Building the Case for Early Intervention

A clinic for musculoskeletal disorders

Background

Musculoskeletal disorders (MSDs) consist of a wide range of disorders that affect the bones, joints, muscles and connective tissue. They include disorders such as lower back pain, osteoarthritis, rheumatoid arthritis and ankylosing spondylitis. These conditions place a major health burden on the UK population and greatly intensify pressures on finite NHS resources. MSDs also have a detrimental effect on the UK economy as they represent the single largest cause of sickness absence in the UK (after coughs and colds)1.

If provided with rapid specialist help, people with MSDs are often able to manage their conditions effectively, improving their quality of life and enabling them to remain within the workforce. Early intervention for people with MSDs can reduce temporary work disability by 39% and permanent work disability by 50%2. Unfortunately, referrals of people with MSDs from primary into specialist care settings can take a long time, resulting in unnecessary discomfort and work absence.

Overview of Sustainable Healthcare pilot

AbbVie supported the creation of the UK’s first Early Intervention Clinic for people who have been signed off work with a MSD. Under the auspices of Leeds Community Healthcare NHS Trust and led by Dr Steve Brennan, the clinic sought to understand if a faster referral from primary care to a specialist would reduce the time people with MSDs are signed off from work and the impact this would have on other health services. The clinic was based on a model from Spain, which has
been shown to improve patients’ health, support them to return to work quicker and save costs to the health service and the wider economy3. Patients being issued a fit note by their GP were referred to Dr Brennan for a 30
minute consultation within five days of the fit note being issued.

Outcomes

Between May 2016 and the end of 2017, there were 283 referrals into the clinic, though 152 of did not meet the eligibility criteria for the pilot study predominantly because they had been out of work for many weeks and months. These patients were seen by Dr Brennan, but as the clinic was looking at the impact of early intervention, their results were not included below.

Of the 131 patients who were eligible, 73 were male and 58 female, with a mean age of 43. 83% were in full time work, 17% part time and 7% were self-employed. Patients were seen on average 3 days after receipt of the referral and had 2.2 appointments with Dr Brennan; this equates to 1.2 hours of clinic time per patient. Of the eligible patients who attended the clinic, the majority of the patients were managed in the EIC and then returned to work. There were a small number of diagnostic referrals (6 x-rays, 4 MRI, 1 diagnostic ultrasound and 2 blood tests). Four patients were referred for knee surgery and four for physiotherapy. One patient went on to Permanent Work Disability (though did not attend follow up appointments) and the average total number of days lost to Temporary Work Disability was 19.75.

Patients were asked: “How likely would you be to recommend the Early Intervention Clinic to Friends and Family if they needed similar care or treatment?” The responses were Extremely Likely, Likely, Neither likely or Unlikely, Unlikely and Extremely Unlikely. 94% of responders scored Extremely Likely or Likely.

In October 2017, Dr Steve Brennan commissioned Incisive Health to interview a small number of GPs and practice managers in the Leeds catchment area for the Leeds EIC to identify potential reasons for the unexpectedly low number of referrals to the clinic (between April 2016 and July 2017 Dr Brennan saw approximately 100 patients).

The main themes emerged as potential reasons for the lack of referrals:

  • Lack of awareness of EIC
  • Forgetting when in consultation with patients
  • Awareness posters/flyers may be overlooked
  • Uncertainty about the eligibility criteria
  • Uncertainty existed as to whether a Fit Note was required or whether there was a minimum amount of time for which the patient had to be signed off work to be eligible
  • Patient unwillingness to travel to the EIC

Conclusions and Impact

While the findings supported the concept that early intervention would reduce the impact on work and health service utilisation, referrals were lower than anticipated. Feedback from local GPs suggested several reasons for this, including a lack of time in consultations to consider the EIC and lack of awareness of the EIC and what it could offer both the patient and the GP.

 This understanding of the environment has fed into a new MSD pathway that is being developed by a group of CCGs in Leeds. The new pathway will see patients diagnosed with an MSD being asked to complete a survey which is reviewed by a physiotherapist who then makes a recommendation for onward referral or treatment.

1. Office for National Statistics, Sickness absence in the labour market: 2016, 9 March 2017. Available at https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/labourproductivity/articles/sicknessabsenceinthelabourmarket/2016 [accessed at April 2018]

2. The Work Foundation, Reducing temporary work absence through early intervention: The case of MSDs in the EU, 2013. Available at: https://www.bl.uk/collection-items/reducing-temporary-work-absence-through-early-intervention-the-case-of-msds-in-the-eu  [accessed April 2018]

[i] Juan Jover, Hospital Clinico San Carlos, A cost-effective, evidence-based solution to reduce the burden of MSDs, Presentation to the EU Summit on Chronic Diseases, 2014. Available at https://ec.europa.eu/health//sites/health/files/major_chronic_diseases/docs/ev_20140403_w3co07_en.pdf [accessed April2018]