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S mskpb 12/01 cottish Government Health Directorate National Musculoskeletal Work Programme Background Paper Purpose

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MSKPB 12/01
cottish Government Health Directorate

National Musculoskeletal Work Programme

Background Paper


In 2007, the Scottish Government Health Directorate (SGHD) set out the intention to undertake a major redesign of patient musculoskeletal pathways in its policy document, The Delivery Framework for Adult Rehabilitation in Scotland. This work aims to improve timely access for patients to the most appropriate information and clinical specialist, and support greater cost effectiveness across the system. Integral to this work is the development of a centralised referral management system. It is intended that the technology within NHS 24 will be utilised as the platform for this.

The key components of the pathway include:

    • self referral for people with MSK conditions via a centralised system

    • increasing self-management

    • reducing complications with early intervention

    • providing greater primary care provision through multi-disciplinary teams

    • decreasing work related absence and enhancing employability

The overarching purpose of the MSK re-design is to ensure that patients self referring into the MSK pathway are triaged into the most appropriate services. These may include self management, vocational rehabilitation services, leisure services, chronic pain services, general musculoskeletal services, other primary care services and secondary care services.

People who are of working age should also be supported to return to work or referred into employability services, as appropriate, early in their rehabilitation journey. Older patients should be signposted into appropriate older peoples pathways (falls pathway) and leisure services.


The Delivery Framework for Adult Rehabilitation in Scotland, provides strategic direction and support to all health and social care services and practitioners who deliver rehabilitation or enablement services to individuals and communities. The vision underpinning the framework is the creation of a modern, effective, multi-disciplinary, multi-agency approach to rehabilitation services that are flexible and responsive in meeting the needs of individuals and communities in Scotland.

One of the key national programmes for the Framework is the development of a National Musculoskeletal (MSK) Programme which aims to bring about significant service redesign to improve the delivery and outcome of musculoskeletal services across Scotland. The redesign focuses on improving access to services by establishing a centralised self referral triage system utilising the technology within NHS 24, which is the national telephone and web based advice service for NHS Scotland. The aim is also to develop telerehabilitation opportunities as well as specific web based rehabilitation resources.
In addition The Scottish Government is committed to delivering a range of actions outlined in Health Works (2009) including the development of the “Scottish Offer”. This sets out what health services should be providing to help people with health barriers to work, the standards that they should be delivered to, how they can be accessed and the links to wider services such as employability. It is the intention to embed the ‘Scottish Offer’ firmly and transparently within the MSK pathway.
NHS 24 is considered to be integral to the delivery of both the Musculoskeletal Pathway and the ‘Scottish Offer’.
Other policy drivers include: 18 week Referral To Treatment Standard, Shifting the Balance of Care, The Scottish Patient Safety Programme, The Better Together Programme and, more recently, the Quality Strategy (2010).
Scale of the Problem
The MSK programme has been identified as a priority due to the fact that: MSK conditions are the most commonly reported type of work-related illnesses and comprise 1 in 4 of all GP consultations and 1 in 7 of all healthcare appointments (all disciplines) in Scotland. These conditions can have an adverse influence on health and quality of life for many individuals, and can limit daily activities. The majority of MSK conditions are managed in primary care and/or AHP services with a lower proportion (<10%) being referred onto secondary services. In Scotland, the cost associated with orthopaedics alone has increased from £180 million in 1999/2000 to over £360 million in 2007/08 .

In addition:

  • The average rate of referral to physiotherapy is 56/1000 however this varies considerably throughout Scotland (22-108/1000)

  • Patients are sometimes referred to orthopaedic surgeons for management of their condition when there is little indication that surgery or specialist care is required. Over 69% of people on the average orthopaedic waiting list do not go on to have surgery. In Scotland in 2010 there were 30,000 patients on a waiting list, therefore over 18,000 of these patients not requiring surgical intervention

  • In the UK 12.25 million work days are lost due to musculoskeletal disorders. with associated costs of £5bn p.a. to the economy due to working days lost.

  • Low back pain is the most common musculoskeletal problem affecting an estimated 18 million people in the UK.

  • In Scotland physiotherapists treat over 64,000 back pain patients p.a. and a minimum of 271,000 MSK patients p.a.

  • 5% of patients presenting to Accident & Emergency have minor sports injuries.

We are living in fiscally constrained times. The NHS in Scotland, similar to the rest of the UK, is being challenged to provide high quality, safe and timely access to the right services with greater efficiency and improved productivity. It has never been so important and timely to establish appropriately responsive and acceptable clinical and cost effective modes of access for the benefit of patients, their carers NHSScotland and the wider economy.

Advances in technology continue to provide real and feasible solutions to such challenges. Access to a range of AHP services need to be explored and NHS 24 is committed to exploit available technology in support of this and improving access to MSK services represents the first consideration in what is seen as a portfolio of service development.

Current Approach in Scotland

Recent healthcare policies have encouraged increasing interest in the concept of patient self-referral, specifically with regard to physiotherapy and some health board areas in Scotland have now adopted this approach. This is a concept not widely known however by the general public and the traditional route via the GP is still most commonly used. Evidence with regard to the efficacy for self referral has been firmly established over the last five years and identified significant benefits for patients, service providers and the wider NHS and society. Additionally, further benefits of streamlining, providing a central national access point into MSK services have been proposed. Benefits that would advantage patients as well as provide greater cost and clinical effectiveness for NHS Scotland.

