Chamber and committees

We believe that the arrangements currently in place make the establishment of such a committee unnecessary.

The Scottish Government Health Directorates are in the process of developing a National Musculoskeletal Programme with the aim of significant service re-design to improve the delivery of services for people with musculoskeletal conditions. Funding has been provided through the Delivery Framework for Adult Rehabilitation for a national lead to support the rollout of this model. In addition a national programme board, chaired by an NHS board chief executive, is being established to ensure implementation.

NHS QIS has appointed a national falls programme manager to establish a network of local falls co-ordinators to share experiences and provide good practice arrangements for assisting people who are uninjured after a fall. The manager''s role involves working closely with the Scottish Government''s Rehabilitation Lead to ensure that the falls project is integrated with other initiatives.

Our Lead Clinician for Chronic Pain has also established a Scottish Chronic Pain Steering Group (SCPSG) to help take forward the recommendations of the NHS Quality Improvement Scotland (QIS) report Getting to GRIPS (Getting Relevant Information on Pain Services) with Chronic Pain in Scotland published in July 2008. That work is focusing on a service model which integrates chronic pain and musculoskeletal services. It also links to the demonstrator chronic pain Managed Clinical Network which we are funding in NHS Greater Glasgow and Clyde.

The Delivery Framework for Adult Rehabilitation in Scotland published in February 2007 focuses on making services local and offering a seamless patient journey that respects people''s potential to overcome barriers to independent living and links strongly with the Scottish Government''s Healthier and Wealthier Strategic

Objectives.

We have recognised the need to re-design many of our rehabilitation services to develop capacity in Primary Care. This includes the appointment of rehabilitation co-ordinators in each NHS board area who have mapped existing services including musculoskeletal (MSK) services and are working to enhance rehabilitation pathways across health and social care. A national pain programme is also underway which includes developing back pain pathways which will ensure timeous and equitable access to pain management advice.

The Scottish Government has a national MSK programme as a collaborative across hospital and primary care services to implement a new MSK model through service redesign. This model focuses on screening and early access to assessment and treatment by a primary care based specialist practitioner as part of a multi-disciplinary team including podiatrists, physiotherapists and nurses. This model has been well tested, evaluated and includes aspects to enhance workforce capacity and productivity.

Information on the exact number of people who have been diagnosed with one of these conditions in Scotland is not available centrally, but national estimates can be given of the number of patients consulting a GP or practice-employed nurse for these conditions, based on information obtained from a sample of Scottish general practices participating in PTI (Practice Team Information). This sample covers the full range of age, sex, and deprivation classes existing in Scotland. The numbers in the PTI sample are too small to provide reliable estimates for haemoglobinopathies. It is also not usually possible for clinical coding to identify reliably those conditions that result from severe trauma, since the condition may be recorded but not its cause. The PTI sample is only representative at national level, so estimates at NHS board-level cannot be provided.

The estimated numbers of people in Scotland consulting a member of the practice team for osteoarthritis and related disorders, osteoporosis and associated fragility fractures, rheumatoid arthritis and related chronic inflammatory diseases, other autoimmune rheumatic diseases and chronic pain syndromes, in the year ending  31 March 2009, are shown in the following tables.

The figures are likely to considerably underestimate the true occurrence of these conditions as patients may be treated in a range of healthcare settings, or indeed patients who do not consult their GP practice in the given year would not be included in these estimates. The Scottish Government is aware that the Arthritis and Musculoskeletal Alliance estimates that, at any one time, there are over 9.6 million people in the UK living with some form of musculoskeletal condition.

