1. Introduction

This specification defines the minimum standards that a community musculoskeletal (MSK) service is expected to meet to improve service quality, reduce waiting times and deliver the best outcomes and experience for patients.

Commissioners can use it to guide how this service is designed, delivered, monitored and improved, and adapt it locally to meet local needs and support integrated care system (ICS) strategic commissioning, in line with the ambitions of the strategic commissioning framework and Medium Term Planning Framework.

This specification aligns to NHS England’s standardising community health services – core component MSK service description and builds on the principles and actions in the community MSK improvement framework to reduce community MSK waits while delivering best outcomes and experience.

It was written with the Getting It Right First Time (GIRFT) community MSK workstream clinical leadership and co-designed with stakeholders experienced in the management of MSK conditions, including patients, clinicians, implementation managers and professional bodies.

The documents informing the rationale and providing the evidence for this specification are signposted.

2. Scope

2.1 Description

MSK conditions can affect joints, bones and muscles and sometimes associated tissues such as nerves. They can range from minor injuries to long-term conditions associated with chronic pain.

MSK health is fundamental to wellbeing and impacts on every aspect of life, including work, learning, caring responsibilities, travel and leisure, exercise, sport and living independently.

When aligned to best practice guidance and pathways, most people with an MSK condition can be assessed, diagnosed and supported to self-manage safely and confidently in the community. For best outcome, a small number will require timely referral to secondary care orthopaedic, rheumatology or spinal services.

Community MSK services support diagnosis, optimise referrals and help people manage MSK conditions safely and confidently. They are largely delivered in community settings, including health centres and clinics, with some integrating digital triage or therapeutic tools and some also offering more specialist services such as diagnostic ultrasound or corticosteroid injections.

Community MSK services work with primary and secondary care, mental health services, the voluntary, community and social enterprise (VCSE) sector and national and local partner organisations that promote physical activity. They can also play a key role in supporting people to stay in work by integrating with local work and health initiatives such as Work Well.

2.2 Population needs and addressing health inequalities

MSK conditions affect over 17 million people in England, with their prevalence increasing with age and higher among more deprived communities.

People with long-term MSK conditions are more likely to have wider health problems such as poor mental health and being overweight or physically inactive. One in 8 people report living with at least 2 long-term conditions, one of which is MSK related.

MSK conditions are one of the leading causes of years lived with disability and reasons for sickness absence (30 million lost work days annually). Prolonged waiting times negatively impact on the person as well as any unpaid carers, the economy and the productivity and performance of the health and care system.

Commissioners should seek to ensure people who are not registered with a health service or those least likely to access services are considered in planning and delivery of community MSK services, through a health equalities impact assessment (EHIA).

2.3 Aim, objectives and principles of a community MSK service

Aim

To deliver a community MSK service for adults and young people aged 16 and over living with MSK conditions that ensures care is:

• high quality – a safe, effective and a positive experience of care through a responsive compassionate dignified approach, delivered through mutual respect
• personalised – shaped by what matters to people, their preferences and strengths, and supports them to make informed decisions about the nature of their care
• equitable – everybody has opportunity to access high quality care

Objectives

1. To deliver high quality triage to support diagnosis and optimise referrals. An interface service is an example of a triage function (defined as a service that incorporates any intermediary levels of clinical triage, assessment and treatment between traditional primary and secondary care).
2. To deliver a high quality therapies function to rehabilitate those who have sustained an injury or are waiting for or recovering from surgery, as well as to help people best manage long-term MSK conditions.

Principles

The principles underpinning delivery of the above aim and objectives are:

• making best use of resource to deliver high quality care
• co-ordinated collaboration with primary and secondary care, mental health services, VCSE organisations, other commissioned community services and local integrated neighbourhood teams
• a data driven population health approach to optimise outcomes, including reducing health inequalities with commissioning and decision-making informed by an EHIA
• best practice condition-specific guidance driving integration across MSK pathways
• provision of timely and clear information, good quality shared decision-making based on evidence, with consideration of appropriate management options and a person’s individual preferences and values
• policies and procedures in place to recognise and escalate potential safeguarding issues
• collection submission and reporting of nationally required data regarding community waiting lists
• quality assurance regarding patient outcomes and experience
• contributing to local prevention strategies by identifying individuals at risk of chronicity and engaging with physical activity, weight management and other community-based assets
• a sustained focus on quality improvement, embedding strategic co-production so that people with lived experience shape system priorities, policy and decision-making – not just service design

3. Care pathway

The sub sections below describe the service description and care pathway aligned to the current framework for delivery of MSK health and care in the community. The exact nature of the care pathway will vary locally.

