A Musculoskeletal PathwayA Musculoskeletal Pathway

Sarah L Mitchell, Rehabilitation Programme Sarah L Mitchell, Rehabilitation Programme Manager, Scottish GovernmentManager, Scottish Government

June Wylie, AHP Professional Officer, Scottish June Wylie, AHP Professional Officer, Scottish GovernmentGovernment

Related Policy DriversRelated Policy Drivers

Shifting the Balance of Care – Shifting the Balance of Care – Extend scope of services provided by non medic

al practitioners outside acute hospital Improve capacity and flow management for sche

duled care 18 week referral to treatment standard18 week referral to treatment standard Delivery Framework For Adult RehabilitationDelivery Framework For Adult Rehabilitation

Equally Well Implementation PlanEqually Well Implementation Plan

Task and Finish Group SGHDTask and Finish Group SGHD

Pathway RequirementsPathway Requirements

Self referral into MSK servicesSelf referral into MSK services

Community AHP led MSK modelCommunity AHP led MSK model

The EvidenceIs patient self referral to physiotherapy:– feasible, appropriate, acceptable, safe, cost

effective, have wider implications?

Yes: national & international trials

10 publications (2 more in press), 73 presentations, 37 peer reviewed, 46 invited international

270,988 referrals to physio from GPs annum (90%MSK)

£1,815016 (2004) based on 22.5% cost benefit

Top Ten conditions presenting to Top Ten conditions presenting to GPGP

What could it deliver – apart from known patient benefits?

Improvement in waiting times

Impact on wider system greater– Less diagnostics– Frees up GP and 2ndry time– Maximises physio efficiency

Why is it not mainstream in Scotland? (40%)

Resources only where history of underprovision

Needs clear policy steer and local accountability

Rationale for utilising NHS 24 as Rationale for utilising NHS 24 as resource for self referralresource for self referral

Single point of access into PT. Single point of access into PT. Improving access to services Improving access to services (especially for remote and rural (especially for remote and rural areas) areas) Systems for self referral to Systems for self referral to physiotherapy need to be physiotherapy need to be streamlined and utilised in a more streamlined and utilised in a more cost effective manner. cost effective manner. Part of a whole systems MSK Part of a whole systems MSK pathwaypathwayOnward electronic referral Onward electronic referral management systemsmanagement systemsSelf management adviceSelf management adviceWebsites as support for self Websites as support for self managementmanagement

A Model For Accessing Ortho ServicesA Model For Accessing Ortho Services

A Community Based Multiprofessional A Community Based Multiprofessional Triage Team / Orthopaedic Assessment Triage Team / Orthopaedic Assessment Service (OAS) – PT’s and Gpwsi Service (OAS) – PT’s and Gpwsi

A centralised referral management system A centralised referral management system – NHS 24 physiotherapy telehealth service– NHS 24 physiotherapy telehealth service

All AHP musculoskeletal services to be All AHP musculoskeletal services to be delivered within a single systemdelivered within a single system

All return clinic appts following surgery seen All return clinic appts following surgery seen by AHP MSK teamby AHP MSK team

Why re-design?Why re-design?UK figures show that in some centres UK figures show that in some centres conversion to surgery between 20-38%. In conversion to surgery between 20-38%. In Scotland figures much the sameScotland figures much the same

Scotland – 30,000 even with 40% conversion Scotland – 30,000 even with 40% conversion still leaves 18,000 people who are having no still leaves 18,000 people who are having no active management and do not require surgeryactive management and do not require surgery

Stockport – implementation of musculoskeletal Stockport – implementation of musculoskeletal pathway in primary care altered conversions to pathway in primary care altered conversions to 75%75%

Glasgow Back Pain Service – Internationally Glasgow Back Pain Service – Internationally acclaimed model!acclaimed model!

Requirements for 18 week Requirements for 18 week deliverydelivery

The delivery of 18 weeks requires fundamental The delivery of 18 weeks requires fundamental service transformation and re-design - doing the service transformation and re-design - doing the same faster will not achieve the 18 week target. same faster will not achieve the 18 week target.