Table 1: Patients in Scotland consulting a GP or practice-employed nurse for osteoarthritis and related disorders: Estimated numbers with corresponding rates per 1,000 population: By gender and age group; financial year 2008-09:

Gender	Age Group	Patients Consulting per 1,000 Registered		Estimated Number of Patients
		Rate	Confidence Interval*	Number	Confidence Interval*
Males	34 years and under	0.2	(0.0-0.3)	182	(0-407)
	35-44 years	1.8	(1.1-2.5)	779	(481-1,077)
	45-54 years	9.5	(6.9-12.2)	3,797	(2,738-4,856)
	55-64 years	31.3	(23.7-38.8)	10,224	(7,754-12,694)
	65-74 years	39.0	(33.4-44.6)	8,485	(7,260-9,710)
	75 years and over	60.4	(50.0-70.7)	8,897	(7,376-10,418)
	All ages	11.7	(10.1-13.2)	31,571	(27,471-35,671)
Females	34 years and under	0.1	(0.0-0.2)	135	(40-231)
	35-44 years	2.6	(2.0-3.3)	1,080	(823-1,336)
	45-54 years	14.6	(11.8-17.4)	5,679	(4,602-6,757)
	55-64 years	39.7	(34.1-45.3)	13,083	(11,233-14,933)
	65-74 years	54.6	(46.9-62.2)	13,693	(11,780-15,606)
	75 years and over	71.3	(60.2-82.5)	17,288	(14,590-19,987)
	All ages	18.4	(16.3-20.5)	50,658	(44,923-56,393)
Total		15.1	(13.5-16.7)	82,252	(73,511-90,993)

 

Table 2: Patients in Scotland consulting a GP or practice-employed nurse for osteoporosis and associated fragility fractures: Estimated numbers with corresponding rates per 1,000 population: By gender and age group; financial year 2008-09:

Gender	Age Group	Patients consulting per 1,000 registered		Estimated number of patients
		Rate	Confidence Interval*	Number	Confidence Interval*
Males	34 years and under	0.0	(0.0-0.1)	45	(12-78)
	35-44 years	0.2	(0.0-0.5)	107	(0-214)
	45-54 years	1.7	(0.0-4.0)	683	(0-1,610)
	55-64 years	1.5	(1.0-2.0)	487	(311-663)
	65-74 years	1.9	(1.1-2.8)	419	(231-607)
	75 years and over	7.1	(4.4-9.7)	1,040	(644-1,436)
	All ages	1.0	(0.6-1.4)	2,769	(1,688-3,849)
Females	34 years and under	0.2	(0.1-0.3)	266	(142-390)
	35-44 years	1.0	(0.6-1.3)	394	(246-541)
	45-54 years	2.6	(1.7-3.4)	997	(661-1,333)
	55-64 years	15.8	(9.3-22.3)	5,195	(3,053-7,337)
	65-74 years	29.1	(18.1-40.2)	7,312	(4,542-10,082)
	75 years and over	31.4	(22.9-39.8)	7,599	(5,544-9,653)
	All ages	7.8	(6.0-9.6)	21,453	(16,508-26,398)
Total		4.5	(3.4-5.5)	24,405	(18,699-30,111)

Note: Some of the estimates in the younger age categories are based on small numbers and should therefore be treated with extreme caution.

Table 3: Patients in Scotland consulting a GP or practice-employed nurse for rheumatoid arthritis and related chronic inflammatory diseases: Estimated numbers with corresponding rates per 1,000 population: By gender and age group; financial year 2008-09:

Gender	Age Group	Patients consulting per 1,000 registered		Estimated number of patients
		Rate	Confidence Interval*	Number	Confidence Interval*
Males	34 years and under	0.4	(0.1-0.6)	464	(166-763)
	35-44 years	1.3	(0.6-2.0)	546	(240-852)
	45-54 years	2.3	(1.6-3.1)	924	(628-1,221)
	55-64 years	4.3	(3.3-5.3)	1,407	(1,070-1,745)
	65-74 years	5.3	(3.4-7.1)	1,150	(747-1,553)
	75 years and over	6.0	(3.7-8.3)	882	(538-1,226)
	All ages	2.0	(1.6-2.4)	5,433	(4,277-6,590)
Females	34 years and under	0.6	(0.3-0.9)	680	(344-1,015)
	35-44 years	3.5	(1.8-5.2)	1,457	(760-2,154)
	45-54 years	5.1	(3.8-6.4)	1,977	(1,475-2,479)
	55-64 years	10.3	(8.4-12.3)	3,407	(2,754-4,059)
	65-74 years	12.3	(10.1-14.6)	3,097	(2,532-3,662)
	75 years and over	7.4	(5.8-9.1)	1,805	(1,403-2,207)
	All ages	4.4	(3.8-5.0)	12,172	(10,553-13,790)
Total		3.2	(2.8-3.7)	17,625	(15,316-19,933)

