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Quarterly magazine of BackCare, the UK’s National Back Pain Association

WINTER n 2018


A ‘national emergency’ Critical and lasting staff shortages putting lives at risk

also in this issue: Coping in the home Shifting the emphasis from downsizing to ‘rightsizing’ Workplace Are you getting the support you need to stay in work? Standards and practices Hip fracture standards to address ‘wide variation’ of care




The realities of using assistive technologies ASSISTIVE technologies, telehealth and telecare systems are playing a greater role in helping older people live at home, but do we really know whether these devices are making a difference? In fact, relatively little is known about the use of high-end technologies over time and their impact in preventing falls, reducing isolation, or anticipating health crises or emergencies, says the National Institute of Health Research (NIHR). Its latest themed review1 examines a wide variety of research around the use of technology in the home and has found huge gaps in what we know about individual preferences and how devices are integrated (or not) into everyday habits and routines. Some devices are already familiar to many, including emergency pendants, fall detectors and bed and chair sensors, while wearable technologies, virtual assistants and service robots promise innumerable applications for the future. This is a high-value, fast-emerging sector which undoubtedly has an important role to play in helping people to manage complex health conditions and stay independent. And yet, much of the evidence to date has been informed by technology “push”, rather than the “pull” of user need, says NIHR. In one study2 it cites, only a third of respondents said that telecare investment was informed by research, while only a quarter had developed telecare strategies with the NHS and other partners. It turns out many devices in circulation are never used or not used fully or as intended3. One

reason for this is that the timing of introducing new technology is often too late – at the point of crisis or advanced illness. Another significant issue is the under-investment in training to support longer term use of technologies in the home, which also underlines the need for greater understanding of the wider context in which services are delivered. The NIHR wants to see more research using mixed methods to evaluate technologies in use, rather than simply lab-style testing or smallscale pilots. Clearly, doing this research is not without its challenges, not least in recruiting older people into studies to the rapid pace at which technologies change. However, it’s the only way to be sure that money is wisely spent and that service providers get the right technology for the right person with the right support.

Richard Sutton Editor


More people experiencing back and neck pain 6-7

Does the rating system improve quality of care? 11

Self assessing back pain using an app 16-17


1) Help at Home – Use of assistive technology for older people (2018, NIHR Dissemination Centre) 2) Is there a clearer role for telecare in adult social care that will deliver better outcomes for older people? (2018, Woolham) 3) Some research has suggested that as much as 40% is never used (2016, Federici) Cover image: Peoplecreations/Freepik

We welcome articles from readers, but reserve the right to edit submissions. Paid advertisements do not necessarily reflect the views of BackCare. Products and services advertised in TalkBack may not be recommended by BackCare. Please make your own judgement about whether a product or service can help you. Where appropriate, consult your doctor. Any complaints about advertisements should be sent to the Executive Chair. All information in the magazine was believed to be correct at the time of going to press. BackCare cannot be responsible for errors or omissions. No part of this printed publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the copyright holder, BackCare. ©BackCare

BackCare BackCare, Monkey Puzzle House, 69-71 Windmill Road, Sunbury-on-Thames TW16 7DT Tel: +44 (0)20 8977 5474 Email: Website: Twitter: @TherealBackCare Registered as the National Back Pain Association charity number 256751. TalkBack is designed by Pages Creative and printed by Severn, Gloucester.

‘Cutting corners’ a factor in work-related MSDs 18-19

Tackling inequalities of exercise among women 20-21 TALKBACK l WINTER 2018


A FULL range of non-surgical options should be offered to women for stress urinary incontinence or pelvic organ prolapse before any operations, NICE has said. There are a number of nonsurgical options that should be considered before surgery. The non-surgical options for urinary incontinence include: lifestyle interventions, physical therapies, behavioural therapies and medicines. For pelvic organ prolapse, other options include: lifestyle modification, topical oestrogen, pelvic floor muscle training and pessary management.

Informed Where surgery is offered, if a woman’s chosen intervention is not available from the consulting surgeon, she should be referred to an alternative surgeon, the draft NICE guideline recommends. Surgical interventions using surgical mesh/tape should only be considered when other non-surgical options have failed or are not possible. In the cases where it is agreed to use surgical mesh/tape, women must be fully informed of the risks, the NICE committee said in the draft guideline. Sir Andrew Dillon, chief executive of NICE, said: “Where surgical mesh/tape could be an option, there is almost always another intervention recommended in our guideline, which does not involve surgical mesh/tape. “If a surgeon cannot provide a full range of choices to the patient, then she should be referred to one who can.”


Image: Pressfoto/Freepik

Non-surgical options ‘should be offered first’ for pelvic organ prolapse

One in six health service posts could be unfilled by the end of the next decade

Shortages of healthcare staff raise the risk of longer waiting times CRITICAL and lasting shortages in the healthcare workforce mean that the forthcoming NHS longterm plan risks becoming an unachievable ‘wish list’ of initiatives to improve the health service, according to a new briefing from the King’s Fund, the Health Foundation and the Nuffield Trust. If unaddressed, these shortages could lead to growing waiting lists, deteriorating care quality and the risk that some of the money for frontline services pledged at the Budget will go unspent, it says. The briefing, The health care workforce in England: make or break?, draws on a new forecast of the staffing gaps emerging in the 1.2 millionstrong NHS workforce. It predicts an increase in NHS staff shortages from more than 100,000 at present to almost 250,000 by 2030, warning that this could mean that more than one in six health service posts are short of an appropriate staff

member by the end of the next decade. The three organisations warn that these shortages could be more than 350,000 if the NHS continues to lose staff and cannot attract skilled workers from abroad. The briefing comes as NHS leaders are poised to publish their blueprint of how the health service can adapt to the next 10 years in response to the £20.5 billion funding boost confirmed by the Chancellor at the Budget. It warns that even before this funding increase was pledged, the NHS could not recruit the staff it needed because of an incoherent approach to workforce policy at a national level, poor workforce planning, restrictive immigration policies and inadequate funding for training places. Funding for education and training dropped from 5% of health spending in 2006/7 to 3% in 2018/19, the equivalent of a £2 billion drop.


