ahp activities in scottish msk services study14sep05.pdf · osteoporosis advice and exercise...
TRANSCRIPT
WORK IN PROGRESS
AHP activities in Scottish MSK services
A scoping study for NHSScotland
Sue Parroy Summer 2005
AHP activities in Scottish MSK services
2 WORK IN PROGRESS
Contents
NHS Argyll and Clyde 3
NHS Ayrshire and Arran 6
NHS Borders 8
NHS Dumfries and Galloway 9
NHS Fife 10
NHS Forth Valley 13
NHS Grampian 16
NHS Greater Glasgow 22
NHS Highland 26
NHS Lanarkshire 28
NHS Lothian 32
NHS Orkney 37
NHS Shetland 37
NHS Tayside 38
NHS Western Isles 42
NHS Argyll & Clyde AHP activities in Scottish MSK services
3 WORK IN PROGRESS
NHS Argyll & Clyde
The geography of Argyll & Clyde is some of the most diverse in Scotland and
presents particular challenges. There is a population of around 418750 K.
Four out of five people live in the areas of Paisley and Renfrew, Greenock and
Port Glasgow, Dumbarton and Helensburgh and other towns. The remaining
population live in remote and rural communities, including 26 inhabited
islands of which only three (Islay, Mull and Bute) have populations over 1000.
Primary Care Direct Access to Physiotherapy – available at four Health Centres in Renfrewshire. [email protected]
Podiatry clinics that have been set up to ease access for patients are varied including: Dropin, direct access, emergency and nail care. A social nail care
programme to be piloted in the north will have MSK input.
sharon.lafferty@renverpct.scot.nhs.uk
Podiatry Biomechanical Service. Patients can self refer or may be referred by their GP, Consultant or other healthcare professional to this community
based service. Alan.Best@renverpct.scot.nhs.uk
Joint working with orthotist, physio and podiatry. Biomechanic (0.5wte) based at Dumbarton [email protected]
Acute care Royal Alexandra Hospital
Musculoskeletal physiotherapy services [email protected]
• Direct Access (selfreferral), Hydrotherapy, • A Hand Clinic • Accident Emergency / Fracture Clinic, with a Senior I input who does injection therapy
• Acute Low Back Pain Clinic (service has links with Diagnostic/Imaging dept, orthopaedics,Neurosurgeon and pain clinic)
• Physio/Nurse led joint replacement review clinics – pilot study for 1 year • Extended Scope Physiotherapy sessions for orthopaedic knee and hand referrals
• Audits have demonstrated that a trained ESP can independently manage appropriately vetted orthopaedic referrals.
Podiatry Consultants and Specialist Nursing Staff may refer to the Specialist Podiatrist within acute sector for multidisciplinary working with Orthopaedist
and onward referral to community based Podiatry Biomechanical Service.
NHS Argyll & Clyde AHP activities in Scottish MSK services
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Occupational therapy Staff are involved in
• The Multi Agency Team for Care at Home (MATCH) team in assessments within A&E and facilitating supported discharges to prevent avoidable
admission.
• Preadmission elective surgery clinics – assessments for patients awaiting elective admission for joint replacement.
• Following assessment by the Occupational Therapist the Technical Instructor continues the rehabilitation process at home and therefore
manage their own caseload with supervision.
Vale of Leven Hospital
Joint replacement surgery Patients are contacted by the Occupational Therapist as soon as their name is put on the waiting list for joint
replacement. OT intervention/Home Visit offered. This allows access to the
service prior to the presurgery assessment clinic.
Inverclyde Royal Hospital, Greenock
Physiotherapy. Very much part of the local community, with clear patient information leaflets. Physiotherapy outpatient services are based around the
acute hospital and three peripheral health centres and one other small clinic.
Weekly meetings allow staff to jointly manage referrals across the patch.
Jenny.irons@
Orthopaedic sessions – There are three ESP sessions (clinics) per month: two spinal and one knee. The consultant currently triages the waiting list and
allocates the referrals to ESP or consultant. Due to staffing constraints this
has been found to be more time efficient than the previously tried ESP
physiotherapy triage; access to diagnostics still has to be established.
A domiciliary and orthopaedic team with a falls project in its infancy.
Other services Multidisciplinary Health Education Groups for Rheumatoid and Osteo arthritic patients delivered by Alan.Best@renverpct.scot.nhs.uk
Rheumatology services within the medical team with nurse lead clinics offering injections. The physiotherapist works closely with these clinics.
An interactive exercise scheme coordinated by the council in Greenock: which any health professional can refer into. Patients take the referral to the
leisure centre of their choice.
Developments ESP Podiatrist to be part of multidisciplinary Orthopaedic Outpatient Redesign
(CCI supported). This project will examine a triage system for orthopaedic
referrals, with Podiatry managing the identified foot and lower limb referrals
in partnership with orthopaedic consultant staff.
