Delivering practice led integrated care for long term conditions - a new approach to managing osteoarthritis

This project aimed to address unmet needs of healthcare professionals and patients in managing OA in primary care. Training, materials to support patient self-management, electronic consultation templates (OA template) and audit tools were adapted from the MOSAICs study to address issues identified at practice level:
- Gaps in GPs' knowledge of how to support self-management in consultations for OA
- Lack of musculoskeletal training and experience for practice nurses in integrating consultations for joint pain with long term condition management
- Lack of integrated primary care management of OA The project was conceived in partnership and supported: South Shropshire NHS practices in proactively managing patients with OA; NHS Shropshire Clinical Commissioning Group's aim in enhancing patients' quality of life by exploring all appropriate options before resorting to surgical treatment; and Keele University MOSAICs team in implementing research evidence for managing OA in consultations. The project supported primary care clinicians in addressing the unmet needs of adults consulting for OA, systematically implementing NICE guidelines by:
- Installing an OA e-template in GP clinical records systems to prompt the recording of quality indicators for OA care.
- Providing high quality patient information - the OA guidebook (developed by patients for patients) see: http://www.keele.ac.uk/pchs/disseminatingourresearch/newslettersandresources/oaguidebook/
- Using a model OA consultation for GPs and practice nurses that was also relevant to other long term conditions.
- developing a training programme for GPs and practice nurses, utilising a 'training the trainers' approach.
- providing a patient completed audit tool.

Through this approach the project supported:
- The uptake of core NICE OA guideline recommendations in primary care consultations (e.g. exercise, physical activity, healthy weight)
- Effective self-management by patients.
- The establishment of multidisciplinary clinical champions who were supported to deliver training and mentoring to other clinicians around the evidence based management of OA in primary care.
- Increased confidence in GPs about making a clinical diagnosis of OA, providing the diagnosis to patients, supporting them in self-management and referring to practice nurses
- Tools to support self-management and referral to practice nurses
- Audit of uptake of core NICE recommendations

Osteoarthritis (OA) is the most common musculoskeletal condition in older people. It is the largest cause of years lived with disability worldwide in adults (aged >45 years - Global Burden of Disease project) and is predominantly managed in primary care with a third of people in the UK (8.75 million) having sought treatment from their general practitioner (GP). Patients and public worked with healthcare professionals to develop the OA Guidebook (based on NICE recommendations) for patients with OA consulting in primary care.

Over the last two years two general practices within the NHS Shropshire Clinical Commissioning Group have worked in partnership with researchers at Keele University, patient groups and six other general practices in the North West Midlands to consider ways of implementing the core NICE guidelines 2008 (Management of Osteoarthritis in Consultations study (MOSAICS). In the MOSAICS pain survey (adults aged ¡Ý45 years) 4777 (40%) reported consulting either a GP or a practice nurse about their joint pain in the previous 12 months. Levels of physical activity were found to be lower and BMI higher in those with joint pain. Pharmacological treatments were used more frequently than core non- pharmacological treatments in older patients. Interviews with GPs revealed unmet training needs and a lack of services to offer OA patients and interviews with patients identified unmet needs for supporting self-management. An audit of general practice revealed inconsistent implementation of NICE OA guidelines and frequent secondary care referrals.

The MOSAICS study generated significant support in South Shropshire, with GPs and practice nurses reporting greater confidence in managing OA and patients feeling that their joint problems were taken seriously; as well as recognition that the core management principles for OA (and skills/knowledge) are shared by other long-term conditions. Within the CCG the South Shropshire locality identified implementation of NICE OA guidelines as a quality initiative and built upon the electronic tools, training and patient materials available via MOSAICs, utilising local champions to spread these innovations. The CCG identified the need for an enhanced musculoskeletal service in primary care, believing that pro-active management of OA should improve the quality of life for patients, select patients for arthroplasty more accurately with better outcomes and improve quality in primary care.

This innovation supported primary care in systematic implementation of the NICE 2008 OA guidelines. We:
1. Embedded an OA e-template in GP clinical records systems to measure quality indicators of care (Edwards et al., 2011)
2. Provided patient information - the OA guidebook
3. Provided education: practice-based in house training and two-day practice nurses programme
4. Supported GPs and practice nurses to deliver a model OA consultation
5. Provided tools to audit the quality of care for OA

We anticipated potential barriers and addressed these before launching the programme:
Anticipated Barrier/Strategy adopted:
- Lack of NHS capacity to engage in 'new' initiatives/Secured funds to facilitate nurses attending training.
- Lack of willingness to engage/Appointed local clinical champions ; OA not prioritised by healthcare professionals /Presented research and audit evidence of burden to general practitioners.
- Lack of integration of new approach into clinical practice/OA e-template integrated into GP IT systems and training for OA consultation Lack of time and support to evaluate innovation/Secured CCG leadership to agree evaluation parameters; e-template allows automated reporting and audit of activity.

