Delays for NHS patients needing musculoskeletal care

Conditions such as back pain and arthritis are the biggest cause of morbidity in the UK. But the pandemic has seen primary and secondary care appointments cancelled or held virtually. In the first of a new series on the “new normal” in medicine, the BMJ’s Kathy Oxtoby reports on the backlogs

“I’ve been in debilitating pain for far too long,” says Sara Schroter, aged 49, who is from London and works at The BMJ. She developed symptoms of severe sciatica in November 2020. Completely immobilised, she attended the emergency department at Christmas, where she received painkillers but no confirmed diagnosis.

In January she resorted to private magnetic resonance imaging (MRI), which showed a herniated disc. In February, after a poor response to an epidural, she was referred for an urgent neurosurgical review by telephone and added to the waiting list for discectomy. Elective surgery had stopped completely owing to covid-19, and she was given no indication of the expected wait.

Musculoskeletal (MSK) conditions such as neck pain, low back pain, and arthritis are the UK’s leading cause (22%) of years lost to disability, and they have a huge societal and economic impact. They affect over 18 million people and lead to 30% of all GP consultations in England.1 They are mostly treated in primary care and the specialties of trauma and orthopaedics and rheumatology.

Schroter’s situation will be all too familiar to the many NHS patients waiting for diagnosis, referral, treatment, or surgery, whose numbers have swelled since the pandemic. Many struggle with even simple daily activities, and many experience the depression and anxiety that can accompany chronic pain.2 Some patients, including those taking immunosuppressants, have been shielding and unable to attend face-to-face appointments.

Schroter felt “lucky” to get surgery in May this year because the surgeon recognised the severity of her condition without seeing her in person. She had been worried about long term nerve damage from the delay. “Life is mostly on hold,” she said beforehand. In pain and with side effects from the drugs, she was unable to work, describing herself as “extremely limited physically: I can’t sit or stand for long.”

Deteriorating conditions

Trauma and orthopaedics is “one of the worst hit” specialties by covid-19, says Sue Brown, chief executive of the Arthritis and Musculoskeletal Alliance (ARMA), a UK umbrella body for patients and professionals.

All non-emergency surgery was cancelled, she tells The BMJ. Inpatient admissions were minimised. Some staff were redeployed to medical and intensive care specialties to help treat patients with covid-19. Rheumatology, surgery, and community physiotherapy were scaled back to just urgent and emergency care. Some outpatient consultations were cancelled, and some were done by video or phone consultation. Brown says that service resumption now “varies,” although “most are back.”

In April 2021 some 635 728 patients in England were waiting for surgery including hip and knee replacements—the most for over a decade—and more than 67 000 had been waiting for over a year.3 (In January 2020 the total was 521 408, with 436 waiting for over a year.) Almost 265 000 patients had been waiting for treatment for longer than the 18 week target after referral.4

The National Joint Registry shows that joint replacements in 2020 were at just 49% of 2019 levels for knees and 57% for hips in England and Wales—at least 100 000 fewer.5 Many were cancelled during the first wave of covid-19.6

“We are seeing patients’ conditions, such as arthritis, deteriorating,” says John Skinner, vice president of the British Orthopaedic Association and a consultant orthopaedic surgeon at the Royal National Orthopaedic Hospital in Stanmore. He tells The BMJ, “Patients are being treated with more advanced disease, which can make the surgery more complicated. We are calling on the government to prioritise these patients.” It should establish centres, “separate from A&E, to deliver planned elective surgery around the clock,” he says.

Rej Bhumbra, consultant trauma and orthopaedic surgeon at Barts Health in London, tells The BMJ, “Teams delivering MSK services aim to save life, save limb, and restore function. But the functional restorative services of treating arthritis, degenerative back pain, and other MSK pathologies have had to defer to saving life in this pandemic.

“This was understandable in the very short term, when we did not know the natural history of this virus. Now, NHS leaders must determine their priorities for patients. The NHS’s ability to deliver services has been adversely affected in the long term.”

He adds, “We need investment in infrastructure and most importantly people, rather than contractual quick fixes, which merely postpone problems. We need investment in the healthcare support workers, nurses, physiotherapists, anaesthetists, occupational therapists, and surgeons delivering care, with increased recruitment and professional development and support.”

Lack of rheumatology data

No national data have been collated to show how the pandemic has affected NHS rheumatology services, says Elizabeth MacPhie, chair of the clinical affairs committee at the British Society for Rheumatology and a consultant rheumatologist at Lancashire and South Cumbria NHS Foundation Trust. Anecdotally, some units cancelled “large volumes” of new and follow-up appointments, she says, because many staff were redeployed, resulting in backlogs and longer waits.

“Some patients are potentially accruing damage to their joints that can’t be reversed,” MacPhie tells The BMJ. Social distancing rules limit the number of patients attending outpatient clinics, and she predicts “at least another 12 months before we’re back to seeing the volumes we used to in face-to-face clinics.”

Chronic workforce shortages mean that rheumatology departments lack sufficient staff to provide a safe level of care, claims a new report by the British Society for Rheumatology. The report, Rheumatology Workforce: A Crisis in Numbers,7 shows a lack of consultants, specialist nurses, and access to other health professionals such as psychologists and pharmacists to provide the level of care recommended by NICE guidance. The society says that these “unacceptable staff shortages” mean that patients are experiencing “progressively worse health, leading to unnecessary disability and pain.”

