The national programme budget for musculo-skeletal (MSK) disease in England for the financial year 2008/09 was £4, 214, 927, 0001 according to the data in the NHS Atlas of Variation from Rightcare and the variation among PCTs in musculo-skeletal expenditure is almost threefold, ranging from just over £40,000 per 1,000 population to almost £120,000. (The degree of variation in investment in musculo-skeletal services does not reflect the variation in the incidence, prevalence or severity of arthritis.)
In Shropshire where I work, the MSK spend is amongst the highest in the country. One of the reasons for this is that we have a Specialist Centre for Orthopaedics in Oswestry (The Robert Jones and Agnes Hunt Orthopaedic Hospital). People retire from the conurbations of the UK to this lovely rural county, and patients come in from elsewhere to have surgery too. This has given Shropshire County PCT a bit of a headache and understandably they tried to reduce the spend on MSK disorders a couple of years ago.
They tried to insist that all patients referred for knee replacement surgery should have an Oxford Knee Score above a certain level.1 Local GPs objected to the ruling and it was eventually withdrawn. Quite rightly they said that each patient was an individual and the assessment of their knee pain had much more to do with other factors rather than their Oxford knee score. The decision for each patient should be the result of an informed discussion between GP, surgeon and patient.
The Oxford knee score was originally intended to be used for assessment of results after surgery. Patients had a score before surgery and then repeated the score after surgery and any improvement could be noted and attributed to the surgery. It was never intended to be a severity score to ration referral for knee replacement.
Knee replacement is actually a pretty effective operation with good cost-benefit ratios and excellent patient outcomes. Figures from the PROMS data show that 82.2% of patients get good or excellent results when asked how they assess the overall result of their knee operation. The pain relief data from PROMS shows that 38% of patients have severe pain problems prior to surgery and this number is reduced to 6% by six months after operation.
The Atlas of Variation shows that treatments and spends on a wide variety of conditions vary widely from one part of the country to another, and this variation is not all due to differences in populations. This is, in fact, a public health issue. We cannot ignore the causative factors in most MSK problems which affect British society in the 21st century: obesity, lack of exercise, and poor childhood fitness levels.
We need to start at school-level and teach children how to eat well and keep fit – this should be compulsory, and physical activity should be a large part in the curriculum.
Yes, there are government moves to tackle these issues, but most of it is relatively low-key. Local authority weight loss schemes are having their funding cut in my area, just when we need it most.
What we need in the UK is a sea-change in national attitudes to food and exercise, and these problems need to be tackled in a similar way to the ban on smoking advertising and smoking in public areas. The population hasn’t been able to follow sensible advice on eating, so we must move to sanctions against the retailers who push fast food and sweets at us all the time.
How about a tax on sugary and fatty foods, and a subsidy on fresh produce? If we start to re-educate children about obesity and eating well in a more forceful way, we can hopefully make some changes in the incidence of many health problems – including joint problems.
That way, when we come to make difficult decisions about knee surgery for obese patients then those rationing decisions will make more sense to our patients. It’s obviously easy to offend when making rationing decisions, but if the approach is correct and based on clinical risk, then I think people would see things differently.
For instance, smoking does have an impact on sperm counts and it seems ridiculous to be spending thousands of pounds on IVF, when a simple measure such as smoking cessation could produce the same results and improve health outcomes for the patient at the same time.
Likewise, there is a clinical risk in hip and knee surgery in obese patients and I think PCTs are justified in asking for weight loss before surgery. It is after all, in the patient’s best interests.
We currently don’t have a lead for MSK problems within the UK. We have cancer leads and tsars of many disease areas, but MSK disorders have been ignored for years.
A national leader for musculoskeletal diseases could help us to formulate policy on preventative measures to tackle osteoarthritis, obesity, lack of fitness and the money spent on MSK disorders throughout the UK. A leader would also ensure a national policy on orthopaedic surgery and abolish the type of postcode lottery seen in the Atlas of Variation.
MSK disorders aren’t ‘sexy’, but they are responsible for a great deal of morbidity and loss of working days in the UK. Nearly 100% of us will have a musculoskeletal ache or pain at some time in our lives and many of us will have our lifestyles changed and loose our independence due to them.
This is the time to take a stand and demand more respect for MSK diseases. Let’s have a national lead and include disorders such as osteoarthritis in QOF. This is the only way to make patients, doctors and politicians take them seriously.
Dr Warburton is currently a GPwSI in Rheumatology and Musculoskeletal Medicine for NHS Telford and Wrekin