 

Table 4: Patients in Scotland consulting a GP or practice-employed nurse for other autoimmune rheumatic diseases: Estimated numbers with corresponding rates per 1,000 population: By gender and age group; financial year 2008-09:

Gender	Age Group	Patients Consulting per 1,000 Registered		Estimated Number of Patients
		Rate	Confidence Interval*	Number	Confidence Interval*
Males	34 years and under	0.0	(0.0-0.0)	10	(0-29)
	35-44 years	0.0	(0.0-0.0)	6	(0-21)
	45-54 years	0.1	(0.0-0.3)	41	(0-101)
	55-64 years	0.1	(0.0-0.2)	32	(0-71)
	65-74 years	0.1	(0.0-0.3)	19	(0-67)
	75 years and over	0.6	(0.0-2.3)	86	(0-340)
	All ages	0.1	(0.0-0.2)	285	(0-646)
Females	34 years and under	0.2	(0.1-0.3)	202	(95-309)
	35-44 years	0.4	(0.1-0.7)	167	(54-280)
	45-54 years	0.6	(0.3-0.8)	226	(127-325)
	55-64 years	0.8	(0.4-1.1)	257	(138-376)
	65-74 years	0.8	(0.0-1.9)	195	(0-481)
	75 years and over	0.1	(0.0-0.2)	34	(9-58)
	All ages	0.4	(0.2-0.6)	1,097	(675-1,518)
Total		0.3	(0.1-0.4)	1,371	(817-1,926)

Note: These estimates are based on relatively small numbers and should therefore be treated with extreme caution.

Table 5: Patients in Scotland consulting a GP or practice-employed nurse for chronic pain syndromes: Estimated numbers with corresponding rates per 1,000 population: By gender and age group; financial year 2008-09:

Gender	Age Group	Patients Consulting per 1,000 Registered		Estimated Number of Patients
		Rate	Confidence Interval*	Number	Confidence Interval*
Males	34 years and under	0.6	(0.4-0.9)	751	(490-1,012)
	35-44 years	3.2	(2.3-4.0)	1,381	(1,013-1,749)
	45-54 years	4.4	(3.1-5.6)	1,745	(1,245-2,244)
	55-64 years	5.5	(3.1-7.9)	1,796	(1,024-2,568)
	65-74 years	3.7	(2.4-5.0)	805	(514-1,097)
	75 years and over	4.1	(2.1-6.0)	601	(312-889)
	All ages	2.7	(2.0-3.3)	7,178	(5,320-9,036)
Females	34 years and under	1.8	(0.8-2.7)	1,975	(870-3,080)
	35-44 years	7.3	(5.6-8.9)	2,998	(2,318-3,678)
	45-54 years	10.0	(7.6-12.3)	3,877	(2,967-4,786)
	55-64 years	11.5	(7.7-15.2)	3,776	(2,528-5,023)
	65-74 years	5.3	(3.6-7.0)	1,337	(906-1,768)
	75 years and over	6.1	(3.6-8.7)	1,483	(869-2,098)
	All ages	5.8	(4.6-7.0)	15,945	(12,557-19,334)
Total		4.2	(3.4-5.1)	23,154	(18,419-27,889)

 

I refer the member to the answer to question S3W-32675 on 21 April 2010. All answers to written parliamentary questions are available on the Parliament''s website, the search facility for which can be found at http://www.scottish.parliament.uk/Apps2/Business/PQA/Default.aspx.

In December 2008, NHS Quality Improvement Scotland (NHS QIS) published its report on a clinical audit of care in rheumatoid arthritis (CARA), to help implement key SIGN guideline recommendations and identify any significant variations in the provision of care. The Scottish Society for Rheumatology''s web-based audit programme, supported by NHS QIS, is currently undertaking further work relating to newly diagnosed rheumatoid arthritis, with specific audit relating to the key recommendations from the CARA project.

