2. Memorandum from Arthritis and Musculoskeletal
Alliance (ARMA)
The Arthritis and Musculoskeletal Alliance (ARMA)—the
umbrella organisation for the musculoskeletal community—welcomes
the Public Accounts Committee's investigation into services for
people with rheumatoid arthritis (RA).
The National Audit Office (NAO) report highlights
a number of limitations in current services for people with RA
and identifies range of improvements that could be implemented
to improve both the efficacy and cost effectiveness of care for
people with RA. These include complex solutions aimed at better
delivery of care in appropriate settings (eg in primary care where
possible and secondary care where necessary), and better integration
of health and social care services
These limitations in the planning and delivery
of RA services are not however peculiar to RA alone and ARMA,
along with its 34 member organisations believes that the inefficiencies
uncovered by the NAO are representative of musculoskeletal services
as a whole. We contend that the current situation is the consequence
of a lack of direction and a poor prioritisation of musculoskeletal
conditions at the national level. We believe that the Department
of Health could readily address this lack of national direction
and ensure that all musculoskeletal services, including those
for people with RA, are organised more effectively and efficiently
for the benefit of patients.
ARMA has uncovered a large body of evidence
to suggest that musculoskeletal conditions are being delivered
without effective planning. Earlier in 2009, for example, ARMA
audited every single Primary Care Trust (PCT) in England to ascertain
its progress in implementing the Department of Health's musculoskeletal
services framework (MSF) of July 2006. The complete findings of
our audit are contained in our report, Joint working[17].
Key findings from the audit include:
1. More than one in five (21%) PCTs do not operate
a Clinical Assessment and Treatment Service (CATS) for musculoskeletal
conditions, despite this being described as the "keystone"'
of the Government's policy in this area. There is a huge degree
of confusion within the NHS over the best location, purpose and
staffing arrangements of CATS.
2. Only 16% of responding PCTs had mapped their
current resources and their use by people with musculoskeletal
conditions.
3. Patients are still experiencing delays in
obtaining an accurate diagnosis of a long-term musculoskeletal
condition. One cause of this—a lack of awareness amongst
GPs—is being exacerbated because less than half (43%) of
PCTs offer education to GPs on how to manage patients with inflammatory
arthritis.
4. 40% of PCTs do not work with voluntary and
community organisations expert in the delivery of care to patients
with musculoskeletal conditions.
5. Over half (57%) of PCTs have not made links
with their local Pathways to Work scheme.
6. A review of the provision of NHS and social
care rehabilitation services initiated by the Department of Health
in 2006 is yet to be completed.
7. 60% of PCTs have not audited the outcomes
of patients with musculoskeletal conditions. Of those that had,
a variety of outcome indicators are used. The lack of nationally
validated outcome measures is cited by a number of PCTs as a reason
for not doing so.
ARMA has also uncovered evidence of widespread
variations in the amount of funding provided to each person with
a musculoskeletal condition, ranging from £204 per patient
in Camden PCT to £632 per patient in Gateshead PCT. This
analysis is at Annex.
In order to address the varied implementation
of the Musculoskeletal Services Framework and the unjustifiable
variations in spending between different PCT areas, ARMA is calling
on the Government to appoint a National Clinical Director for
Musculoskeletal services. More than 10 million people in the UK
are living with musculoskeletal disorders and more than 10.8 million
working days are lost as a direct consequence of these conditions.
With an ageing population and increasing levels of obesity these
figures will continue to rise. The appointment of a National Clinical
Director would provide for the first time, clear leadership for
musculoskeletal services, a line of communication between the
musculoskeletal community and government and a mechanism for developing
a coherent strategy to maintain the musculoskeletal health of
the UK population as effectively and efficiently as possible.
We would be happy to discuss our work further
with you if this would be of assistance.
Annex
ANALYSIS OF MUSCULOSKELETAL PROGRAMME EXPENDITURE
1. BACKGROUND
The Department of Health published its programme
budgeting data—which lists the expenditure on a range of
different programme areas, including "problems of the musculoskeletal
system"—on 16 July 2009.[18]
2. ANALYSIS
— To assist policymakers in understanding
how this expenditure breaks down at the Primary Care Trust (PCT)
level, ARMA conducted an analysis of programme budgeting data
to ascertain the average spend on a person living with a musculoskeletal
condition in each area of the country, shown in the table below.
