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 flattens inside a decade. Being good is no longer enough and there is constant pressure to specialise, or to extend scope, simply to stay relevant and employable. We have quietly turned (in my opinion) the single most cost-effective profession in healthcare into one of the least attractive to enter and then we act faintly surprised when the workforce pipeline starts to thin. The opportunity here is enormous and it is worth being specific about why. The twenty per cent reduction was on the community list - the smaller and earlier queue, which is precisely what makes it exciting rather than marginal. Treat and mobilise people earlier in the community and you take pressure off the trauma and orthopaedics list further downstream, which remains the single largest elective queue in the country [8]. Keeping patients moving, at work, and off surgical waiting lists will reduce expensive problems in years to come. And those who do still need surgery will arrive in better physical and mental shape, which is a precursor for faster recovery, less time spent in hospital, and less cost to the system on the way through. The model also does something rather neat which deserves more credit. By pulling movement and mental health into the same visit, it chips away at the two biggest contributors to that £212bn bill at the same time and movement (psst, it is rather good for the brain as well as the body). The link has been known for years but we simply do not commission or broadcast it as though we believe it. If the system were serious - and by system I mean something rather more durable than a revolving door of health secretaries - it would do four fairly obvious things: * It would fund the workforce in the tens of millions rather than the low single figures * It would treat compliant hybrid digital MSK pathways as a genuine clinical priority, where the whole population can access at the front door. * It would build in-house rather than reflexively buying off-the-shelf products to fill the gap. This is not complex tech and return on investment multiples when there are no licence fees going to external developers. * It would actually scrutinise what it has already bought, because a surprising amount of tech has never been shown, independently, to do very much at all. Don’t get me started on a medical device’s defined intended use versus how it is being deployed in the system. So here is where I keep landing as this issue travels a long way beyond MSK. We consistently mistake cost and complexity for value. The expensive, complicated, heavily branded intervention feels serious, so it gets the money and the contract. Meanwhile the cheap, simple, effective solutions are overlooked as if it cannot possibly be the answer. Pilots happen, credit ensues, yet the budget to achieve impact at scale never materialises. For me simple, good physiotherapy is affordable, effective and scalable. Its only real crime is that it is not shiny. So I will leave you with the same question I opened with, because I’m yet to see a satisfying answer - if a pilot scheme can knock a fifth off the waiting list on a shoestring and proven its effectiveness across twenty-three areas, why on earth are we not throwing cash at it? References * GIRFT (2026) National rollout of GIRFT’s musculoskeletal (MSK) Community Delivery Programme, thanks to £3.2m government funding. gettingitrightfirsttime.co.uk * GIRFT (2025) GIRFT starts work on £3.5m government programme to reduce waiting times for elective community MSK services. gettingitrightfirsttime.co.uk * Keep Britain Working Review (2025) summary of the £212bn annual cost of ill-health economic inactivity, approximately 7% of GDP. economicsbydesign.com * GOV.UK (2026) MSK patients to get faster care and help returning to work (MSK affects nearly 18 million people in England). gov.uk * NHS England Musculoskeletal health (over 20 million people in the UK; up to 30% of GP consultations; over 30 million working days lost annually). england.nhs.uk * Hansard, UK Parliament (2024), citing the Office for Health Improvement and Disparities: MSK conditions are the third largest area of NHS spend at around £5bn a year. hansard.parliament.uk * GIRFT (2026) Evaluation shows MSK waiting lists reduced by 20% during GIRFT pilot. gettingitrightfirsttime.co.uk * The King’s Fund (2025) Waiting Times for Elective (Non-Urgent) Treatment: Referral to Treatment (RTT) (trauma and orthopaedics has the largest specialty waiting list). kingsfund.org.uk This is a public episode. 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