3.1 Optimising access and reducing waiting times

The Medium Term Planning Framework asks integrated care boards (ICBs) to achieve point targets for community services waiting time performance (not service-line specific):

• by end 2026/27: at least 78% of community health service activity occurring within 18 weeks
• by end 2028/29: at least 80% of community health service activity occurring within 18 weeks

18-week targets do not supersede clinical standards for community health services pathways.

The GIRFT Further faster community MSK handbook asks community MSK services to go further and formulate a recovery plan where the waiting list for priority patients exceeds the 2-week threshold or the waiting list for non-priority patients exceeds 12 weeks.

Priority patients should be seen within 2 weeks of receipt of referral and are defined as those:

• who have had recent surgery or a procedure requiring rehabilitation
• who have had recent injury, fracture or dislocation requiring rehabilitation
• with acute or complex needs with high levels of pain (such as acute back pain) leading to significant loss of function or disturbed sleep and an inability to work or undertake caring responsibilities

Community MSK services must:

• collect, submit and report on measurable indicators in the NHS England SitRep regarding waiting times for patients
• ensure services are accessible via self-referral. Self-referral allows patients to refer into the service without seeing their GP or another member of the primary care team
• have pathways in place to access triage and therapies from primary care and therapies from secondary care

3.2 Delivering triage function and optimising referrals

Providers of community MSK services should put in place a system to recognise red flag signs or symptoms suggestive of urgent and emergency conditions in line with NICE guidance, to enable onward referral as per agreed local pathways.

Through integration into local pathways and in collaboration with diagnostic providers, community MSK services should be able to request diagnostics aligned to best practice guidance, access results and use these to inform decision-making regarding management.

Providers should establish a collaborative co-ordinated process to enable referral to:

• therapies and other community-based health and social care resources such as intermediate care, social prescribers, health and wellbeing coaches or employment support
• secondary care such as orthopaedics, spinal services, pain services and rheumatology, making best use of Advice and Guidance or virtual multidisciplinary meetings aligned to best practice pathways

3.3 Delivering therapies function, rehabilitation and supported self-management

Providers of community MSK services should:

• establish locally agreed rehabilitation protocols to guide fracture and post-surgical or procedural rehabilitation
• use evidence-based interventions such as peer support, self-management education and health coaching to support self-management
• offer group interventions to appropriate patients to support MSK therapies capacity (for example, ESCAPE-pain)
• use evidence-informed digital resources to support rehabilitation and the management of long-term conditions for appropriate patients and provide alternatives for others
• establish collaborative approaches with the independent and VCSE sectors to support therapies capacity to deliver rehabilitation or support people to manage long-term MSK conditions in a variety of community venues
• develop collaborative approaches with local work and health initiatives to support those with MSK conditions to remain or return to work, and with local weight management services and physical activity support
• signpost patients experiencing anxiety and depression in the context of their MSK condition to local talking therapies services
• routinely collect a patient reported outcome measure (PROM) and patient reported experience measure (PREM) as part of a therapeutic assessment and management plan to inform quality evaluation and improvement

3.4 Managing missed appointments and implementing patient initiated follow-up

Providers of community MSK services should:

• use language and communication methods that consider patients who do not speak English, cannot read due to literacy or visual issues or do not have access to smart phones or emails; in line with requirements set out in the Accessible Information Standard (2025)
• send appointment reminders using a person’s preferred method of communication, including letters, text messages or phone calls. All reminders should allow two-way communication with patients
• use standardised booking processes that patients find easy to use
• offer patients the option of a virtual or telephone consultation if requested and where clinically appropriate
• consider providing appointments during evenings and weekends for patient convenience
• implement patient initiated follow-up and build this into service reporting, where clinically appropriate and agreed between the healthcare professional and patient
• routinely monitor and regularly audit do not attend (DNA) rates to understand potential causes and inform planning to maximise clinical capacity and reduce inequity and health inequalities. Review notes of DNA patients and attempt to communicate with them to share next steps (this blog describes an approach taken to improve patient engagement with physiotherapy)
• hold a list of patients who can attend at short notice to fill last minute cancellations

3.5 Acceptance and exclusion criteria

These generic criteria may be adapted to align to and enable the local development or establishment of pathways of care.

