Integrated Musculoskeletal Teams

Musculoskeletal medicine has undergone a considerable change since the Department of Health released the musculoskeletal services framework in 2006.  Clinical musculoskeletal teams in the UK have moved away from the familiar physician-led model and the use of extended scope practitioners is now widely accepted as best practice. Musculoskeletal teams mostly consist of extended scope practitioner physiotherapists although, in some NHS trusts and MSK partnerships, other allied health professionals such as podiatrists, osteopaths and occupational therapists work alongside physiotherapists in multidisciplinary musculoskeletal teams.

I am currently writing an initial scoping document aimed at assessing the current makeup of musculoskeletal teams and looking at any quality, efficiency and productivity improvements that can be made by making musculoskeletal teams truly multidisciplinary.  I am very interested in hearing the opinions of musculoskeletal physicians, nurses, clinicians, and allied health professionals working in musculoskeletal multidisciplinary teams or those that are interested in doing so.  I also welcome comments from patients, professional bodies and healthcare regulators.

It could be argued that the clinical role of an extended scope practitioner is predetermined by the position in the care pathway that the extended scope practitioner is working in (usually between the patient’s general practitioner/physiotherapist and secondary care consultants).  My question and interest relates to whether non-physiotherapist clinicians can work as extended scope practitioners rather than should we be integrating osteopathy, podiatry or occupational therapy (as examples) within musculoskeletal NHS teams – the efficacy of which is a different topic entirely.

As a guide, I’m interested in comments from potential and existing extended scope practitioners or from physicians that work alongside non-medical clinicians in this field.  I am interested in what training issues there might be, what governance arrangements might be necessary and particularly any potential conflicts that you might foresee.

Having worked in multidisciplinary teams for the vast majority of my 20 year NHS career I can only see advantages but I have benefited from supportive, forward-thinking employers and colleagues that have patient management as a core value.  I appreciate, however, that working in a multidisciplinary team might pose a number of questions and it is this that I am trying to explore in this scoping exercise.

Please feel free to comment below or use the contact page should you wish to discuss this privately.  I am happy for comments to be anonymous but will moderate out abusive comments et cetera.


20 thoughts on “Integrated Musculoskeletal Teams

  1. I can see that some Osteopaths would find it very difficult to be told how to examine in a standardised way. However if this is the way forwards then may be more of us need to be prepared to do so in order to be more integrated into the healthcare system.

  2. Interesting thoughts, I see no reason why ANY clinican who has a good understanding of anatomy, physiology, pathology, pain and psychosocial issues can not be an ESP role regardless of their title. They clearly need to have had with the right experience and training and demostrate competence. I disagree that current ESP roles are predetermined or that we all examine in a standardised way. As an ESP my role is evolving and highly flexible. In these times of efficiency, effectiveness and of course evidence we have to adapt and change constantly. For example the whole xray all suspected frozen shoulders is a perfect example, currently we are looking into this and changing practice. I never examine in a standard way, each patient I see is individual and so each is examined individually and referred on or not dependant on presentation and symtoms.

  3. My concern regarding the greater integration of AHPs into ICATS settings is based on the perception that some MSK AHPs still encouarge therapist reliance rather than a self management ethos. Also, how do other professions deal with chronic pain management – which in my experience is a much rarer presentation in private practice compared to the NHS.

  4. Any HCP that can demonstrate competency could undertake an ESP role but here is where the problem lies. Current methods for ESP training are not fit for purpose (ESP modules/MSc), certainly not for our primary care setting and therefore an in-house training programme ensures our staff are safe,competent. This could be applied to any HCP with a wide understanding of patho/anatomy/pain/psyc/healthcare mx. When ‘training’ Physio’s for an ESP role they have had to learn to take off the Physio hat initially and think broader in their questioning and narrow down objective so even physio’s who have the knowledge need training in applying it so this COULD be applied to any HCP.

