The need for integrated people-centred models of care

As healthcare evolves, there is an increasing need for a fundamental paradigm shift in how healthcare is funded, managed and delivered to allow the provision of “integrated, people-centred health services” . There is no “one model” of integrated, people-centred care, rather this should be seen as a service design principle underpinning strategies designed to improve access and encourage universal health coverage, and to enhance primary and community-based care. Placing people and communities at the centre of health services makes services more comprehensive and responsive, more integrated and accessible, and offers a coordinated method to address the diverse range of health needs facing humanity. There are well-documented benefits to a people-centred approach that include improved access to, and satisfaction with, care; improved efficiency of delivery; a reduction in costs; more equitable uptake; improved health literacy and self-care; better relationships between patients and their care providers; and a greater ability to respond to healthcare crises .

Whereas healthcare was once primarily focused on the management of infectious diseases, there is now an increasing shift towards the burdens associated with ageing populations, urbanisation and the globalisation of unhealthy lifestyles and their associated non-communicable diseases, mental health problems and injuries . As populations age, people suffer from multi-morbidities that are chronic and require long-term care from multiple disciplines which, in turn, increases both the complexity and costs of their treatment over the life course . Whilst there is both good evidence on the merits of this type of healthcare reform and a very compelling case for change , the transformation process is not a simple one and requires simultaneous whole-of-sector changes across many challenging domains .

The World Health Organization (WHO) has identified 5 interdependent strategic directions required to achieve greater person-centred care, which need to be locally developed and negotiated within specific country contexts . These directions include the following:

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  Empowering and engaging people

  
  
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  Strengthening governance and accountability

  
  
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  Reorienting the models of care (MoC)

  
  
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  Coordinating services

  
  
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  Creating an enabling environment .

Inherent within this level of health service reform is a need to reorient and educate the health workforce.

Recognition of the burden of musculoskeletal conditions

There has been a slow recognition of chronic musculoskeletal (MSK) conditions, their impact on the community and the personal burden from both a societal and government perspective . MSK conditions contribute significantly to the Global Burden of Disease (GBD), and this has increased dramatically (46%) in the last 2 decades, particularly in developing countries (60% vs 20% increase). In the global context, as a group, MSK disorders caused 21.3% of all years lived with disability (YLDs) and this is second only to mental and behavioural disorders that accounted for 22.7% of YLDs . MSK disorders have the fourth greatest impact on the health of the world population, considering both death and disability . GBD report data indicate that disability due to MSK conditions is estimated to have increased by 45% from 1990 to 2010 . The major burden can be attributed specifically to low back pain (49.6%), neck pain (20.1%) and osteoarthritis (10.5%). These are separate from MSK injuries. In Europe, up to 18% of primary care consultations are for MSK conditions . Unfortunately, the WHO does not as yet specifically recognise and address MSK conditions in its action plans, but rather addresses them more generally—largely under the broader headings of non-communicable diseases and injury. Whilst there is a significant overlap with the principles of management for other chronic diseases, specific approaches are required for many MSK conditions such as spine disorders that require focused prevention strategies to minimise disabling back pain recurrence and lost workforce capacity. Importantly, not all MSK conditions are chronic, and the application of contemporary, evidence-based management can prevent many from becoming so.

Models of care

One means of addressing these conditions is using a MoC and health network approach to address the escalating burden of these conditions . A MoC is an evidence-informed policy or framework that outlines the optimal manner in which condition-specific care should be made available and delivered to consumers . It aims to address current and projected community need in the context of local operational requirements, facilitating the introduction or operationalisation of strategies or methods “that work” into practice based on best available evidence. The guidance provided encourages optimal care and is coined as “the right care for the right person, delivered at the right time, by the right team, in the right place, with the right resources” . There are many examples of MoC in the MSK area, such as fragility fractures, arthritis, spinal care and injuries . To address the demand and burden of MSK conditions, a competent health workforce is required to support the effective implementation of MoCs and the associated models of service delivery. It is acknowledged that countries across all socioeconomic levels have challenges in terms of performance, deployment, retention and education of the health workforce . Therefore, the successful implementation of a MoC relies on addressing the complex interplay of macro-, meso- and micro-level factors. These factors include health systems and policy, socio-economic factors, delivery systems, infrastructure, the number and competencies of health practitioners, and participation by consumers in the co-care of their conditions .