— The methodology used in the analysis
is set out beneath the table.
— As the table shows, there is a huge variation
in spending on musculoskeletal services: in 2007-08 for example,
this stretched from £204 per patient per year in Camden
PCT to £632 in Gateshead PCT.
PRIMARY CARE TRUST
| Total
number
of children
(A)
| Total
number
of
adults
(B)
| Estimated
number of
children with
musculoskeletal
conditions (C)
| Estimated
number of
adults with
musculoskeletal
conditions (D)
| Expenditure on
musculoskeletal
conditions in
2007-08 (£000s)
(E)
| Estimated
expenditure on
musculoskeletal
conditions per
person with a
musculoskeletal
condition in
2007-08 (F)
|
Camden PCT | 44,410 |
188,066 | 43 | 47,017
| £9,596 | £204 |
| Bexley Care Trust | 54,012 |
156,834 | 53 | 39,208
| £8,268 | £211 |
| Ealing PCT | 75,638 | 244,609
| 74 | 61,152 | £14,614
| £239 |
| Hammersmith and Fulham PCT | 34,004
| 135,992 | 33 | 33,998
| £8,409 | £247 |
| Westminster PCT | 39,522 |
194,978 | 39 | 48,745
| £12,072 | £247 |
| Hounslow PCT | 54,036 | 166,803
| 53 | 41,701 | £10,367
| £248 |
| Luton PCT | 51,588 | 133,456
| 50 | 33,364 | £8,311
| £249 |
| Brent Teaching PCT | 65,457 |
214,374 | 64 | 53,593
| £13,354 | £249 |
| Richmond and Twickenham PCT | 40,899
| 132,068 | 40 | 33,017
| £8,385 | £254 |
| City and Hackney Teaching PCT | 58,525
| 161,954 | 57 | 40,488
| £10,523 | £260 |
| Wandsworth PCT | 52,942 | 227,203
| 52 | 56,801 | £14,873
| £262 |
| Kensington and Chelsea PCT | 36,141
| 154,373 | 35 | 38,593
| £10,187 | £264 |
| South West Essex PCT | 101,940
| 295,424 | 99 | 73,856
| £19,575 | £265 |
| Redbridge PCT | 64,247 | 175,730
| 63 | 43,933 | £11,764
| £267 |
| Barking and Dagenham PCT | 49,017
| 116,207 | 48 | 29,052
| £7,867 | £270 |
| South East Essex PCT | 79,381
| 253,967 | 77 | 63,492
| £17,948 | £282 |
| Mid Essex PCT | 87,171 | 269,110
| 85 | 67,278 | £19,364
| £287 |
| Solihull Care Trust | 51,871 |
154,681 | 51 | 38,670
| £11,131 | £287 |
| Islington PCT | 38,148 | 149,127
| 37 | 37,282 | £11,079
| £297 |
| Bradford and Airedale PCT | 140,136
| 357,499 | 137 | 89,375
| £26,670 | £298 |
| Bedfordshire PCT | 103,260 |
308,456 | 101 | 77,114
| £23,096 | £299 |
| Wakefield District PCT | 80,666
| 252,520 | 79 | 63,130
| £19,045 | £301 |
| Leicester City PCT | 81,833 |
226,866 | 80 | 56,716
| £17,147 | £302 |
| West Hertfordshire PCT | 135,910
| 400,480 | 132 | 100,120
| £30,332 | £303 |
| Blackpool PCT | 33,081 | 107,023
| 32 | 26,756 | £8,173
| £305 |
| Suffolk PCT | 135,856 | 452,116
| 132 | 113,029 | £34,858
| £308 |
| Kirklees PCT | 102,684 | 289,285
| 100 | 72,321 | £22,372
| £309 |
| Berkshire East PCT | 101,012 |
283,213 | 98 | 70,803
| £22,056 | £311 |
| Leeds PCT | 179,500 | 587,581
| 175 | 146,895 | £45,813
| £312 |
| Calderdale PCT | 50,651 | 149,770
| 49 | 37,443 | £11,877
| £317 |
| Portsmouth City Teaching PCT | 46,485
| 153,037 | 45 | 38,259
| £12,231 | £319 |
| Telford and Wrekin PCT | 42,760
