A national qualitative survey of community-based musculoskeletal services in the UK

C. Roberts, E. A. Dolman1, A. O. Adebajo2 and M. Underwood3

University of Sheffield, Northern General Hospital, Sheffield S5 7AU,
1 Unit for Professional Development, Trent Postgraduate Deanery, Postgraduate Education Centre, Queen's Medical Centre, Nottingham NG7 2UH,
2 Department of Rheumatology, Barnsley District General Hospital NHS Trust, Gawber Road, Barnsley, South Yorkshire S75 2EP and
3 Barts and the London, Queen Mary's School of Medicine and Dentistry, Mile End, London E1 4NS, UK


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Objective. To determine the characteristics of community-based musculoskeletal services provided by primary care organizations within the UK.

Methods. Members of five professional groups within UK primary care organizations (n=461) were sent a questionnaire.

Results. The response rate by organization was 71% (328/461). Respondents described 350 community-based musculoskeletal services, 233/328 (71%) organizations had one or more musculoskeletal services within their community. Five main forms of service provision were: a scanning service, a rehabilitation service, physiotherapy services, joint or soft tissue injections and the implementation of integrated care pathways. In 162 services, patients were assessed, reviewed or triaged, by a ‘non-consultant’ health-care professional (physiotherapist or general practitioner), at an intermediate level between primary and secondary care. The purpose of the service was described in 292/350 services, only 39/350 had clear evaluation strategies and 53/350 had consideration of individual training needs.

Conclusions. There are a wide range of musculoskeletal services flourishing within the community sector, whose quality may be variable. Whilst there is good evidence to suggest systematic planning of these services, we are concerned about the lack of data to support their effectiveness in terms of clinical outcomes, monitoring of service delivery standards and ongoing professional development of service providers. Commissioners of such services must ensure they have taken account of the evidence base and met any identified needs of local populations. Services should have a clear purpose with an appropriate evaluation strategy, and well-defined dissemination mechanisms. An integrated educational strategy for staff within the service must be sensitive to issues relating to accreditation, appraisal and revalidation.

KEY WORDS: Musculoskeletal, Primary care organizations, Intermediate care, Qualitative, Clinical governance.


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Musculoskeletal disorders cause much long-term disability in the UK [1], accounting for 15% of general practice consultations. Many patients are thought to be referred inappropriately from primary to secondary care [2], and there are concerns about GPs' preparedness to deal with them [3]. To address this, there are several initiatives to manage referrals to the acute sector including: nurse-led secondary care rheumatology clinics [4], demand management by prioritizing primary care referrals [5], an acute rheumatology service for GPs and other clinical units [6], triage of orthopaedic referrals by trained physiotherapists [7] and rheumatology telephone helplines [8].

The establishment of locally governed primary care organizations [912] should promote greater collaborative working to reduce inequalities, to improve access to primary care for poorly served groups and to develop further the efficient use of resources through greater sharing of staff and facilities [13]. Although musculoskeletal conditions are a major cause of disability, their management does not have a high priority because they are rarely fatal, are considered irreversible and are associated with old age. There may be poor uptake of existing musculoskeletal provision, for example hip and knee arthroplasty, because of a lack of knowledge, negative attitudes and low expectations [14].

We describe a ‘snapshot’ survey of community-based musculoskeletal services provided by primary care organizations existing in May 2001. In addition, we sought to identify elements within these services that might inform the development of a model of best practice for musculoskeletal services across the UK.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
All primary care organizations within the UK were identified from a range of web- and paper-based information sources. A postal questionnaire, with one reminder after 6 weeks, was sent to the holders of five professional roles within each of these organizations: business manager, chairperson, chief executive, clinical governance lead and commissioning lead. Respondents provided information on current or planned community-based musculoskeletal services. Data were collected on aspects of clinical governance, including the services' specific aims and objectives, provisions made for staff development, dissemination of service access information, evaluation mechanisms, outcome measures incorporated and funding streams identified. At the time this study was planned, research ethics committee approval for a study of this nature was not required. We used SPSS (version 10) for numerical analysis and free text comments were transcribed into QSR-Nudist (version 4). A content analysis of the qualitative data using a constant comparative approach was performed to provide a basis from which a conceptual framework could emerge. Validity was ensured by considering the emerging explanations for our data reiteratively [15, 16]. The number of respondents mentioning an item is given allowing a relative comparison of different data [15].


