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Introduction

This quality statement is an aspirational description of what good looks like for children, young people and adults receiving Musculoskeletal (MSK) health and care services throughout the life-course. It is an important resource for multi-professional stakeholders with whom it has been co-produced, and who will work together as equal partners in the delivery of person-centred care (including health, social care, independent, third sector and those with lived experience). The overarching aim is to improve and protect the MSK health of the population from an early age, reduce the number of people developing MSK conditions and to improve the health and well-being of people with MSK conditions.

MSK conditions are the most common cause of long-term pain and physical disability globally. They account for 4 of the top 10 causes of 21% of the total years lived with disability in the UK and are estimated to affect 32% of the population of Wales (974,000 people) [footnote 1]. They are often long term MSK conditions that disproportionally affect certain groups of citizens and are strongly linked to deprivation, ethnicity, age, and gender  [footnote 2]. MSK conditions can impact individuals, their families, education, and employment. It is estimated 23.3 million working days were lost in the UK in 2021 due to MSK conditions  [footnote 3].  

MSK conditions often effect multiple body areas and systems, requiring joined up multi-professional care. They can impact physical, emotional, social, economic and mental health, making MSK conditions a significant public health concern. MSK conditions are a common co-morbidity that drives self-reported ill-health and limits people’s ability to manage other long-term health conditions (such as cardiovascular, metabolic, and respiratory health)  [footnote 2]. With changing determinants of health and an aging population with growing co-morbidities, musculoskeletal health is a large and increasingly important component of growing, living, learning, working, and aging well. 

There is a broad spectrum of MSK conditions which generally fit into four groups:

  1. Inflammatory conditions (e.g. rheumatoid arthritis, juvenile inflammatory arthritis)
  2. Conditions of MSK pain (e.g. as a result of injury, osteoarthritis and back pain)
  3. Bone health (e.g. osteoporosis and fragility fractures) 
  4. MSK related neurological dysfunction – (e.g. spinal cord compression due to spondylosis)

Whilst some MSK conditions are either self-limiting (e.g. minor injuries) or treatable with simple supportive treatments, some require medical or surgical intervention and many are long-term conditions (lasting more than 3 months) requiring a more complex, person centred, long-term and sustainable management strategy. 

A proportion of people with MSK conditions will benefit from surgery as part of their pathway of care. The National Clinical Strategy for Orthopaedic Surgery (NCSOS) programme has defined the standards and blueprint required to deliver a high quality, safe, sustainable, and equitable Orthopaedic surgical service for the population of Wales. This MSK quality statement should be read in conjunction with the NCSOS blueprint

The MSK Strategic Clinical Network (SCN) will be created in 2023 under the new NHS executive and national clinical framework to guide the progression of MSK services to achieve the aims of a Healthier Wales and the Wellbeing of Future Generations (Wales) Act 2015. The network will develop national leadership, local engagement and collaborative partnership working to ensure there is a long-term and consistent approach to improving the MSK health of the population whilst preventing and managing MSK conditions throughout the life course. 

The introduction of quality statements was signalled in A Healthier Wales and has been described in the National Clinical Framework as the next level of national planning for specific clinical services. Quality statements form part of the enhanced focus on quality and will be integral to the future planning and accountability arrangements for the NHS in Wales.

There is a need to ensure that equity of access is provided for those people who  face inequity, such as, deprivation, ethnic minority, rural and LGBTQ+ communities and pathways will need to be flexible to deliver this. The Welsh Government’s 'More than just words' plan to strengthen Welsh language in health and care services through the ‘active offer’ principle should become an integral part of service provision. Service providers should build on current best practice and plan, commission and provide care based on this principle.

This approach aligns with the National Clinical Framework, which places specific emphasis on the development of high value national clinical pathways and the Quality Safety Framework which emphasises the importance of systemic local use of the Quality Management System. It also enables a focus on co-production and cross-working with other groups to address areas such as prevention, rehabilitation, pain management, care for those who are critically ill or at end of life as well as collaboration with other conditions.  

A system-wide approach to quality requires a culture that embeds continuous learning and improvement at its heart. This should be underpinned by a clear definition and understanding of what good quality looks like, utilising national and benchmarked standards, peer review and audit. 

The Duty of Quality requires Welsh Ministers and NHS bodies to ensure quality-driven decision-making and planning is in place to ultimately deliver better outcomes for all people who require health services. Quality needs to be system-wide; applied across all clinical and non-clinical services within the context of the well-being and health needs of the population.

