George Peat

Objectives To quantify provider-level variation in musculoskeletal (MSK) health outcomes, consultation experience and opioid prescribing in general practice using a validated case-mix-adjustment model, and to evaluate the feasibility of applying Achievable Benchmark of Care (ABC) and funnel plots to derive performance benchmarks. Design Prospective observational cohort study. Setting 30 general practices across 13 primary care networks within a defined geographical region in England, UK (primary care). Participants 1875 adults aged ≥18 years consulting general practice with non-inflammatory MSK pain between September 2021 and July 2022 who consented to data linkage. Of these, 1317 (70%) completed 3-month follow-up. Patients with inflammatory arthritis were excluded. Interventions None. Primary and secondary outcome measures Primary outcome was 3-month change in Musculoskeletal Health Questionnaire (MSK-HQ; range 0–56, higher scores better) score. Secondary outcomes were patient-reported poor consultation experience and opioid prescribing within 14 days of consultation. Multivariable case-mix models included demographic and clinical variables. Provider-level variation was assessed using funnel plots. ABC methodology defined achievable benchmarks based on top-performing providers. Results Mean unadjusted 3-month MSK-HQ improvement was 4.9 points. After case-mix-adjustment, the weighted mean improvement was 4.8 points, with provider-level adjusted gains ranging from 3.0 to 5.7 points. ABC benchmarks were 5.7 points for MSK-HQ improvement, 4.4% for poor experience and 19.6% for opioid prescribing. Case-mix-adjustment altered provider rankings compared with crude analyses. Funnel plots identified two providers exceeding the 95% control limit for opioid prescribing; no outliers were observed for MSK-HQ. Conclusions Case-mix-adjusted benchmarking of MSK care in general practice is feasible: combining case-mix models, ABC benchmarks and funnel plots offers a transparent framework for provider comparison. The low baseline response rate, which varied between networks, means the variation observed should be interpreted cautiously rather than as an assessment of individual providers. Trial registration number ISRCTN18132064.

Objectives Though non-traumatic wrist disorders (NTWD) are common, little is known about how clinicians direct their management. In this study, we aimed to explore clinical decision-making and practice behaviour in managing those with non-traumatic wrist disorders. Design This is a qualitative study using semi-structured, face-to-face and remote interviews. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis Setting UK-based clinicians from across private and public healthcare settings were selected through involvement in a previous online survey. Participants Data were collected from 15 clinicians using semistructured interviews (April–August 2024). Interviews were audio-recorded, transcribed verbatim and analysed using reflexive thematic analysis. Results We analysed the data into five overarching themes. The first theme, ‘listening and acknowledging concerns’, described the concentration, empathy and attention involved with initial interactions. The second theme, ‘What this means to me’, described how clinicians interpreted and communicated information about a patient’s wrist condition, often co-constructing explanatory narratives with patients through the use, modification or deliberate avoidance of diagnostic labels. Clinicians differed in the value they attributed to specific diagnoses, with some viewing them as essential for guiding management and others favouring function-based explanations. In the third theme, ‘having an honest conversation’, clinicians expressed the need to reach a shared and realistic understanding of what was achievable going forwards. The fourth theme, ‘managing what matters’, reflected the pragmatic sentiment held by clinicians in working towards clear functional goals that really matter to the individual patient. The final theme, ‘sitting with uncertainty’, encompassed the importance of allowing people to find their own ways of coping and how explaining certain uncertainties may be of value to patients. Conclusions This study provides the first description of UK clinicians’ practice behaviour regarding NTWD across professional groups and healthcare settings. The findings reveal that effective care is driven by a sophisticated blend of professional integrity, relational skills and clinical pragmatism, particularly when faced with diagnostic uncertainty and resource limitations.