£20 million boost for social care research adult social care research and training for research staff. The new funding will allow the School’s partner organisations to build on their work in areas such as mental health, dementia, and care homes. Two new partners have joined the School –

King’s College London and the University of Birmingham – joining the LSE and the universities of Bristol, Kent, Manchester and York. The School will launch a call for research proposals next summer, 2019.


SOCIAL care research in England will get up to £20m in new funding through the National Institute for Health Research. Government investment will fund the next five years of the NIHR School for Social Care Research, which supports

The health and social care sectors differ markedly in their structure, funding and culture

Govt lacks strategy for integrating health and social care systems THE Government still lacks an effective overall strategy or plan to achieve its long-held aim to integrate the health and social care systems and, currently, the Public Accounts Committee (PAC) sees no realistic prospect of progress. Financial pressures and an ageing population have both increased the need for joined-up working, however the squeeze on local authority funding is blocking progress, the PAC says. Councils reduced real-terms spending on adult social care by 5.3% between 2010-11 and 2016-17, while the number of

people in England aged 85 and over rose by 28% between 2006 and 2016. There has been plenty of talk within government about how to support and accelerate the integration of health and social care. In the past 20 years, there have been 12 white papers, green papers and consultations, and five independent reviews and consultations. Despite this, there exists a range of longstanding legal, structural and cultural barriers hindering the pace and scale at which change can happen. “If Government is serious about delivering the benefits of integrated health and social

care, it must act to make it happen,” PAC chair Meg Hillier said. “We urge Government to set out a costed 10-year plan for social care to go alongside its proposed 10-year plan for the NHS. Social care has suffered long-term underfunding and it is unacceptable that councils, under considerable financial pressure and facing growing demand for care services, must wait until 2020 for clarity. “Government must also step up efforts to break down barriers to integration across the country. Its departments and agencies need to work together more effectively to support the roll-out of best practice.”



More people experiencing regular Simple ways to ward off the modern-day triggers of back and neck pain...

MORE people in the UK are experiencing back or neck pain each week than they were five years ago, according to new research from the British Chiropractic Association (BCA). The consumer research, which looked at trends from the past five years, revealed the number of people experiencing back or neck pain on a weekly basis has risen from 40% to 49%. Moreover, two thirds (65%) of us now experience back or neck pain each month, up 16% over the same period. The findings also show that most common triggers of back or neck pain, according to people experiencing the condition, have changed. The number of people who reported sitting still for long periods of time as a trigger for their back or neck pain has risen from a third (35%) to almost half (45%). This is reflected by the

45% say that sitting still for long periods of time is a trigger for back or neck pain

number of people who blame their jobs for their back or neck pain, with a fifth now pointing to work as a key trigger. Sport and exercise have also made it in the top five triggers, pushing aside housework and DIY. Sleeping remains a key trigger, particularly for women, with 11% more reporting this as a cause of their back or neck pain than men. While the rates of back or neck pain have fallen slightly for both genders, women remain 7% more likely to experience the condition. Catherine Quinn, President of the British Chiropractic Association, said: “Back pain is a relatively common condition which is usually not serious and can


back and neck pain be easily prevented, so these findings should come as a wake-up call to all of us! That sport and exercise make it into the top five triggers for back pain concerns me as staying active is one of the best ways to stay strong and reduce your chances of back pain. In my experience, back pain from sport often comes when people do not take time to build up their intensity and instead lift the heaviest weight they can find or go straight on a 10K run when they are not ready. NHS programmes such as the “Couch to 5K” are great ways for people to gradually build up their activity levels.” There are a number of simple steps everyone can take to protect themselves from some of the most commons triggers of back and neck pain and combat the effects of sitting still for long periods. Those who are experiencing back or neck pain on a weekly basis should consider incorporating more exercise and general movement into your routine where you can. Catherine Quinn shares her top tips for preventing regular back or neck pain:

Take a break When sitting for long periods of time, whether you’re at work, driving or catching up on box sets, ensure you stand up and move around every 30 minutes. Simple activities such as stretching and shoulder shrugging can also help to keep your body moving when you’re sitting for longer periods of time.

Image: Luis_molinero/Freepik

Stay active Physical activity can be beneficial for managing back pain, as a stronger body can cope better with the demands you make of it. However, if this is of a moderate to high intensity, it’s important that you warm up and down properly to get your body ready to move! If a previous injury is causing you pain, adapt your exercise or seek advice. Activities such as swimming, walking or yoga can be less demanding on your body while keeping you mobile.

Work in comfort When at work, make sure your desk is set up to support a comfortable position. This is different for everyone so if you don’t feel comfortable in your current set up, try altering the height of your chair or screen.

Don’t strain your neck! The head is a heavy weight, so sitting with it forward of your body when using smartphones or tablets can put unnecessary strain on your neck and back. When using this technology, try keeping your head straight above your body, or position your screen in front of you so you’re not compelled to look down.

Straighten Up The BCA has created a programme of threeminute exercises, Straighten Up UK, which can be slotted in to your daily schedule to help prevent back pain by promoting movement, balance, strength and flexibility in the spine. If you are experiencing pain for more than a few days you should seek professional help, for example from a chiropractor, who can assess you and help you to get moving again without pain.