ESP Podiatrist will undertake part of the Orthopaedic Outpatient Redesign
process within a primary care setting to enable a proportion of the patient
journeys to remain within the community rather than be acute based.
NHS Argyll & Clyde AHP activities in Scottish MSK services
5 WORK IN PROGRESS
Development of Podiatry supported self–help educational groups allowing
patients a role to play in their own health management.
Temporary funding obtained from Community Outpatient Services to expand
Acute Low Back Pain clinics into the Health Centres.
Temporary funding obtained from Centre of Change and Innovation to
increase Extended Scope Practitioner sessions in Orthopaedic clinic. The
intention is to see patients referred with lumbosacral problems.
Lottery funding has been obtained to pilot an Occupational Health
Physiotherapy service across Argyll & Clyde.
Inverclyde Royal Hospital, Greenock
Pain Clinic – physiotherapy input to a pain clinic, with access to a clinical psychologist and a pain management programme.
Injection clinics – Physiotherapy led clinics in one of the health centres.
Electronic referral protocols on the hospital “sky” system and in the future electronic physiotherapy referral.
Selfreferral to physiotherapy will be considered when the results of the national trial are published.
NHS Ayrshire & Arran AHP activities in Scottish MSK services
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NHS Ayrshire & Arran
NHS Ayrshire & Arran provides a range of care to around 367,000 people. It is
home to 7.2% of all Scotland’s population. There is a wide mix of urban and
rural areas.
AHP services are managed individually across the board, although there is a
move toward single system working. All the physiotherapy staff are employed
by the General Hospitals division with some staff working in primary care
facilities.
Most of the physiotherapy staff involved in musculoskeletal services are
employed by the General Hospitals Division with some staff working in
primary care facilities. [email protected] There are some staff
in the Community care division who also see patients with musculoskeletal
conditions. [email protected]
Physiotherapy Direct Access Introduction of direct access via selfreferral at Brooksby Out Patient Clinic in Largs as part of a Glasgow Caledonian University one year
study. [email protected]
Orthopaedic Clinics There are 7 Orthopaedic Consultants at Crosshouse Hospital and 5 at The Ayr Hospital.
• Two Physiotherapy Extended Scope Practitioners work in the orthopaedic clinics. One working at Crosshouse Hospital 5 sessions per week and the
other working at Ayr Hospital 4 sessions per week.
• One Physiotherapist treats patients in the Physiotherapy Department of Crosshouse Hospital for injection therapy. [email protected]
Falls Classes in Ayrshire to identify musculoskeletal neuromuscular problems and coping strategies with patients who are at risk of falls or who have
already fallen. [email protected]
Hydrotherapy in Crosshouse Hospital and restricted access to Hydrotherapy at Arroll Park, Ayr. Contact Susan Middleton in Physiotherapy in Crosshouse
Hospital.
A Physiotherapy Orthopaedic outreach service is provided to patients discharged from the orthopaedic wards of Crosshouse Hospital to facilitate
prompt discharge. [email protected]
Early supported discharge, for patients with fractured neck of femur, is provided by Physiotherapy from the Orthopaedic ward at Ayr Hospital.
NHS Ayrshire & Arran AHP activities in Scottish MSK services
7 WORK IN PROGRESS
A service is provided for ante and post natal women with pelvic and/or low
back pain. [email protected]
A programme is provided for patients with chronic pain in Ayrshire Central
Hospital. [email protected]
Rheumatology Two senior Rheumatology physiotherapists work in out patients and clinics at Crosshouse and Ayr Hospitals. There is input to the
rheumatology wards and MultiDisciplinary rheumatology education sessions
for patients and relatives. There is a ‘One Stop’ Multidisciplinary
Inflammatory Joint Disease Clinic for patients, held in Heathfield Clinic and
Ayrshire Central Hospital. [email protected]
Podiatry Podiatry service, reconfigured in 2003, is now needs, rather than demand led. Patients can selfrefer to podiatry and they will be given a care
programme. Healthcare professionals Ayrshirewide can refer to Podiatry, but
there is no dedicated MSK podiatry service or any podiatrists working
alongside orthopaedic clinics. There are clear written protocols of care, patient
information and pathways. [email protected]
Other Services Domiciliary Physiotherapy board is provided Ayrshire wide.
Functional restoration classes for patients with chronic low back pain. Contact
Cathy Gill in Physiotherapy at Ayr Hospital.
Referrals from Occupational Health are given priority to try and facilitate staffs
attendance at work. [email protected]
Osteoporosis advice and exercise classes [email protected]
Qualified fitness instructors lead exercise classes in the community to which
physiotherapists and other health professionals can refer patients.
Developments Injection therapy by the Physiotherapy ESP in the Orthopaedic Clinics in Ayr
and Crosshouse Hospitals. Contact [email protected]
Pilot of a pathway for patients with osteoarthritic hips and knees. To filter out
patients attending Orthopaedic Consultants who do not require surgery.