Introduction: Increasingly detailed investigation confirms that the best management of those with non-traumatic wrist disorders (NTWD) remains elusive, and considerable potential for improvements to care exists. This study aimed to use a modified virtual nominal group technique (vNGT) to facilitate clinician stakeholder discussions to create consensus statements and recommend priorities for future improvements in the management of NTWD in the UK. Methods: We created knowledge-gap topic areas and developed statements to reflect these. Preliminary ranking, silent reflection and idea generation occurred prior to the workshop. Two 2-hour vNGT workshops were conducted (n=8 and n=7; specialist hand therapists (8), first contact practitioners (2), generalist secondary care physiotherapists (2), wrist and hand specialist orthopaedic surgeons (2), specialist rheumatology physiotherapist) during which five nominal questions were discussed to create consensus statements (November 2025). Ranking of statements from all activities occurred 1 week following completion of the final workshop. Results: Direction was given for key components of assessment noting that specific diagnosis should be attempted, and de Quervain’s tenosynovitis should be considered a distinct entity to grouped NTWD. Where specific diagnosis was deemed unattainable, a transition to a non-specific approach was recommended. Participants emphasised the importance of considering patient’s lived experience and functional goals when informing management decisions. Prognosis and self-management strategies should be prioritised, avoiding either over-investigation for non-specific problems or generic management for distinct treatable conditions. Conclusions: UK-based clinician stakeholders, predominantly from secondary care, developed consensus-based priority statements regarding future improvements for the management of people with NTWD. Competing clinician perspectives were found regarding diagnostic specificity, resulting in apparently contradictory consensus priorities and highlighting underlying divisions in how NTWD are conceptualised and managed.

Allied Health Professionals (AHPs) have a key role to play in addressing well-documented health inequalities in rural and coastal areas, but unequal AHP workforce distribution is a key challenge to them doing so. This systematic scoping review explores available international evidence on the AHP workforce in rural and coastal areas. It aims to map the existing literature and identify the key variables associated with the establishment of a more sustainable workforce. Following the Joanna Briggs Institute (JBI) guidelines a search was carried out in academic databases Medline, CINAHL, Web of Science and Business Source Premier, and policy and grey literature database Overton. 10,494 studies were identified. Following title and abstract screening and full-text review, 49 studies were identified for inclusion. Narrative synthesis identified eight key rural and coastal AHP workforce domains. Four are directly connected to the rural context, and four are related to generic human resource factors, but have distinct and potentially unique implications when considered in the rural context for the attraction and retention of AHPs. Findings are presented as an evidence‑informed framework designed to guide future scholarship and initiatives to improve AHP workforce recruitment and retention in rural and coastal areas.

Objective: Unlike several other fields of healthcare, little is known about the size of ‘therapist effects’ on patient outcomes following rehabilitation for musculoskeletal conditions. We aimed to estimate the proportion of variance in patient outcomes from a structured rehabilitation program explained by therapist effects. Methods: For our observational cohort study we accessed data from the national multicentre Good Life with osteoArthritis in Denmark (GLA:D) osteoarthritis management program. Analyses included 23,021 consecutive eligible adults with hip or knee osteoarthritis (mean (SD) age 65.0 (9.8) years, 71% female) treated by 657 therapists between October 2014 and February 2019. The primary outcome was ≥30% reduction in pain intensity on 0-100 VAS at 3 months. Therapist effects were estimated as the variance partition coefficient (intra-class correlation coefficient (ICC)) from two-level random intercept logistic regression models before and after adjusting for patient-level case-mix factors and therapist-level characteristics (number of patients treated, days since therapist certification). Analyses were repeated for a range of secondary outcomes using multiply imputed data and complete-case analysis. Results: 52% of patients reported a ≥30% reduction in pain intensity on 0-100 VAS at 3 months. In the null model the ICC was 0.007 (95%CI: 0.005, 0.009), which changed little after adjusting for patient- and therapist-level covariates. Upper confidence limits for ICC estimates across all secondary outcomes in multiply imputed and complete case analyses were less than 0.03. Conclusions: In a nationally implemented osteoarthritis management program delivered by trained healthcare professionals, therapist effects made a minimal contribution to variation in patient outcomes. KEY MESSAGES: What is already known on this topic: ‘Therapist effects’ - defined as the effect of a given therapist on patient outcomes as compared to another therapist - have been observed in several fields of healthcare and have important consequences for selection, training, and service improvement. In musculoskeletal rehabilitation five previous studies suggest that 1-12% of variation in patient-reported outcomes may be attributable to therapist effects, but these estimates were based on relatively small datasets resulting in substantial uncertainty. What this study adds: Our cohort study analysed registry data from 2014-2019 on 23,021 patients and 647 trained therapists from the nationally implemented GLA:D structured osteoarthritis management program in Denmark. We found that therapist effects accounted for less than 3% of total variation in patient-reported pain and quality of life outcomes 3 months after beginning the program How this study might affect research, practice, or policy: Our findings suggest that contextual factors that relate to therapist effects – therapist characteristics or therapist-patient interaction and alliance - make a minimal contribution to variation in patient outcomes from this structured, group-based rehabilitation intervention. Any contextual effects must be attributable to alternative sources, e.g. patient expectations, intervention setting.