Unlocking match funding for physical activity projects COMMUNITY sport and physical activity projects are being helped to generate partnership funding by crowdfunding part of their costs. ‘Crowdfunding Towards an Active Nation’ has seen 23 projects invited to take part and raise funds from the general public that will unlock match funding from Sport England. All the selected projects are already in receipt of funding from the Community Asset Fund (CAF), which is dedicated to enhancing spaces such as canal towpaths and open spaces and has already received more than 3,000 applications. To enable Sport England to help as many projects as possible, the projects have received a portion of their requested funding via CAF before also being invited to crowdfund. Whatever they crowdfund, up to £15,000 will be matched by Sport England. Executive director of property Charles Johnston said: “We strive to ensure that any projects we invest in are financially sustainable so they can benefit their community for years to come, and often refer applicants to further sources of funding. “The partnership with Crowdfunder is one of many ways we are learning how projects can ensure maximum success with fundraising, so we can better support them to raise investment.” Ten projects have launched so far, with more than £40,000 being raised to date.



The Government is being urged to do more to promote the Access to Work scheme, as latest research by charity Versus Arthritis reveals that thousands of people with arthritis and related conditions are likely to be missing out on the support they need to remain in the workplace.

What you can do about it Versus Arthritis is calling on people to share its new report with local MPs and encourage them to raise the issues around Access to Work with the Secretary of State for Work and Pensions. Details on how to write to your MP can be found on the charity’s website.


Image: Dragana_Gordic/Freepik

Are you getting the support


you need to stay in work? A NEW study of more than 1,500 people with arthritis and related conditions found that more than half (59%) had never heard of the Government’s Access to Work scheme. A further 10% had heard of it but did not know what it does. The scheme, run by the Department for Work and Pensions since 1994, is designed to support people over 16 who have a disability or health condition with work-related needs. The grant awarded by the scheme can fund things like specialist equipment, support workers, transport to and from work and mental health support services. It is available in England, Scotland and Wales. A similar but separate scheme operates in Northern Ireland. The charity warned that the UK is losing the talent and expertise of thousands of people across many industries and sectors. For those with arthritis, not being supported at work can have a significant personal effect and leave people isolated and in pain with significant negative impact on income and wellbeing. The survey also found that as a result of their condition: l 35% had been forced to reduce their working hours l 26% had changed the type of work that they do l 19% had to give up work entirely or had taken early retirement.

More than half of arthritis sufferers have never heard of the Access to Work scheme Employers are legally required to make reasonable adjustments to ensure workers with disabilities, including people with arthritis and related conditions, aren’t disadvantaged or discriminated against in the workplace. However, 51% of survey respondents said their employer had not made all the reasonable adjustments they needed. “The Access to Work scheme can provide some of this much-needed support, but it’s currently falling short,” Morgan Vine, campaigns manager at Versus Arthritis said. “The UK is experiencing its highest levels of employment in almost 50 years, yet only 63% of people with arthritis are in the workplace, compared to 81% of working age adults without a health problem. If the Government is serious about supporting one million more disabled people into work by 2027, it must act now.” n The new charity, Versus Arthritis, is the result of the merger of Arthritis Research UK and Arthritis Care.

Pete’s story... Pete, a recently retired teacher of 40 years who has ankylosing spondylitis and rheumatoid arthritis, described how the right support may have helped him avoid early retirement. “I’ve been a teacher all my life,” said Pete. “The last two years of work were agony for me. I was so tired and had already stopped working a couple of days a week. It’s almost painful to be that tired. I had no idea that I was entitled to any support from my employer, or the Government. When I came back to work after surgery, I had ‘nice to see you back’, but no offer of help. My colleagues were very empathetic and the kids were great, but I was never offered support. I had 40 years with wonderful people, but when you’re constantly living on the edge of pain, what can you do?”

THERE IS little evidence that organisations have begun to work through the implications of an ageing workforce – but employers are helping nobody with silence on retirement, a new study from the University of Kent says. Age discrimination legislation and the abolition of compulsory retirement at 65 means that employers are worried about talking to older workers about retiring, for fear of being accused of ageism. However, this creates uncertainty on both sides, says Kent’s Professor Sarah Vickerstaff. Line managers cannot plan for succession because they don’t know when people will go, and employees have little support in making decisions about when to retire or how to ease into retirement. Furthermore, flexible working may not be the key to gradual retirement. “Our analysis suggests that access to flexible working arrangements is exaggerated,” Professor Vickerstaff said. “Many simply cannot afford

Image: Freepik

Retirement – the new ‘taboo’ in the workplace?

Employers must do more to engage, train and provide opportunities for older workers to work part time, often women are already working part time and many occupations do not support this way of working. Realism is needed about the genuine restraints to taking up flexible working opportunities.” Nor is everyone fit – either physically or mentally – to work into their late 60s. Professor Vickerstaff said: “We find that

a person’s ability to work beyond 60 has probably been determined well over a decade before.” Poor psychological health and adverse events, even as far back as childhood, can have a profound impact on working life and the subsequent ability of older adults to extend their working years. Both policymakers and employers need to address these challenges, researchers suggest. To extend working lives, employers must do more to engage, train and provide opportunities for older workers and start conversations about retirement. Government should explore options for flexible withdrawal of state pension for those who cannot afford to take phased retirement, adopt a cross-government national skills strategy for older workers and target interventions at promoting good physical and mental health throughout the lifecourse.