The aim of this paper is to examine current and emerging workforce characteristics and to explore how capacity can be increased to support the implementation of MoC to ensure that people with MSK conditions receive optimal care to promote MSK health. Health outcomes, both patient and economic, are dependent on the quality of training of the healthcare worker (HCW). The thinking behind health education and options for delivery and assessment has evolved dramatically over the last few decades and continue to do so, but few outside the teaching domain appreciate or understand the importance and complexity of the issues. These issues will be presented in some depth using language that makes them clear to the “non-educationalists”. The major focus will be on building health workforce capacity to support the implementation of MoC using contemporary education strategies to deliver not only a competent health workforce, but also well-informed and empowered patients and communities. The role of the consumer, funding models and future priorities for MSK health will also be discussed.

Population changes

The global population is growing rapidly and with it, the need to provide appropriate healthcare. Advances in technologies and healthcare products also increase expectations and demand for higher quality care. With increasing longevity, there is a disproportionate increase in the global population that is aged—and with it, an accumulation of chronic and aged-related conditions placing even further demands on limited healthcare resources . Many of these conditions such as chronic pain, spinal conditions and fall-related injuries are MSK in nature and are reflected in MSK conditions being the second greatest global cause of disability . A workforce is required with the specific competencies and resources needed to address these MSK conditions.

Health workforce capacity

There is a deficiency in both the currently available and emerging workforces having the necessary competencies and capacity to support coordinated/integrated health service delivery and to address MSK and related conditions within this evolving health paradigm . There are examples of successful extended MSK practice roles (discussion to follow) that have been applied to address service delivery deficiencies in areas such as spinal care, arthritis, osteoporosis and injury management, but need to be further developed to address global deficiencies. In a landmark commissioned review of global health professional education for the Lancet in 2010, it was reported that there were approximately 2420 medical schools, 467 schools or departments of public health, and various nursing educational institutions globally . This allows the training of approximately 1 million new health workers across a range of professions every year, but institutional shortages are impacted by inequities in distribution, within and between countries. The USA, China, Brazil and India have over 150 medical schools each; however, there are 36 countries without medical schools, with 26 countries having 1 or no medical schools in sub-Saharan Africa. Thus, there is a lack of alignment between population size and national disease burden .

Global disparities also exist between urban and rural areas in terms of HCW distribution for all health disciplines, with relatively greater deficiencies occurring rurally . A global target is for 80% of countries to have reduced the disparity in HCW distribution between rural and urban areas by 50% by 2030 .

There are also major deficiencies in the data available to accurately quantify current workforce numbers and the trends relative to need. The care of patients with MSK conditions (especially in the acute setting) has been distributed to other settings or specialities, making identification of exact needs difficult to achieve, for example MSK patients admitted to surgical wards instead of orthopaedic wards. Unfortunately, there is a paucity of data regarding the health workforce who specifically address MSK disorders, and particularly in low-income countries where health services are generally less available. As a case example, World Spine Care (WSC), an organisation formed to help address the burden of spine conditions in underserved communities, found that there were essentially no conservative spine care services available to people in rural communities such as Shoshong and Mahalapye in Botswana , a country where the disability burden of neck and low back pain accounted for the leading cause of YLDs in 2013 . As a solution to this, WSC initiated a programme to address spine pain in collaboration with the Botswana government and local communities that includes the provision of conservative spine care as well as training of local Batswana (through international scholarships) to facilitate capacity building of the local MSK health workforce and to enable programme longevity and sustainability. To date, an orthopaedic surgeon has completed his surgical spine fellowship and 2 other Batswana citizens are studying in Canada and the United States to become primary spine care clinicians (chiropractor and/or physiotherapist) with a contractual commitment to work in the WSC clinic on the completion of their programmes.