Community MSK services accept those presenting:

• with suspected or diagnosed MSK conditions affecting the upper limb, spine and lower limb
• with chronic MSK related pain and disability
• for post-injury or post-surgical or procedural MSK rehabilitation

Exclusion criteria:

• aged 15 or under
• unable to attend an outpatient appointment – this group may instead receive intermediate care (rehabilitation, reablement and recovery) services or domiciliary care
• non-MSK related pain or disability
• patients with red flag signs or symptoms requiring urgent or emergency referral to secondary care services

3.6 Interdependencies with other services

High quality integrated community MSK services should work with the following services to support delivery of high quality care:

• primary care services: local primary care networks, general practice services including MSK first contact practitioners, health and wellbeing coaches and social prescribing link workers
• community care services: integrated neighbourhood teams, intermediate care, other commissioned community care services, community diagnostic centres, mental health services including talking therapies, substance misuse services
• secondary care services: through provider collaboratives, urgent and emergency care services, cancer services, diagnostics and local orthopaedics, spinal rheumatology and pain management services
• social care services: through health and social care partner provider services focused on public health or employment support, work and health initiatives, weight management services, stop smoking services and physical activity services
• third sector: VCSE sector organisations; charities, community groups and social businesses focused on addressing social, environmental or economic needs in partnership with healthcare; patient advisory groups

3.7 Workforce

Delivery of the specified aim and objectives of community MSK services requires a diverse multidisciplinary and dynamic workforce. Dynamic workforce planning should be collaborative and aligned to national and system-level priorities, informed by a robust methodology and drawing on data, staff and partner feedback.

The workforce must be well led and sustainably resourced with robust governance and effective collaboration with partner service providers, organisations and users.

The leadership team is responsible for the sustained delivery of high quality, personalised, equitable care. It needs to be system focused and transformational across clinical and operational domains. It is accountable to commissioners and provides assurance to partners regarding both performance and productivity.

The multidisciplinary team includes physiotherapists, including those working at an expert (consultant) and advanced practice level, and may include other allied health professionals (such as podiatrists, occupational therapists or osteopaths), GPs with an extended role in MSK or sports and exercise physicians. The clinical team is supported by operational and administrative staff.

The workforce should:

• engage and work alongside patients as partners
• have the knowledge, skill mix, levels of practice from support worker to multiprofessional consultant practice and capacity to sustainably deliver both triage and therapies functions to meet the needs of the local population
• demonstrate competence in personalised care approaches and behaviour change techniques relevant to chronic pain and long-term MSK conditions
• have the capability to administer fit notes (see Fit note: guidance for healthcare professionals)

All staff should have clearly defined and annually reviewed job plans describing each person’s duties, responsibility, accountability and objectives. They should feel psychologically safe, well-supervised and supported to innovate, reflect and learn. A resourced continual professional development strategy must be in place for all staff.

Resources

• NHS England Enable the workforce
• NHS England Multidisciplinary team toolkit
• NHS England Allied health professionals job planning: a best practice guide
• NHS England Multi professional consultant-level practice capability and impact framework
• NHS England Multi-professional framework for advanced practice 2025
• NHS England Advancing practice in emerging areas workforce transformation resource
• Personalised Care Institute e-Learning
• Department for work and Pensions Fit note: guidance for healthcare professionals

4. Applicable service standards

4.1 Digital infrastructure

Digital health technologies offer unique opportunities to improve MSK services for patients. Community MSK services are required to use national guidance and frameworks on the procurement and contracting of digital technologies and services.

This checklist (on the Futures Collaboration Platform; login required) has been created to support those involved in the process of selecting and procuring a suitable digital health technology. It covers the key requirements for assessing and evaluating digital tools to facilitate their safe and effective adoption within the care pathway.