Image: Freepik


Desk bound staff should stand up for their health IT IS recognised that sitting down for long periods of time, even for those who do some exercise regularly, can lead to poor health. Teams from the University of Leicester and Loughborough University wanted to investigate simple solutions to reducing sitting time in the office. The research, funded by the National Institute for Health Research (NIHR), found that giving height-adjustable workstations to staff, alongside a brief education seminar, posters and providing feedback on sitting behaviour (ie the SMArT Work programme), reduced sitting time and increased standing while at work, which resulted in lots of work and wellbeing benefits. The Stand More At Work (SMArT Work) study involved 146 office workers from the University Hospitals of Leicester NHS trust who were randomly assigned to one of two groups. One set of people received the SMArT Work programme and the other group was asked to continue as normal. After 12 months, participants in the intervention group spent 83 minutes fewer per day sitting down at work than the control group. Measures of sitting, standing and movement time were recorded using a


small device worn on the thigh. Participants also completed questionnaires on their performance at work, job satisfaction, engagement, musculoskeletal issues, fatigue, wellbeing and sickness absence. Dr Fehmidah Munir, Reader in Health Psychology from Loughborough University and the National Centre for Sport and Exercise Medicine East Midlands, said: “For people who work in an office environment, sitting down for most of the day is very common. We know this is bad for their health, but people feel restricted to this posture because of the job and the environment. We have shown that it is possible to significantly reduce the time spent sitting while at work with the SMArT Work programme.”

Fatigue Dr Charlotte Edwardson, Associate Professor from the University of Leicester, said: “Those who received the SMArT Work programme reported improvements in their work performance, work dedication and engagement, quality of life and reduced levels of sickness presenteeism, feelings of fatigue and musculoskeletal issues, such as lower back pain.

“Presenteeism, together with absenteeism, is estimated to cost UK employers more than £30 billion a year. Approximately nine million working days are lost to musculoskeletal problems. So, the SMArT Work programme could help employers make headway into these two issues.” Dr Sophie O’Connell, Research Associate at Leicester’s Hospitals, said: “In response to the study findings and the fantastic feedback from the participants who received the SMArT Work programme, we are preparing the SMArT Work resources for roll out. The resources will be freely available on the programme website very soon for organisations to access.” Judy Queally took part in the study. She said: “Before I started the study I suffered from a back problem. Even having been to my GP and being sent for a couple of x-rays, I still couldn’t get to the bottom of it. Since being part of the SMArT Work study I have the flexibility to stand whenever I want and I have no back problems at all.” The SMArT Work study was funded by the NIHR with support from the NIHR Leicester Biomedical Research Centre.


WHILE the Care Quality Commission (CQC)’s “Ofstedstyle” inspection and rating regime is a significant improvement on the system it replaced, it could be made more effective, according to the first major evaluation of the approach introduced in 2013. The current regime for assessing the performance of health and care services was the centrepiece of the then government’s response to the Francis report into the failures of care at Mid Staffordshire NHS Foundation Trust. The research, carried out by The King’s Fund and Alliance Manchester Business School between 2015 and 2018, examined how it was working in four sectors – acute care, mental health care, general practice and adult social care – in six areas of England. The report, funded by the National Institute for Health Research, found that the impact of the inspection regime came about through the interactions between providers, CQC and other stakeholders, not just from an individual inspection visit and report. It suggests that relationships are critical, with mutual credibility, respect and trust being very important. The report argues that CQC should invest more in the recruitment and training of its workforce and calls on providers to encourage and support their staff to engage openly with inspection teams. The report highlights a number of areas for improvement in CQC’s approach to regulation. It cautions that the focus on inspection and rating may have crowded out other activity


Does the rating system improve the quality of care services?

Providers should encourage and support their staff to engage openly with inspection teams

Focus more on regular, ‘less formal’ contact with providers which might have more impact. It recommends that CQC focuses less on large, intensive but infrequent inspections and more on regular, less formal contact with providers, helping to drive improvement before, during and after inspections. The evaluation found significant differences in how CQC’s inspection and ratings work across the four sectors it regulates. Acute care and mental health care providers were more likely to have the capacity to improve and had better access to external improvement support than general practice and adult social care providers. The

report recommends that CQC thinks about developing the inspection model in different ways for different sectors, taking into account these differences in capability and support. The researchers also analysed data on A&E, maternity and GP services to see if CQC inspection and rating had an impact on key performance indicators, but found only small effects. There was also little evidence that patients or GPs were using ratings to make choices about maternity services. The “risk-based” system using routine performance

data which CQC used to target inspections was found to have little connection to subsequent ratings. The report suggests the CQC uses a wider range of up-to-date data to develop a more insightful way of prioritising inspections. Ruth Robertson, report author and Senior Fellow at The King’s Fund said: “When CQC identifies a problem in a large hospital, there is a team of people who can help the organisation respond, but for a small GP surgery or care home the situation is very different. We recommend that CQC develops its approach in different ways in different parts of the health system with a focus on how it can have the biggest impact on quality.”



Simple adaptations can help us live Life-changing adaptations made in the home can enable people managing health conditions or loss of mobility to carry out everyday activities.

A NEW report from the Centre for Ageing Better, Adapting for ageing, jointly published with Care & Repair England, identifies examples of good practice from across England on providing life-changing adaptations in the home to enable people to carry out everyday activities such as cooking, bathing or using the toilet. The report reveals innovative approaches and calls for other councils and service providers to learn from the good practice it has uncovered. These include raising awareness of available support and how to access it, delivering home adaptations quickly and without meanstesting, linking adaptation

The number of older people in need of help with everyday living is forecast almost to double in the next 25 years TALKBACK l WINTER 2018

services with vital home improvements and working with handyperson services. There is rising demand for aids, adaptations and accessible housing across England as people live for longer and increasing numbers of older people live with multiple long-term health conditions or experience reductions in mobility. Recent analysis by LSE shows the number of older people in need of help with everyday living is expected almost to double in the next 25 years.