We have highlighted to the Scottish Society for Rheumatology (SSR) the benefits of a Managed Clinical Network (MCN) for rheumatoid arthritis, as an MCN approach would help promote multi-disciplinary working and develop standards of care. MCNs require an evidence base, and SIGN Guideline 48 on rheumatoid arthritis provides this. They are also required to participate in audit, and CARA would satisfy this core principle. We have also highlighted the benefits of an MCN approach to the Arthritis and Musculoskeletal Alliance and the National Rheumatoid Arthritis Society, since the voluntary sector must be involved in all MCN developments.

In addition, we have indicated our support for the Scottish Society of Rheumatology''s wish to encourage greater involvement of primary care teams, in order to promote a multi-disciplinary approach to rheumatoid arthritis care, and a willingness to work with the Royal College of General Practitioners Scotland on the possibility of developing GPs with a special interest in rheumatoid arthritis.

We have drawn the recommendations of the NHS QIS osteoporosis audit (2005) to NHS boards'' attention to help ensure that people who have sustained a fracture receive appropriate therapies to prevent osteoporotic fractures in future.

HDL 2007 13 of 21 February 2007 expects NHS boards and community health partnerships (CHPs) to have a combined falls and bone health strategy in place. It was also issued to local authorities, as robust falls and fracture management and prevention strategies are imperative for residents in care homes, because of their high incidence of falls and fractures.

We are in the process of developing a National Falls Programme with the aim of significant service re-design to improve the delivery of falls services. The re-design focuses on how both access to services and assessment procedures can be managed by a multi-professional team working in a community setting. NHS QIS has appointed a national falls programme manager to establish a network of local falls co-ordinators to share experiences and provide good practice arrangements for assisting people who are uninjured after a fall.

An osteoporosis Directed Enhanced Service (DES) has been extended until  March 2011 to all Scottish GP practices to ensure eligible women who have had a fragility fracture are investigated for possible osteoporosis.

We have appointed rehabilitation co-ordinators in each NHS board area who are responsible for mapping existing local rehabilitation services in health and social care, re-designing services with the support of the National Implementation Group, integrating health and social care rehabilitation services and promoting case and care management approaches in rehabilitation and enablement teams. This critical overview of rehabilitation services will ensure that all rehabilitation teams develop services based on patients'' needs, rather than historical service delivery models.

Information on the number and percentage of hospital stays where a musculoskeletal condition or fracture diagnosis was recorded as a main diagnosis by NHS board of treatment for the latest available financial year is given in the following table.

Number of NHS Hospital Stays for which a Musculoskeletal Condition or Fracture Diagnosis is Recorded^{1, 2, 3, 4} by NHS Board, Financial Year Ending 31 March 2009

NHS Board of Treatment	Number of Hospital Stays with a Musculoskeletal or Fracture Main Diagnosis	Total Number of Hospital Stays	Percentage of Stays with a Musculoskeletal or Fracture Main Diagnosis (%)
Ayrshire and Arran	7,269	86,919	8.4
Borders	1,996	21,990	9.1
Dumfries and Galloway	2,479	31,305	7.9
Fife	5,727	59,711	9.6
Forth Valley	4,105	38,510	10.7
Grampian	10,753	104,704	10.3
Greater Glasgow and Clyde	29,334	345,236	8.5
Highland	5,468	60,694	9.0
Lanarkshire	8,259	117,831	7.0
Lothian	14,051	166,348	8.4
Orkney	336	4,582	7.3
Shetland	403	3,857	10.4
Tayside	9,130	84,031	10.9
Western Isles	367	6,167	6.0
Golden Jubilee	2,574	16,739	15.4
Total	102,251	1,148,624	8.9 =SUM(ABOVE)

Source: NHS National Services Scotland''s Information Services Division (ISD)

Notes:

1. These statistics are derived from data collected on discharges from non-obstetric and non-psychiatric hospitals (SMR01) in Scotland. Data are based on date of discharge.

2. The basic unit of analysis for these figures is a continuous stay in hospital. Probability matching methods have been used to link together individual SMR01 discharge episodes for each patient, thereby creating linked patient histories.