Community MSK services commit to reducing the impacts of digital exclusion and digital poverty on their population through the development of the EHIA. The framework for NHS action on digital inclusion supports NHS staff to enable and encourage greater access to and improved experiences of healthcare, and increased adoption of digital approaches where appropriate. Appropriate alternatives to digital should be provided for those it is not suitable for.

Digital standards

The key national guidelines describing the standards that service providers must demonstrate their adherence to are:

• UK Government Technology Code of Practice (on the Futures Collaboration Platform; login required)
• NHS Data Standards Directory
• AI and Digital Regulations Service for health and social care
• Digital clinical safety strategy and guidance
• What good looks like framework
• Evidence standards framework for digital health technologies

Workforce digital skills

Providers need to ensure their workforce has the appropriate skills and training to use and support patients with digital technology. NHS England resources that support improving staff digital skills include:

• Improving the digital literacy of the workforce
• Profession and service specific digital capabilities frameworks
• New programme offers all AHPs the opportunity to build digital and data skills

4.2 National standards services are expected to meet

National Institute for Health and Care Excellence

Adherence to NICE guidance for MSK conditions:

• NG59 (low back pain and sciatica)
• NG226 (osteoarthritis)
• NG193 (chronic pain)
• NG100 (rheumatoid arthritis)
• NG65 (axial spondyloarthritis)
• PH44 (physical activity: brief advice in primary care)
• HTG712 – digital technologies for managing non-specific low back pain
• GID-HTE10057 – digital technologies for managing mild to moderate hip or knee osteoarthritis
• GID-HTE10069 – digital platforms for pre- and postoperative rehabilitation for hip or knee replacement
• NG197 – shared decision making
• PH6 – behaviour change: general approaches

NHS England

• Actively manage long waits for community health services, reducing the proportion of waits over 18 weeks and developing a plan to eliminate all 52-week waits
• No priority patients waiting more than two weeks, no patients waiting longer than 52 weeks
• Accessible Information Standard

Chartered Society of Physiotherapy

• Musculoskeletal physiotherapy 8 quality standards
• Rehab on track: community rehabilitation best practice standards | The Chartered Society of Physiotherapy

Care Quality Commission

• Regulations for service providers and managers

5. KPIs and quality measures

5.1 Quality statement

Community MSK service providers should routinely collect access metrics alongside PROMs and PREMs, informed by local population insights and aligned to the NHS outcome framework domains:

Domain 1 – Preventing people from dying prematurely
Domain 2 – Enhancing quality of life for people with long-term conditions
Domain 3 – Helping people to recover from episodes of ill-health or following injury
Domain 4 – Ensuring people have a positive experience of care
Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm

These measures should be used to support decision-making, service evaluation and continuous quality improvement.

Commissioners must have a regular, data driven, contract review process in place with providers and other stakeholders as necessary, looking at performance against national and local indicators.

The aim in taking a data driven approach is to improve access to timely and appropriate MSK care, reduce unnecessary hospital referrals, support better long-term outcomes, reduce inappropriate imaging and enhance patient experience across the MSK pathway.

Services must routinely stratify access, referral and outcome data by deprivation quintile, ethnicity and other relevant protected characteristics to identify and address unwarranted variation. Employment status should also be measured and considered.

5.2 National key performance indicators

National requirements aligned to community health services reporting requirements

All providers must collect, submit and report on measurable indicators in the NHS England monthly Community Health Services Situation Report (CHS SitRep) regarding waiting times for patients.

All activity completed under a community MSK service (regardless of whether triage, therapy or combined through a single point of access) must be reported under the community MSK service line.

National requirements aligned to referral to treatment (RTT) waiting times rules guidance

Providers must also ensure they continue to comply with RTT reporting guidance where this applies (for example, regarding interface services).

5.3 Local performance indicators to inform contractual review meetings

All providers should collect data to inform regular contractual review meetings with commissioners and other stakeholders as necessary. The frequency of collection should be locally determined.

The specific nature of some of the following indicators may be adapted to local models of delivery, diagnostics access and pathways. This list is not exhaustive and additional indicators may be monitored locally, agreed between commissioner and provider.

Access indicators

Triage function indicators

Therapy function requirements

Service metrics

Publication reference: PRN02320