and its impact on the NHS.

Cost breakdown for various categories within musculoskeletal disorders per CCG. Data sources\Expenditures

per CCG.xlsx

15

As expected, both CCGs spend the greatest proportion of money on day case and elective

admissions. East and North Herts CCG spend overall more money per 100,000 population on

musculoskeletal disorders but less on day case and elective admissions. The categories above are not

exhaustive and other costs may be incurred by the CCGs that combine with the above to give the

total spend shown.

The spend profile for complex patients in each CCG is also shown below using data from the

commissioning for value packs.

16

Using the Public Health England Spend and Outcome Tool we can further analyse the categories of

spending in the two main Hertfordshire CCGs. The Spend and Outcome Tool compares CCGs with

other CCGs nationwide during 2015 and compares the money spent on each category with the

outcomes achieved for that category. Deviations in Z score of greater than 2 are said to be

statistically significant and warrant further investigation.

17

Spend compared with outcome for hip replacements commissioned by East and North Herts CCG.

Spend compared with outcome for hip replacements commissioned by Herts Valleys CCG.

18

Spend compared with outcome for knee replacements commissioned by East and North Herts CCG..

Spend compared with outcome for knee replacements commissioned by Herts Valleys CCG.

19

For most spend and outcome indicators measured by the Public Health England tool, both main

Hertfordshire CCGs spend slightly more than average and have outcomes slightly worse than

average though none of these is statistically significant. This includes the knee and hip replacements

in the charts above and further indicators such as osteoporosis registers, fragility fractures and

treatment of fragility fractures.

6 Social and economic impact of musculoskeletal conditions

According to the Labour Force Survey, in the UK over 8 million working days were lost due to

musculoskeletal disorders that were caused or made worse by work. Clearly the economic impact of

lost working days is huge to the economy. This is without factoring in people who as a consequence

of musculoskeletal disorders are now on long term disability allowances.

We can determine the economic impact of musculoskeletal conditions by looking at the NOMIS

database which provides official labour market statistics for the U.K. In Hertfordshire the largest

group of claimants for Disability Living Allowance (DLA) are people suffering from arthritis,

highlighting the burden of this condition economically.

Data sources\Breakdown of DLA for MSK in Hertfordshire.xlsx

45.6%

6.8%

17.4%

20.6%

5.2%

1.6%

2.7%

0.1%

Disability living allowance claims in Hertfordshire, 2015

Arthritis

Spondylosis

Back pain - other / Precise

diagnosis not Specified

Disease of the Muscles, Bones

or Joints

Trauma to Limbs

Traumatic

Paraplegia/Tetraplegia

Other Major Trauma

Double Amputee

20

Local Authority: District

Arthritis Spondy

losis

Back pain - other

Disease of the Muscles,

Bones or Joints

Trauma to

Limbs

Traumatic Paraplegia / Tetraplegia

Other Major

Trauma

Double Amputee

Broxbourne

490 80 190 230 50 10 10 ~

Dacorum

600 90 230 260 80 30 40 ~

East Hertfordshire

390 60 170 210 40 20 30 ~

Hertsmere 380 50 140 190 40 20 30 ~

North Hertfordshire

500 70 180 210 50 20 40 ~

St Albans 370 70 140 190 40 20 10 ~

Stevenage 480 70 170 180 50 ~ 30 ~

Three Rivers 330 40 110 130 30 10 10 ~

Watford 370 60 160 160 40 20 30 ~

Welwyn Hatfield

430 70 170 200 60 20 20 ~

Hertfordshire Total

4,340 650 1,650 1,960 490 150 260 10

A breakdown of DLA claimants in Hertfordshire by district and condition as per the Department for Work and

Pensions.

Disability living allowance expenditures for musculoskeletal disorders per district in Hertfordshire. Data

sources\Breakdown of DLA and awards for MSK.xlsx

The total DLA spend for musculoskeletal conditions in Hertfordshire is £840,977.50 again

demonstrating the impact to the economy of musculoskeletal conditions. This figure does not

include a number of categories such as those who are unable to work and have not claimed benefits,

employed people on sick leave (either short term or long term), and the spending in primary care

and secondary care on musculoskeletal conditions.

The social impact of musculoskeletal disorders is difficult to quantify however we can examine

where the impact may lie. There is a burden on those around the person suffering from

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musculoskeletal disorders with those people having to take on additional economic and domestic

responsibilities. There is an impact on the quality of life of the person with condition and those

around them as well, as there may be a reduction in socialising and other activities which they may

otherwise have been able to perform. There is also often a stigma attached to certain

musculoskeletal conditions where conditions such as fibromyalgia or chronic back pain are seen as

conditions that can be overcome should the person want to overcome them and people on long

term sick leave may be resented for being part of a ‘benefit culture’.