Rising demand More than 90% of people over the age of 65 live in ordinary, mainstream housing (rather than specialist retirement accommodation). Only 7% of UK homes meet basic national accessibility requirements (ie level access to the entrance, a flush threshold, sufficiently wide

doorways and circulation space, and a toilet at entrance level). Previous research shows that investment in adaptations is highly cost-effective, helping to improve wellbeing, keep people out of hospital, prevent or delay moves into residential care, and reduce the need for carers. This is particularly true when they are installed early on and in combination with repairs and improvements. There needs to be a more consistent approach to measuring the outcomes of home adaptations and improvements as part of an integrated approach to housing, health and care. The report adds that it is imperative that national government continues to fund the Disabled Facilities Grant (DFG) and ensure councils have sufficient revenue funding to provide the services that deliver the adaptations effectively.



in our homes for longer Researching the uses for assistive technology THERE has been considerable investment recently in developing and evaluating assistive technologies for older people, though this is a relatively new field and there are important gaps in what we know. A recent review by the National Institute for Health Research (NIHR) looks at research around the use of technology in the home, remote monitoring systems and designing better environments for older people. Many devices are never used and more are not used fully or as intended. Reasons for this include the timing of introducing new technology – often too late, at the point of crisis or advanced illness. Under-investment in training to support longer term use of technologies in the home is another issue. A number of studies have explored integrated monitoring and response systems to check the health, wellbeing

and safety of older people living at home. They range from systems using sensors, alarms or wearable technology to cameras, smart televisions and service robots. Some collect data on health status, movement or eating and drinking, while other systems are more interactive. There are challenges in doing this research, says the NIHR, from recruiting older people into studies to the rapid pace at which technology changes. Research has focused more on high-end digital technology than evaluation of more basic devices to help toileting, mobility, vision and everyday tasks. Also, little is known about the use and impact of technologies in preventing falls, reducing isolation, or anticipating health crises or emergencies.

Moving from downsizing to ‘rightsizing’ MANY older people are staying put until a sudden crisis, such as divorce, eviction or failing health, forces them to move, according to new research. The Rightsizing: Reframing the housing offer for older people report commissioned by Greater Manchester Combined Authority and funded by the Centre for Ageing Better looks at the types of houses older people live in across the UK, the sort of house moves they make, and the reasons why. Despite common assumptions that most people want to downsize or enter specialist accommodation as they age, the report reveals that when it comes to choosing a home, older people are motivated by the same desires as other age groups. For example, wanting more space for guests, moving to a nicer area, and better access to green spaces. For these reasons, the authors call for UK local authorities, planners and developers to shift their emphasis from downsizing to “rightsizing”, when it comes to planning housing for older people. “Rightsizing” is described as an older person’s active choice to move home as a means of improving their quality of life. The research reveals that many over50s cannot move home in the way they would like, due to a lack of suitable housing options and inadequate provision of support and advice. Just 3.4% of people over the age of 50 move home each year, which is half as many moves compared to the rest of the population. Although those with higher levels of wealth can more easily move, and those on the lowest incomes receive more support from social care providers, those on low and middle incomes can find themselves trapped in homes no longer appropriate for them as they age. The current focus on providing extra-care housing and age-restricted retirement living might be serving the needs of some groups, but these are not suitable for everyone and are not always embedded within existing communities. Local plans should explore diverse, adaptable housing options within existing communities, says the report.



Aiming to embed prevention into every contact with musculoskeletal patients

Moving towards lifelong support and helping people to self-manage MUSCULOSKELETAL disorders should be a public health priority because they may require long-term care and increase the risk of chronic disease, according to physiotherapist Anna Lowe, physical activity clinical champion for Public Health England. It was important that musculoskeletal disorders were recognised as long-term conditions which could impact on people’s overall health and wellbeing, she said. “By defining them as long-term conditions we are moving away from the idea of episodic care towards lifelong support and enabling people to selfmanage,” Ms Lowe told delegates at the recent Physiotherapy UK 2018 conference. “Caring for these needs requires partnership with patients over the long term, rather than single, unconnected episodes of care.” An estimated 17.8 million people in the UK have a musculoskeletal condition, almost 29% of the population. Ms Lowe explained that long-term conditions account for half of GP appointments, 64%


of outpatient appointments and 70% of inpatient bed days. “£7 in every £10 spent on the health and care budget is related to long term conditions – so there is a compelling rationale for them to be an essential task for the NHS and for services and systems to be built around that,” she said. Ms Lowe added that a recent systematic review showed that osteoarthritis increased the risk of a chronic condition later in life, such as cardiovascular disease, metabolic syndrome and arterial stiffness.

Life-shortening “So we are not just dealing with something that is potentially confined to one joint or a number of joints, as osteoarthritis is linked to a number of systemic, chronic and life-shortening conditions,” she said. “Musculoskeletal disorders have the potential to affect our relationships, our work, our hobbies and everything we hold dear – so they can have a significant impact on our mental health as well.” Ms Lowe believes physiotherapists

should be striving to positively influence their patients’ behaviour and embed prevention into every contact with musculoskeletal patients. She said smoking was a good example of a modifiable risk factor and a prevention opportunity for physiotherapists. They could offer brief advice that could help stop the escalation from one condition to many conditions. Advice from the London Clinical Senate shows that helping people stop smoking is the highest value contribution to health that any clinician can make. And yet, a Public Health England survey of how often AHPs gave brief advice about smoking to their patients, revealed that 23% never offered such advice. “That was because they didn’t feel confident to do it and didn’t think it was their role,” Ms Lowe said. “But there is a gold standard about how to deliver a brief advice on smoking. It’s a really easy, short online course1 that I suggest the whole workforce would benefit from taking.” 1)


