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Time for GPs to give up on musculoskeletal care?

27 March 2018

Graeme Wilkes has been invited to present an MSK examination masterclass; knee at at Pulse Live London and will be illustrating that it may be time to utilise those with better knowledge to really benefit their patients.

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The challenge to keep up to date is one for all clinicians but none more-so than for GPs. I am no longer technically a GP, having left the Register last year after 23 years. I left daytime General Practice in 2007 to join Connect Health working as a musculoskeletal (MSK) GPwSI initially and then as a Consultant in Sport and Musculoskeletal Medicine in 2010 having been admitted to the Specialist Register by the GMC.

For the first four years of General Practice I saw the reported 14% (not 30% as widely quoted) MSK presentations in my day without any experience or relevant training. I managed to avoid Orthopaedics, Rheumatology or A&E jobs and my undergraduate training probably consisted of 6-8 weeks in those areas as a disinterested spotty youth. That experience is not unusual. Since I have been teaching GPs over the past 11 years, there is a wide admission amongst GPs that, with a few exceptions, this was their experience too.

There is no doubt that knowledge levels in primary care in MSK are relatively poor. However, in 1994 when I hit the ground running it wasn’t really a problem. People don’t die of MSK problems. There was always non-steroidal anti-inflammatory drugs (NSAIDs) and if you were stuck, the only decision was whether to send to Orthopaedics or Rheumatology. That may depend on who last taught at the NSAID drug company sponsored lunch aka education event.

I have been invited to present to GPs at Pulse Live in London today on “The Knee”. I am informed that a popular request is to demo examination of the knee and questions about injections. I have included a couple of colour pictures of knees and will briefly mention injections but is this really what is needed? How can I bring up to speed this audience who have progressed from spotty young people like myself to over-run, over-burdened and flagging 40 and 50-year olds, with an ever increasing knowledge base to understand and, in the case of MSK, no base to start from? Can I / they really make a difference at this stage?

So, I am going to use the knee to illustrate that it’s time to utilise those with better knowledge to really benefit their patients… and no it’s not Orthopaedics or Rheumatology.

This is because Rheumatologists have enough inflammatory disease on their hands and are in short supply. Orthopaedics also have their hands full but have also been managing to practice without a firm evidence -base in many areas for many years and GPs I am sure don’t understand this, as there is no incentive for the Orthopods to tell them. The standard X-ray and/or MRI , steroid injection and refer to Orthopaedics is significantly contributing to the financial issues in the NHS. If you don’t believe me read “Get it Right First Time” report by the British Orthopaedic Association – the clinical variation, choice of cases, infection rates, failure rates and litigation costs are a huge drain:

I will be showing the GPs at Pulse Live the evidence that a large proportion of Knee Arthroscopies have poor outcomes where the knee is degenerate. Does every Anterior Cruciate tear need grafting – you would think so from all the people you know who have had one (two in my family!), but the evidence suggests most don’t. In addition, there is little need for GPs to X-ray or MRI anyone based on Royal College of Radiology guidelines. Most GPs, I suspect do this for a diagnosis where clinical skills are lacking – “Knee pain – what’s the diagnosis please”.

So, what’s the answer? – PHYSIOTHERAPY!

I have worked with excellent physios for 23 years – in professional rugby, at the Olympic Games, and a host of other sporting environments, as well as in the NHS in the last 11 years. When I started with Connect an old GP colleague of mine on a practice visit said, “I don’t refer to Physiotherapy because it doesn’t work”. The problem for him was that there is physiotherapy and there is physiotherapy. Connect Health have just published excellent clinical outcomes in a series of 4271 physiotherapy patients – 68% had a significant improvement.

We assess patients early (within 48 hours) and performance manage what our physios do:

  • no ultrasound machines (largely useless)
  • biopsychosocial approach
  • empowering patients to self-manage and understand pain.

Almost all NICE guidelines and specifically for knee conditions recommend exercise-based rehabilitation before a sniff of a needle or scalpel.

The challenge is that physiotherapy has been undervalued and underfunded and so hasn’t been producing the results (apart from as evidenced by Connect I am pleased to say and claimed, but not evidenced by some other providers). All that wasted money on operations and radiology would buy a lot of quality rehabilitation and leave mountains of cash left over. It’s evidenced everywhere you look but it just doesn’t happen.

So, my message at Pulse Live will not be which meniscal test is better than another, but stop the X-ray and MRI scanning and pressure your CCG to properly fund the community physiotherapy service AND importantly performance manage it. Ensure that your service is at least hitting our published benchmark. Let those who have the training and skills make a difference to our community. We will see a more mobile population, less expenditure on operations infections and litigation to help the Chancellor and you know what…. improvements in mental health, reduction in diabetes and a few less post-op infections, DVTs. PEs and those occasional deaths. Seems like an obvious direction to me.

GPs becoming deskilled I hear the call? Too late mate!

Graeme Wilkes’ MSK examination masterclass: Knee will take place at Pulse Live London at 11.40 on Tuesday 27th March. Follow the conversation on Twitter #PulseLive

Pulse Live London - Time for GPs to give up on musculoskeletal care?
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