Classification: Official
Publication reference: PR2022

Introduction

Integrated high quality community musculoskeletal (MSK) services are integral to a productive high-performing healthcare system supporting the management of MSK conditions.

Most people with MSK conditions can be diagnosed and well managed in the community. A smaller number require timely referral to secondary care orthopaedic, rheumatology, spinal or pain management services to enable best outcomes.

Most community MSK services have a triage function to support diagnosis and optimise referrals, and/or a therapies function to rehabilitate those who have sustained an injury or are recovering from surgery, as well as to help people best manage long-term MSK conditions.

Community MSK waiting lists were rising before the Covid pandemic, due to increasing demand as well as workforce supply issues. The backlog of patients has further increased due to the unprecedented impact of the pandemic.

This framework will support integrated care systems (ICSs) to reduce commissioned community MSK waiting times while delivering best outcomes and experience for patients. It includes defining principles, recommended actions across primary, community and secondary care and further resources.

Given the integral role of commissioned community MSK services in local health systems, this framework supports the transformational ambitions of the NHS Long Term Plan, Fuller stocktake report, Elective recovery plan, 2024/25 priorities and operational planning guidance and the new NHS England operating framework.

It has been co-produced and co-designed with key stakeholders experienced in the management of MSK conditions including patients, clinicians, implementation managers and professional bodies.

Defining principles for reducing community care waiting while delivering best outcomes and experience for patients 

1. ICSs should support and enable local leadership to adapt and adopt these defining principles and the following actions, accounting for population need and resource availability.
2. Take a co-ordinated, collaborative and co-produced system approach across the ICS, neighbourhood-based partnerships and provider collaboratives, including equality analysis to ensure findings are implemented to meet local need.
3. Undertake a population health approach focused on optimising outcomes, including reduced health inequalities and paying particular attention to demographics of patients who may need additional support.
4. Apply best practice condition-specific guidance and pathways, working with primary and secondary care, mental health services, social services and the third sector.
5. Ensure clinical decisions are based on evidence and good quality shared decision-making, matching appropriate options for management to a person’s individual preferences and values.

Actions for primary care services

1. Recognise urgent and emergency MSK conditions requiring onward referral and make a timely referral as per local pathways.
2. Use MSK first contact practitioners (FCPs), whose role aligns with Care Quality Commission regulatory guidance and who are integrated into the local MSK care system, to support shared decision-making on diagnosis and management.
3. Make best use of patient resources and non-medicalised interventions to improve supported self-management for MSK conditions, signposting patients to accessible evidence-based resources to support self-management and making best use of health and wellbeing coaches and social prescriber link workers.
4. Where access to FCPs is limited, or signposting to supportive self-management resources and interventions has failed to bring about improvement in a patient’s condition, make best use of:
   • MSK community triage services where available, to further support shared decision-making on complex MSK conditions, diagnostics and/or secondary care referral
   • MSK community therapies services to provide rehabilitation and/or help people to best manage their long-term MSK conditions.

Actions for community MSK services

• The GIRFT community MSK Further Faster Handbook (available on the FutureNHS platform) has a checklist against which community leads can assess current practice aligned with these actions.  
• Collaborate with primary and secondary care leads to implement and optimise timely referral pathways into commissioned community MSK services. This will include expanding self-referral and integrating the use of FCPs as a diagnostic role.
• Provide timely and clear information to support patients waiting for community MSK services once a referral from primary or secondary care is received, including access to supported self-management and peer support.
• Collect and report on measurable indicators in NHS England’s community health services monthly situation report.
• Formulate a recovery plan where the waiting list for priority patients exceeds the two-week threshold and/or the waiting list for non-priority patients exceeds 12 weeks.
• The objectives of this plan are:
  1. no priority patients waiting more than two weeks, and this must be sustained
  2. no patients waiting longer than 52 weeks, with no patients waiting over 18 weeks by Q1 25/26
• Priority patients are defined as:
  • patients who have had recent surgery/procedure requiring rehabilitation and/or
  • patients who have had a recent injury, fracture or dislocation requiring rehabilitation and/or
  • patients with acute and/or complex needs with high levels of pain leading to significant loss of function and/or disturbed sleep, and/or an inability to work or undertake care responsibilities.

The waiting-time threshold for priority patients is two weeks, and all should be assessed within this time. 

The recovery plan should include:

• validating the waiting list by removing repeat referrals, identifying patients already receiving care within the service, identifying those who would benefit from care in another services, and asking all patients if they still wish to be seen and directing them to resources to support self-management where appropriate. If patients state they no longer wish to be seen, they can be removed from the waiting list provided they have capacity, understand the decision being made and have had all their communication needs met
• being as productive as possible with follow-up capacity to free more clinical resource to validate the waiting list and assess new patients.
  Actions to include:
• • offer the option of virtual / telephone consultations if requested and where clinically appropriate
  • monitoring and understanding did not attend (DNA) rates and taking measures to reduce
  • ensuring consistent and personalised discharge decision-making
  • using patient initiated follow up (PIFU) where appropriate
  • making best use of digital resources to support rehabilitation and to support the management of long-term MSK conditions for appropriate patients
  • using group interventions to support MSK therapies capacity, eg Escape-pain
  • using evidence-informed interventions such as peer support, self-management education and health coaching to support self-management
  • using local Improving Access to Psychological Therapies (IAPT) services as an option for any patient experiencing anxiety and/or depression in the context of their MSK condition
  • establishing collaborative approaches with the independent and third sectors (charities, social enterprises and voluntary groups) to support therapies capacity to deliver rehabilitation and/or support people to manage long-term MSK conditions in a variety of community venues.

Actions for planned secondary care

1. Supporting FCPs and community MSK triage services around referral decisions where required: for example, providing advice and guidance/specialist advice or engaging with virtual multidisciplinary meetings.
2. Collaborating with community leads to manage any increase in demand for community MSK services associated with the clinical validation of elective waiting lists.
3. Collaborating with community leads to optimise timely referral pathways into commissioned community MSK services for patients requiring MSK therapies.
4. Promoting good communication and patient safety practices by publishing annually an assessment of secondary care performance against the requirements in the NHS Standard Contract 2021/22 along with a plan to address any deficiencies.

Further resources

• NHS Accessible information standard
• Support for carers
• The GIRFT Further Faster community MSK FutureNHS platform
• The BestMSK Health Collaborative FutureNHS platform has a range of resources, including a primary and community care toolkit and a toolkit and case studies to develop and integrate FCP services.
• The Outpatient and Recovery Transformation FutureNHS platform has specialty resources for MSK across orthopaedics, rheumatology and spinal conditions. This include implementing PIFU and referral optimisation integrating advice and guidance/specialist advice.
• The ARMA (Arthritis and Musculoskeletal Alliance) website signposts the most relevant and useful resources and information specifically about MSK health inequalities, prioritising those which have a UK focus, which draw useful findings or are most likely to help those trying to address health inequalities.
• NHS England has produced decision support tools for Dupuytren’s contracture, carpal tunnel syndrome, hip osteoarthritis, knee osteoarthritis and chronic primary pain.
• The MRI spinal leaflet for clinicians is aimed at reducing unwarranted variation in requests for MRI scans for spinal conditions and was developed by spinal clinicians in collaboration with lived experience partners. It supports clinicians when considering whether an MRI scan is appropriate. A patient leaflet is also available.
• These charities have resources to help people manage their MSK conditions:
  • Arthritis Action
  • Versus Arthritis.
• Tools to support secondary care providers’ contractual requirements: The interface between primary and secondary care: key messages for NHS clinicians and managers and Standard contract provisions primary and secondary care implementation toolkit.