7 Future needs

As with the U.K. in general Hertfordshire has both an ageing and growing population. The bulk of

health and economic impact relating to musculoskeletal disorders in due to conditions related to

ageing such as osteoarthritis and osteoporosis. As a result the health and economic impact of

musculoskeletal disorders will only increase with time.

An age pyramid demonstrating the increase in population and the ageing population of Hertfordshire from

2012 to 2037.

Merely focusing on the population increases and the increase in median age ignores the impact

modifiable risk factors will have on the increasing burden of musculoskeletal disorders. Modelling

from Sweden suggests an increase of 26,000 people per 100,000 people aged over 45 consulting

with their doctor regarding a joint osteoarthritis. [42] Considering Sweden has lower rates of risk

factors for developing musculoskeletal disorders such as lower rates of obesity and smoking, the

impact on the U.K. may well be greater.

22

Arthritis Research UK have attempted to estimate the prevalence of knee osteoarthritis in 2020 and

2035 only taking into account the increase in population and the prevalence of obesity.

Future projected increase in knee osteoarthritis based on projected population increases and increase in the

prevalence of obesity. [43]

The increase in the number of people with arthritis in the U.K. is projected to go up from 4.71 million

people in 2010 to a possible 8.30 million people in 2035. This projected increase will have a huge

consequence on the NHS and the economy as a whole and efforts to address modifiable risk factors

for musculoskeletal conditions are clearly essential to limit this looming burden of disease.

8 Current services

A number of services are available in Hertfordshire to people suffering with musculoskeletal

conditions and to prevent worsening or increasing their burden of disease. As with every local

authority appropriate physiotherapy, medical and surgical management are available to those who

fit local criteria.

In addition to these services there are other initiatives encouraging people to reduce their burden of

musculoskeletal disease. Hertfordshire Health Walks are free guided walks to promote physical

activity. 55 health walks occur every week with 38,000 participations across 2015. [44]

Exercise referral schemes are available to those with certain conditions such as severe osteoarthritis

in order to improve function and reduce morbidity. A Weight Watchers scheme is also available with

a free 12 week subscription to those with a motivation to lose weight and a BMI above 28.

23

A frailty vehicle project is being initiated in East and North Herts CCG. Funding has been approved

for one vehicle thus far which will take referrals from GPs and aim to improve patient treatment and

reduce hospital admissions through specialist assessment of referred patients in their own homes. A

pilot service successfully treated 69% of its patients at home compared with a usual ambulance treat

at home rate of 40%. [45]

A National Audit on rheumatoid arthritis treatment measured compliance of CCGs to NICE

guidelines. There is data from East and North Hertfordshire NHS Trust (E&N Herts NHS Trust) but

West Hertfordshire Hospitals NHS Trust was not included due to lack of data. Nationally, 17% of

symptomatic patients presenting to their GP were referred within 3 working days to rheumatology

services compared to 10% in E&N Herts NHS Trust. 38% of patients nationally were seen by a

rheumatologist within 3 weeks, compared to 44% in E&N Herts NHS Trust. Nationally 53% of

patients started DMARDs within 6 weeks of referral, but in E&N Herts NHS Trust, 0% of patients

received this treatment. 50% of patients in E&N Herts NHS Trust were prescribed steroids at the

time of working diagnosis compared to 76% nationally. 99% of patients nationally who reported side

effects from medication were given advice within 1 working day of contacting the rheumatology

service, compared to 100% in E&N Herts NHS Trust. It must be noted that sample sizes for the

results above varied making it difficult to ascertain statistical significance and local protocols and

treatment pathways may affect how the trust performed when compared with national guidelines.

[46]

9 Users views

Using the PROMs (Patient Reported Outcome Measures) database we can evaluate the performance

of the two main CCGs in Hertfordshire compared with England. Questionnaires are filled in before

and after surgery using the EQ-5D standardised outcomes measure to evaluate performance.

Health gain from performing primary hip replacements by CCG, compared with England.

Health gain from performing primary knee replacements by CCG, compared with England.

24

As we can see both main Hertfordshire CCGs perform similarly to the England average in both

primary hip and knee replacements. None of the differences in performance above are statistically

significant.

There is very little data looking at how satisfied patients are with the current state of

musculoskeletal services in Hertfordshire. Regardless, progress is being made to increase usability

and efficiency of musculoskeletal services. For instance Herts Valleys CCG is attempting to

streamline their community physiotherapy service to ensure a central triage point and consistency in

service across the CCG area.