Although fundamental to the problem, workforce numbers alone do not address the issue of capacity to deliver required healthcare outcomes, with training, infrastructure, equipment and consumables all being important variables . However, the data currently available do show gross shortages in health workforce numbers, which has made Universal Health Coverage a key priority for the WHO and the focus of many of its strategic health plans, including the Global Strategy on Human Resources for Health: Workforce 2030 .

Workforce migration

As is the case in any area of employment, HCWs are impacted by working conditions, career prospects and remuneration. When disparities exist in these factors, either within or across borders, the potential is created for migration that consequently has a further negative impact on health service availability in those communities that are already underserved by health services .

Efforts to address health workforce issues have tended to focus on the need-based projection of workforce requirements, and how to increase the supply of HCWs to meet projected needs . For example, overall numbers of nurses have increased in the past decade, but in developed nations (and likely developing nations), these numbers are still insufficient to meet future projected demand . However, developed nations are also more likely to attract nurses from developing nations, who are willing to migrate to improve their financial security . Globally, some sectors, departments and even governments are experiencing significant financial pressure and have suspended employment of new graduates (despite the need for additional nurses), with significant impacts on some areas of employment . The shortfall in the medical workforce can be seen worldwide, resulting in a highly competitive market for medical specialists between Australia, Canada, United States, Scandinavia and other Central European countries . In the current trends, these shortages will increase globally and become severe by 2030, and particularly in low-income countries unable to compete with remuneration and conditions offered in higher income countries .

Collaborative practice

As part of its future workforce strategy, the WHO focused efforts to promote Interprofessional Education (IPE) to support collaborative practice. In 2010, this resulted in a subsequent requirement to push forward these new models of education to help address workforce needs . Collaborative practice models, with advanced practice skill sets, working to one’s full professional scope of practice and minimisation of health professional hierarchies, have been demonstrated to address HCW shortages, improve coordination and quality of care and to improve the satisfaction of work life quality for health professionals working in these models . Moving towards interprofessional training and collaborative practice therefore has the potential to mitigate, to some degree, the pressures on workforce inadequacy and to improve retention of HCWs.

“Brain drain”

Associated with HCW migration is the “brain drain” factor, which has implications far beyond immediate service provision. Those commonly targeted are often the “best and brightest” and potential future leaders in their professions, both socially and politically, and most likely to provide innovative and effective local healthcare solutions. Their migration also represents a potential loss of local champions, educators and mentors for additional health workforce recruits, thus further reducing capacity. Psychologically, the loss of key staff from a service can worsen morale, lead to a sense of hopelessness and an associated greater workload for the further depleted service. This is a very difficult issue to address particularly in communities where threats to the health and safety of the HCW are an additional driver to migration. Improved data collection, financial and non-financial incentives, ethical codes of conduct with regard to migration, and agreements between countries are all specific strategies that have been proposed to address worker migration . Hiring practices and incentives for HCWs should address, for example, job security, workload and support systems, a safe work environment, gender equity and future career paths through professional development and continuing education . The broader consequences of “brain drain” are complex and variable, with suggestions that in some circumstances, there can be a net beneficial effect due to “incentivisation” of the remaining population to further their education. Any such potential benefits, however, are delayed and conditional on the resources to provide additional education. Providing training resources to the source country helps to both replenish the workforce deficit and provide an additional pool of HCWs from which to source . The ethics of human resource “poaching” by wealthier nations is an important consideration that needs to be further addressed by global guidelines and policies .