Bharat Kandikonda is a GP in Middlesbrough who works part time in rheumatology in secondary care. In November he started a clinic at his practice for joint injections to help clear the backlog of patients with MSK problems who couldn’t receive this monthly treatment in hospital. Patients in chronic pain used to wait an average of six weeks to see a rheumatology specialist, he says; they now wait seven months.

Many patients find that dedicated NHS helplines are unanswered or have reported them closed, says Ailsa Bosworth, national patient champion for the National Rheumatoid Arthritis Society. Calls to the charity’s helpline from March to May 2020 rose from about 150 to more than 800 a month, she tells The BMJ, with “patients panicking because they haven’t been able to see their consultant in months.”

“At a loss to help”

UK general practices have continued to provide consultation during the pandemic, with patients triaged for face-to-face or remote consultation on the basis of clinical need. More patients are being seen in person now: total weekly appointments in England number seven million, one million more than before the pandemic.8

Martin Marshall, chair of the Royal College of General Practitioners, says that there are “ways to deliver care to patients with musculoskeletal health conditions remotely” but that given the nature of MSK problems, particularly new ones, “physical examinations are often necessary and face-to-face appointments will have been facilitated. In-person appointments have been facilitated throughout the pandemic, if clinically necessary.”

Elspeth Wise, a GP in South Shields, recalls “a massive drop in people presenting” at the start of the pandemic. Care of patients with MSK disorders has often been managed by telephone, she tells The BMJ, and this can make it difficult “to distil down exactly where the patient’s pain is.” The practice now assesses people by phone and invites “a reasonable proportion” of patients in if they need examining.

Sudden cancellation of joint replacement surgery has also been challenging, says Wise. “Patients have been in horrendous pain, and some have been crying on the phone. I have felt at a loss to help,” she says, but she hopes that “first contact practitioners” will help. These physiotherapists with enhanced training see patients without a referral.9

Louise Warburton, a GP and clinical lead for the one stop Telford MSK Service, which offers assessment and treatment, tells The BMJ, “It’s going to take a year to get back to the status quo, assuming no more lockdowns. A lot of the work now is to prioritise people who need to be seen more urgently.”

Nerve injuries from covid-19

Schroter says that GPs, a physiotherapist, and a surgeon did “everything they could” for her in phone consultations—but that she wanted to see a clinician “face to face.”

Chris Mercer, a musculoskeletal specialist adviser for the Chartered Society of Physiotherapy and consultant physiotherapist at University Hospitals Sussex, tells The BMJ that during the pandemic about 80% of consultations at his service occurred by phone or video. Before the pandemic only 40% of consultations were carried out this way as part of normal practice.

Mercer foresees a “big demand” for physiotherapy services in the coming months because of the surgical backlog, as well as the peripheral nerve injuries caused by covid-19. Remote consultations are set to continue in all aspects of MSK care to tackle long waits. Some patients prefer these because it means taking less time off work to attend. However, the ARMA chief executive Brown says that neither digital nor face-to-face consultations should be the default, as “what is crucial is doing what is most appropriate for the patient.”

NHS England’s collaboration on Best MSK Health, launched in February, also emphasises appropriate care.10 This “is starting to move MSK towards the priority it deserves,” says Brown. It advises that patients should be sent to secondary care only if necessary and that online consultations or support groups can help people with chronic pain.

The Department of Health and Social Care has earmarked an extra £1bn to tackle backlogs, as well as £160m to help hospitals carry out more operations and cut waiting times. But as the total number of people waiting for hospital treatment tops five million for the first time,11 leaked government costings suggest that these sums will be nowhere near enough.12

During the pandemic many rheumatology patients have had no choice but to manage their conditions themselves, and this is likely to continue. Bosworth, who has inflammatory polyarthritis, says that now more than ever, with MSK and rheumatology services under pressure, patients need to know how to advocate for themselves and seek support, which is where patient groups can help.

“When you live with a very painful disease like rheumatoid arthritis,” she says, “you become accustomed to pain and to saying you’re OK when you’re not. We’re going to have to learn to know when to say, ‘I’m not coping, and I’m not fine.’”

“I wanted to see a health professional face to face”

Joanne Ryan, in her 40s and from London, had an emergency discectomy in 2005 after a fall on the stairs and recently sought help with new pain.

“It was pretty bad at the time, but since then I’d not had major issues until this January,” she says. “During lockdown I didn’t realise how sedentary I’d become. Then one day while I was on the sofa my back completely seized up. I couldn’t move and was frightened.

“A few days later I got a phone appointment with a GP who didn’t know my history—which is important, as I don’t want to have another back operation. The outcome wasn’t helpful: I was prescribed some co-codamol and told I could refer myself to a local MSK service online.

“In pain, with limited mobility, I waited 10 days for an appointment with the service, which was a telephone call with a physio. I felt that the consultation was not appropriate for my condition. Again, they had no idea of my previous condition. There was no continuity. I was never offered the opportunity to see someone face-to-face.

“I was then referred to a phone app, with exercises and videos and some explanation on how to do them. But with this approach there’s no interaction, so motivation is difficult.

“My condition has now improved because it’s been so long, and I’ve been trying to be mobile. But what I wanted was to see a health professional face to face and to be reassured that I didn’t need a scan.

“Back problems are going to be an issue for a lot of people because we’ve been stuck at home, sedentary, without suitable conditions for working at home—and the stress of the pandemic probably isn’t helping. People like me are going to cost the NHS more money down the line.”

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Patient consent obtained.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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