Contact [email protected]
NHS Borders AHP activities in Scottish MSK services
8 WORK IN PROGRESS
NHS Borders
The Borders is a large geographical rural area, which covers 1,820 square
miles. The Borders Primary Care NHS Trust provides a wide range of
community, mental health and primary care services across this area to a
Borders population of 106,000. It has no single main centre and over 30% of
the population live in centres of 1,000 or more. The larger towns in the
Borders are Hawick (16,000), Galashiels (14,000), Kelso (10,000), Peebles
(7,000), Selkirk (6,000), Jedburgh (4,000) and Duns (2,540). The rurality of
the area and the dispersed nature of the population are key issues for the
delivery of health services, requiring many people to make long journeys for
the delivery of health facilities.
Podiatry There are no extended roles and limited triage of the referral into the
orthopaedic service at present.
Primary care Every health centre has access to on site podiatry.
Acute care Biomechanical podiatry service based in the orthopaedic workshop at Borders
General Hospital 4 days per week. This service sees patients on referral from
GP’s, consultants and other healthcare professionals.
NHS Dumfries & Galloway AHP activities in Scottish MSK services
9 WORK IN PROGRESS
NHS Dumfries & Galloway
The population served is just 146,500, but within a large geographical area of
about 2,400 square miles. Dumfries and Galloway stretches from Langholm in
the East to Stranraer in the West, and from Kirkconnel and Carsphairn in the
North down to the Solway Coast. There are a number of community hospitals
throughout the region, and an intermediate unit (including maternity services
and medical & surgical beds) in Stranraer.
Acute care A multiprofessional AHP orthopaedic triage in Dumfries and Galloway This team has been established for an number of years and covers musculoskeletal and rheumatology services. The OTs, physiotherapists and
podiatrist pride themselves on integrated working. Once each week they
jointly triage all general referrals coming into the orthopaedic service, and
manage a large percent between them. The team also runs joint
physiotherapy and podiatry outreach clinics. The physiotherapists above are
qualified to administer injection therapy
Other MSK services include
• PT triage of GP refs to physiotherapy out patient services • Joint OT /PT MSK hand clinic • Joint PT/ Pod MSK appointments • OT and PT involved in development of Orthopaedic integrated care pathways
Rheumatology services
• Joint OT/PT Rheumatology clinics for people with established disease and newly diagnosed patients
• Patient education groups for RA (close links with local Arthritis Care Org • There is an OT on call system for acute hand/orthotic interventions has been developed with Rheumatology clinics because of the rural area.
• OT pre op assessment of all proposed hand surgery for Rheumatoid patients
Other services There is good partnership working between hospital and social services OTs
about home equipment and the needs of patients undergoing proposed THJR
surgery.
Dumfries & Galloway Council believes itself to be the only council in Scotland
that has a contract with Dumfries & Galloway NHS for all orthopaedic
aftercare. (equipment). [email protected]. Patients have a pre
operative home visit and assessment by council OT staff and equipment is
provided. There is a “standard hip pack” and similar for knees. The council
bills on a per capita basis plus a travel allowance.
NHS Fife AHP activities in Scottish MSK services
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NHS Fife
Fife has a resident population of 349,429 (2001 census). 7.5% of the
population are aged 75+, compared to 7.1% in the rest of Scotland. As the
elderly population increases, there is also a 1% decrease in the age range 21–
31, with a declining birth rate.
Changes in the delivery of health services are planned for Fife to balance the
need for high quality, specialist provision, with improvements in local
community services. Consultation with NHS staff and Fife residents, is
ongoing through the ‘Right for Fife’. A Diagnosis and Treatment Centre (DTC)
will be built at St Andrews within five years.
AHP services are managed separately across the board area.
Primary care Self referral to physiotherapy in West Fife. paul.lynch@fifepct.scot.nhs.uk
Physiotherapy services in GP surgeries for over 10 years and well established, selfsufficient and not reliant on hospital services.
dennisbradley@fifepct.scot.nhs.uk Physiotherapy injection therapy
expanding. There are now two Clinical Specialist Physiotherapists in this area:
mhairileslie@fifepct.scot.nhs.uk; paullynch@fifepct.scot.nhs.uk
Joint physiotherapy and podiatry biomechanics clinics were established in 1995 . These aim to improve the patient journey and reduce
waiting times for each discipline by providing a holistic package of care.
Unfunded developments alongside these include acupuncture
LauraMcBride@fifepct.scot.nhs.uk and sports massage.
Podiatry musculoskeletal clinics – These started in 1994. Initially this was held 1 session per week in a local clinic and involved only podiatry staff.