3. Up to six diagnoses (one principal and five secondary) are recorded on SMR01 returns. Only the main diagnosis position of the first episode of the hospital stay has been used to identify stays relating to musculoskeletal conditions or fractures.

4. The following International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes have been used to identify musculoskeletal conditions or fracture diagnoses:

M00-M25: Arthropathies.

M30-M36: Systemic connective tissue disorders.

M40-M54: Dorsopathies.

M60-M79: Soft tissue disorders.

M80-M94: Osteopathies and chondropathies.

M95-M99: Other disorders of the musculoskeletal system and connective tissue.

M00-M99: Diseases of the musculoskeletal system and connective tissue.

S02: Fracture of skull and facial bones.

S12: Fracture of neck.

S22: Fracture of rib(s), sternum and thoracic spine.

S32: Fracture of lumbar spine and pelvis.

S42: Fracture of shoulder and upper arm.

S52: Fracture of forearm.

S62: Fracture at wrist and hand level.

S72: Fracture of femur.

S82: Fracture of lower leg, including ankle.

S92: Fracture of foot, except ankle.

T02: Fractures involving multiple body regions.

T08: Fracture of spine, level unspecified.

T10: Fracture of upper limb, level unspecified.

T12: Fracture of lower limb, level unspecified.

T14.2: Fracture of unspecified body region.

I refer the member to the answers to questions S3W-32676 and S3W-32677 on 21 April 2010. All answers to written parliamentary questions are available on the Parliament''s website, the search facility for which can be found at http://www.scottish.parliament.uk/Apps2/Business/PQA/Default.aspx.

Funding has been provided through the Delivery Framework for Adult Rehabilitation for a national lead to support the roll out of the National Musculoskeletal Programme. It will look to develop integrated multi-disciplinary teams working within community settings, and onward referral mechanisms, in order to improve access to diagnosis and treatment, reduce waiting times, enable self management and, where appropriate, to facilitate early return to work and avoid long-term absence and long-term dependency on social security benefits. Pain management services are integrated in the programme.

The information requested is not held centrally. National estimates can however be given of the number of patients consulting a GP or practice-employed nurse for musculoskeletal conditions, based on information obtained from a sample of Scottish general practices participating in PTI (Practice Team Information). This sample covers the full range of age, sex, and deprivation classes in Scotland. The PTI sample is only representative at national level, so estimates at NHS board-level cannot be provided.

The estimated number of people consulting a member of the practice team for a musculoskeletal condition in Scotland, by gender and age group, in the year ending 31 March 2009, based on PTI data, is shown in the following table. Estimates are standardised by deprivation. As musculoskeletal conditions may be treated in a range of healthcare settings and indeed some patients may not report their symptoms at all (especially sprains, backache or cramps), the figures provided are likely to underestimate significantly the true incidence of musculoskeletal conditions in Scotland.

Patients in Scotland consulting a GP or practice-employed nurse for a musculoskeletal condition:

Estimated Numbers with Corresponding Rates per 1,000 Population by Gender and Age Group; Financial Year 2008-09

Gender	Age Group	Estimated Number of Patients		Patients Consulting per 1,000 Registered
		Number	Confidence Interval*	Rate	Confidence Interval*
Males	4 years and under	2,641	(2,164-3,118)	18.2	(14.9-21.4)
	5-14 years	15,296	(13,257-17,335)	51.3	(44.5-58.2)
	15-24 years	36,833	(32,489-41,176)	102.9	(90.8-115.0)
	25-34 years	54,232	(46,484-61,981)	142.7	(122.3-163.1)
	35-44 years	76,054	(69,424-82,685)	175.3	(160.0-190.6)
	45-54 years	83,760	(76,932-90,587)	209.7	(192.6-226.7)
	55-64 years	88,566	(83,062-94,070)	270.8	(254.0-287.6)
	65-74 years	59,156	(55,189-63,122)	272	(253.8-290.2)
	75 years and over	48,425	(45,189-51,661)	328.5	(306.5-350.4)
	All ages	466,622	(441,918-491,326)	172.4	(163.3-181.5)
Females	4 years and under	1,964	(1,428-2,501)	14.2	(10.3-18.1)
	5-14 years	16,059	(13,939-18,180)	56.5	(49.0-64.0)
	15-24 years	47,928	(43,205-52,651)	137.2	(123.7-150.7)
	25-34 years	62,092	(56,896-67,288)	174.6	(160.0-189.2)
	35-44 years	100,955	(93,575-108,335)	245.6	(227.7-263.6)
	45-54 years	109,419	(103,285-115,553)	281	(265.3-296.8)
	55-64 years	106,166	(100,608-111,724)	322.2	(305.3-339.1)
	65-74 years	91,772	(86,951-96,593)	365.7	(346.5-384.9)
	75 years and over	93,103	(86,739-99,467)	384.2	(357.9-410.5)
	All ages	632,491	(607,147-657,835)	229.9	(220.7-239.2)
Total		1,099,726	(1,052,213-1,147,239)	201.5	(192.8-210.2)