    Results
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Response rate
One or more individuals responded from 328/461 (71%) of the primary care organizations operational on May 2001 (Table 1Go). Response rate ranged from 16% for chief executives to 33% for business managers. One response was obtained from 38% (174/461) of primary care organizations, two responses from 26% (126/461) and three responses from 6% (27/461). To validate the dataset, a subgroup of 52 organizations, where multiple responses were provided by clinicians in different roles, was examined for consistency of responses to questions about service quality. In 40 of these there was reasonable concordance, but in two there were major discrepancies casting doubt as to whether they were describing the same or different services.


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TABLE 1. Response rate from primary care organizations

 

Service profiles
The responding organizations (328/461) varied in size from five practices, totalling 13 100 patients in a Northern Irish commissioning group, to 218 practices with 960 000 patients in a Scottish primary care trust. The average profile was: 139 912 patients, 24 general practices, 77 general practitioners, 46 practice nurses and 114 community nurses. Of the 153/328 (47%) organizations confirming their date of inception, a third (47) reported less than 6 months and only six more than 3 yr.

The services
Two hundred and thirty-three (233/328) organizations had at least one musculoskeletal service. Respondents described 350 community-based musculoskeletal services and were aware of 87 other services. This probably overestimates the true number because of the inconsistencies in the dataset. Neither organizational size nor type appeared to have had an effect on service delivery. Five main service types were identified: provision of a scanning service, a rehabilitation service, physiotherapy, joint or soft tissue injections and the implementation of care pathways. Others included: discharge schemes, self-help, NHS Direct links and advice clinics. A physiotherapist or a general practitioner led three-quarters of the services (Table 2Go).


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TABLE 2. Who delivers which services where explicitly identified (n=237)

 

Service quality
Most (174/350) services were clearly identifiable as being located within community-based settings, 17/350 services were delivered within acute trusts. The clinical focus of the services was: back pain (74) orthopaedic related (55), musculoskeletal (55), regional joint problems (31), rheumatology (27), soft tissue (12) and osteoporosis (5). There were many references to complementary therapies. Multidisciplinary teams including staff from a wide range of clinical disciplines often delivered services. In 292/350 services, respondents described the service's aims and objectives (Table 3Go). Ninety-two services had specific aims and 37 had specific service objectives. In 162 services, patients were either assessed, reviewed or triaged by a ‘non-consultant’ health-care professional. Seventeen respondents commented on service funding issues and it was clear that the identification of funds to continue services was a problem. There was also some evidence of commercial interest, for example commercial support for an osteoporosis screening service. Forty-one respondents reported explicit patient benefits including ease and equity of access for patients, including ethnic minority groups.


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TABLE 3. Some aims and objectives of community-based musculoskeletal services

 

Training and development of service deliverers
Two hundred and thirty-two respondents (Table 4Go) described a wide range of training and development approaches to support service delivery. Although half of the respondents showed awareness of the range of issues, less than a quarter (53) had planned for specific educational strategies for service providers. At one end of the scale (Table 5Go) education was seen as an integral part of service development that would include profession-specific and generic training, along with appraisal, and planning of learning within a framework of professional development (38). At the other end, training was seen as a benefit, rather than a requirement of effective service delivery (6). Identified training needs often reflected the employment status of the staff delivering the service rather than the needs or quality of the service. Educational providers were more likely to be local, led for example by a GP specialist in musculoskeletal medicine (13 services), a physiotherapist specialist (12), a consultant rheumatologist (5) or an orthopaedic surgeon (5 services). In 43 cases, the specific content of training activities was described, including soft tissue injuries, triage, pain management techniques, acupuncture and sports medicine. A specific level of competency for non-consultant staff to deliver services (e.g. to diploma level) was mentioned in only six cases.


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TABLE 4. Respondents' views on the training and development of health-care professionals delivering the service (n=232)

 

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TABLE 5. Approaches to training for service deliverers

 

Dissemination
Some respondents referred to potential users of the service, for example ‘local health-care professionals' or ‘primary health-care teams’, as routes for dissemination, although many specified general practitioners as their target audience. Some were sceptical of the need for dissemination, claiming services were ‘common knowledge amongst partners of practice’.