These clinics now provide care approx 3 days per week in each locality, in
various clinics, throughout Fife. [email protected] JulieArmstrong@fife
pct.scot.nhs.uk
Integrated Response Team. This was developed within the acute sector, the management has moved to LHCCs. This primary care based team with
OTs, physiotherapists, social work and rehabilitation assistants offers 14 days
of therapy based at home and is jointly funded. Team members come to
hospital to assess patients and set up care packages.
Rheumatology – Fife Rheumatology Disease Unit based at the Sir George Sharp Unit. This is a consultant led community rheumatology service with
some access to inpatients. The non medical team providing services across
Fife is community based and made up of OTs, nurses, physiotherapists and a
fulltime podiatrist All AHPs in rheumatology are specialists. The philosophy of
the service is to teach patients long term selfmanagement of their disease.
The physios emphasise the use of local exercise facilities, the OTs run a joint
protection group and also visit work environments to facilitate keeping
NHS Fife AHP activities in Scottish MSK services
11 WORK IN PROGRESS
patients at work and podiatrists hold 8 biomechanics sessions throughout Fife.
AdeleOsborne@fifepct.scot.nhs.uk, Joan.smith@fifepct.scot.nhs.uk and
jane.gibbson@fifepct.scot.nhs.uk
Acute care There are 8 WTE Orthopaedic Consultants, 1 Associate Specialist and 2 staff
grades. AHPs are also involved with 4 Consultant Anaesthetists who work part
time within pain services
AHP staff work across 2 acute hospital sites; Queen Margaret Hospital in
Dunfermline [QMH] and Victoria Hospital in Kirkcaldy [VHK]. A service is also
provided to GP patients within Dalgety Bay surgery. A wide range of clinical
experience is provided by rotation of staff across acute sites and to outreach
at Dalgety Bay.
Victoria Hospital in Kirkcaldy [VHK]
Orthopaedic Clinics – This started in 2005. since 1998, physiotherapy extended scope practitioners have been established within the orthopaedic
service in QMH.
• Total of 5 staff involved in ESP role • ESPs able to authorise xrays and MRI tests • Direct referral by ESP to theatre list with specific Consultants • PGD under development for injection therapy • Piloting use of image intensifier for specific injection therapy, working with radiologist [email protected]
Joint biomechanics clinic – Podiatry and joint physiotherapy/podiatry MSK clinics since 1998. Referrals to these clinic come from Physiotherapists and
Orthopaedic consultants. Consultants from other fields also use the service
e.g Pain clinics and diabetes. Some patients are still referred to orthopaedics
when conservative biomechanical intervention would be of benefit. Green,
A pilot for patient self referral is running within Dalgety Bay surgery at
present. Results of pilot due later this year.
Queen Margaret Hospital in Dunfermline [QMH]
Orthopaedic clinics since 1998, physiotherapy extended scope practitioners have been established within the orthopaedic service in QMH.
Joint physiotherapy and podiatry clinics – as at VHR since 2001.
Joint A & E therapy service for older people – This is under development with occupational therapy and physiotherapy. [email protected] An
A&E occupational therapy service for older people with MSK problems has
been in place at both sites for 18 months, with an audit about to be
published. A physiotherapist has just joined the service and they will become
the ‘Therapy A&E team’. [email protected]
NHS Fife AHP activities in Scottish MSK services
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The Technical Instructor 2 role within outpatients has been developed to be the first point of contact for selected new outpatients sent directly from
Accident and Emergency and Orthopaedic clinic.
Modern Hydrotherapy facility and Biodex isokinetic facilities.
Good links with leisure centres particularly in the West of Fife.
lynn.speed@fifepct.scot.nhs.uk
Joint biomechanical physiotherapy and podiatry service for anterior knee pain referrals come via orthopaedic consultant
[email protected] or angela.green@fifepct.nhs.uk
Elective surgery. All elective hip and knee patients are seen by an Occupational Therapy Assistant T2. The role in preadmission clinic has
developed over three years. Social service OTs visit four weeks before surgery
to check and deliver equipment. This has freed up professional time.
Therapy hand team of occupational therapist and physiotherapist share skills.
Pain management – Locally developed multidisciplinary pain management programme well established within QMH. Pain services under pressure to
meet demand and resources limited.
Developments Podiatry • Introduction of a referral management system that extends the current triage of orthopaedic referrals to include primary care practitioners.
• Use of software to facilitate process mapping and decision support. • Provision of podiatry as part of triage at orthopaedic clinics to further reduce inappropriate referrals to consultant orthopaedic surgeons and aim
to reduce waiting times.
7 day occupational therapy service [email protected]
CCI redesign funding granted through the Orthopaedic outpatients
programme
[email protected] will project manage the CCI bid which
includes:
• Enhancement of existing ESP team to work across Acute and Primary Care, increasing the team from 5 to 12
• Investigate the need for extended Podiatry role within Orthopaedic service • Nurseled review clinics already in place for joint replacement patients. Further development to include new patients.