| 118,150 | 42 | 29,537
| £9,516 | £322 |
| Southwark PCT | 57,921 | 200,324
| 56 | 50,081 | £16,413
| £327 |
| Croydon PCT | 87,459 | 247,683
| 85 | 61,921 | £20,313
| £328 |
| Kingston PCT | 40,098 | 131,915
| 39 | 32,979 | £10,842
| £328 |
| East and North Hertfordshire PCT | 137,526
| 412,267 | 134 | 103,067
| £34,163 | £331 |
| East Riding Of Yorkshire PCT | 68,583
| 235,713 | 67 | 58,928
| £19,703 | £334 |
| Cambridgeshire PCT | 136,171 |
440,903 | 133 | 110,226
| £36,949 | £335 |
| Buckinghamshire PCT | 128,080
| 368,542 | 125 | 92,136
| £30,897 | £335 |
| Havering PCT | 57,703 | 179,509
| 56 | 44,877 | £15,276
| £340 |
| North Tyneside PCT | 46,617 |
157,468 | 45 | 39,367
| £13,504 | £343 |
| Hull PCT | 68,040 | 212,004
| 66 | 53,001 | £18,187
| £343 |
| Lambeth PCT | 62,453 | 227,294
| 61 | 56,823 | £19,502
| £343 |
| Doncaster PCT | 72,908 | 220,235
| 71 | 55,059 | £19,016
| £345 |
| Medway PCT | 69,943 | 195,264
| 68 | 48,816 | £16,975
| £347 |
| Manchester PCT | 117,442 |
368,069 | 114 | 92,017
| £32,085 | £348 |
| West Kent PCT | 167,408 | 494,842
| 163 | 123,711 | £43,203
| £349 |
| Liverpool PCT | 104,838 | 339,150
| 102 | 84,787 | £29,696
| £350 |
| North Lincolnshire PCT | 38,070
| 120,189 | 37 | 30,047
| £10,542 | £350 |
| County Durham PCT | 118,272 |
391,219 | 115 | 97,805
| £34,556 | £353 |
| Sheffield PCT | 124,779 | 409,472
| 122 | 102,368 | £36,525
| £356 |
| Darlington PCT | 24,101 | 74,102
| 23 | 18,526 | £6,631
| £357 |
| Greenwich Teaching PCT | 60,090
| 170,372 | 59 | 42,593
| £15,423 | £362 |
| Hampshire PCT | 302,211 | 933,699
| 294 | 233,425 | £85,266
| £365 |
| Enfield PCT | 70,511 | 197,358
| 69 | 49,340 | £18,076
| £366 |
| Derbyshire County PCT | 161,760
| 530,936 | 158 | 132,734
| £48,630 | £366 |
| Bristol PCT | 94,019 | 334,105
| 92 | 83,526 | £30,762
| £368 |
| Worcestershire PCT | 128,557 |
416,820 | 125 | 104,205
| £38,780 | £372 |
| Stoke On Trent PCT | 62,671 |
195,446 | 61 | 48,862
| £18,211 | £372 |
| Berkshire West PCT | 114,311 |
340,790 | 111 | 85,198
| £31,766 | £372 |
| South Staffordshire PCT | 140,521
| 442,536 | 137 | 110,634
| £41,309 | £373 |
| Torbay Care Trust | 30,433 |
108,688 | 30 | 27,172
| £10,211 | £375 |
| North Yorkshire and York PCT | 175,861
| 591,483 | 171 | 147,871
| £55,919 | £378 |
| West Essex PCT | 65,556 | 196,100
| 64 | 49,025 | £18,563
| £378 |
| North East Essex PCT | 71,601
| 246,371 | 70 | 61,593
| £23,355 | £379 |
| Sutton and Merton PCT | 89,103
| 288,551 | 87 | 72,138
| £27,511 | £381 |
| Great Yarmouth and Waveney PCT | 50,292
| 170,382 | 49 | 42,595
| £16,281 | £382 |
| Harrow PCT | 49,719 | 148,786
| 48 | 37,196 | £14,239
| £382 |
| Cornwall and Isles Of Scilly PCT | 117,731
| 408,211 | 115 | 102,053
| £39,395 | £386 |
| South Birmingham PCT | 84,749
| 262,265 | 83 | 65,566
| £25,331 | £386 |
| Rotherham PCT | 60,677 | 183,211
| 59 | 45,803 | £17,781
| £388 |
| Haringey Teaching PCT | 57,328
| 183,075 | 56 | 45,769
