Community Appointment Days vs Standard Physiotherapy for People with a Musculoskeletal Condition

BACKGROUND A third of the UK population have a musculoskeletal (MSK) condition. These conditions contribute to work absence, reduced wellbeing and societal participation, progression to multimorbidity, and are the third largest area of NHS spend. Physiotherapy (standard care) has long wait times and is often limited to management of the referring diagnosis with no capacity for health promotion or wider health/social care needs. Community Appointment Days or ‘CADs’ were developed to enable a more personalised approach to support people with MSK conditions with symptoms, wider long-term conditions, and additional health and social care issues they face. Local evaluations provide early evidence of high patient satisfaction and potential cost savings from co-location of services. However, effectiveness remains uncertain, as is the collective action needed to ensure equitable CAD deliverability nationally. AIM To determine whether CADs should become a part of standard care for people with MSK conditions, and if so, how to optimise implementation. OBJECTIVES 1. Deliver a cluster randomised controlled trial (RCT) to determine the clinical- and cost- effectiveness of CAD vs. standard care. 2. Deliver a process evaluation to explain the RCT results and inform implementation (if effective) to optimise healthcare equity and future sustainability. 3. Inform knowledge mobilisation of patients, professionals, managers and commissioners to use findings. METHODS Normalisation process theory as a theoretical lens across 4 workstreams (WS). WS1: Sixteen UK-wide sites (Trusts delivering standard care) will be enrolled in a multi-centre pragmatic parallel group cluster superiority RCT with integrated pilot. Adults >/=18 years on MSK standard care wait lists will be invited. Evaluation of quality of life, work, and adverse events at 3- and 6- months. WS2: Cost-utility analysis to compare the incremental health outcome, quality adjusted life years, with the incremental cost between CADs and standard care at baseline, 3- and 6- months. Comparison of monthly wait list volume, patient-initiated follow-up volume, and waits >18 weeks for the 6-months post services offering CAD or standard care. Markov models will be used to estimate the lifetime cost-effectiveness of CAD by projecting long-term outcomes and associated healthcare costs. WS3: Mixed methods process evaluation with data from WS1-2, interviews with people with MSK conditions (those who declined, accepted and did not attend, or attended CAD/standard care), managers and commissioners, and focus groups with CAD staff. Evaluation of the role of context in reach, acceptability, fidelity, perceived mechanisms of impact, and to explain outcomes in WS1-2. WS4: Knowledge mobilisation of inclusive and accessible novel outputs (e.g. digital stories, animations, service spec templates, business plans, implementation toolkits, journal articles) through a supportive network of networks to people with MSK conditions, the public, policy and decision makers, service staff, and the academic community. Study within a trial: Exploring feasibility of evaluating carbon effectiveness of CAD vs standard care. IMPACT This proposal will determine whether the approach delivers (or not) on the proposed value gains of improved personalised care (and quality of life), access equity, standard care demand, health promotion, and reduced work absence.