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.
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
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
within five days of the fit note being issued.
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
- Forgetting when in consultation with patients
- Awareness posters/flyers may be overlooked
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
- Patient unwillingness to travel to the EIC
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.