THE Chartered Society of Physiotherapy’s (CSP) new standards of practice for physiotherapists working with patients with hip fracture were formally launched at Physiotherapy UK. Pip White, CSP professional adviser, described how the variable findings from the Hip Sprint audit – involving more than 130 acute trusts – prompted the CSP to create the new standards. ”There are more people living with hip fracture now and rehabilitation is vital,” Ms White said. “We need to deliver better quality of care to those experiencing hip fracture. As part of this, we should expect to be part of multidisciplinary teams that plan and deliver rehabilitation.” The conference heard from Iona Price about her late mother’s experiences of recovery from a hip fracture. She was diagnosed with delirium while in the acute ward and deteriorated in that environment. Discharge from hospital led to her delirium “lifting”, but discharge also meant a new referral was required. “Although she was able to undertake rehabilitation at home, it wasn’t there when she needed it,” said Ms Price. Jocelyn Hopkins, advanced physiotherapist practitioner at Weston Area Health Trust, talked about their audit experience. “We initially found we were not meeting the first three standards,” she told delegates. “Mobilisation is key and it is a routine part of hip fracture care, but it’s everyone’s role. We started by getting patients out of bed during mealtimes with the help of nursing colleagues. Within 12 months of making changes, we had achieved the first three CSP standards.”

Photo: Freepik

Hip fracture standards to address ‘wide variation’ of care

Mobilisation is key and it is a routine part of hip fracture care Pippa Ellery, clinical lead at Cornwall Partnership NHS Trust, provided a community physiotherapy improvements perspective. This has included providing more focused service delivery, particularly around early mobility. “We have also improved as a team, for example, identifying when patients are in pain. Additionally, we have improved links with the acute trust, freeing up time in physiotherapy.”

Antony Johansen, consultant orthogeriatrician and clinical lead for the National Hip Fracture Database (NHFD), told the conference: “You can make a big impact by taking rehabilitation seriously. The 4AT score is a rapid clinical test for delirium and it is the most important assessment a physiotherapist can use. I would urge you to use it with any patients you have concerns about.”

CSP standards at a glance... l A physiotherapist assesses all patients on the day of, or day following, hip fracture surgery l All patients are mobilised on the day of, or day following, hip fracture surgery l All patients receive daily physiotherapy that should total at least two hours in the first seven days post-surgery.

l All patients receive at least two hours of rehabilitation in subsequent weeks post-surgery until they have achieved their goals l All patients moving from hospital to the next phase of rehabilitation are seen by their new rehabilitation provider within 72 hours

l A physiotherapist is part of every Hip Fracture Programme’s monthly clinical governance meeting l Physiotherapists share their assessment findings and rehabilitation plans with all rehabilitation providers to enable clear communication with the MDT.



Now you can use a smartphone Image: Freepik

Digital technology is making big strides in the health sector. Here we look at some of the latest developments that can offer help for back pain sufferers.

Existing outcome measures can be migrated to digital media

Prescribing physical activity in the treatment of health A NEW digital tool will help healthcare professionals advise patients on how physical activity can help manage their conditions, prevent disease and aid recovery. The Moving Medicine tool focuses on helping to address common long-term health conditions, such as cancer, depression, musculoskeletal pain and type 2 diabetes. Evidence shows that one-in-four patients would be more active if advised by a GP or nurse, yet nearly three quarters of GPs do not speak about the benefits of physical activity to patients due to lack of


knowledge, skills or confidence. Developed by the Faculty of Sport and Exercise Medicine in partnership with Public Health England and Sport England, Moving Medicine provides healthcare professionals with the latest evidence to address the knowledge and skills gap in the NHS and support healthier outcomes for patients as a result. Dr Alison Tedstone, Head of Physical Activity at Public Health England, said: “With millions accessing the NHS every day, healthcare professionals play a vital

role in helping people to better understand the health benefits of physical activity. “Taking the time to have these conversations has the power to inspire people to move more and make a big difference to their health.” Moving Medicine is a major component of the Moving Healthcare Professionals Programme, designed to support healthcare professionals embed physical activity into their approach to treating patients for common conditions.


or tablet to assess back pain PATIENTS can assess their own back pain using an app on their phone or tablet as effectively as current paper methods, say researchers from University of Warwick. A new study, published in the open access Journal of Medical Internet Research, shows that digital versions of established measurements for assessing back pain to be equally as reliable and responsive, opening the possibility for their use by patients for routine measurements and clinical trials. For health issues that can’t be readily measured, such as pain and depression, clinicians will often use self-assessment to monitor change. In most cases, this will take the form of a paper-based assessment. These go through very

thorough validation exercises to ensure that they measure what they intend to robustly and accurately. The researchers created mobile app versions of the most commonly used measures in back pain trials: the Roland Morris Disability Questionnaire (RMDQ), visual analogue scale (VAS) of pain intensity, and numerical rating scale (NRS). These were developed with support from the University of Warwick Higher Education Innovation Fund with the aim of being used in clinical trials and for routine clinical measurements. Lead author Dr Robert Froud from the University of Warwick Clinical Trials Unit said: “We have taken existing outcome measures and shown that they can be

migrated to digital media and used in that format just as effectively as their paperbased versions. Our intention is to develop technology that allows people to securely complete these kinds of assessments on their own phones and tablets in a way that is safe, secure and accurate. “If you can accurately monitor in clinical practice what’s happening to patients’ health, then analytically there is a lot that could be done with the data that will benefit patients. For example, we may be able to detect that particular treatment approaches are working better for certain types of people. We hear a lot about machine learning, but a learning healthcare system is perhaps next.”

