Ensuring that patients with musculoskeletal pain receive the right treatment at the right time is the goal of a major new study. Daniel Allen reports
A simple set of questions asked of patients who consult their GPs about musculoskeletal (MSK) pain could improve outcomes and help save the NHS money, according to a leading physiotherapy researcher.
Nadine Foster, professor of MSK health in primary care at Keele University, is heading a team that has been awarded a £1.93 million grant to develop a new treatment model. The grant, awarded by the National Institute for Health Research, will fund a five-year programme designed to ensure a more patient-centred and tailored approach to care.
MSK problems represent the single largest group of chronic conditions seen by GP practices. ‘How to manage this enormous workload poses huge challenges for primary care services,’ says Professor Foster. ‘While many patients have mild complaints which could be self-managed with appropriate support, some have more serious or persistent problems that research has shown would benefit from treatments such as exercise programmes or pain management.’
For busy clinicians, distinguishing mild from more serious MSK conditions can be problematic. Should they offer simple advice or refer on? This lack of clarity has resulted in wide variations in care, according to Professor Foster. ‘Some patients are offered unnecessary treatments while others do not get access to effective treatments.’ The result is inefficiency – the patient does not receive the right treatment at the right time – and extra cost to the health service.
A stratified approach that helps GPs group patients according to their risk of persistent pain and disability could be the answer. Using a matched treatment programme, those at low risk can be given simple advice on self-management, while more serious problems can be referred to a specialist physiotherapist, for example.
There is good evidence that this kind of approach is effective. An earlier Keele University study found that adopting a simple tool to screen patients and then match them to appropriate treatment pathways was effective in managing back pain. The STarT Back project demonstrated health benefits over traditional management of back pain, achieved at a lower cost per patient.
Professor Foster says: ‘In this new five-year programme of work we are going to see if we can extend what we’ve been doing with back pain to a much broader group of patients.’
Those with neck, shoulder, knee and multiple-site pain will be included in the trial, as well as those with back problems.
‘That’s a real step up in terms of scale and ambition and we don’t know if it’s going to work,’ she says. ‘We don’t know, for example, if it will work equally well with shoulder-pain patients as it did for back-pain patients. But we do know that clinicians don’t want to have different screening tools for different pain problems.’
Feeling ‘dismissed’ by GPs
A large proportion of patients presenting at GP practices with MSK pain have a good prognosis, Professor Foster says. Advice, reassurance and some help with pain control is often all they need. But because the GP is usually the gatekeeper to other services, those with more severe problems can get frustrated. ‘Often what patients tell us is that they feel as though they are being a little bit dismissed by their GP, as though their problem hasn’t been legitimised.’ They continue to seek care from their GP and struggle to get access to NHS services that could prove more beneficial.
Money could be saved
Looking at the ‘big hitters’, the key factors that can predict which patients are likely to have a good outcome, will help the researchers compile an index of risk. ‘Based on that, clinicians can make better decisions about which types of patients need the treatments we have available,’ Professor Foster says.
It would be wrong to make early assumptions about findings from the new study but previous research, including STarT Back, has demonstrated that as well as improving patient outcomes, a stratified approach can halve days lost from work. ‘That is really quite an amazing outcome,’ Professor Foster adds.
Dr Neil Langridge, vice-chair of the Musculoskeletal Association of Chartered Physiotherapists, believes the Keele study promises a number of benefits.
‘It will, hopefully, give support to GPs who are in a very difficult position, having to make quick decisions on referral pathways for patients, and enable them to refer more effectively. That’s going to help with therapy and patient expectations. Patients will be more likely to get the right treatment at the right time.’
Being in a better position to help as a result of earlier referral will also encourage greater job satisfaction among physios, Dr Langridge says.
For Professor Alan Stilman, medical director of Arthritis Research UK, which funds the primary care research centre at Keele, where Professor Foster is based, a good outcome from the study would be enhanced patient satisfaction. ‘Patients tell us GPs don’t know how to treat them, that they are not listened to. This will provide a tool that sets the right tone for a dialogue between the patient and the GP. And I think it will mean that the resources available will be used more appropriately.’
Whatever their findings, Professor Stilman thinks the researchers will have little problem integrating them into practice. ‘This is where the Keele team have been so phenomenally successful,’ he says. ‘There’s a whole range of ways of doing it but they have the appropriate levels of engagement with health professionals. With their work on back pain, they produced something that was useable and practical, and could deliver results. They could demonstrate that it was going to save money and GP time.’ fl
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