| £17,792 | £388 |
| Lewisham PCT | 62,026 | 195,393
| 60 | 48,848 | £18,996
| £388 |
| North East Lincolnshire Care Trust | 41,888
| 121,663 | 41 | 30,416
| £11,853 | £389 |
| Bromley PCT | 74,592 | 228,912
| 73 | 57,228 | £22,622
| £395 |
| Bournemouth and Poole PCT | 70,168
| 251,067 | 68 | 62,767
| £24,842 | £395 |
| Brighton and Hove City PCT | 55,069
| 204,031 | 54 | 51,008
| £20,263 | £397 |
| Tower Hamlets PCT | 54,244 |
160,279 | 53 | 40,070
| £16,073 | £401 |
| Nottingham City PCT | 71,815 |
233,419 | 70 | 58,355
| £23,709 | £406 |
| Isle of Wight NHS PCT | 30,339
| 107,646 | 30 | 26,911
| £10,947 | £406 |
| Northamptonshire PCT | 166,990
| 493,518 | 163 | 123,379
| £50,287 | £407 |
| Herefordshire PCT | 39,811 |
134,967 | 39 | 33,742
| £13,871 | £411 |
| North Staffordshire PCT | 45,661
| 158,440 | 44 | 39,610
| £16,342 | £412 |
| West Sussex PCT | 180,823 |
593,033 | 176 | 148,258
| £61,650 | £415 |
| Northumberland Care Trust | 69,707
| 241,567 | 68 | 60,392
| £25,165 | £416 |
| Wiltshire PCT | 111,322 | 323,599
| 108 | 80,900 | £33,732
| £416 |
| Bury PCT | 47,120 | 134,996
| 46 | 33,749 | £14,086
| £417 |
| Bassetlaw PCT | 25,325 | 81,269
| 25 | 20,317 | £8,517
| £419 |
| Warwickshire PCT | 122,285 |
393,872 | 119 | 98,468
| £41,377 | £420 |
| Barnet PCT | 82,990 | 248,481
| 81 | 62,120 | £26,126
| £420 |
| South Gloucestershire PCT | 60,075
| 182,100 | 59 | 45,525
| £19,257 | £422 |
| Leicestershire County and Rutland PCT | 155,950
| 489,329 | 152 | 122,332
| £51,892 | £424 |
| Gloucestershire PCT | 138,784
| 440,314 | 135 | 110,079
| £47,058 | £427 |
| East Lancashire PCT | 98,287 |
275,232 | 96 | 68,808
| £29,537 | £429 |
| Sandwell PCT | 77,826 | 223,571
| 76 | 55,893 | £24,054
| £430 |
| Norfolk PCT | 155,748 | 567,890
| 152 | 141,972 | £61,094
| £430 |
| Coventry Teaching PCT | 81,824
| 240,947 | 80 | 60,237
| £25,972 | £431 |
| Peterborough PCT | 39,922 |
109,681 | 39 | 27,420
| £11,884 | £433 |
| Lincolnshire PCT | 161,373 |
537,262 | 157 | 134,316
| £58,350 | £434 |
| Warrington PCT | 47,953 | 144,825
| 47 | 36,206 | £15,740
| £434 |
| Dudley PCT | 72,860 | 228,437
| 71 | 57,109 | £24,837
| £434 |
| Oxfordshire PCT | 150,241 |
462,582 | 146 | 115,646
| £50,412 | £435 |
| Walsall Teaching PCT | 66,432
| 183,324 | 65 | 45,831
| £20,099 | £438 |
| Shropshire County PCT | 66,857
| 218,301 | 65 | 54,575
| £24,050 | £440 |
| Surrey PCT | 260,289 | 812,099
| 254 | 203,025 | £90,124
| £443 |
| Heywood, Middleton and Rochdale PCT | 55,164
| 148,799 | 54 | 37,200
| £16,539 | £444 |
| Waltham Forest PCT | 59,804 |
168,447 | 58 | 42,112
| £18,725 | £444 |
| Dorset PCT | 86,693 | 295,573
| 84 | 73,893 | £32,906
| £445 |
| Halton and St Helens PCT | 76,448
| 227,746 | 74 | 56,937
| £25,512 | £447 |
| Swindon PCT | 48,133 | 144,408
| 47 | 36,102 | £16,195
| £448 |
| Birmingham East and North PCT | 112,211
| 285,975 | 109 | 71,494
| £32,196 | £450 |
| South Tyneside PCT | 35,336 |
115,621 | 34 | 28,905