• Introduction of ESP led clinics in Primary Care alongside development of referral guidelines for GPs into Orthopaedic service
• Redesign of present referral management system to ensure that the patient is seen by the most appropriate healthcare professional
NHS Forth Valley AHP activities in Scottish MSK services
13 WORK IN PROGRESS
NHS Forth Valley
Forth Valley has a population of 279,500 served by two district general
hospitals in Falkirk and Stirling. A single regional hospital in Larbert is planned
for 2009.
The boundaries of Forth Valley stretch as far as Loch Lomond in the West,
Crianlarich in the North, and beyond Dollar in the East, which highlights the
rural needs which this Division must meet.
Orthopaedic redesign work in Forth Valley is led by an orthopaedic working
group which has GP, orthopaedic consultants, public health consultant,
radiology, physiotherapy, nursing and senior management representation.
Primary care Physiotherapy
Musculoskeletal service – Physiotherapy in place in 12 of the health centres in addition to main hospital departments.
• All MSK physiotherapy staff work from the same clinical directorate and under the same management.
• Most Senior I MSK physiotherapy staff in the Stirling locality, are not permanently sited in one health centre, and are rotated around different
health centres and into the main hospital department every 23 years.
• Two of the ESPs in orthopaedic clinics are mainly primary care practitioners and come into the hospital to carry out ESP sessions.
Back Pain Management – referral pathways to secondary care are currently being reviewed. A pilot was run initially for 6 months from
1st March 2004 to August 2004 involving 3 sessions from Extended Scope
Practitioners in primary care screening referrals to orthopaedics and GP direct
access to MRI. This has reduced the number of direct referral letters by 75%
from the three pilot sites, compared to the 6 months prior to the pilot. It has
also reduced the number of patients who do go on to see the consultant by
85%. Following redesign of back pain referrals, the majority of back pain
patients will be managed in Primary care, by GP and physiotherapists, the
ESPs will also work with an orthopaedic consultant in his clinic weekly.
Backfit classes are provided in mixed locations, some in local leisure centres and one on a hospital site. [email protected]. There
are also council run exercise referral schemes with concessionary rates for
patients referred from physiotherapy.
Pilot osteoporosis programme in North West Stirling, proactively identifies high risk patients and offers a programme for advice, screening and exercise.
Fiona Downie (Stirling Royal Infirmary) [email protected]hb.scot.nhs.uk
Occupational health physiotherapy sessions offered for both staff in Primary Care and the Division
NHS Forth Valley AHP activities in Scottish MSK services
14 WORK IN PROGRESS
A Joint Podiatry and Physiotherapy Paediatric clinic currently being piloted one session per week between Oct 04 –April 05.
Podiatry
Acupuncture clinics recently introduced within Primary Care to treat foot conditions such as Plantar Fascitis.
A Rheumatology clinic held weekly (one session) Orthotics provided to control excessive pronation in the RA foot. [email protected]
Acute care Physiotherapy
A computerised outpatient management system (SCI) was introduced in physiotherapy to replace the paper system in Stirling. This linked with the
rest of the hospital and directly with some GPs. Booking of appointments and
patient tracking has become easier. The electronic system also gives the
physiotherapist uptodate clinical information on the patient prior to the
appointment.
The time saved has been equivalent to the service getting a new fulltime
physiotherapist and amounts to an extra 400500 patients being seen per
year.
Direct electronic booking for physiotherapy appointments has been introduced
with referral protocols. [email protected]
Orthopaedic MSK physiotherapy. 6 ESP sessions in place. 4 in Stirling and in Falkirk. The patient triage/selection process differs depending on
consultant. Some consultants triage patients to be seen by the ESP, in others
the ESP works autonomously with the orthopaedic team and general clinic
referrals are triaged as they arrive.
• ESPs have injection training and can refer for Xray (not MRI), nerve conduction, bone scans and order bloods.
[email protected] and [email protected]
• A weekly ESP injection clinic at SRI physio department is held.
Stirling Combined Back Clinic (fortnightly clinic). ESP Physiotherapy, psychology, consultant in pain management and specialist nurse work
together managing patients with low back pain of less than six month
duration. Based on back pain guideline recommendations. Aimed at
addressing psychosocial factors early and prevention of chronicity.
• Regular audit includes back to work indicators, follow up at 3 months, 6 months and one year. Psychology resource is minimal and often although
the referral protocol states the clinic is for sub chronic pain, chronic
patients benefit from this resource also. Waiting time usually no more than
8 weeks.
• The Back Book is recommended. Posters advertise that it can be purchased in the local pharmacies.
NHS Forth Valley AHP activities in Scottish MSK services
15 WORK IN PROGRESS
Orthopaedic medicine clinic – In conjunction with an Orthopaedic surgeon a physiotherapist provides a weekly clinic for patients with acute and post
acute musculoskeletal conditions.