The revised Health and Care Quality Standards - NHS Wales Executive ensure direct alignment between the duty of quality and standards, ensuring the simplified framework can be widely and flexibly applied.  

Health boards – as integrated healthcare organisations – are responsible for the delivery of MSK services in line with professional standards and the quality domains and enablers set out below.  They will respond to this Quality Statement through the integrated medium term planning process. 

The MSK Strategic Network and its implementation and operational networks will support health boards to improve the quality, consistency, and value of healthcare delivery. Detailed service specifications will be developed to support the commissioning and accountability arrangements including key metrics for delivering high quality and sustainable MSK services that meet the needs of the population. Many statements reach across and connect between domains and are therefore allocated pragmatically.

Health and quality standards

There are 12 health and care quality standards for people with MSK conditions.

Safe

1.    Effective integrated care with appropriate multi-professional involvement, communication, monitoring and follow up to meet individual needs. 

2.    Decisions relating to care are appropriately documented showing the shared decisions that were made and the rationale behind them, including consideration of risk, benefits and potential outcomes of considered interventions. 

3.    Evidenced safety improvement programmes are embedded utilising the All-Wales incident reporting system to identify themes and share collective learning points.

Timely

4.    Where possible, populations at high risk of developing MSK conditions are identified through local needs assessments and actively supported with primary prevention strategies before the onset of symptoms of MSK conditions. 

5.    Mild symptoms in the early stages of MSK conditions are recognised and responded to with appropriate secondary prevention and supported self-management strategies. 

6.    Timely access to appropriate and agreed onward steps within the defined community care pathway, including:

  • access to appropriate diagnostics
  • access to appropriate information, education and secondary prevention / supported self-management strategies
  • access to appropriate supportive treatment in primary care or specialist MSK services
  • appropriate escalation to sub-specialist MSK services 

7.    Timely implementation of new national clinical guidance relating to MSK conditions. 

Effective

8.    Care for people presenting with symptoms of an MSK condition is consistent with nationally agreed, locally optimised, high value, evidence-based pathways of care. 

9.    MSK pathways clearly describe the local, place-based services at each stage of the pathway. These should include: promotion, prevention, early accurate diagnosis, supportive treatment, preparation and intervention. 

10.    MSK pathways enable access to public health interventions that enable people with, or at risk of developing MSK conditions, to remain active and independent for as long as possible.

11.    People presenting with MSK symptoms receive an early accurate diagnosis, in line with the MSK pathway recommendations. 

12.    Diagnosis is compassionately communicated with precise information and signposting to organisations and services that can provide support. 

Efficient

13.    Building on and expanding new ways of working which improve efficiency.

14.    Using technology to enable the safe and efficient management of MSK conditions.

Equitable

15.    Co-produced regional and local services that utilise local needs assessment to understand and actively work to meet needs of the local population not being addressed by existing services. 

16.    National MSK pathways implemented at a local level to ensure transparency, support equity of access, promote consistency in standards of care and address unwarranted variation.

17.    Children and young people with MSK conditions receive tailored support during transition to adult services in line with the transition standards: Transition and handover from children's to adult health services

Person centred

18.    Communication is kind, empathetic, accurate and effective. 

19.    People are signposted to, or provided with, accurate and approved evidence-based information that aligns with pathway recommendations in a format that meets their individual needs.

20.    People and their carers are engaged in "what matters" conversations where their values, preferences and wishes are understood and included in shared decision making.

21.    People and their carers are actively engaged in shared decision making and are supported to understand their condition and the personalised care options available to them.  

22.    Services are able to respond appropriately to the often unpredictable and fluctuating nature of MSK conditions. There is flexible monitoring and follow up to enable changes to personalised treatment plans.

Enablers

Leadership

23.    A nationally led approach through the MSK Strategic Clinical Network and its implementation and operational delivery networks and clinical reference groups will support health boards, trusts and independent contractors to deliver equitable regional and local services.

24.    Clinical reference group membership will appropriately reflect the multi-professional nature of MSK pathways and services. 

Workforce

25.    A transformed, multi-professional, whole system workforce to better meet future needs of people with MSK conditions.

26.    A workforce that is supported, developed, and trained to meet current and future needs, address recruitment and retention challenges and which is sustainable and equitably distributed. 

Culture 

27.    A multi-professional approach to person centred care is culturally embedded in all MSK pathways of care. 

28.    Multi-professional teams engage in appropriate, timely and constructive discussion and collaboration to deliver joined up, person-centered, outcome focused, services.

29.    A culture where a person’s needs across the biopsychosocial spectrum are sought, understood, and actively considered as part of their MSK care.

