Focus on Keele - Primary focus
Published on 01 January 2011
The very latest from our first centre of excellence – the Arthritis Research UK Primary Care Centre.
It’s a known fact that many people with common types of arthritis and musculoskeletal conditions such as osteoarthritis and back pain continue to receive a less than ideal service from their family doctor.
For every GP that offers patients physiotherapy, advice about weight loss, exercise, self-management and different types of pain relief, there are many more that send them away with variations on the following line: “It’s your age; you’ll have to learn to live with it; there’s nothing that can be done.”
This is something that the Arthritis Research UK Primary Care Centre at Keele University is on a mission to do something about.
Firstly, by training health professionals to deliver better care and treatment to patients; secondly, by trialing practical treatments that will help to improve their daily lives, and thirdly by trying to ensure that best practice happens in all GP surgeries across the land, not just in a few enlightened pockets.
"...trying to ensure that best practice happens in all GP surgeries across the land"
It’s this third aim that is the most difficult to achieve. However, the vital research needed to establish best practice being performed at Keele is providing the evidence base – the ammunition if you like – that will help Arthritis Research UK to campaign nationally and to press the government to give musculoskeletal conditions greater priority status in the NHS. (They currently barely register as a major health issue, despite the fact that one in five GP visits are due to musculoskeletal-related conditions.)
Since the primary care centre at Keele was awarded centre of excellence status by Arthritis Research UK two years ago, the research team has been making enormous strides, attracting several millions of pounds of further funding from the National Institute for Health Research (NIHR, the research arm of the NHS) and other big funders on the back of the £2.5m over five years from the charity. This has enabled new director Professor Elaine Hay and colleagues to embark on an ambitious range of research studies into osteoarthritis, back pain and other related conditions that will have a major impact on improving treatment.
Professor Hay, who was one of the founders of the primary care centre along with previous director Peter Croft, acknowledges that translating research evidence into practice is an area they are keen to develop.
“We’re moving more into this applied area,” she explains. “There are two translational gaps – getting the results of basic science into clinical trials, and getting the results of clinical trials into everyday practice. It’s that second part we want to motor on and address.
“As well as training allied health professionals (AHPs) such as physiotherapists and occupational therapists, we want to do more to influence policy in healthcare and GP commissioning, and our trials are helpful in providing the sort of evidence that will underpin that. We don’t want to just measure the clinical benefit of our research, but also the health economic benefit to the NHS and to wider society.”
Most of the clinical studies currently underway at Keele follow a pattern. Researchers identify a problem (with the input of their thriving patient user group), for example, osteoarthritis of the hand. They examine how it affects people, how common it is, and so on, and then develop a practical treatment or intervention that might help, which they then test as part of a rigorous randomised controlled trial, often involving patients from local GPs surgeries in North Staffordshire and Cheshire.
At the moment there are a number of such promising trials under way, and Arthritis Today will report fully on their results as they start coming through this year (2011).
The three year STarTBack trial, due to report in 2011, is expected to show that targeting people with back pain and giving them different types of treatment according to their particular needs rather than a “one-size fits all” approach may be the best way of dealing with the condition.
The new NIHR five-year spinal pain programme is developing this approach a stage further. Nadine Foster, Professor of Musculoskeletal Health in Primary Care, who is working on the programme, together with Professor Hay and Professor Danielle van der Windt (director of epidemiological studies), says: “Despite many hundreds of trials looking at different ways of treating back pain, treatments currently on offer very often make little difference.
“We hope that findings from our current and new programmes of research will change this situation, if we can show that selecting individuals for treatment which has been tailored to their particular needs and characteristics, and training practitioners to provide that treatment, reduces pain or improves the patients’ ability to cope with their pain and enables them to do more.”
One novel aspect of the programme is looking at the feasibility of a new post; a vocational adviser to work in two or three GP practices with people with back pain who may be struggling to cope at work, and by liaising with both the patient, the employer and the GP to find ways of keeping that person in employment before they drop out of the workplace.
“We have found that many doctors and physiotherapists have rather negative or unhelpful ideas about back pain, and its treatment, and we found that they tend not to recommend exercise and a return to normal work and activities to their patients, even when they are presented with patients in whom it would be clearly beneficial to stay active,” adds Professor van der Windt. “The challenge is to find ways of intervening early – before patients become established on long-term sickness benefit.”
Several further programmes of work, funded by Arthritis Research UK and the NIHR, are underway. Dr George Peat, senior lecturer in clinical epidemiology, is building up a picture of the different types of osteoarthritis of the knee, hand and foot, with clinical trials to improve treatment in the pipeline. Rheumatologist Dr Ed Roddy is looking at the clinical and cost effectiveness of interface clinics set up in some areas, in response to Department of Health recommendations, to treat common musculoskeletal conditions. These multi-disciplinary clinical assessment and treatment centres are staffed by specialist GPs, rheumatologists and extended scope physiotherapists, and early findings from Dr Roddy’s research highlight how common anxiety, depression and work loss are in patients attending these clinics. Other clinical trials are looking at the long-term effectiveness of exercise regimes, delivered by physiotherapists, and whether specific exercise, provided by occupational therapists, relieves pain in osteoarthritis of the hand.
The NIHR osteoarthritis programme is aiming to improve the way that osteoarthritis patients are treated in general practice in a number of ways.
“We have identified that osteoarthritis is poorly identified in primary care and as a result, core treatments which can have a positive impact on pain and function are often not initiated,” says Dr Christian Mallen, a part-time GP and Arthritis Research UK primary care fellow. “There are lots of things that we know work in osteoarthritis – exercise, aids and equipment, pain relief, weight loss, exercise – the difficulty is to get people to use them and keep using them. We need to get these things ingrained into people’s lifestyles, so that their pain doesn’t stop them doing things. Often people are given advice at the beginning but it’s not re-iterated later on.”
As a result, in collaboration with Dr Mark Porcheret, a GP and the Royal College of GPs’ “osteoarthritis champion” the team is developing a “model consultation” based on NICE guidelines. The model consultation on osteoarthritis between a GP and his or her patient doesn’t involve being told to go away and get on with it, but involves practical information that has been tailored for this patient group, looking at pain relief and medication, giving positive messages about an osteoarthritis diagnosis that something can be done and signposting them to the next step – visiting the practice nurses. The Keele team, led by Krysia Dziedzic, Arthritis Research UK Professor of Musculoskeletal Therapies, is now developing a training package for practice nurses, whom they believe could play a much bigger role in treating arthritis patients, not least because they are very experienced members of the primary care team, but also because they have half an hour consultations, rather than the two-minutes GPs have time for.
"The Keele team is now developing a training package for practice nurses, whom they believe could play a much bigger role in treating arthritis patients"
To back up the model consultation, the team is also working on an osteoarthritis guidebook aimed at patients, developed with health service users, to guide people in their self-management, which is currently being evaluated. More details will follow in future editions of Arthritis Today.
Professor Dziedzic is determined that all this good work in establishing best practice will have a significant impact on the lives of all patients in the country, not just the lucky few who happen to live in North Staffordshire. “I have been working in research for 20 years, and I don’t want to work for another 20 years if none of my work has any impact on practice,” she says. “We’re all dedicated to making that happen.” Watch this space.