  5. I think there are a number of challenges in your question. I see no reason why an osteopathy can not be trained into the role of an ESP. In the commissioning provider model that the NHS is embedding as it moves further away from PCTs provision becomes a numbers game. This new system focus on patient conditions and not the practitioners. The CCGs will develop a spec that focus on the types of patients and it is unto the provider to say how they will deliver the service with in the allocated money. Unlike a lot of the other medical professions Osteopath do not delicate to health care assistants to carry out some of the treatment and allow costs to be reduced.
    Also remember that the non medical staff in the NHS use Agenda for Change as a process of renumeration and this rewards not only experance both in work and CPD but also factors such as freedom to act etc. Titles and roles allow a career path. I think most osteopaths set their price and tend not to change job titles. May AHPs continue to learn about their profession post qualification as they do their rotations.

  6. having worked in the NHS and delivered a successful AQP contract there is a place for Osteopathy, however as for working as an ESP specifically would present several challenges.
    1 Osteopaths (and please excuse generalisations) tend to work alone and have their own examination process – so some re training would be required, and some would need to shift to thinking more medically(?)
    2 Osteopaths along with a number of professions such as chiropractic do often come up with a diagnosis which isn’t necessarily medical/reproducible and not exactly the same as another osteopath might come up with – i.e. we don’t diagnose appendix problem we might diagnose a right sacro iliac – but another practitioner may say L5. This needs to change anyway but possibly teaching needs to change to reflect this – if we are working as an ESP diagnosis would have to be standardised.
    3 – as far as I can tell (and a previous contributor alluded to this) the NHS is worried about numbers and cost effectiveness rather than patient satisfaction and outcomes – Osteopaths would have to make a shift in thinking to be able to say this is the problem and go and spend sometime in the group physio sessions rather than have hands on with us? this could produce conflict as often the cheaper numbers approach may not be the best outcome long term for the patient?
    4 – the challenge is do the NHS want more ESP physio’s or physio – lite or will they accept us as ESP Osteos who bring our own skills and unique approach?
    5 – NHS wants evidence based medicine – rightly so, does Osteopathy have enough to be included in the NHS as a fully fledged profession? NICE guidelines include it at present for neck and back pain but will that still be there when they are revised and will this limit Osteos to neck and backs only?
    6 – having worked in a multidisciplinary team previously with everyone from dentists to physios it worked really well when the team was supportive of each others skills – but when certain people have ego issues – i.e. one profession looked down on another this fell down, more of a personality issue but training of doctors and physios not used to working with Osteos may be of benefit as otherwise their only experience of osteo maybe negative as this may be via the patients who have come from private Osteopathy to the NHS and by the fact they are presenting to the NHS didn’t get help.

  7. Although ESP may be best considered practice, its not universally common practice. Although the clinical role may be predetermined for a particular provider service its not a standardised role across all varied service providers. If MSK examination procedures are being delivered in a rote standardised format it sounds as if an ESP is wasted because routine examinations should be the work of a band 5 or 6 qualified Physiotherapist. Reading this I fear I have a very different view of the role of an NHS MSK ESP Physiotherapist. To me this role is first contact, having specialist training in diagnostics, capable of carrying out ultrasound scanning, refer for NHS ct/ mri scans, x-rays. In terms of clinical I would expect them to be certified as a prescriber, to be able to make the diagnostics, to carry out injections in clinic. Perhaps an Osteopath may provide some clinician input / manual therapy for neck & back treatment if NICE still recommends, but not across the spectrum of MSK work. This is a case of drawing a line, to support ESP Physiotherapists as we push toward the goal of the profession in primary care

  8. As a chiropractor currently working as a NHS Spinal ESP I can confirm it it is possible and many of the skills needed are already present in chiropractic and osteopathy. There are cultural barriers in language and NHS systems but nothing unsurmountable
    There is an appetite in these professions for more ‘joined up’ working but unclear directions on how to proceed. I feel the successful delivery of many AQP contracts shows that this is possible. Where it has been tried few significant barriers are reported from pulling closer together to patients benefits.