Twenty-eight respondents described reinforcement of the dissemination using ‘regular’, ‘monthly’ or ‘quarterly’ activities. There was evidence of reliance on hierarchical or peer-based cascade mechanisms through ‘locality managers’, ‘heads of service meetings' and ‘word of mouth via relevant practices’.

Face-to-face dissemination mechanisms were used by 137 services with 37 different approaches including forums, working groups, seminars, workshops, conferences, road shows and discussion. Traditional, distance-based mechanisms were used by 155 services with 27 different approaches including information packs, mail shots, referral protocols, newsletters, care pathway diagrams, guidelines and leaflets. Electronic, distance-based mechanisms were used by nine services, including electronic mail and web sites. Few were planning to review the effectiveness of the dissemination.

Evaluations and outcomes of services
Of 195 respondents reporting evaluation of services, only 32 described appropriate outcome measures (Table 6Go). Nine respondents gave specific examples of previously validated clinical measures and there were two references to cost-effectiveness, but no details were provided as to how this was to be done. Either the size of a waiting list or the time spent on it was referred to by 53 respondents as an indicator of outcome. Thirty-nine services had specific outcomes monitored, usually the impact on waiting lists. One service claimed ‘the introduction of community-based back pain triage had reduced waiting times from 6 months to 2 weeks for referrals’. Other, related, service measures that were used included referral patterns, number treated, discharge profiles and proportion of patients who failed to attend. As well as routinely collected data, evaluation approaches included: ‘audit’ (46), ‘surveys' (8), ‘questionnaires' (23) and ‘patient interviews' (1). In some cases the reports provided by the deliverers of the service to the commissioning bodies were considered to be the evaluation. Forty respondents mentioned patient satisfaction as part of outcome measurement, but no further details were provided as to how this was to be identified or assessed. In the cases where a questionnaire was used as the data collection tool, almost 70% of them were to be completed by the patients. Only 23 respondents reported using any form of external evaluation and only nine services had explicit plans for long-term evaluation.


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TABLE 6. Approaches to evaluation for service deliverers

 

Limitations of the study
Despite a creditable response rate, the accuracy of estimated prevalence of these services is limited owing to the use of multiple responders. We cannot be sure that an individual responder was the best-qualified person in the organization to complete the questionnaire and conversely we cannot exclude some double counting of services. Within the resources available we were not able to explore these issue further. However, the data are broadly indicative of the numbers and types of services provided. We are unlikely to have underestimated the number of primary care organizations providing such services. Our data allow a qualitative analysis focused on reported frequencies and identification of approaches to particular issues of service delivery.


    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
This is the first comprehensive study of musculoskeletal services in primary care organizations across the UK. We have not, in this study, considered the impact such services may have on the acute sector.

The evolution of musculoskeletal services in primary care organizations shows a distinct trend towards the intermediate assessment and treatment of patients between primary care and the acute sector. There is an emphasis on multidisciplinary and inter-agency team working, and on the expansion in the traditional assigned roles for professionals, and in particular physiotherapists and general practitioners, acting as community-based musculoskeletal specialists. An imminent new contract for GPs may be one way forward to fund and develop such services [17].

Primary care organizations are expected to bring a more systematic and clinically rigorous approach to managing chronic diseases [18]. Musculoskeletal services appear to have been systematically planned at least in terms of having appropriate aims, with the majority referring to a desire to reduce waiting lists. Nevertheless, we are concerned about the effectiveness of these services and the apparent lack of monitoring of clinical outcomes or service delivery standards. As the majority of the services were not available in all local practices, effective dissemination is needed to ensure equity of access.

Reference to the training and development of professionals delivering services was patchy, although there were examples of sound educational practice. It is important that training for such staff should be integral to their ongoing continuous professional development and should be supported through the organizational business plan, i.e. based on both individual and service needs. There may well be issues of establishing a standard of competence for community-based musculoskeletal specialists and issues relating to accreditation, appraisal and revalidation need to be addressed [19].