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10 Evaluation and Recommendations

10.1 Evaluation

Musculoskeletal disorders are an increasing burden on the NHS and a large cause of morbidity on

the population. In Hertfordshire this is exacerbated by a growing and ageing population straining

services that are already available. CCGs are focusing on their primary care services, increasing

management of musculoskeletal disorders in the community, and thereby reducing the much larger

secondary care costs of surgery and hospitalisation. From a public health point of view, many of the

same interventions that are seen to be beneficial to the population’s health as a whole to reduce

incidence of heart disease, diabetes etc. apply to musculoskeletal disorders as well. Stopping

smoking would reduce the incidence of rheumatoid arthritis, losing weight would decrease incidence

of osteoarthritis and a healthy, balanced diet would reduce incidence of osteoporosis.

Implementation of accessible community physiotherapy services with comprehensive patient

education regarding their condition to better inform preventative measures they can take would

reduce demand for services and increase wellbeing.

10.2 Gaps in evidence

• Identifying early metabolic changes in populations at high risk of osteoarthritis to determine

risk factors for increased mortality.

• Link between hand osteoarthritis and use of keyboards, mobile phones etc.

• User views only available for hip and knee replacements. We do not know how happy other

service users are with the treatment of their musculoskeletal disorders.

• The economic impact of musculoskeletal disorders goes beyond the healthcare costs and

disability living allowance detailed in this needs assessment. There is an impact on carers,

family and society as a whole that remains unquantified.

• Prevention of musculoskeletal disorders would be much better than dealing with the

conditions once they have arisen. Though we are able to identify key risk factors (e.g.

Vitamin D deficiency causing osteoporosis) adoption of interventions to rectify these issues

remain underdeveloped despite some good evidence (Vitamin D food fortification). [47]

I. Gaps in Hertfordshire data

• Modelling could be performed to estimate the increase in prevalence of musculoskeletal

disorders in Hertfordshire based on the increasing population, ageing population and

increased incidence of risk factors associated with developing certain musculoskeletal

disorders to give a clearer picture of the demand for services in the future. At present we

know the U.K. wide demand will almost double over the next 20 years. [43]

• It is difficult to analyse trends in performance indexes and spending due to much of the data

only having been recorded for 2-3 years. Having more data available over the next for years

will help identify long term trends and reasons for them.

• Much of the inter-Hertfordshire disparities in the prevalence and predicted prevalence of

musculoskeletal disorders appears to lie in the socioeconomic differences and differences in

the prevalence of certain risk factors of musculoskeletal conditions. However it is difficult to

26

provide good evidence to support this hypothesis and perform in depth analysis of local

differences.

II. Gaps in current service provision

a. Local inequalities

• The local inequalities that have been noted earlier are mainly as a consequence of the

prevalence of risk factors predisposing to musculoskeletal disorders. It is unclear what other

local inequalities are present and whether there may be local inequalities based on the

quality of the services that are being provided.

b. Local practice vs best practice

• Again it is unclear what local policies are regarding management of musculoskeletal

disorders and whether they contrast with national guidelines.

10.3 Recommendations

⇒ A life course approach to optimising bone health. Prioritise reducing childhood

obesity, increasing physical activity and healthy eating.

⇒ Opportunistic advice during every consultation to reinforce physical activity

guidelines. Making every consultation count.

⇒ All patients with a chronic disease should be referred to a rehabilitation programme

which includes an exercise intervention. [48] This would help with both primary and

secondary prevention of musculoskeletal disorders.

⇒ Opportunities for physical activity targeted at specific groups in the community. For

instance, for working age adults physical activity can be part of commuting (cycling

to work / walking to work schemes) whereas for young children martial arts or

dance classes may be more productive.

⇒ Psychological support early on in the treatment of conditions that cause pain or loss

of function. Often patients are referred to chronic pain services a few years after

being initially diagnosed reducing the effectiveness of psychological or psychiatric

interventions. Early pick up of ‘yellow flag’ symptoms that indicate psychosocial

barriers to recovery could reduce the risk of long term disability. [49]

⇒ The option of self-referral to physiotherapy may result in earlier uptake of services

and the reduction of morbidity.

⇒ Comprehensive pre-operative education programmes reduce anxiety, length of stay

and improve outcomes for hip and knee replacement surgery. [50]

⇒ Increasing speed of referral, diagnosis and treatment to comply with NICE guidelines

will improve the patient experience and reduce morbidity.

⇒ Regular audit of performance compared with NICE guidelines should be encouraged

to give a better indication of performance. For instance though we have data for the

performance of East and North Herts NHS Trust on rheumatoid arthritis, we do not

have sufficient quality data for West Hertfordshire NHS Trust.

27

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