Current weaknesses in the present system also include an often prolonged wait for services specifically relevant to MSK conditions as well as national variation in referral rates resulting in inequity of access for patients across Scotland. In terms of the AHPs, physiotherapists are the largest (but not the only profession) providing these services with up to 750 WTE delivering dedicated MSK services nationally. At the end of 2009, the waiting list for NHS Physiotherapy was estimated at 20,000 people across Scotland, with waiting time figures variable across the country (Parliamentary business 2009). This can result in patients’ problems becoming chronic which may have consequences for patients’ health & wellbeing (Derrett 1999) and for the economy (Maniadakis 2000). Additionally, prompt and timely treatment and/or advice may mean that the individuals are able to remain at or return to work whilst receiving treatment or return faster with more prompt management (SGHD, 2007).

NHS Inform is the patient information, advice and guidance arm of NHS 24. The SGHD are supporting the development of advice and information for the public in relation to a range of conditions including MSK conditions. This work has seen the launch of ScottishBacks and further collections are under development in relation to other MSK conditions. This work is seen as a pivotal in terms of enhancing self management and will form an integral part of the NHS 24 MSK pathway.

The National MSK Programme: Overall Objectives     

The overall aim of the MSK Programme is to ensure that:

  • Within NHS Scotland, people with MSK conditions have timely access to the most appropriate advice and guidance, and/or healthcare professional at all stages of the rehabilitation pathway.

The objectives encompass developing a national pathway that supports:

  • patient self-referral to a centralised, national resource

  • early identification of musculoskeletal conditions

  • access to advice, guidance and resources that support self management

  • a menu of management options that offer an extended, direct route into a range of healthcare providers at local level

  • interface arrangements that align the NHS 24 triage and referral management model with local services including Scottish Working Lives

  • redesigned local AHP pathways based on evidence and local context

  • the ability to provide evidence of clinical and cost effectiveness

In relation to work and employment, specifically

  • ensuring that work is a key outcome of the rehabilitation pathway;

  • ensuring that all staff have knowledge of the health benefit of work and have responsibility for ensuring onward referral to employability services;

  • ensuring that functional capacity measurement is incorporated into all pathways;

  • rapid transfer of patients into employability services where appropriate;

  • a reduction of sickness absence in the workplace;

  • rapid transfer of patients into secondary care, when appropriate, through agreed integrated care pathways;

  • the ability to identify individuals with mental health problems and ensuring appropriate interventions/interface with breathing space or other mental health services

Anticipated benefits
There are a number of anticipated benefits associated with the pathway for a range of key stakeholders. These include:
For patients

  • Knowledge of how to gain potential access, well known number

  • Direct timely access to high quality, safe and effective MSK triage

  • Faster access to high quality information and advice to support self management

  • Faster access to the right local service provider, if appropriate

  • Faster access to services that support people to stay in work, i.e. Scottish Working Lives and Scottish Offer occupational programmes

  • Less personal inconvenience and expense associated with having to attend for further medical assessment, investigations and prescribed medication

  • Enhanced user experience

For local service providers

  • Decreased inappropriate and/or unnecessary use of medical out of hours and emergency services

  • Decreased inappropriate and/or unnecessary use of GP practice time

  • Decreased inappropriate and/or unnecessary investigations i.e. x-ray and MRI

  • Decreased inappropriate and/or unnecessary prescribing of medication i.e. anti-inflammatories and analgesia

  • Decreased utilisation of other out patient services

  • Increased knowledge of local MSK epidemiology and service requirements to support more accurate workforce planning


  • Equitable access for MSK patients to appropriate management options

  • System aligned with Quality Ambitions and IoM six dimensions of quality

  • Decreased inter and intra regional variation

  • Increased knowledge of local MSK epidemiology and service requirements

  • Consistent, high quality information and advice developed and maintained nationally

  • Enhanced user experience

  • Greater economies of scale and efficiencies; Doing it once for Scotland

A national MSK Pathway is developed and piloted in two early implementer sites overseen by a MSK Programme Board with appropriate representation. Two sites have been identified and are actively keen to participate in this work. These include:

  • NHS Lanarkshire

  • NHS Lothian.

Appropriate working groups are established to progress the work in relation to:

  • Redesign of NHS 24’s approach to the triage and management of MSK conditions including the development of the self management platform within NHS Inform

  • Redesign of local pathways in the early adopter sites

  • Evaluation

  • Data Management

Anticipated Key Milestones

a. NHS 24 components

  • NHS 24 model:  NHS 24 sign off   December 2010

  • Finalisation of NHS 24 PID and Evaluation Plan: January 2011

  • Finalisation of MSK pathway PID and Evaluation Plan January 2011

  • Review of Algorithms and dispositions:  Jan - Feb 2011

  • Changes to NHS 24 operating model:  March - June 

  • NHS 24 Training & preparation:  June-July 2011

  • Implementation within early adopter sites:  July 2011


b. Local Pathway & Employment Components

  • Development of overall Pathway data requirements and data collection mechanism Jan – July 2011

        • Development/Implementation of National & Local

Engagement Strategies Jan - July 2011

  • Development/Implementation of National & Local Marketing Strategies

Jan – July 2011

  • Development of local Interface arrangements:  Jan - July 2011

On-going development of self management Platform by NHS Inform:

Jan - June 2011

Model goes live, pilot period in 2 early adopter sites July 2011

c. Evaluation and potential for national roll out

  • Monthly review of data Aug – Jan 2012

  • Formal six monthly report Jan – Feb 2012

  • Consideration of evaluation for national roll out March 2012

Potential national roll out: preparations April 2012 onwards

MSKPG background paper 12/01/11 vs 3

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