Standards of Care – Overarching Principles

Standards of care for people  with musculoskeletal conditions

Overarching Principles

There are many myths about these conditions – but the most damaging of all is that nothing can be done.

Something can always be done – be it providing details of a local support group, or designing a service which means that people see the right specialist at the right time.

As part of ARMA’s Standards of Care project, a group of people with a range  of musculoskeletal conditions has come together to identify what needs to  happen in health services to enable them to minimise the pain and disability of  arthritis, and to help people remain independent.

They have suggested  reasonable expectations of care and services for all people with musculoskeletal conditions. People have a right to:

• Access to appropriate services for all people with musculoskeletal conditions
• Timely diagnosis and treatment
• Information
• Services which are centred on the needs of users
• Independence and self-determination

These are presented in this document as draft ‘overarching principles’ for your  comment.

Please note that this part of the project does not attempt to suggest  detailed standards of care for particular conditions (these are being developed at  the moment, and will be the subject of further consultation).

The over-arching principles are necessarily broad and generic to all musculoskeletal conditions. We are seeking comment on whether these principles are appropriate, complete and meaningful, in your view.

  Access to appropriate services for all people with musculoskeletal conditions

It is a stated aim of the NHS national plan that health services should be genuinely national, offering access to consistently high quality, timely and accessible services right across the country.

Everyone should have access to services and receive treatment and care on the basis of need. People should be treated as individuals and be provided with packages of care that meet their needs.

This means that health and social care partners need to work together to put people right at the centre. They need to listen to people’s views and act upon them; and they need to involve and support carers whenever necessary.

1. Access to services that meet the agreed standards of care. All people with musculoskeletal conditions should have fair access to appropriate treatments and health care services, with flexibility maintained to meet local and personal needs. Care and its delivery should reflect best practice, agreed guidelines and existing standards. Moreover; people should not be discriminated against in the services they receive due to their age, gender, culture, or religious beliefs.
2. Accessible services. All health care services should be fully physically accessible and should be located and designed appropriately for people with a range of mobility impairments. In addition to meeting the requirements of current legislation, particular care should be given to the specific access requirements of people with musculoskeletal conditions, including: fully accessible buildings, close proximity to public transport and sufficient disability car parking spaces, range of appropriate waiting room chairs, clinics located conveniently within hospitals and clinics located within reasonable distance, with appropriate transport if necessary to other clinics or services likely to be used by people with musculoskeletal conditions.

  Timely diagnosis and treatment

There is clear evidence that for many musculoskeletal conditions prompt diagnosis, provision of pain relief, appropriate treatment and information has both short-term and long-term benefits. For some conditions (for example rheumatoid arthritis) early diagnosis and treatment may be critical to the long term impact of the condition.

1. Early assessment and treatment. All people with musculoskeletal conditions should be entitled to early assessment in order to establish a diagnosis as soon as possible, followed by appropriate treatment, pain relief and information. However, the search for a diagnosis should not delay a thorough assessment and treatment of any pain or loss of function, indeed for some people this may be a higher priority than obtaining a diagnosis. For this to happen, the general public, health care professionals and service providers need a greater awareness of musculoskeletal conditions. Since many people’s first point of contact with the NHS is via their General Practitioner (GP), GPs need timely open access to investigativeprocedures to aid prompt diagnosis.
2. Speedy referral to specialist services. People with musculoskeletal conditions should have timely access to appropriate specialist services both hospital and community based, such as rheumatology, orthopaedics, musculoskeletal services, including specialist health professionals such as nurses, physiotherapists, occupational therapists, podiatrists, application officers, orthotists and GPs with a special interest in musculoskeletal disease.

3. Well trained community based health professionals. The majority of people with musculoskeletal conditions will be managed in the community setting. These people require access to community based health professionals, e.g. GPs, pharmacists, nurses and allied health workers who need to be able to offer high quality, modern healthcare management. Appropriate and adequate education and information on musculoskeletal conditions needs to be incorporated into all undergraduate medical, nursing and other health professional courses, and into postgraduate primary care and other training programs. Ongoing educational support should be readily available to GPs and fellow members of the primary healthcare team. This will enable earlier assessment, support the maintenance of the patient within the community, and promote timely referral for investigation and secondary care opinion where appropriate.

4. Access to multidisciplinary services. The physical and social impact of musculoskeletal conditions must be acknowledged. People with musculoskeletal conditions are entitled to expect their GP to have quick and easy access to all members of a multidisciplinary primary healthcare team such as occupational and physiotherapy services, in order to maintain their independence within the community. When appropriate, there must be timely access to GPs with a specialist interest in musculoskeletal conditions, rheumatology liaison nurses and hospital based dedicated rheumatology and orthopaedic multidisciplinary teams.

