Innovating beyond digital: A comprehensive ICS approach to musculoskeletal care
Dr Carey McClellan explores how supported self-management tools can help integrated care systems to support MSK patients across their entire care pathway.
Musculoskeletal (MSK) injuries and conditions impact approximately 20 million people in the UK, making them the leading cause of disability. They affect people’s daily lives, the NHS, the workplace and the economy.1
In fact, MSK problems cost the NHS £5 billion ever year, account for 14-18 per cent of all GP appointments in England, and result in 24 million lost working days annually.2,3 Despite this already substantial burden, the prevalence of MSK conditions is rising due to a combination of an ageing population and lifestyle factors.4
The case for self-management
The value in supporting people to self-manage MSK conditions as early as possible is well researched, and recommended within national guidelines and policy.5-13 However, it is not delivered consistently or at scale. A recent report by The Arthritis and Musculoskeletal Alliance (ARMA) highlighted the variation in strategy, leadership and prioritisation of MSK conditions across integrated care boards (ICBs) despite it being one of six priorities in NHSE’s major conditions strategy.
NHS England’s ‘Best MSK Health Collaborative’ and Getting It Right First Time’s (GIRFT) community MSK workstream have both highlighted the absolute need to adopt evidence-based digital technology to support people with MSK injuries and conditions.14 At the same time, there is a growing emphasis on the link between health and economic inactivity and a new government focused on improving both.15
Early intervention holds the key, but people are waiting too long
GIRFT has highlighted the need for early intervention in the MSK care pathway to reduce the primary impact and longer-term consequences. Additionally, not enough is being done to support people, or minimise the time they spend, on waiting lists. The BMA estimates that 8 million patients are currently waiting for consultant-led elective care.16 However, the number does not include the ‘hidden backlog’ – those who have not yet presented for care or are waiting for other services (e.g., physiotherapy or investigations).
There are up to six waiting stages before an orthopaedic procedure, each offering a chance to reduce deconditioning, encourage self-management, support a person’s return to work, and possibly avoid costly surgical intervention. Extended waiting times for MSK treatment at any point on this journey take a toll on patients’ physical and mental health, leading to deconditioning, increased pain, lesser quality of life, difficulty to work and, in some cases, irreversible deterioration.17
Enabling people to self-manage their recovery
Digitally supported self-management tools help integrated care systems (ICSs) to support MSK patients across their entire care pathway. They help people to trust their recovery, utilise less healthcare resource and return to work more quickly and safely.
For maximum impact, digital self-management pathways should be made available to people at the earliest possible opportunity wherever they connect with the health system or seek help – in the community (pharmacies, libraries, leisure centres), primary care (GP, first contact practitioner), urgent care or secondary care (elective care). Self-management support is suitable for 80 per cent of all new, recurrent, or long-term MSK conditions, including people on waiting lists.18
Tools like getUBetter enable people to self-manage their recovery by following a recovery and prevention pathway defined by their local healthcare system. And, because it’s digitally enabled, it supports people to manage their condition 24 hours a day, 365 days a year, taking them through their recovery day-by-day, and providing them with the knowledge, skills, and confidence to help themselves. Support is provided through triage, advice and guidance, exercises, outcome measures, dynamic safety netting and referral when necessary.
getUBetter also supports people by connecting them to treatment, local support and public health services (e.g., smoking cessation, weight reduction and return to work).
Behaviour change model
For a digital platform to have a positive impact on people and the NHS, it must be trusted, and help people change their behaviour. That’s why getUBetter was designed with an underpinning COM-B behaviour change model as its foundation.19 The COM-B model is a theoretical framework that incorporates key components (capability, opportunity, and motivation) considered to affect behaviour.
For example, all content has been created with behaviour change at its core and tailored depending on the individual’s stage of their recovery and how they are feeling. Content includes support to mitigate against negative behaviours and promote positive behaviour; it is personalised, targeted, and localised to clinical pathways, health services and community support. getUBetter includes support for safety netting as well as other factors such as psychological elements of MSK recovery, the relationship between work, home, and health and system obstacles to work. All can influence someone’s ability to recover, live and work well.
Digitising isn’t enough to drive clinical transformation and positive impact
The NHS is littered with examples of poorly designed patient-facing applications that have not been co-designed with their users. This leads to a frustrating experience and short-lived engagement.
An iterative design process ensures content is accessible, intuitive, inclusive, and easy to follow, while barriers to adoption such as digital exclusion are minimised.20 Working in partnership with ICB clinicians, champions and transformation stakeholders is essential. Their local expertise is crucial for ensuring that any digital tool integrates seamlessly into routine care. This ensures the best approach for deployment and adoption, and creates a blueprint for NHSE scale and adoption.21
The impact of digital self-management
Lord Ara Darzi’s Independent Investigation of the NHS in England confirms that it must move care into the community, enable patients to take active involvement in their own care, digitise, and help tackle economic inactivity. MSK digital self-management tools are ideally placed to play a central role in realising this.22
Earlier this year, NICE published an Early Value Assessment approving the use of five digital tools for use in the NHS for non-specific low back pain – the biggest cause of days taken off work.
An economic evaluation conducted by Health Innovation Network (HIN) South London highlighted the scale of the burden of back pain, and the possible return on investment that can be achieved by deploying digital self-management tools. The independent report demonstrated that a cost saving of more than £1.9 million for back pain alone could be achieved per area (place) of an ICS with a population of 330,000 through deploying digital self-management.23
Further research conducted by the HIN demonstrated that when using getUBetter, an ICS can expect a 13 per cent reduction in GP follow-up appointments, a 50 per cent reduction in MSK-related prescribed medication, a 20 per cent reduction in physiotherapy referrals, and 24-66 per cent fewer urgent care attendances. A Somerset NHS Foundation Trust evaluation revealed that 50 per cent of patients awaiting MSK physiotherapy appointments felt their needs were met after using getUBetter, prompting them to remove themselves from the waiting list. Those in NHS South East London ICS who utilised getUBetter before their physiotherapy appointments required 40 per cent fewer sessions compared to patients who did not use the app.24 NHS Frimley ICS reported 11 per cent fewer sick notes, helping people back to work.
The MSK problem in the UK is a complex one to solve and requires close collaboration with patients, clinicians, ICB leads, transformation experts, health systems, and the government to ensure the solution reflects local needs. While technology has a role as an enabler in digitising ICS-wide MSK pathways, it is not achievable without clearly defined methodologies of co-design, behaviour change and clinical transformation.
If you’d like to hear more about this approach and blueprint, please sign-up for the forthcoming webinar, Transforming MSK care across complex health systems with digital self-management support: Technology vs methodology on 26 September 2024.
List of references
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