30.    A culture that utilises a whole system approach including social, education, employment, and peer support.

31.    A culture that enables supported self-management as locally as possible. 

Information

32.    A national approach to informatics systems and data that enables greater integration of care and provides relevant, high quality, standardised data to drive service improvement.

Learning, improvement and research

33.    Services for people with MSK conditions will be measured and held accountable for quality of care and its outcomes, using agreed metrics including registries, clinical audit, PROMs and peer review. 

34.    Improved insight into patient experience through PREMs, understanding “what matters” to better plan care and service improvement needs and ensure people affected by MSK conditions achieve the outcomes that matter to them. 

35.    Further develop excellence in MSK research, innovation and education informed by lived experience, to enable the delivery of high quality, evidence-based care that aims to better prevent, manage, treat and limit the impact of MSK conditions.

Whole-systems approach 

36.    Multi-professional teams will work with local partners to build and sustainably support MSK health in the community. 

37.    A multi-professional whole system MSK capability and competency frameworks will enable the workforce to develop the required knowledge and skills including biopsychosocial approach, supported self-management and health coaching. 

38.    MSK services will work in partnership with other clinical strategic, implementation and operational delivery networks and where possible join up services for those with multiple interacting co-morbidities.

Glossary

Quality statement    

High-level statement of intent for what “best” looks like for services for people with musculoskeletal conditions.

Co-production 

A way of working in partnership, by sharing power between health professionals and people who draw on care and support, carers, families and citizens.

Supported self-management 

An approach that supports and empowers a person central role in acquiring knowledge and skills to manage their health conditions. 

Shared decisions 

A joint process in which a healthcare professional works together with a person to reach a decision about care. NICE guidelines on shared decision making.

Service specifications     

Written guideline that sets out details on how specific services will be delivered and measured.
pathways. A care pathway is a multidisciplinary healthcare tool for a specific group of people with a predictable clinical course, in which the different tasks or interventions by the professionals involved are defined, optimised and sequenced.

Evidence-based  

Denoting an approach to medicine, education, and other disciplines that emphasizes the practical application of the findings of the best available current research.

Biopsychosocial 

An inter-disciplinary approach that respects the interconnection between biology, psychology and social-economic factors.

Value based health care  

Delivering the best possible healthcare outcomes for our population with the resources that we have.  

Unwarranted variation 

Refers to variation that cannot be explained by illness, medical need, or the dictates of evidence-based medicine, often referred to as the ‘postcode lottery’.

Third sector   

Charities and non-governmental organisations.

Multi-professional      

Multi-professional working describes a group of individuals across health, social care, independent and third sector working together in a professional way as equal partners to ensure effective and smooth co-ordination in the delivery of person-centred care and support. 

Co-morbidity 

The simultaneous presence of two or more diseases or medical conditions in one person.

Determinants of health   

The range of social, ecological, political, commercial and cultural factors that influence a person’s current state of health and their chances of maintaining good health or becoming ill or injured.

Supportive treatments  

Helping people deal with symptoms and impacts of a disease or condition, where cure is not possible. 

Interventions   

A health intervention is an act performed for, with or on behalf of a person or population whose purpose is to assess, improve, maintain, promote or modify health, functioning or health conditions.

Footnotes

1. Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results [Online] 2020. 

2. The State of MSK Health 2021 (versusarthritis.org)

3. Office for National Statistics. Sickness absence in the UK labour market 2021. ONS [Online] 2022.

Annexes

Annex A: service specs and pathways  

The Musculoskeletal (MSK) Strategic Network will develop service specifications and pathways for MSK services to inform accountability discussions and commissioning decisions. These will be added as it becomes available.

Annex B: Example metrics (evolving) 

Outcomes for the individual 

  • Patient Reported Outcome Measures (PROMs)
  • Core set – EQ5D5L
  • Specialist services - MSK HQ 
  • subspecialist services
  • National data sets – International Consortium for Health Outcomes Measurement (ICHOM) where available
  • PIFU (Patient Initiated Follow Up)
  • SOS (see on symptom)

Experience of the individual

  • Patient Reported Experience Measures (PREMs)
  • Friends and family test
  • Person stories 

Alignment to standards and guidance

  • Transition standards for children and young people

National clinical audits

  • National Early Inflammation Audit (NEIAA) 
  • National Hip Fracture Database (NHFD) database
  • Fracture Liaison Service (FLS) database  
  • Future MSK audit

National registries 

  • National Joint Registry (NJR) 
  • Adult rare diseases