  9. Thank you for all your comments – I’m a little in awe of the response, actually (I’m relatively new to social media and blogs). I will try and answer some of the points raised, both privately and as comments in due course but I feel that I should restate the fact that the purpose of canvassing opinion is not directly related to osteopathy or osteopaths but more about the role of ESPs in general.
    Most ESPs are physios.
    Is that correct?
    Are physios the only clinicians capable of filling ESP roles?
    Could, for example, a podiatrist work alongside an ESP physio (as an ESP) in a lower limb ICATs?
    Naturally, I have my own opinions on this but I’m trying to establish (in a very unorthodox/social media-led way) whether there is an appetite for collaborative working. (My opinion is that I have a rich and varied working life as an ESP alongside trusted physic ESPs, podiatrists, OTs, GPwSIs, and consultant physicians but our team is somewhat unique).
    This is really interesting (for me, at least) and I would really appreciate the word spreading – the richer the debate, the better care MSK patients will receive.

  10. Any healthcare professional (whether physio, osteo, pod etc) has the potential to carry out an ESP role in their area of expertise, provided they share the ethos of what an ESP’s role and remain clincially objective. My feeling is that there is a need for more a clearly defined framework of competencies and ‘desirables’ in order to best structure training for new ESPs, which may differ depending on original training. As most would-be ESPs will be well qualified, up to date clinicians with wide and varied experiences (inter and intra professional) the detail help determine more specific training needs.

  11. This topic is interesting, being an Extended Scope Practioner (ESP) is as it says on the tin, being able to work beyond the the scope of your normal practice. Therefore it is not necessary to be a physiotherapist, it is necessary to be an health care professional who has been trained up to be competent to work beyond your normal scope of your health care professional training. I think there are so many physiotherapists doing it because it is an NHS funded role on the most part and a very large proportion of physiotherapists work in the NHS. The bigger issue is regarding competency, where the role needs close management, as there needs to be a set standard of qualification of a competency sign off expert in order to ensure a standard quality necessary to be an ESP. Otherwise the ESP role is just become diluted and lose its standing as a health care professional with extra “expert” knowledge and training.

  12. I did not know what an ESP was nor what their abilites were until I was trained as a clinical MSK triager a few years ago. I am a GP and therefore a service user and have found working alongside various ESPs incredibly useful in improving my knowledge and therefore managing my own patients more comrehensively in General Practice. I can confidently tell my patient that the ESP who sees them will be able to assess them holistically. They will request and interpret diagnostics when required and be able to give the patient a comprehensive management plan. Referrals owards for Orthopaedic input will also be made without me having to do it, which is great.

  13. I would echo Adam’s points and agree that the ESP title should be available to any clinician irrespective of background as long as they have the right skill set and meet the competencies.
    I think mutlidisciplinary working should be encouraged as every clinician will have a different perspective.
    I have always found the ESP title confusing and i think it is for patients.
    Surely it would be better to use ‘musculoskeletal (insert you preferred body part here) specialist/practitioner’.

    Your question around effectiveness and efficiency is a difficult one. How would this be assessed?

  14. I think that osteopaths could certainly work as extended scope practitioners in theory. With respect to additional training, the following skills might be advantageous:
    Advanced decision making and differential diagnosis
    Triage training
    Image recognition
    Upper or lower quadrant training

  15. The creation of the ESP role was due to the fact that the musculoskeletal training for Doctors was, and still is I believe, very poor and physiotherapy or orthopaedic departments were being completely overwhelmed with referrals. An intermediary triage system was created in response to this and partly because of the lack of available medical practitioners with the requisite skills and secondarily for financial reasons training up non-medical practitioners (originally physiotherapists) seemed like a good idea. Since then the concept has developed to ensure adequate training competencies etc. Partly because of the success of this development primary care seems to be even more inclined not to get involved with the management of MSK patients especially when the referrer is a primary care assistant (advanced nurse practitioners etc.) who, with the greatest respect, would not recognise a wrist drop even if it slapped them in the face. This effect is increased when there is a ‘package’ contract with the provider with no limit on the patients referred into the system. The overall result is paradoxically delayed treatment, extra hassle for the patient and greater expense. Surely now that the ESP role has been created it should be placed in the primary care environment with practitioners who have both the skill to both manage and treat patients themselves expediently?