Source: NHS National Services Scotland''s Information Services Division (ISD).

Healthcare professionals in Scotland are expected to take account of the national clinical guidelines produced by the Scottish Intercollegiate Guidelines Network (SIGN) which contain recommendations for effective practice based on current evidence.

There are several key clinical guidelines relating to musculoskeletal conditions, including:

SIGN Guideline 111 on the management of hip fracture in older people, covering pre-hospital care, management in the emergency department, pre-operative and post-operative care, discharge planning and rehabilitation;

SIGN Guideline 71 on the management of osteoporosis, which aims to ensure the timely identification and treatment of people at highest risk of developing osteoporosis, as well as those who already have the disease, and

Revised SIGN Guideline 48 on the management of early rheumatoid arthritis, due to be published in summer 2010. The guideline addresses diagnosis and pharmacological treatment of rheumatoid arthritis, and the role of the multidisciplinary team in improving care.

In addition, the Scottish Government issued guidance as HDL(2007)13 on  21 February 2007 which expects NHS boards and community health partnerships (CHPs) to have in place a combined falls and bone health strategy. The HDL sets out specific actions for both NHS boards and CHPs to take forward work on falls and falls prevention.

The Scottish Government Health Directorates are in the process of developing a National Musculoskeletal (MSK) Programme with the aim of significant service re-design to improve the delivery of MSK and chronic pain services. The re-design focuses on how both access to services and assessment procedures can be managed by a multi-professional team working in a community setting.

Officials from Scottish Government Health Directorates are setting up a meeting with the National Rheumatoid Arthritis Society (NRAS) to consider how the new approach to the management of RA being piloted in the East of England Strategic Health Authority sits with the development of the National Musculoskeletal Programme.

We are also seeking to develop minimum datasets for use within community-based musculoskeletal rehabilitation in Scotland. A Consensus Development Conference is being held on 12 May to evaluate the available scientific and practice based information on the assessment of a range of musculoskeletal conditions encountered in a community based setting and develop an evidence-based consensus statement with recommendations for practice and future research to inform clinical standards, best practice statements and clinical guidelines.

In addition, the Scottish Public Health Network (SPHN) has included in its work plan for 2010-11 an update of the Scottish Needs Assessment Programme (SNAP) report on RA in adults, originally published in December 2002.

We have set milestone targets towards delivery of the 18 weeks referral to treatment time target. The current standards are 12 weeks for both a first outpatient consultation and for inpatient and day case treatment. The inpatient and day case treatment will reduce to nine weeks from the end of March 2011.

The Scottish Government are currently working with NHS boards on the development of integrated care pathways for musculoskeletal services and on re‘designing services to remove delays or blockages in the patients journey through hospital services. This will ensure that the most efficient and effective good practice is also spread across the whole of NHSScotland. For example the Golden Jubilee National Hospital has developed an enhanced recovery programme for orthopaedics which has resulted in the length of stay for patients being reduced from six days to  four days at the hospital.

The hospital is now helping lead the development of the enhanced recovery programme in hip and knee replacements across Scotland, working alongside all other boards. The sharing of such good practice will deliver equitable and high-quality driven care through services across Scotland.