Inpatient activity
• Arhthroplasty nurses deal with follow up arthroplasty patients on both hospital sites
• Orthopaedic rehabilitation beds “step down” • Therapyled inpatient rehabilitation unit – [email protected]
Other services Pain management service – two pain clinics run in Forth valley, both led by consultant anaesthetists and specialist nurses in pain management.
Physiotherapy input is minimal due to lack of resources but both sites have
two sessions of physiotherapy specialist and one session of psychology.
Resources are too limited to have a formal pain management programme.
The team work very closely with the Pain Association Scotland classes.
Joint Rheumatology Clinics.
• ‘One stop clinic’. Rheumatologists, physiotherapists and occupational therapist. anita.carr@ fvah.scot.nhs.uk
• At Falkirk Royal a podiatry RA clinic runs in tandem with Consultant RA clinic twice a month.
Pain Management Class. This is a selfrun class by the patient support group associate with Pain Association of Scotland. Very close links with the
pain clinic. http://www.painassociation.com/about.html
NASS (national ankylosing spondylitis society) classes held (non NHS).
Osteoarthritis hydrotherapy class held in Calander Mclaren High School (non NHS).
Developments Centre for Change and Innovation (CCI ) bid to unify the referral pathway for
back pain.
CCI bid examining referral protocols for lower limb arthritis the use of ESPs,
arthroplasty nurses and GPSI.
Podiatry setting up Biomechanics clinics within Primary Care in 2005.
NHS Grampian AHP activities in Scottish MSK services
16 WORK IN PROGRESS
NHS Grampian
The population of Grampian is 523,400. Half its boundary forms a border with
the North Sea while inland it is mainly rural. Aberdeen is the largest urban
area and the main focus of activity, and is home to 40 per cent of the region's
population.
The NHS in Grampian employs over 16,000 staff. It is one of the largest
employers in the north east of Scotland, serving a population of 525,000
across 3,000 square miles.
It has an annual budget in excess of £600 million, providing 3,400 beds in 26
hospitals. Acute services are centred at Aberdeen Royal Infirmary and Dr
Grays in Elgin. Primary care and community services are provided through 20
health centres and 31 clinics, and general medical services from 87 GP
practices and 360 GPs.
Orthopaedic outpatient services are provided to residents of three NHS Board
areas Grampian, Orkney and Shetland.
Physiotherapy There are Grampianwide physiotherapy care pathways and flow charts across
the city and for referral into secondary care.
Grampian Wide Low Back Pain Physiotherapy Pathway – development of a pathway for physiotherapists working in both the acute and primary care
sectors. Includes standardised assessment forms and guidelines for
assessment and patient management, patient information leaflets, and an
electronic version of the pathway for GPs to use during consultations. The
group are working with other colleagues across Scotland in the development
of a Scotlandwide pathway. Gillian Grant, Clinical Specialist Physiotherapist,
Aberdeen. [email protected]
Primary Care Physiotherapy in primary care. There are senior physiotherapists in most GP practices, with clear physiotherapy Grampianwide care pathways and flow
charts. [email protected] There is one clinical specialist physiotherapist
(?ESP) for one area of Aberdeen with no access to diagnostics.
Podiatry [email protected] – more information awaited.
NHS Grampian AHP activities in Scottish MSK services
17 WORK IN PROGRESS
Aberdeen City
Aberdeen City Acute Low Back Pain Physiotherapy Service. This development aims to improve access to services for patients with acute
low back pain and to maximise the potential within primary care to manage
this patient group. This service is provided to a number of practices in the
North of the City and is hoped that this is the first stage in a citywide roll out.
[email protected] or [email protected]
City Wide Physiotherapy Primary Care Triage. All primary care outpatient
clinics in Aberdeen now operate a ‘triage’ system where all patients are seen
for initial assessment within a 34 week timescale. A full assessment of their
problem is carried out and the best course of action determined. From this
initial assessment they may be given advice, exercises, referred for group
rehabilitation, hydrotherapy, given an appointment for treatment (immediately
or onto a waiting list), or referred back to their GP. The emphasis is on early
intervention/advice and promotion of patient selfmanagement.
Contact Lynn Morrison: [email protected]
Aberdeenshire
Banff and Buchan
Triage At Peterhead all back pain patients are triaged and offered one of three options, advice then placed on waiting list for physiotherapy if required,
open discharge, or discharged. In Banff this service extends to all MSK
patients
Optin – Where there are higher waiting times the patient will initially be informed that a long waiting list exists and that they will be contacted when
there is an available appointment. Two weeks prior to sending them their first
appointment they are contacted to confirm whether or not they still require to
see the physiotherapist.
Exercise Recommendation Scheme This is jointly funded with the Princess Royal Trust. All MSK patients are given the opportunity to continue
on with selfmanagement by attending the local leisure centre. They are given
8 free sessions.