Population changes

The global population is growing rapidly and with it, the need to provide appropriate healthcare. Advances in technologies and healthcare products also increase expectations and demand for higher quality care. With increasing longevity, there is a disproportionate increase in the global population that is aged—and with it, an accumulation of chronic and aged-related conditions placing even further demands on limited healthcare resources . Many of these conditions such as chronic pain, spinal conditions and fall-related injuries are MSK in nature and are reflected in MSK conditions being the second greatest global cause of disability . A workforce is required with the specific competencies and resources needed to address these MSK conditions.

Health workforce capacity

There is a deficiency in both the currently available and emerging workforces having the necessary competencies and capacity to support coordinated/integrated health service delivery and to address MSK and related conditions within this evolving health paradigm . There are examples of successful extended MSK practice roles (discussion to follow) that have been applied to address service delivery deficiencies in areas such as spinal care, arthritis, osteoporosis and injury management, but need to be further developed to address global deficiencies. In a landmark commissioned review of global health professional education for the Lancet in 2010, it was reported that there were approximately 2420 medical schools, 467 schools or departments of public health, and various nursing educational institutions globally . This allows the training of approximately 1 million new health workers across a range of professions every year, but institutional shortages are impacted by inequities in distribution, within and between countries. The USA, China, Brazil and India have over 150 medical schools each; however, there are 36 countries without medical schools, with 26 countries having 1 or no medical schools in sub-Saharan Africa. Thus, there is a lack of alignment between population size and national disease burden .

Global disparities also exist between urban and rural areas in terms of HCW distribution for all health disciplines, with relatively greater deficiencies occurring rurally . A global target is for 80% of countries to have reduced the disparity in HCW distribution between rural and urban areas by 50% by 2030 .

There are also major deficiencies in the data available to accurately quantify current workforce numbers and the trends relative to need. The care of patients with MSK conditions (especially in the acute setting) has been distributed to other settings or specialities, making identification of exact needs difficult to achieve, for example MSK patients admitted to surgical wards instead of orthopaedic wards. Unfortunately, there is a paucity of data regarding the health workforce who specifically address MSK disorders, and particularly in low-income countries where health services are generally less available. As a case example, World Spine Care (WSC), an organisation formed to help address the burden of spine conditions in underserved communities, found that there were essentially no conservative spine care services available to people in rural communities such as Shoshong and Mahalapye in Botswana , a country where the disability burden of neck and low back pain accounted for the leading cause of YLDs in 2013 . As a solution to this, WSC initiated a programme to address spine pain in collaboration with the Botswana government and local communities that includes the provision of conservative spine care as well as training of local Batswana (through international scholarships) to facilitate capacity building of the local MSK health workforce and to enable programme longevity and sustainability. To date, an orthopaedic surgeon has completed his surgical spine fellowship and 2 other Batswana citizens are studying in Canada and the United States to become primary spine care clinicians (chiropractor and/or physiotherapist) with a contractual commitment to work in the WSC clinic on the completion of their programmes.

Although fundamental to the problem, workforce numbers alone do not address the issue of capacity to deliver required healthcare outcomes, with training, infrastructure, equipment and consumables all being important variables . However, the data currently available do show gross shortages in health workforce numbers, which has made Universal Health Coverage a key priority for the WHO and the focus of many of its strategic health plans, including the Global Strategy on Human Resources for Health: Workforce 2030 .

Workforce migration

As is the case in any area of employment, HCWs are impacted by working conditions, career prospects and remuneration. When disparities exist in these factors, either within or across borders, the potential is created for migration that consequently has a further negative impact on health service availability in those communities that are already underserved by health services .

Efforts to address health workforce issues have tended to focus on the need-based projection of workforce requirements, and how to increase the supply of HCWs to meet projected needs . For example, overall numbers of nurses have increased in the past decade, but in developed nations (and likely developing nations), these numbers are still insufficient to meet future projected demand . However, developed nations are also more likely to attract nurses from developing nations, who are willing to migrate to improve their financial security . Globally, some sectors, departments and even governments are experiencing significant financial pressure and have suspended employment of new graduates (despite the need for additional nurses), with significant impacts on some areas of employment . The shortfall in the medical workforce can be seen worldwide, resulting in a highly competitive market for medical specialists between Australia, Canada, United States, Scandinavia and other Central European countries . In the current trends, these shortages will increase globally and become severe by 2030, and particularly in low-income countries unable to compete with remuneration and conditions offered in higher income countries .