Key to overcoming these challenges was the partnership between the implementation team at Keele University and the NHS in forming a project team. This included a CCG GP clinical lead, clinical leads for education/training, project leadership and support for evaluation. Whilst funding was provided (via NHS England Regional Innovation Fund) to pump prime the change management process, an unexpected barrier to implementation was that GPs felt that services were delegated to them without funding to support their delivery, they were therefore cautious about engaging in a worthwhile but unfunded initiative. The clinical champions and CCG clinical lead were key to addressing this. Clinical champions engaged with practices locally. Senior Clinical Leadership meant that the CCG developed and supported a business case to commission primary care enhanced services for OA. Pump priming costs incurred in this project included a launch event, one year funding for five clinical champions (practice nurses/GPs) and backfill costs for practice nurses to attend training. Tools provided to support the project included the OA guidebook for patients, and installation of the e-template into the GP clinical systems.

This project supported primary care in implementing NICE OA guidelines in clinical practice through:
1) 'training the trainers'
2) local champions
3) training GPs and practices nurses in the OA consultation
4) supported self-management
5) installation of e-OA template.

Progress was monitored throughout the year, with measures such as engagement with training events, and practice visits. During 2014 we showed that:
- appointing clinical champions has successfully supported engagement of practices with the project (13/14 practices fully engaged)
- training for practice nurses in OA management was successful (appendix 1)
- the OA e-template has been installed in all practices
- the OA guidebook was reprinted to reflect the NICE 2014 OA recommendations
- supporting implementation of change can lead to development of new pathways of care. NHS Shropshire CCG now supports an OA enhanced service pilot in primary care. Installation of the OA e-template was completed at the end of 2014, and allows audit of core NICE interventions. Evaluation of the project at CCG level is linked to their agreement of an OA enhanced service. The CCG monitors a number of clinical measures including:
- imaging and orthopaedic surgery referrals
- reduction in clinical variation, through implementation of an electronic OA template to guide practice - demonstrating uptake of core NICE interventions
- patient satisfaction and clinical outcomes through implementation of NICE guidelines, nurse led LTC clinics and access to written information (OA guidebook). This project has exceeded expectation in that the CCG have supported a pilot of a new OA enhanced service for primary care. Throughout 2014 we have developed a toolkit of resources and training to help healthcare practitioners to overcome those barriers which have prevented adoption of the NICE OA guidelines into clinical practice - this means in 2015 the following resources are readily available to any team wishing to take this forward:
- On line training for GPs (via RCGP)
- Established training course for practice nurses (via Education for Health)
- Web resources:OA e-template, training tool and audit tools submitted to NICE endorsement programme (http://www.keele.ac.uk/pchs/disseminatingourresearch/researchtools/oae-template)
- Patient satisfaction audit tool
- Integrated OA e-template within GP IT clinical systems

Key to the success of this project has been:
- the creation of strong and trusted partnership and leadership between the academic implementation team and the NHS in South Shropshire, aligning NHS priorities to latest research evidence
- alignment with NICE guidance and support from NICE implementation consultant (Chris Connell)
- clear and accessible credible 'product' allowing ease of interpretation and translation within the NHS;
- strong clinical leadership within the locality, securing engagement with the project
- integrated solutions to support NICE implementation e.g. OA e-template
- creating the 'capacity for change' through the provision of project management support
- clinical champion expertise, to facilitate development of care pathways within the local context
- working with clinicians and patients to develop solutions to support the OA consultation e.g. the OA e-template to be used easily in busy GP consultations
- patient involvement in developing high quality patient information and patient satisfaction materials (review of OA Guidebook);
- the academic/clinical partnership to develop and deliver high quality training and resources that are relevant to practising clinicians.
Challenges experienced have included:
- 'front line' practitioners having difficulties with time and resources to secure engagement in launch event and training days
- lack of audit/evaluation support for NHS organisations to access
- balancing the value of releasing practice nurse staff to attend training against the pressures of delivering clinical services. A further challenge is to ensure this is approach is accessible at a national level. Working with national partners (Arthritis Research UK, Royal College for General Practitioners and Education for Health) we have ensured the training programme for practice nurses is available at a national level, with OA training for GPs incorporated into the RCGP on-line training modules.