5. Rapid access to services when symptoms worsen. Musculoskeletal conditions can fluctuate, and symptoms may suddenly worsen. All people with musculoskeletal conditions should have access to advice, treatments and support during such periods. Examples might include access to a rheumatology nurse practitioner helpline, and community-based ancillary services.

  Information

In recent years there has been a subtle yet fundamental shift in the balance between service provider and service user. The consensus is that better information is needed, and that this will, ultimately, lead to a greater degree of involvement by service users. Better care and improved health for everyone depend on the availability of good comprehensive information, which is accessible, when and where it is needed.

Accurate, high quality and consistent information is needed to deliver the vision of a user-centred service.

1. Accessing information and support. All people with musculoskeletal conditions should have access to high quality information in an accessible format at all stages of care – including diagnosis – in order to manage their condition effectively. Primary and Secondary Care settings should offer information in a variety of formats about the relevant condition and treatments as well as indicating further information on treatments and health care services, advice o n day-to-day living with the condition, local support groups, help-lines, social services, benefits and other means of support offered by voluntary organisations. Information should be tailored to the needs of the patient, their carer and family and should be offered at an appropriate time.
2. Accessing information about maintaining and improving musculoskeletal health. People should have access to information about musculoskeletal health and healthcare services through such outlets as their community pharmacist, primary care facilities, voluntary sector organisations, schools, libraries and leisure facilities. People should be encouraged to adopt life-habits that maintain and promote good musculoskeletal health.

  Services which are centred on the needs of users

Recent research and policy reviews have pointed the way to partnership and whole system working. Such systems are characterised as:

• Services organised around the user.
• Participants recognise that they are part of an interdependent system.
• Participants ha ve shared visions, objectives and resources.
• Boundaries between organisations are seamless to the user.

1. Patient-centred services. All health services for people with musculoskeletal conditions should address the needs of the service users. Services should therefore be designed to improve quality of life, preserve independence, and limit the impact of the condition on a person’s work and/or daily activities, and to empower people with musculoskeletal conditions to manage their condition effectively.
2. Integrated co-ordinated care and support across and between sectors. People with musculoskeletal conditions are not solely defined by their diagnosis and may have other health and social care requirements, including psychological care, that need to be recognised and supported. All people with musculoskeletal conditions should have access to continuous and co-ordinated services and support between health care, social care, benefits, housing, transport and other service sectors.
3. Sensitivity and consideration. Service users should be treated with sensitivity – particularly during the communication of diagnoses, and should be respected as individuals with regards to personal values and aspirations. Service users should be given an opportunity to express their views. They should be given feedback in case of complaint.
4. Convenience of care. Service delivery should be designed to be flexible and responsive to service users’ needs, with appropriate choice about providers.
5. Continuity of care. People with musculoskeletal conditions have the right to expect high quality health care for the duration of their condition – with appropriate support and monitoring during treatment and regular specialist reviews where appropriate. Primary care is the most likely setting to promote continuity of care given its pivotal position between community and hospital based services.
6. Continuity and quality of care is greatly enhanced by seeing the same health care professionals each time with strong communication links between health professionals in differing health care settings. This is particularly important for people with severe musculoskeletal conditions who may need to see a range of health professionals at different times. Wherever possible, major changes to the structure or make up of that team should be communicated to these service users.

   Independence and self determination.

The traditional view of patients as passive compliant recipients of care and services is no-longer seen as the ideal model. Research has shown the benefits of a greater involvement of patients, particularly people living with long term conditions, in understanding, monitoring, reviewing and deciding their care needs. These benefits include:

• Increased and better quality self management
• Improved well-being
• Better risk management
• The reduction in pain
• Lower levels of depression

1. Partners in care – the service user as a member of the health team. People with musculoskeletal conditions should be regarded as equal and active partners in decision-making about their own health care options. This requires service users to be educated and empowered to take responsibility for their care pathways. At the same time, patients recognise the need to take responsibility for their musculoskeletal health, including taking appropriate lifestyle measures such as weight loss and appropriate exercise.
2. User-led self management training and support networks. There needs to be wider recognition of importance of user-led selfmanagement  initiatives (such as the expert patient programme) and  support networks or self-help groups. Many such groups not only provide  contact with other people with musculoskeletal conditions but also  supervised exercise sessions and other functions.
3. Involvement of service users in developing health care policies and practices.Services users should be involved in helping to shape services through dialogue and partnership working. The knowledge and experience of people with musculoskeletal conditions should be utilised, involving and consulting them in the development of local and national health care policies and practices. Such consultation which can offer a unique perspective on service delivery can often provide imaginative solutions and improvements to health care services and can ensure services meet the needs of service users.