  16. ‘Clinical musculoskeletal teams in the UK have moved away from the familiar physician-led model and the use of extended scope practitioners is now widely accepted as best practice’

    Really? So it’s widely accepted that it’s best practice not to have physicians involved?

    With all due respect I disagree, and also with the surprise you feel that perhaps other professionals can’t become ESP’s – is there a special physiotherapist gene that allows you to become super specialised in a topic?

    Podiatrists in particular have been in MDT MSK services since 2005 at least, learning injection techniques, ordering XR and scans and liaising with medical colleagues.

    I would be interested to know how a Chiropracter and Osteopath become an ESP. For an ESP physio there is surely a minimum amount of clinical experience, and qualifications? Do you need a chiropractic MSc to be an ESP Chiropracter?

    Finally, my experience of working in an MDT with a physician, excellent (in the main) physio’s and podiatrists is that allied professionals often need the support of a physician, whether it be complex case management, diagnostics, standing up to orthopaedic colleagues, and particularly in learning not to investigate the crap out of everything.

    An MDT works best with a reasonably wide skill mix, mutual respect and a drive to improve the care we offer to patients – but we knew that already didn’t we?

  17. Good summary by Nick Straiton on March 3, 2016. Sounds very familiar to my experience.
    Scary having tried this NHS package but it is certainly time for review. Manager’s ideas of economy do not necessarily equate service efficiency, patient efficacy or eventual national savings.
    Diagnosis is a minefield. A medico legal case may have had a dozen opinions from different sorts of practitioner offering differing labels and offering different treatments. This is like a Tower of Babel even if the advisors were very nice and polite. Researchers may gain from considering all these differing perspectives. The service however needs rigourous appraisal and continuing improvement.

  18. Interesting comment from Anonymous on 3rd March.
    From what I’ve read here, no-one is suggesting that physician’s are side-lined. This is certainly not suggested at all in the MSK Framework, anyway.
    In my department, ESPs do the role of the old fashioned surgical reg – triage, initial hx, ax in the outpatient dept and the request and management of imaging. They are well trained and a phenomenal safe pair of hands. They know their limitations and, more importantly, do not view themselves as ‘mini’ doctors and know when to ask for an opinion regarding a pt that is more medical. TBH, they are also a fantastic font of knowledge from our point of view too – I get an expert physio opinion when I need one too.
    I know nothing about osteopaths, chiropractors or podiatrists but from where they came is not an issue in this case – it’s more about the quality of their ESP training and the governance that is in place.
    From a management point of view they are also good value for money – give me an 8a/b at the top of their game any day.

  19. Jonathan as to your question whether a non physiotherapist professional can work as an ESP. As an Occupational Therapist, yes we can do ESP work. However I think depends on the level of expertise and experience and training. I have done ESP work for the last 5 years. I think as long as one has adequate training, prefereably at masteres level and beyond and continue with developing their clinical skills by constant updating and challenging themselves to learn and broaden their knowledge I think there is room for other Allied health professional to do ESP work. ESP work at times can be challenging and I think one need to know their limitations and perhaps from time to time need to ask for help. I always think that from time to time we ought to work along side consultant colleagues as we can challenge our assessment skills, diagnostics and treatment managment.

  20. Lower limb ESP roles for Podiatrists are nothing new. There are many employed across the country in MSK (CATS) services. They offer a valuable contribution and are often effective in dealing with multiple joint pains due to their expertise in lower limb assessment, function and gait analysis.
    These roles are often 8a/b with MSc education and competency in MSK imaging and injection therapy. Foot and ankle pains are more common than hip pain and often debilitating. I welcome the opportunity for more of these roles to complement the wider medical teams: Orthopaedics, GPwSpIs, MSK physicians or Rheumatologists.

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