An array of funding sources was being used included Health Action Zone funds, regeneration budgets and pharmaceutical company sponsorship. Unified budgets for primary care organizations [20] should mean a greater alignment of clinical and financial responsibility.

Our study has implications for service development of this type. First, these services should not be developed without careful thought and planning. It is important to identify the musculoskeletal needs of the local population and to develop a sustainable model of care depending on available capacity and funding. Ideally, all stakeholders whether in primary or secondary care should be involved so as to develop a joined-up service built on existing networks and strengths.

A regular re-examination of the evidence base is required to set or review appropriate aims and objectives for the service. Clear and appropriate outcome measures for both clinical and service delivery must be defined for each service element and a quality assurance approach to service delivery is essential. A variety of dissemination mechanisms should be used to publicize the service on a regular basis with the effect of the mechanisms being used also evaluated on a regular basis.

This study has identified a number of areas that require further research. These include the development of national guidelines for those setting up these services, the development of competency levels for those undertaking this work and evaluation of the various service delivery models.


    Acknowledgments
 
This study was supported by a grant from the Arthritis Research Campaign (ARC). We thank the ARC for help in distribution of the questionnaire.


    Notes
 
Correspondence to: C. Roberts. E-mail: c.roberts1{at}sheffield.ac.uk Back


    References
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Martin J, Meltzer H, Eliot D. The prevalence of disability among adults. London: Office of Population Census and Surveys, 1998.
  2. Hosie GAC. Teaching rheumatology in primary care. Ann Rheum Dis 2000;59:500–3.[Free Full Text]
  3. Roberts C, Adebajo AO, Long S. Improving the quality of care of musculoskeletal conditions in primary care. Rheumatology 2002;41:506–11.
  4. Hill J. Patient satisfaction in a nurse-led rheumatology clinic. J Adv Nurs 1997;25:347–54.[CrossRef][ISI][Medline]
  5. Hurst NP, Lambert CM, Forbes J, Lochead A, Major K, Lock P. Does waiting matter? A randomized controlled trial of new non-urgent rheumatology outpatient referrals. Rheumatology 2000;39:369–76.[Abstract/Free Full Text]
  6. Smith EC, Berry H, Scott DL. The clinical need for an acute rheumatology referral service. Br J Rheumatol 1996;35:389–91.[ISI][Medline]
  7. Daker-White G, Carr AJ, Harvey I et al. A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health 1999;53:643–50.[Abstract]
  8. Hughes RA, Carr ME, Huggett A, Thwaites CEA. Review of the function of a telephone helpline in the treatment of outpatients with rheumatoid arthritis. Ann Rheum Dis 2002;61:341–5.[Abstract/Free Full Text]
  9. Wilkin D, Gillam S, Smith K. Tackling organisational change in the new NHS. Br Med J 2001;332:1464–7.[CrossRef]
  10. Scotland Primary Care Organizations http://www.show.scot.nhs.uk/organizations/orgindex.htm (accessed 1 May 2001).
  11. Wales Primary Care Organizations http://www.wales.nhs.uk/lhg/ (accessed 2 April 2001).
  12. Northern Ireland Primary Care Organizations http://www.nhssb.n-i.nhs.uk/ (accessed 2 April 2001).
  13. Wilkin D, Dowsell T, Leese B. Modernising primary and community health services. Br Med J 2001;322:1522–4.[Free Full Text]
  14. Woolf AD, Akesson K. Understanding the burden of musculoskeletal conditions. Br Med J 2001;322:1079–80.[Free Full Text]
  15. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. Thousand Oaks: Sage Publications, 1994.
  16. Denzin N, Lincoln Y. Collecting and interpreting qualitative materials. Thousand Oaks: Sage Publications, 1998.
  17. General Practice Committee. Your contract, your future: General Practice contract and explanatory notes. London: British Medical Association, 2002.
  18. Department of Health. A first class service. London: Department of Health, 1998.
  19. General Medical Council. Revalidation. (www.gmc.org.uk; accessed 1 April 2002).
  20. Majeed A, Malcolm L. Unified budgets for primary care groups. Br Med J 1999;318:772–6.[Free Full Text]
Submitted 1 October 2002; Accepted 5 February 2003