Collaborative practice

As part of its future workforce strategy, the WHO focused efforts to promote Interprofessional Education (IPE) to support collaborative practice. In 2010, this resulted in a subsequent requirement to push forward these new models of education to help address workforce needs . Collaborative practice models, with advanced practice skill sets, working to one’s full professional scope of practice and minimisation of health professional hierarchies, have been demonstrated to address HCW shortages, improve coordination and quality of care and to improve the satisfaction of work life quality for health professionals working in these models . Moving towards interprofessional training and collaborative practice therefore has the potential to mitigate, to some degree, the pressures on workforce inadequacy and to improve retention of HCWs.

“Brain drain”

Associated with HCW migration is the “brain drain” factor, which has implications far beyond immediate service provision. Those commonly targeted are often the “best and brightest” and potential future leaders in their professions, both socially and politically, and most likely to provide innovative and effective local healthcare solutions. Their migration also represents a potential loss of local champions, educators and mentors for additional health workforce recruits, thus further reducing capacity. Psychologically, the loss of key staff from a service can worsen morale, lead to a sense of hopelessness and an associated greater workload for the further depleted service. This is a very difficult issue to address particularly in communities where threats to the health and safety of the HCW are an additional driver to migration. Improved data collection, financial and non-financial incentives, ethical codes of conduct with regard to migration, and agreements between countries are all specific strategies that have been proposed to address worker migration . Hiring practices and incentives for HCWs should address, for example, job security, workload and support systems, a safe work environment, gender equity and future career paths through professional development and continuing education . The broader consequences of “brain drain” are complex and variable, with suggestions that in some circumstances, there can be a net beneficial effect due to “incentivisation” of the remaining population to further their education. Any such potential benefits, however, are delayed and conditional on the resources to provide additional education. Providing training resources to the source country helps to both replenish the workforce deficit and provide an additional pool of HCWs from which to source . The ethics of human resource “poaching” by wealthier nations is an important consideration that needs to be further addressed by global guidelines and policies .

Rheumatology

Examination of workforce issues has been undertaken specifically relating to professions recognised as being involved in MSK health. Al Maini et al. highlighted that although the number of rheumatologists is greater in developed countries than in developing countries, there are worldwide and regional shortfalls in both. Rheumatologists are generally located within urban regions, with severe shortages in rural areas. Of particular note was the severe shortage of paediatric rheumatologists. Primary care practitioners with no formal training in rheumatology were most likely to fill these service gaps. These shortages have a negative impact not only on primary prevention and health promotion efforts, clinical practice and service delivery, but also on opportunities to conduct epidemiological, clinical, basic and translational research . More rheumatologists are needed with training better aligned to service requirements and with necessary funding and policy support to address infrastructure/resource requirements, research and education.

Orthopaedics

Depending on funding and regulations for admissions and training, attraction and supply of orthopaedic surgeons vary from very high in the urban areas of wealthy developed countries with private funding models and generous remuneration opportunities to very low or non-existent in rural regions of poorer countries . For example, in India, less than 30,000 orthopaedic surgeons cater for 1.2 billion people (1 orthopaedic surgeon per 400,000 people) . Even in affluent countries such as Australia, the Royal Australasian College of Surgeons (RACS) has identified that the numbers of those completing surgical training will need to increase to provide an adequate service to the Australian population, because of the increasing population and increasing age . These numbers are also affected by changes to safe working hour and rostering regulations. This resultant reduction in the work hours has changed both service provision models by trainees and their training experience . To compensate for this, there is an increasing trend towards more consultant-driven practice and more years of post-fellowship training to address the shortfall in experience by trainees. Although realignment of existing orthopaedic surgeon numbers and skill sets may address some regional deficiencies, the overall number of orthopaedic surgeons needs to increase drastically globally to address the current and increasing future demand.