Back Rehabilitation Groups are provided at three different sites in this area. Contact Britt Hyman for all of the Banff and Buchan services.
NHS Grampian AHP activities in Scottish MSK services
18 WORK IN PROGRESS
Central [email protected]
Selfreferral. This began in Inverurie in 2002 and has now extended to four other sites in this area. Patients can refer themselves directly into the
physiotherapy department without first having to visit their GP. All patients
are seen within 48 hours of selfreferral.
Triage – All patients in this area are seen within 10 days of referral or earlier. Following the assessment patients may be given advice and or a home
exercise plan. They will then be given an appointment for treatment, put onto
the routine waiting list, referred back to their GP, given an open discharge or
offered back rehabilitation classes
Equal Access – A group of physiotherapists meet regularly to ensure that all patients in this area are offered equal access for back rehabilitation. This may
mean patients having to travel to get earlier access to a class.
Deeside [email protected] or
Triage – Early assessment/triage clinics are currently running in Aboyne HC. All patients are seen within 2 weeks of their referral for full assessment. They
are then either discharged with advice, given a review appointment in about 2
weeks (with exercises etc to be doing in the meantime), referred back to the
GP, or referred on to a pilates/muscle balance class (running from the new
year). The emphasis is on patients taking ownership of their conditions and
on early intervention and treatment if necessary. If the pilot in Aboyne is
successful then triage will be rolled out to the other outpatient clinics in
Desside.
Kincardine [email protected]
SelfReferral service is provided for patients at Auchenblae and Inverbervie. Any patient requiring physiotherapy can directly refer themselves
to the physiotherapy department for assessment.
Back Pain Service. The back pain classes are provided in the local leisure centre, there has been good uptake of leisure services by patients following
discharge from the groups.
Pain Clinic This is a nurse led clinic with physiotherapy and occupational therapy support. Patients are referred via the GP for multidisciplinary support
and rehabilitation
NHS Grampian AHP activities in Scottish MSK services
19 WORK IN PROGRESS
Moray [email protected]
Dr Gray’s Hospital Back Pain Service – For the last 3 years all back pain patients who attend the back class are given the opportunity to continue their
exercise programme at the Moray Leisure Centre. A link session is held every
6 weeks where the patients are introduced to the Moray Leisure Centre by
Physiotherapy staff from Dr Gray’s hospital together with Moray Leisure
Centre staff.
Moray Physiotherapy MSK Team has links with two orthopaedic clinics for direct referral of shoulder and acute knee injuries.
Selfreferral – Patients wishing to selfrefer complete a form found in the GP surgery. These are screened by the Senior physiotherapist and appointments
offered as appropriate
Orthopaedic Triage – Physiotherapists triage patients who have been referred to the orthopaedic surgeons and decide on future management e.g..
Surgery, podiatry, physiotherapy etc. This includes education sessions for
GPs.
Acute care Routes into MSK services are varied and dependant on GP referral.
Aberdeen Royal Infirmary
A physiotherapyrun spinal triage. This has run for 10 years and there are two physiotherapists in the back clinic for four hours per week. The
service runs alongside the consultant clinic. Physiotherapists may refer for x
ray (not MRI) and list for procedures. About 40% of patients are referred on
to the physiotherapy service for further treatment. It has been estimated that
this triaging allows for an extra 700 new appointments per annum, reduces
waiting time and ensures that the right professional sees the patient.
GP with special interest working at the hospital alongside a physiotherapist
Injection protocols. Physiotherapy injection protocols agreed (in particular for use on Shetland) but not implemented.
Exercise and links to leisure: A technical instructor (TI2) who has been in post five years leads rehabilitation classes. They have had additional
development including exercise coaching and City and Guilds qualifications.
[email protected] . There are good links to community
leisure centres across Grampian, with a notice board in the physiotherapy
department listing all leisure facilities.
Back Pain Rehabilitation Group. Run by one of the ESPs in back pain based on the Klabber Moffat approach. [email protected]
NHS Grampian AHP activities in Scottish MSK services
20 WORK IN PROGRESS
Pain clinic: Physiotherapy clinical specialist in Chronic Pain works with the pain team two mornings per week and takes forward some vocational
Occupational Health. NHS Grampian currently provides occupational health physiotherapy to around 7,000 staff employed by the acute trust across two
sites. This is a selfreferral system and is looking to be rolled out across
Grampian in the future. [email protected]
Rhuematology – Lesley Davidson [email protected]
• National ankylosing spondylitis society (NASS) hold classes in the hydrotherapy pool. NHS physiotherapy staff supports this class.
• Specialist ankylosing spondylitis clinic – This physiotherapy/registrar led clinic is for measurement and review of patients. The physiotherapist
may give advice, refer on for physiotherapy or facilitate admission to ward.
• Rheumatoid Arthritis Management Programme (RAMP) is a multi professional service for patients who have been newly diagnosed with
Rheumatoid Arthritis. The team includes a physiotherapist, occupational
therapist, nurse and pharmacist.