Exoskeleton technologies Identifying the risks offer glimpse of social in manual handling care of the future



performance. Isle of Wight Council has established a pilot with informal carers to see whether the use of such devices can assist the carer with their day-to-day manual handling tasks. A business case and specification will be developed and regulation and national interest for this area will be researched. The Social Care Digital Innovation Programme promotes digital pilots that will advance frontline practice, improving systems and enabling integration across adult social care. Earlier this year, 12 councils were awarded £20,000 each in the first phase of funding. Up to £700,000 has been made available and nine projects have now been chosen to design and implement their solution.

updated to reflect the latest research and experience of how the tool is used in the workplace. It includes new illustrations, new team handling categories and weight limits, a more comprehensive score sheet, screening questions to check which assessment you should do, and space to list your control measures. (Although there have been some changes to categories and scoring, the main messages about preventing risks have altered little since the 2014 version. There is no change in policy or regulation.)

The tool helps employers to understand, interpret and categorise the level of risk


Image: Nikitabuida/Freepik

EXOSKELETON devices for carers are among nine social care digitisation projects to receive new funding from NHS Digital and the Local Government Association. Exoskeletons are wearable devices that work in tandem with the user to augment

THE Manual Handling Assessment Charts (INDG383) is a tool to help identify highrisk workplace manual handling activities. Employers and safety representatives can use the tool to assess the risks posed by lifting, carrying and team manual handling activities. It will help you understand, interpret and categorise the level of risk of the various known risk factors associated with these activities. There is a numerical and colour coding score system to highlight and prioritise assessment of highrisk manual handling tasks. This version has been


‘Cutting corners’ a key risk factor In the construction, healthcare and transportation and storage sectors, there are significantly higher rates of work-related musculoskeletal disorders (WRMSDs) than other sectors. The Health and Safety Executive has produced a new study gathering information from employers and workers on their understanding of WRMSDs.

NEITHER employers nor workers in three major sectors of the economy consistently understood the terms “musculoskeletal disorder” and “MSD”, according to a new HSE study. MSDs tended to be thought of as injuries, often specifically as the result of an accident, rather than conditions that develop gradually. Employers found it difficult to determine the root cause of an MSD and whether it was work-related or relevant to the worker’s job. Many believed that while MSDs could be caused by the job or daily tasks such as bending, awkward positions or lifting, they also believed they were also due to natural ageing and lifestyle choices. Employers said that back pain was the MSD they encountered most often, but many did not have detailed data to back this up. However, across all three sectors workers were aware that repetitive, strenuous or sedentary roles were the


MSDs tend to be thought of as injuries primary causes of MSDs. The risks associated with these roles were often compounded by challenging contractual pressures or other targets as well as different workplace cultures, eg a “macho” attitude in construction and the “patient first” mentality of nurses in healthcare. In addition, corner-cutting and not using the correct equipment was common practice across all sectors, further increasing the risk to worker health.

Hindered productivity Although available across all three sectors, equipment (eg for lifting or moving patients, materials, merchandise) was more readily available in construction and transport and storage, but workers often felt it hindered

productivity and prolonged the task. In the healthcare sector, equipment availability varied significantly by hospital trust, department and ward.

Poor communications For some employers, communications – usually posters – were the primary form of intervention cited to prevent MSDs. The places that posters were displayed (eg away from where work actually took place or in managers’ offices) and their poor upkeep often gave the impression their content was of low importance. The tone, messages and content of posters about MSDs or health and safety were often confusing, abstract, or seen as ineffective. The tone of communications ranged from legalistic and wordy to patronising, obvious and childish. Some posters had an authoritative or militant message that workers found disengaging. Training content was widely felt to be uninspiring and lacking relevance to


in work-related MSDs Image: Freestockcenter/Freepik

Award seeks to reward MSD ‘risk reduction through design’

workers’ actual jobs or duties, for example manual handling training showing nurses how to lift boxes instead of patients. In addition, training facilities were often viewed as boring and sterile environments that brought back negative memories of school for workers. This deterred participation, attention, retention and implementation of information from these sessions. The physical space and layout of these rooms did not promote physical activity – attendees were often sat down “watching” rather than “doing” and the content of training sessions had often been seen multiple times by individual workers. Out-dated technology further undermined perceptions of the importance and quality of training. Training generally showed best-case scenarios, which rarely reflected the context, environment or equipment that workers experienced in reality.

What can be done? The research suggests opportunities to improve the support provided to employers and workers: n Raising the profile and priority of MSDs, with solutions tailored or targeted to meet the needs of each sector n Raising awareness of the link between MSDs and other associated – but “higher priority” – occupational health conditions, eg stress n Reviewing the language around MSDs, to ensure greater clarity and understanding n Improving the relevance and quality of training and communications, eg via role modelling n Exploring how to reward the development and application of MSD prevention and management skills by workers – not just attendance at training n Considering how to encourage or coerce workers to use the correct equipment n Further consideration of the role of psychological and social factors in relation to MSDs, and how they can be effectively addressed.

THE HSE has teamed up with the Chartered Institute of Ergonomics and Human Factors (CIEHF) to sponsor an annual MSD “riskreduction through design” award and want businesses to nominate design changes that have made a real impact in 2018. Designs that have or can reduce MSD risks for the greatest numbers of workers will obviously be attractive, but the scheme also wants to encourage novel, innovative or niche solutions that may not have quite that breadth of benefit. The HSE is looking to inspire others to think more actively about design-based solutions and that will be the judges’ main criteria. Entries should be submitted on no more than two sides of A4, explaining the problem, the solution, the MSD benefits, any wider benefits, and what your workforce think about the changes. Submit your nominations to by 31 January 2019.