Orthopaedic nursing

There is also a global increase in the demand for orthopaedic nursing care, linked to the ageing population . Anecdotal evidence suggests that the number of specialist orthopaedic nurses is decreasing and enrolments in specialist postgraduate training are falling. Changes in orthopaedic surgical technique have impacted the way orthopaedic nursing is delivered, with more rapid patient mobilisation and less immobilisation in bed or the need to manage specialised traction devices. These changes have led to a dilution of the orthopaedic nursing specialty to the point where others outside of orthopaedics (and nurses within orthopaedics) no longer see orthopaedic nursing as a true specialty area .

Allied health

Workforce shortages are more difficult to determine for the allied health workforce. While countries such as Australia have some data on allied health professions managed by the Australian Health Practitioner Regulation Agency (including physiotherapists, podiatrists, medical radiation, occupational therapists and pharmacy), the information is generally not adequate to assist policy development and planning for the future and similar systems do not exist across all countries.

Canadian experience

Over the past decade, Canada has undertaken a collaborative approach to human health resource planning within the “Framework For Collaborative Pan-Canadian Health Human Resources Planning” . The priority in Canada was also to plan for a self-sustaining health work force to reduce reliance on the “importing” of health skills. Data from all training programmes and regulatory (licensing) bodies were collected for all professions, demonstrating that while some professions increased the number of Canadian graduates, many other professions remained static or had decreasing numbers of graduates. From 1995 to 2004, health professions that specifically managed MSK conditions (physicians, nurse practitioners, physiotherapists, chiropractors and occupational therapists) remained essentially static, despite the increasing burden of these disorders in Canada .

Education: why, what and how?

Originally, the role of medical education was to equip students with all the knowledge, skills, problem-solving abilities and attitudes needed for the rest of their professional lives. In recent decades, however, the role of the healthcare professions has changed and is changing so rapidly that this educational approach no long suffices. Learning has moved from “informative” (teaching students what they need to know) to “formative” (forming the students into knowledgeable experts) and including “transformative” (educating the students to become mature experts), progressively producing the “expert”, the “professional” and finally the “enlightened change agent” with a greater community and global understanding/perspective of health .

To ensure that healthcare professionals can be the lifelong learners they need to be and that the system needs them to be, meta-cognitive abilities (such as reflective practice and self-regulation skills) are a critical competency . Whereas formerly the main focus of education was on teaching knowledge and skills , it is now changing to include learning-to-learn and self-regulated learning skills . This does not mean that having sufficient knowledge and skills is unimportant. Quite the contrary, they are essential as they form a base from which subsequent self-regulated learning needs to be directed and can be advanced .

Metacognition refers to “thinking about thinking”, it is a form of reflective practice whereby through regular analysis of one’s own learning activities and performance, we can better identify our own strengths and weaknesses and manage the effectiveness of our own learning . Such metacognition does not always come naturally and therefore, its incorporation in educational programmes as a core competency to support the effective implementation of MoCs is important .

Another critical area in health professions education is clinical reasoning . It is the subject of much research and debate. Whilst some believe that problem-solving and clinical-reasoning ability can be taught as a more or less generic skill, others argue that they are largely domain specific and idiosyncratic, and are best acquired with deliberate practice and problem-solving exercises . The role of the teacher is to coach and provide feedback on the reasoning and decision-making demonstrated by students. Although it may be domain specific, well-organised, specific knowledge is required to solve problems and reason critically, and this can be taught. The processes by which each student applies the knowledge to solve problems, however, are more learner specific .