| £13,037 | £450 |
| Central and Eastern Cheshire PCT | 106,210
| 339,577 | 103 | 84,894
| £38,943 | £458 |
| Hillingdon PCT | 62,825 | 177,466
| 61 | 44,366 | £20,365
| £458 |
| Trafford PCT | 51,969 | 158,735
| 51 | 39,684 | £18,223
| £459 |
| Wolverhampton City PCT | 59,391
| 178,144 | 58 | 44,536
| £20,463 | £459 |
| Devon PCT | 161,852 | 570,349
| 158 | 142,587 | £66,378
| £465 |
| Newcastle PCT | 59,510 | 201,351
| 58 | 50,338 | £23,711
| £470 |
| Tameside and Glossop PCT | 57,270
| 167,989 | 56 | 41,997
| £19,835 | £472 |
| North Tees PCT | 47,695 | 140,827
| 46 | 35,207 | £16,689
| £473 |
| Stockport PCT | 68,393 | 213,095
| 67 | 53,274 | £25,502
| £478 |
| Middlesbrough PCT | 37,451 |
106,654 | 36 | 26,664
| £12,781 | £479 |
| Bolton PCT | 69,242 | 193,287
| 67 | 48,322 | £23,404
| £484 |
| Derby City PCT | 67,443 | 203,580
| 66 | 50,895 | £24,729
| £485 |
| Cumbria PCT | 113,340 | 388,763
| 110 | 97,191 | £48,141
| £495 |
| Sefton PCT | 64,598 | 206,041
| 63 | 51,510 | £25,640
| £497 |
| North Somerset PCT | 46,272 |
155,539 | 45 | 38,885
| £19,373 | £498 |
| Sunderland Teaching PCT | 64,335
| 209,655 | 63 | 52,414
| £26,183 | £499 |
| North Lancashire PCT | 72,655
| 253,686 | 71 | 63,421
| £31,912 | £503 |
| Eastern and Coastal Kent PCT | 176,343
| 539,556 | 172 | 134,889
| £68,302 | £506 |
| Blackburn with Darwen PCT | 45,260
| 105,927 | 44 | 26,482
| £13,512 | £509 |
| Hartlepool PCT | 23,477 | 67,655
| 23 | 16,914 | £8,662
| £511 |
| Western Cheshire PCT | 56,978
| 188,711 | 56 | 47,178
| £24,205 | £512 |
| Nottinghamshire County PCT | 149,704
| 489,231 | 146 | 122,308
| £62,796 | £513 |
| East Sussex Downs and Weald PCT | 74,852
| 251,880 | 73 | 62,970
| £32,783 | £520 |
| Newham PCT | 74,790 | 179,714
| 73 | 44,928 | £23,604
| £525 |
| Knowsley PCT | 39,563 | 110,723
| 39 | 27,681 | £14,653
| £529 |
| Central Lancashire PCT | 107,119
| 331,592 | 104 | 82,898
| £43,959 | £530 |
| Heart of Birmingham Teaching PCT | 90,215
| 191,941 | 88 | 47,985
| £25,502 | £530 |
| Salford PCT | 53,799 | 169,062
| 52 | 42,266 | £22,473
| £531 |
| Redcar and Cleveland PCT | 32,324
| 100,489 | 31 | 25,122
| £13,359 | £531 |
| Milton Keynes PCT | 62,036 |
170,412 | 60 | 42,603
| £23,346 | £547 |
| Hastings and Rother PCT | 39,076
| 132,322 | 38 | 33,081
| £18,137 | £548 |
| Bath and North East Somerset PCT | 42,632
| 143,386 | 42 | 35,847
| £19,883 | £554 |
| Plymouth Teaching PCT | 59,905
| 190,392 | 58 | 47,598
| £26,830 | £563 |
| Barnsley PCT | 56,325 | 175,226
| 55 | 43,806 | £24,698
| £563 |
| Ashton, Leigh and Wigan PCT | 73,290
| 228,306 | 71 | 57,076
| £32,870 | £575 |
| Southampton City PCT | 54,733
| 190,878 | 53 | 47,720
| £27,679 | £579 |
| Somerset PCT | 122,782 | 390,326
| 120 | 97,582 | £56,685
| £580 |
| Wirral PCT | 76,537 | 233,284
| 75 | 58,321 | £34,407
| £589 |
| Oldham PCT | 61,936 | 160,426
| 60 | 40,107 | £23,714
| £590 |
| Gateshead PCT | 45,005 | 149,038
| 44 | 37,260 | £23,570