Interest grows in innovative solutions THERE is a growing appetite for new and innovative ideas to tackle musculoskeletal disorders – from identifying risk, to sourcing effective training and introducing ergonomic improvements. The Health and Safety Executive is encouraging employers and workers to think differently about the risks from MSDs and its “Go Home Healthy” microsite provides useful guidance, resources, tools and case studies to help organisations to Think, Tailor and Test their approach to managing MSDs in their workplace.



Physios join primary care teams in Ulster

More aftercare needed for

PHYSIOTHERAPISTS will be part of multi-disciplinary teams at GP practices in Northern Ireland. This will include the formal establishment of practice-based physiotherapists working alongside GPs, mental health specialists, social workers and nurses to better meet the needs of the local population. Tom Sullivan, policy and public affairs manager for the Chartered Society of Physiotherapy in Northern Ireland, welcomed the Department of Health decision. He said: “This will help deliver the transformation of health services at a critical time and ensure that patients are better able to access the right care at the right time in the right location. These posts will also help cut secondary referrals, save money and reduce pressure on GPs.”

New CPD scheme for osteopaths THE new continuing professional development (CPD) scheme for osteopaths began in October. Central to the new scheme is the concept of connecting osteopaths with each other and with other health professionals. Osteopaths will join the scheme, with its three-year cycle of CPD, at various times over the next year depending on when they next renew their registration. The General Osteopathy Council will write to each osteopath with their next renewal of registration forms to let them know what date they start on the new CPD scheme.


Older people can be uniquely exposed to issues such as bereavement, isolation and illness SELF-HARM is not just a problem in young people, new research has shown. People over 65 who harm themselves are more likely to die by suicide than other age groups, according to the study published in The Lancet Psychiatry by University of Manchester and Keele University academics. Funded by the NIHR Greater Manchester Patient Safety Translational Research Centre, the study analysed patient records using the Clinical Practice Research Datalink and found that 4,124 patients harmed themselves between 2001 and 2014, mostly by taking overdoses of medication.

It showed that people over 65 who self-harm are 20 times more likely to die an unnatural death and 145 times more likely to die by suicide than people of the same age who had not self-harmed.

Vulnerable The study also found that only 12% of older patients who selfharmed had a record of being referred to a mental health service for aftercare. Professor Nav Kapur, one of the authors of the paper, said: “We sometimes think of self-harm as a problem in younger people and, of course, it is. But it affects older adults too and the concerning issue is the link with increased risk of suicide.

“Older people might be particularly vulnerable as they are uniquely exposed to issues such as bereavement, isolation and physical as well as mental illness. They also might fear the consequences of becoming a burden to their family or friends, or not being able to function from day to day. “We hope our study will alert clinicians, service planners and policy makers to the need to implement preventative measures for this potentially vulnerable group of people. Referral and management of mental health conditions are likely to be key.” www.patientsafety.manchester.



older adults who self-harm GPs to prescribe activities to keep loneliness at bay GPs across England will refer lonely patients to community activities like cookery classes, walking clubs and art groups by 2023, as part of the Government’s new strategy to tackle loneliness. This will be called “social prescribing” and will mean doctors can try to improve their patients’ wellbeing through activities rather than medicine. Another initiative, trialled in Liverpool, New Malden and Whitby, will get postal workers to check on isolated people and help them link up with their communities or family as part of delivery rounds. The Government is

THE National Joint Registry has updated the MDS forms for primary and revision shoulder and elbow replacements. This was after input and collaboration with the British Elbow and Shoulder Society Executive Council and Arthroplasty Working Groups. During the process it became clear that revision surgery means any further operation on a patient’s joint replacement to remove, change or reduce any of the components. It has been suggested by some stakeholders that some shoulder arthroplasty procedures should be considered a “conversion” rather than a “revision”.

also spending £1.8m on improving community spaces, transforming underused areas and creating new community cafés, arts spaces and gardens.

Did you know? n The number of over-50s suffering from loneliness is set to reach two million by 2025/6. That will be a 49% increase in 10 years. n 200,000 older people haven’t had a conversation with a friend or relative in the past month. SOURCE: AgeUK


Image: Sport England

Targeting women who feel left behind by traditional exercise “THIS GIRL CAN” has launched a new phase of its Lottery-funded campaign that’s working to drive down the gender gap in sport. Fit Got Real aims to build on the campaign’s achievements so far, as well as specifically reaching out to women of backgrounds and ethnicities who feel left behind by traditional exercise. Jennie Price, Sport England’s chief executive, hopes the new message will help tackle the stark inequalities of exercise levels among different groups of women. “Many of the pressures of modern life do not make it easy for women to have the confidence and motivation to be active,” she said.

“Fit Got Real will celebrate the creative and often unconventional ways many women are fitting exercise into their busy lives.”

Updated definition for joint revision surgery

The failure of a replaced shoulder or elbow joint is usually multifactorial and can be a complex interaction of patient, implant and surgical factors. Conversion implies that the implant construct is blameless in any failure mechanism and this can be misleading. Therefore, in relation to shoulder and elbow replacement surgery, BESS and the NJR Implant Scrutiny Group will continue to consider a revision as any further operation to remove, change, add or reduce any of the components, and such procedures will be recorded thus on the new MDS forms.





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28 APRIL 2019

Call Sri on 020 8977 5474 TALKBACK l WINTER 2018





Profile for BackCare

TalkBack, winter | 2018 (BackCare)  

TalkBack is the quarterly magazine of BackCare, serving those with a personal or professional interest in back pain with news, views and edu...

TalkBack, winter | 2018 (BackCare)  

TalkBack is the quarterly magazine of BackCare, serving those with a personal or professional interest in back pain with news, views and edu...

Profile for backcare