For professional training around MSK disorders, the knowledge base largely revolves around spinal and extremity clinical anatomy and associated imaging; normal form and function of MSK tissues; biomechanics; and the related pathophysiology and clinical manifestations of MSK injury and disease processes . However, recent initiatives also highlight the critical importance of embedding core competencies in pain assessment and management in prelicensure contemporary curricula for health professional education . Given that pain is such a key determinant of disability in MSK conditions, this competency-based educational upskilling can act as a key lever to support the successful implementation of MSK MoC . Furthermore, continuing professional educational models that incorporate interprofessional models of upskilling can help build workforce capacity to support the effective implementation of MoC . Although the behavioural, social and professional bases of practice are fairly generic across health, some of the biomedical science foundations of clinical reasoning for MSK practice are very specific and depend on knowledge that is not transferable from other specialties/domains. The more the teacher knows and understands about the topic, and the more he/she is able to reflect on the reasoning process and identify potential gaps in knowledge or understanding, the more concrete and focussed will be the feedback to the student. As a learner’s knowledge base and expertise increases, teaching and learning methodologies also need to adapt, typically moving from a highly structured, scaffolded approach to a more open, coaching approach, allowing the students to increasingly take responsibility and control over their own learning and assessment .

Encoding specificity in human learning is the phenomenon that memories are more easily retrieved if the environment or context at the time of learning is similar to those at the time when retrieval is needed. In other words, if initial learning occurs in a similar context to that which is intended to be applied, it is more likely that it will be retrievable when required. Further, humans are better at using the learned knowledge, if it is learned in the form and order in which it has to be applied . This has important implications in health education design. Examples include anatomy teaching for MSK application , and the management of emergency scenarios where high fidelity simulations are often used in training to support high stakes decision making and teamwork .

There has been a large amount of research to determine how students learn and it is clear that learning in context, active learning and collaborative learning are more efficient . These learning principles must be applied to education programmes aimed at developing MSK workforce skills as we move from siloed, hospital-based MSK healthcare delivery to community-based, multidisciplinary and integrative care.

Although the cognitive aspects of learning are important, so too are the more transformative aspects including the development of professional identity; understanding professional and ethical boundaries; the ability to deal with uncertainty and unpredictability; and the development of resilience .

Interprofessional education

As part of the Global Workforce strategy and the move towards integrated, people-centred healthcare, there has been a strong push towards the implementation of IPE strategies with particular emphasis on the healthcare professional as a collaborator and communicator . IPE formats vary from case discussions with reflections of roles and simulations to physical co-presence of different professions during training . Although evidence supporting IPE continues to grow, there is a paucity of IPE programmes that actually involve fully integrated clinical co-training of different HCWs. The implementation of IPE programmes has several major barriers: they are difficult to plan and coordinate, and require a large commitment and collaboration across a range of professions and faculties within a teaching institution. Unless carefully planned with good engagement and positive representation of all roles, the outcomes may be the opposite of the desired goals, with resulting professional resentment rather than mutual respect and collaboration. For example, there are arguments to suggest that IPE programmes are better introduced earlier rather than later in curricula, before professional biases have been established. With better articulation of the collaborator role and careful planning, advances in IPE will be made. To provide guidance and assistance in the adoption and development of collaborative learning models, the WHO subsequently produced global guidelines in 2013 that used recent research to underpin health professional training transformation . With the significant number and diverse type of health professionals managing MSK complaints in their practices, and the enormous burden these conditions cause, learning through IPE “with, from and about each other” around MSK specific curricular content can be an optimal way of promoting future interprofessional collaboration among emerging health providers.

Although there is a widespread and growing evidence that IPE may improve interprofessional collaboration, promote team-based healthcare delivery, improve efficiency of care delivery and enhance personal and population health, definitive evidence linking IPE to desirable intermediate and final outcomes does not yet exist, with more rigorous research required . “Milestones” and “entrustable professional activities” (EPAs) are being explored as a possible solution to some of the difficulties associated with the current approaches to IPE (discussed below).

Practice points

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