Objective: Unlike several other fields of healthcare, little is known about the size of ‘therapist effects’ on patient outcomes following rehabilitation for musculoskeletal conditions. We aimed to estimate the proportion of variance in patient outcomes from a structured rehabilitation programme explained by therapist effects. Methods: For our observational cohort study, we accessed data from the national multicentre Good Life with osteoArthritis in Denmark (GLA:D) osteoarthritis management programme. Analyses included 23 021 consecutive eligible adults with hip or knee osteoarthritis (mean (SD) age 65.0 (9.8) years, 71% female) treated by 657 therapists between October 2014 and February 2019. The primary outcome was ≥30% reduction in pain intensity on 0–100 visual analogue scale (VAS) at 3 months. Therapist effects were estimated as the variance partition coefficient (intraclass correlation coefficient (ICC)) from two-level random intercept logistic regression models before and after adjusting for patient-level case-mix factors and therapist-level characteristics (number of patients treated, days since therapist certification). Analyses were repeated for a range of secondary outcomes using multiply imputed data and complete-case analysis. Results: 52% of patients reported a ≥30% reduction in pain intensity on 0–100 VAS at 3 months. In the null model, the ICC was 0.007 (95% CI 0.005 to 0.009), which changed little after adjusting for patient-level and therapist-level covariates. Upper confidence limits for ICC estimates across all secondary outcomes in multiply imputed data and complete-case analyses were <0.03. Conclusions: In a nationally implemented osteoarthritis management programme delivered by trained healthcare professionals, therapist effects made a minimal contribution to variation in patient outcomes.

Objectives To estimate the direction and magnitude of socioeconomic inequalities in outcome, experience and care among adults consulting for a musculoskeletal pain condition. Design Multicentre, prospective observational cohort with repeated measures at three waves (baseline, 3 months and 6 months after index consultation). Setting 30 general practices in North Staffordshire and Stoke-on-Trent, England. Participants 1875 consecutive, eligible, consenting patients, aged 18 years and over, presenting with a relevant SNOMED CT-coded musculoskeletal pain condition between September 2021 and July 2022. Interventions Standard care. Primary and secondary outcome measures Primary outcome was patient-reported pain and function using the Musculoskeletal Health Questionnaire (MSK-HQ score, 0–56). Secondary outcomes were patient experience (overall dissatisfaction with consultation experience, dichotomised) and an indicator of care received (opioid prescription within 14 days of index consultation). Using multilevel models, we examined inequalities in primary and secondary outcomes by area deprivation (Index of Multiple Deprivation derived from patient residential postcode), before and after adjusting for sociodemographic and survey administration variables, clinical case-mix and selected practice-level covariates. Results Compared with patients from the least deprived neighbourhoods, patients from the most deprived neighbourhoods had significantly poorer MSK-HQ scores at baseline (mean 22.6 (SD 10.4) vs 27.6 (10.1)). At 6 months, the inequality gap in MSK-HQ score widened (difference in mean score after adjustment for all covariates: 1.94; 95% CI: −0.70 to 4.58). Opioid prescription was more common for patients living in the most deprived neighbourhoods (30% vs 19%; fully adjusted OR: 0.69; 95% CI: 0.44 to 1.08). Only 6% of patients overall reported being dissatisfied with their consultation. Analysis of multiply imputed data produced a similar pattern of findings to complete-case analysis. Conclusions Substantial inequalities in the chronicity, severity and complexity of musculoskeletal pain problems are already present at the time of accessing care. Inequalities in pain and function do not reduce after accessing care and may even widen slightly. Trial registration number ISRCTN18132064; Results.