We hope our latest edition of Health Matters – on the subject of “Productive healthy ageing and musculoskeletal (MSK) health” – will help you and other health professionals by compiling key facts, figures and evidence of effective interventions.
Longer, healthier lives are a benefit to society in many ways, including financial, social and cultural, because older people have skills, knowledge and experience that benefit the wider population. There is an opportunity to utilise this increased longevity as a resource, whilst challenging ageism and the view that retirement is about ‘sitting more and moving less’.
Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters questions we received from professionals across the UK at the recent launch teleconference.
Our Q&A panel was joined by Professor Dame Carol Black, Principal of Newnham College, Cambridge and a special adviser to the Department of Health and PHE on work and health, and Professor Karen Walker-Bone, Director of the Arthritis Research UK MRC Centre for MSK Health and Work.
Question 1 (Access to physiotherapy)
First of all, I would like to congratulate PHE for putting together this resource. I'm just wondering what else we can do to get the message out and empower local communities and local decision makers to understand and invest in these new tools? For instance I'm conscious that people in Scotland have direct access to physiotherapy in terms of self-referral in many areas.
We should perhaps take a slightly more holistic view of this. Of course for some people physiotherapy is important but for quite a lot of MSK aches and pains you can, first of all, have perhaps one lesson and then do quite a lot yourself. You can do things in groups, you can do swimming. Think much more about what are the things that we as human beings can do to protect our MSK system and then of course as and when required, have input; whether it be physiotherapy or anything else. We've all got to work together to understand that we need to keep our own MSK system going ourselves.
Could we start teaching children about MSK health and wellbeing? Could we make PE fun again? Could we find things that they enjoy doing whilst they're at school that they might keep doing after they leave school? Be more imaginative, talk to them about their own diets. That’s going to have much more beneficial long-term effects than any individual healthcare resource that we could provide. Clearly there's a source of remediation once someone has a severe MSK problem and you know that we've got an evidence-base for some of the things that you've pointed to. But actually it’s even better if we could go towards most of us accepting that MSK pain is a normal part of our lives, that it need not be a disabling part of our lives and that we can be empowered to manage it without too much medical assistance.
Question 2 (How public health can support the frailty QoF)
We're looking at implementing a three-tier physical activity program in our local authority for falls prevention, strength and balance. We've been quite involved in the conversations with local CCGs around the implementation of the frailty Quality and Outcomes Framework (QOF) within the new GP contract. I was wondering about any advice from PHE about how to make the most of this because I think although it's being targeted currently at those who are severely frail. Some GPs are stratifying people into groups which include low frailty and no frailty. They are identifying those with no frailty at 65 and without any intervention they may go on to become frail. There could be opportunities for us to support those people that have been identified in those groups to remain in those groups or to improve them. I'm not quite sure what would be recommended and what kind of levers and mechanisms we have to do that when obviously there's going to be an awful lot of work for our GP colleagues focusing on those who are severely frail.
The first thing to say is that none of us around the table is a frailty expert, that's very much the geriatric end of the spectrum. Of course what's been of interest recently, is that we've been doing a study in working age people, aged 50 to 64, throughout England and interestingly we've found that around 4% of people even in that age group would fulfill the criteria for frailty and a much bigger percentage, something like 10%, would fulfill the criteria for pre-frailty. The important message to take home from this is that we've put frailty into the QoF because we recognize that frailty is a predictor of lots of very serious things; falling over, being admitted to hospital, becoming dependent on other people for care and of course mortality. We know that you can reverse frailty even in much older people with a combination of diet and exercise interventions and that's why it's come into the QoF with a great future potential.
But all of us around the table this afternoon are really keen to communicate that we don’t want to wait until people are 85 and frail, we'd really far rather have a life course approach to this, and get all of us beyond the age of 40, 50, 60, 70 to adopt a self-managed excellent diet, high quality exercise that's around balance and strength - we need that to be a normal part of healthy life rather than just something that we target at the frailer end of the spectrum.