| £632 |
| |
| | | |
|
3. METHODOLOGY
The table above was calculated, as follows:
— Columns (A) and (B) are taken from the Department
of Health's estimates of the child and adult populations in each
Primary Care Trust area (children are defined as males and females
aged 0-19, and adults are defined as males and females aged 20+).[19]
— The estimate of the number of children with musculoskeletal
conditions (column C) is derived from:
— The Department of Health estimates that 12,000 children
in England live with a musculoskeletal condition.[20]
— Given that there are 12,318,410 children in England
(NHS Information Centre, Attribution dataset GP registered
populations 2008, 30 January 2009) this suggests that
0.097% of children in each Primary Care Trust on average live
with a musculoskeletal condition.
— Each value for the number of children in a Primary
Care Trust area is multiplied through by 0.00097 to obtain
the estimated number of children in each Primary Care Trust area
living with a musculoskeletal condition (column C).
— The estimate of the number of adults with musculoskeletal
conditions (column D) is derived from:
— The Department of Health estimates that one in four
adults in England live with a musculoskeletal condition.[21]
— Each value for the number of adults in a Primary Care
Trust area is therefore multiplied through by 0.25 to obtain
the estimated number of adults in each Primary Care Trust area
living with a musculoskeletal condition (column D).
— Expenditure on musculoskeletal conditions in 2007-08 (the
latest year for which figures are available) (column E) is taken
from the Department of Health's National Programme Budgeting Project.[22]
— The estimated expenditure on musculoskeletal conditions
per person with musculoskeletal conditions (column F) is calculated
by dividing the overall spend on musculoskeletal conditions (column
E) by the estimated total number of adults and children living
with musculoskeletal conditions (columns C and D respectively)
November 2009
17
http://arma.uk.net/pdfs/MSF%20Review_FINAL1.pdf Back
18
Department of Health, Programme budgeting data, 16 July
2009; available here: http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudgeting/DH_075743?IdcService=GET_FILE&dID=200999&Rendition=Web Back
19
NHS Information Centre, Attribution dataset GP registered populations
2008, 30 January 2009; available here: http://www.ic.nhs.uk/webfiles/publications/gpregpopulations2005/GP%20Registered%20Populations%20-%202008.xls Back
20
Department of Health, A joint responsibility: doing things
differently, 12 July 2006; available here: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4138413?IdcService=GET_FILE&dID=11304&Rendition=Web) Back
21
Ibid. Back
22
Department of Health, Programme budgeting data, 16 July
2009; available here: http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudgeting/DH_075743?IdcService=GET_FILE&dID=200999&Rendition=Web Back
|
