Show Notes
A community pilot reduced musculoskeletal waiting lists by 20%, and its reward was a national budget smaller than the pilot itself. The announcement, stripped of its press-release gloss, identifies an initiative that reduced community musculoskeletal waiting lists by a fifth that is now going national. The reward for that success is a grand total of £3.225m, which I had to read twice as I was expecting more zeros [1]. The pilot that proved the model in the first place cost £3.5m [2], so the reward it has earned, namely the budget to do exactly the same across every health system in England, is somehow smaller than the pilot that produced it. A bit of backdrop before we get to the outrage - because the scale of it really does matter. Ill health now costs the UK economy somewhere in the region of £212bn a year, a figure published in last autumn’s Keep Britain Working Review and worth roughly seven per cent of GDP [3], and my dear old friend MSK sits second only to mental health among the drivers of that bill. MSKMag readers will know that musculoskeletal conditions affect nearly 18 million people in England [4] and account for somewhere between a fifth and a third of GP appointments, depending on whose figures you happen to trust [5]. They also make up the third largest area of NHS spend at around £5bn a year [6], so when you set the national rollout against that £212bn you land at roughly 0.0015 per cent of the problem, which is a rounding error for the Treasury. Let’s be clear, none of this is a criticism of the work itself, which is genuinely very good. GIRFT’s MSK Community Delivery Programme cut eighteen-week community waits by twenty per cent across seventeen integrated care boards between December 2024 and March 2025 [7]. It did so with deeply unglamorous ingredients, namely community clinics, local clinical leadership and one-stop appointment days that bundle assessment, treatment, mental health support and physical activity into a single visit rather than scattering them across four separate letters and four separate days off. There is no miracle buried in any of this, just a sensible, joined up pathway run by the right people, close to where patients actually live. I have a bit of skin in this game because I spent years involved in one-stop initiatives in orthopaedics and rheumatology, the very kind that GIRFT now references. Their simplicity was a key ingredient in why they worked, with patients seen, assessed, imaged and started on a plan inside a day instead of bouncing around the system for the better part of a year. The point worth holding onto is that the model is genuinely repeatable and translatable, which is to say it is not a clever local fluke that happened to work because of one brilliant clinical lead, it is a method and methods can be copied and scaled. Which is exactly where it grates, because the seventeen-area pilot cost £3.5m and a second cohort of six more areas took another £2.2m [1]. In effect, the model has now been proved twice, across twenty-three systems and rewarded with a national budget of £3.225m to cover the entire country. England has forty-two Integrated Care Boards (ICBs) where the pilot areas received up to £300,000 each. The national rollout funding works out closer to £77,000 per area, which is roughly a third of what the trailblazers got to do precisely the same job [1]. The unspoken brief reads something like, “erm guys, can you do the same again, at scale, for less money than you spent the first time?” Anyone who has ever run a service will recognise both the request and the quiet despair this ignorance tends to produce. The deeper problem sits underneath the budget line; in the workforce, and I talk about this a lot on my various channels because the gap is real and it is widening. Becoming a physiotherapist today means obtaining near-perfect grades, no meaningful tuition concession of the sort we used to offer, a brutal job market the moment you qualify and a salary that flatten
More from MSKMag OutLoud
It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com