So how can we help primary care? – by public health complementing the local offer from our primary care colleagues. You lose balance as you get older and that's the sort of thing that is really, really important. There are a number of different ways in which help could be provided, whether it's through dancing or yoga or whatever people are interested in. It doesn’t matter what you do, as long as you do something that engenders strength, balance and bone health. Make it fun – it doesn’t have to be going to the gym. What's fun for one person isn't necessarily fun for another person; you have to allow for some choice as well.
Question 3 (MSK pain and exercise)
I'm from the Health Innovation Network in the MSK Program here and I lead on our joint pain advisor service. It's really good to see you've got ESCAPE-pain in Health Matters. I just wanted to highlight another programme called Joint Pain Advisor which is also recognised by NICE as helping people with self-management. This is delivered through the health trainer model, through health advisors or outreach work in the voluntary sector and it very much focuses on one-to-one approach getting people to exercise, to reduce weight and adopt healthy living and also includes a social prescribing element and this is something that we've piloted in two sites, with very good results. What the advisors do is to actually take away the fear of exercising and that's a big thing for people to try to get them back to the journey of good MSK health and get them participating again and returning back to work if that has been preventing them from doing so.
It’s interesting that you mentioned pain because one of the things that our friends at Arthritis Research UK have talked about is the importance of managing pain in order to allow people with MSK problems to stay active and we shouldn't forget that sometimes pain is a barrier to access these things.
Question 4 (Encouraging people to stay active throughout life)
I'm a health and wellbeing lead for a non-profit company whose focus is on getting more people more active. How do we make a ubiquitous call to action to primary and secondary care and the community, to get people more active and get behaviour change embedded at almost every contact point and have a sort of national activity therapy service?
This is what we are trying to do now in terms of making every contact count. There are very good existing programs. They are targeting specific age groups but we need to be targeting earlier. We also need to make the association between the importance of being physically active and mental well-being and good weight control, especially where children are concerned, because those links aren’t made all the time by everyone.
In health we are better than other places but we need to reach out to our partners in education, in planning departments, those looking after our environment and our housing. We need to move towards a society where it is just built into every day of our lives. We may need to look at other countries for good examples.
Staying active is a thing that should be in every young person’s life. It isn’t something that has to be a programme that we have to inflict on people later on. Instead you should grow up in an environment where you do run around and have fun and play sports at school. Preferably you walk to school rather than being taken in a car. But it is how we get these things to be a pattern in life that we just all do. We don’t want it to be seen as therapy, it should be seen as part of living.
Think about public health in the workplace. It can be all kinds of really, really small things when it comes to physical activity. You can form a walking group that goes out at lunch. This doesn’t require any great resources. You can find a spot where you may do some yoga or you might do tai chi outside. You may have bicycles which the staff can take out at lunch and go for a ride. You could walk up the stairs instead of sending somebody an email. You could have the lifts put as far away as possible. You could, make sure that in the canteen the healthiest food is slightly cheaper than the unhealthy food and it is the first thing you see. There are multiple ways you can look after people’s mental health at work which will help them I think in their physical health. So it doesn’t have to cost a lot of money. Some very good small companies have shown that you can achieve a lot by doing little things.
Question 5 (Meaning of productive healthy ageing)
My question is about the term productive healthy ageing. Sometimes people say that public health can be maybe nanny state-ish and this is quite an aspirational term. I would think of it in a positive light. But I am just wondering what testing has been done on the term productive healthy ageing and the kind of implications it has with using people as a resource into older age.
We have been engaging with a range of stakeholders at national level over the last 12 to 15 months. We have tested some of the narrative, the language and exactly what you have just said with a range of people. The overriding the responses have been positive and it is now a question of how we package it for all across the system.
Productive healthy ageing - what does that mean to different people? Some people think it means that you have got to carry on working until you’re 80. In our first infographic we have put some elements of how we have been thinking around productive healthy ageing. It combines financial security, health and wellbeing, a person’s resilience, their connectedness as well as their physical health. We see it as productive for the person. We haven’t seen it as just productive for the workplace and economy; the examples are all about how it would be productive for the individual.
