Musculoskeletal Matters in Primary Care

Gill Wakley, Ruth Chambers, Paul Dieppe

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315348193
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Widespread recognition of the benefits of minimally invasive procedures in surgery and medicine is resulting in the rapid development of new advances and new techniques in every speciality. This series of books sets out to meet the needs of those responsible for applying the techniques. This volume deals with the field of minimal access gynaecology. Areas covered and techniques described include: advances in instrumentation and equipment for minimal access surgery; operative endoscopy in the treatment of infertility; laparoscopic assisted vaginal hysterectomy and total laparoscopic hysterectomy; advancements in laser fibre optic delivery systems compared to existing electrosurgery techniques; and operative hysteroscopy with electricity.

CHAPTER 1

Clinical governance and the management of musculoskeletal disorders

The range of musculoskeletal disorders is very wide, and overlaps occur between the specialties of rheumatology and orthopaedics, as well as between the many disciplines involved in caring for patients with these conditions. A selection of topics has been made to represent what might be of concern to a primary care team that is aiming to improve the management of this particular part of their workload.

Clinical governance is inclusive - making quality everyone’s business, whether they are a doctor or a nurse, a pharmacist or other independent contractor, a manager, member of staff or a strategic planner. We need to know where we are now, and where we want to get to, if we are to drive up standards of healthcare.

Clinical governance involves doing ‘anything and everything required to maximise quality’.^5,6 It should create a culture and working environment in which people thrive and feel fulfilled by their work but where, at the same time, under-performance is identified and corrected.

Components of clinical governance

The components of clinical governance are not new. However, bringing them together under the banner of clinical governance and introducing more explicit accountability for performance is a new style of working.

The following 14 themes are core components of professional and service development which, taken together, form a comprehensive approach to providing high-quality healthcare services and clinical governance.⁵ These are illustrated in the tree diagram shown in Figure 1.1.

Figure 1.1 ‘Routes’ and branches of clinical governance.

If you interweave these components into your individual and workplace-based personal and professional development plans you will have addressed the requirements for clinical governance at the same time.⁷

1. Learning culture: in the practice, primary care organisation or department.
2. Research and development culture: in the practice or throughout the health service.
3. Reliable and accurate data: in the practice, and in the NHS as a seamless whole.
4. Well-managed resources and services: as individuals, as a practice, across the NHS and in conjunction with other organisations.
5. Coherent team: well-integrated teams within a practice, including attached staff.
6. Meaningful involvement of patients and the public: including users, carers and the general population.
7. Health gain: activities to improve the health of staff and patients within a practice, between practices, and in a primary care organisation.
8. Confidentiality: of information in consultations, in medical notes and between practitioners.
9. Evidence-based practice and policy: applying it in practice, in the district and across the NHS.
10. Accountability and performance: for standards, performance of individuals and the practice - both to the public and to those in authority.
11. Core requirements: good fit with skill mix and whether individuals are competent to do their jobs,- communication, work-force numbers and morale at practice level.
12. Health promotion: for patients, the public, your staff and colleagues - both opportunistic and in general, targeting those with most needs.
13. Audit and evaluation: for instance, of the extent to which individuals and practice teams adhere to best practice in clinical management or human resources.
14. Risk management: being competent to spot those at risk; reducing risks and probabilities of ill health.

The challenges to delivering clinical governance

Delivering high-quality healthcare, with guaranteed minimum standards of care for users at all times, is a major challenge. At present the quality of healthcare is patchy and variable. We are not very good at detecting under-performance and then taking the initiative and rectifying it at an early stage. The small number of clinicians who do under-perform exert a disproportionately large effect on the public’s confidence. Causes of under-performance in an individual might be a result of a lack of knowledge or skills, poor attitudes or ill health. The Arthritis Research Campaign have discussed the difficulties that some patients have experienced when consulting their doctors about arthritis. A news article on their website in October 2000 (see list of websites in the Appendix) gives two typical stories of lack of expertise shown by the doctors, and blames this on the lack of education at medical school. Although most medical schools now include rheumatology, it is reported that in five medical schools doctors had received no clinical rheumatology teaching at all. Most doctors who qualified a few years ago will not have had any rheumatology teaching, and will be in even more need of postgraduate learning. However, a lack of management capability is nearly always an important contributory factor to inadequate clinical services, and provision can be patchy.

We need to understand why variation exists and explore ways of reducing the inequalities. Variation in the quality of healthcare provided is common - between different practices in the same locality, between staff of the same discipline working in the same practice or unit, and between care given to some groups of the population rather than others. For example:

• the rates of referral to hospital may differ by fourfold between one doctor and another for the same condition
• some general practices have direct access to physiotherapists, whilst others have to refer patients to a hospital specialist first.

Clinical governance offers a co-ordinated approach to overcoming these areas of risk through a blend of clinical and organisational improvements in the quality of healthcare practice.

Learning culture

Education and training programmes should be relevant to service needs, whether at organisational or individual levels. Continuing professional development (CPD) programmes need to meet both the learning needs of individual health professionals and the wider service development needs of the NHS. You should no longer opt for CPD activities according to what you want to do, but rather according to what you need to do. Clinical governance underpins professional and service development.

Individual personal development plans

will feed into a

workplace or practice-based personal and professional development plan

that will feed into

the organisation’s business plan

all of which are

underpinned by clinical governance.⁵

Thus focusing on musculoskeletal disorders would be a good topic for a practice personal and professional development plan with a mix of learning about the effective clinical management of musculoskeletal disorders in a healthy and safe work environment.

Applying research and development in practice

The conclusions of the many thousands of research papers about musculoskeletal matters that are published in reputable journals each year are rarely applied in practice. This is because few health professionals or managers make time to read such journals systematically, and they are unaware of the research findings. Moreover, most practice teams do not have a system for reviewing important research papers and translating that review into practical action. The primary care organisation might help by feeding important new evidence to its constituent practices or pharmacies, the therapy units and clinics, or indeed the general public, with suggestions or templates for making changes in practice, backed by resources to enable change to occur.

Incorporating research-based evidence into everyday practice should promote policies on effective working, improve quality and expand the clinical governance culture.

Research published in the 1980s challenged the accepted view at that time about the treatment of rheumatoid arthritis. This was that drugs were started for systematic relief, and then disease-modifying anti-rheumatic drugs (DMARDs) were added one by one, starting with the least toxic one. The new approach using DMARDs early in the disease has proved very successful, but many primary care teams are unaware of this research and still delay the introduction of DMARDs if systematic relief is achieved by other means.

Reliable and accurate data

Clinicians, patients and administrators need reliable and accurate data to connect individuals or their healthcare records to other knowledge that is relevant to the care of the patient. Set th...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• About the authors
• Glossary of common abbreviations and terms used
• Introduction
• 1 Clinical governance and the management of musculoskeletal disorders
• 2 Managing the initial presentation of musculoskeletal disorders
• 3 Osteoarthritis
• 4 Gout
• 5 Non-steroidal anti-inflammatory drugs
• 6 Rheumatoid arthritis
• 7 Systemic lupus erythematosus and similar connective tissue disorders
• 8 Polymyalgia rheumatica and giant-cell arteritis
• 9 Osteoporosis
• 10 Neck and shoulder pain
• 11 Musculoskeletal disorders and physical disability
• 12 Disability and employment
• 13 Draw up and apply your personal development plan
• 14 Draw up your practice personal and professional development plan
• References
• Appendix Sources of help
• Index