Access to services needs changing– planning Access to services needs changing– planning strategystrategy

Demand management for orthopaedic services Demand management for orthopaedic services in primary care is key to meeting access targetsin primary care is key to meeting access targets

AHP’s given opportunity to deliver on improving AHP’s given opportunity to deliver on improving access and the necessary referral management access and the necessary referral management processprocess

Service transformationService transformation

Service transformation will require not only Service transformation will require not only the ability to influence processes, but to the ability to influence processes, but to change change mindsets, cultures, activities, mindsets, cultures, activities, and organisational power basesand organisational power bases. .

Quote – Albert EinsteinQuote – Albert Einstein

Insanity: Insanity: doing the same thing doing the same thing over and over again and over and over again and expecting different results.expecting different results.

CommunityAHPMSK

Services

Integrated MSKTeam

PhysiotherapyPodiatry

OTDietician

ProstheticsRadiography

Specialist nurseGPwsi

Self Referral via NHS 24

Self management and advice

(MKN, working backs etc)

GP Referral

Walk in Self Referral

Electronic Referral

Vocational Rehabilitation

Services & Chronic Pain Services

Orthopaedicwaiting list

Rheumatologyservices

Other acute services

Electronic Referral

GP Referral Electronic Referral

Referral ManagementReferral Managementelectronic and appointment given to patient at time of call. In electronic and appointment given to patient at time of call. In future a reminder text message will be sent to the person one future a reminder text message will be sent to the person one day prior to appointment.day prior to appointment.

Appropriate interventions will be delivered or sign posted by Appropriate interventions will be delivered or sign posted by AHP team including discharge and onward referral to; AHP team including discharge and onward referral to;

vocational rehabilitation teams, vocational rehabilitation teams,

self management programmes,self management programmes,

leisure facilities leisure facilities

the community based advanced practitioner mthe community based advanced practitioner multi-professional ulti-professional triage team for a specific orthopaedic assessment. This team triage team for a specific orthopaedic assessment. This team will screen to identify whether surgical opinion is necessary or will screen to identify whether surgical opinion is necessary or any other secondary care service required.any other secondary care service required.

  

Benefits of this change in service deliveryBenefits of this change in service delivery

Improve access to diagnosis and treatmentImprove access to diagnosis and treatment

Reduce waiting timesReduce waiting times

Improve conversion rates to surgery in secondary careImprove conversion rates to surgery in secondary care

Provide greater efficiency and productivityProvide greater efficiency and productivity

Support shifting the balance of care and other Government Support shifting the balance of care and other Government policies (rehab framework, patient experience etc)policies (rehab framework, patient experience etc)

Develop and enable a self management culture for Develop and enable a self management culture for patients in Scotlandpatients in Scotland

Promote health and well beingPromote health and well being

Facilitate early return to work and avoid long term absence Facilitate early return to work and avoid long term absence and long term dependency on benefits and long term dependency on benefits

Critical success factorsCritical success factorsA single system MSK serviceA single system MSK service

Scoping work to identify the most accessible locations Scoping work to identify the most accessible locations where services can be provided– utilising leisure facilities where services can be provided– utilising leisure facilities as well as well CHP facilities.as well as well CHP facilities.

A system of in-reach into acute hospitals to allow AHP A system of in-reach into acute hospitals to allow AHP staff work with Orthopaedic Consultants in secondary staff work with Orthopaedic Consultants in secondary care, while remaining primarily based outside acute care, while remaining primarily based outside acute hospitalshospitals

Training to be undertaken to develop advanced Training to be undertaken to develop advanced practitioner skills. practitioner skills.

Detailed evaluation plan and baseline data set to be Detailed evaluation plan and baseline data set to be developed before the start of the change so that the developed before the start of the change so that the impact can be fully understood. impact can be fully understood.

The future of MSK pathways The future of MSK pathways requires …….requires …….

NHS Boards to think radically about new NHS Boards to think radically about new solutions to MSK services solutions to MSK services The need to overcome professional The need to overcome professional barriers to explore more productive and barriers to explore more productive and effective optionseffective optionsUsing lessons learnt and available Using lessons learnt and available evidence to design servicesevidence to design servicesSupport to fully explore greater Support to fully explore greater productivity and efficiency in delivering productivity and efficiency in delivering MSK servicesMSK services