But it is interesting that you have talked of it in another way and therefore other people may think of it like that. It has been described as being able to do as much as possible for as long as possible in your working and non-working lives. That is a rather good way of describing it. It is being able to do things, it has got energy about it and a feeling that it is for you and your life. It could either be in your working life or it could be in your non-working life. One of the things that we also have been discussing at length is trying to get the language that feels right to the majority around moving away from the deficit model to an asset based model. That means focusing on what older people and age brings as we grow older. We are doing some work with WHO on ageism. We want to get away from thinking of older people as a burden and regard them as an asset to society.
Question 6 (Taking vitamin D supplements)
I am from the British Dietetic Association and I am a dietitian by training. I have a comment but also a question for you. I will start with the comment. The British Dietetic Association has got a work-ready programme and we now have 90 dietitians who can go into workplaces and assess the workplace for nutritional readiness and suitability for its workforce, be they young or old. This is a good way of actually preventing obesity problems in the future as we get in at an early stage to give the right sort of nutrition messages and get people ready for their retirement so that they are less likely to become frail or become obese and unable to exercise. Of course the messages that we give are not just around nutrition. They will be around exercise as well because we wholeheartedly believe that you can’t have one without the other and still achieve MSK health.
My question is this. I went to the New Scientist Live Exhibition which is open to the public. I was talking to some older people about Vitamin D. I had one lady where I said, that as dietitians we like to suggest that you eat as much food as possible to get all the nutrients you need. But for Vitamin D that is not always possible. So now we are recommending supplements. And this lady said “I am not having that, no, I just want to eat normal food,” and she walked away. So I thought well that message hasn’t got out to her that you can't achieve your vitamin D intake by diet alone. So how do we convince people that they need to take vitamin D tablets?
I think you will probably have this challenge of supplementation much more often in older people because a certain generation of our community who tend to be at older ages are quite averse to medications or anything they perceive to be medications. I suspect the next generation might feel a little bit differently about supplementation, but there is a piece of research actually missing about how to package the messages about vitamin D for bone health for this particular tranche of older adults. They are a group who’ve been very resilient, very robust; they don't seek medical care unnecessarily. The messaging strategy for them may need to be a little different than strategies for younger generations.
There’s also an opportunity to work with our colleagues and community pharmacies, and we have a programme of healthy living pharmacies which is now very extensive with something like 4,000 or 5,000 pharmacies signed up. Vitamin D supplementation does not seem to be particularly prominently displayed or particularly promoted in pharmacy so it may be that there’s work to do there - we’d love to hear from anybody who’s got experience of promoting vitamin D supplementation in any way.
Question 7 (Linking productive healthy ageing with everybody active every day)
How do we link this work around MSK to some of the ambitions that were set out in Everybody active every day? We need to make sure that this is about the connectedness of so many aspects of health – it’s not a single issue item, they are cross-cutting themes.
We do have to apologise sometimes for producing multiple documents from PHE, all of which land on the same desk in local government and the NHS. The messages are entirely consistent, but there may be some confusion of initiatives. So we possibly just need to think about our messaging to make it clear that these are the same messages for different stages of the life course. We will make sure that we capitalise on the excellent work that was done around everybody active every day and make sure that we lay that into the MSK work. What we are trying to do particularly with the everybody active every day programme is to shift the whole population down the route of exercise but of course for MSK there’s also a tiered approach for people who have existing osteoarthritis. So there’s a slightly different approach for people who have existing diseases, but the benefits of activity are very strong for those. It’s really important that we add MSK conditions it because so many, many people will be affected by MSK conditions and traditionally once they get a bit of arthritis, they sit down and don't do this and don't do that. We really need to challenge that in addition so that the message is no different and is coherent across whatever health condition and whatever prevention you want to do.
The good news is that whichever part of the health area we look at we come back to say that diet and exercise are the right interventions.
If you have any further questions, the older people team here at Public Health England will be pleased to answer them. So please send your question by email to email@example.com .
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