• Adolescence Transition Service – for children with juvenile idiopathic arthritis Support is offered from a multiprofessional team, which helps
with the smooth transition from children to adult services.
Physiotherpy in A&E – A senior I physiotherapist works alongside the orthopaedic consultants and A&E staff. Together with an Emergency Nurse
Practitioners (ENP) they provide care immediately post soft tissue injury and
fracture treatment. ENP refer soft tissue injury ankles for their review with
physiotherapist 57 days post injury. Patients post fractures are triaged to
refer on for further physiotherapy or selfmanagement.
Geriatric Orthopaedic Rehabilitation Unit – Main physiotherapy input done by a TI 2.
Occupational Health. Self referral for all hospital staff for occupational health physiotherapy.
NHS Grampian AHP activities in Scottish MSK services
21 WORK IN PROGRESS
Occupational therapy Is provided via community hospitals and community based rehabilitation teams, as part of a wide and varied caseload. There is not a dedicated
service.
Elective surgery – [email protected] Occupational Therapy cover for 4 wards – staffing consists of 1 full time Senior I, 2 x part
time Senior 2 s, and a full time Basic Grade. Occupational Therapy input is
provided for a variety of elective surgical patients including arthroplasty,
spinal surgery, resection of tumour, amputation and ilizarov. Input with
discharge planning in conjunction with the multidisciplinary team and various
community agencies.
Preassessment clinics – for total hip replacement, total knee replacement and spinal surgery patients. Occupational Therapy intervention through initial
assessment and liaison with the Community Occupational Therapists for
provision of equipment for home. Education of post surgery precautions and
functional implications carried out.
Patient journey group – Occupational Therapy involvement in the development of orthopaedic integrated care pathways leading to more
streamlined service.
Rheumatology is primarily linked to ward services, other than hydrotherapy. Occupational Therapy outpatient service is via referral from consultant
rheumatologists.
Geriatric day hospital – Occupational Therapy service is provided to day patients as part of a wide and varied case load.
Developments Implementation of Multiprofessional Triage and Intermediate Treatment
team in Orthopaedic OutPatients. (CCI supported). The project aims to
reduce outpatient waiting times and improve patient access by developing a
new intermediate tier of care provided by GPs with a special interest and
extended scope practitioners in an appropriate setting.
Primary Care Based Triage – CCI supported – provision of a physiotherapy/GP service for patients in the primary care setting with the
main aim to triage the patients and offer the most appropriate intervention
e.g., physiotherapy, injection therapy, etc it is hoped that this will reduce the
numbers of referrals sent on to the orthopaedic surgeons
Occupational health physiotherapy telephone advice service, for all staff.
To develop Occupational Therapy role within back pain rehabilitation
programmes.
Selfreferral and triage will be extended to other primary care areas in
Grampian over the next year
NHS Greater Glasgow AHP activities in Scottish MSK services
22 WORK IN PROGRESS
NHS Greater Glasgow
NHS Greater Glasgow works to provide health care to 870,000 people living in
local communities around The City of Glasgow, East Dunbartonshire
(Milngavie, Bishopbriggs, Kirkintilloch), West Dunbartonshire (Clydebank),
South Lanarkshire (Rutherglen & Cambuslang), East Renfrewshire (Eastwood)
and North Lanarkshire (SteppsMoodiesburn corridor).
Primary care Direct access (self referral) to physiotherapy for all our health centres, either through telephone triage or dropin clinics are in the process of being
rolled out to the north of the city. Contact [email protected]
who was the project manager in primary care.
Podiatryled biomechanical GPs have had open access to a service for over five years. Previously these patients would have been referred to
orthopaedics. By April 2005 there will be selfreferral to podiatry for patients
across Glasgow April 2005). [email protected]
Rolling out of physiotherapy led injection therapy service at sites within primary care. Patient group directive in process of being set up in conjunction
with pharmacy. [email protected] or
[email protected] for outcome of patient satisfaction
questionnaire with regards to service.
Greater Glasgow Back Pain Service which comprises clinical specialists and a lead clinician crossing both primary and secondary care. The service
consists of mainly physiotherapists and has links with psychology, culture,
leisure, imaging and orthopaedics – rolled out 2001.
[email protected] Further details to follow.
A service for homeless people employs both physiotherapists (1.5wte) and podiatrist (0.8WTE). Many have MSK problems. The service includes
domicillary visits to hostel and temporary accommodation dwellers, clinic
appointments in the purpose built health centre and self referral clinics in
homeless drop in centres. In the case of orthopaedic patients, efforts are
made to facilitate attendance to fracture /ortho clinic appointments and liaise
with orthopaedic staff.
[email protected] (Physio)
[email protected] (Physio) or
[email protected] (Podiatrist).
Primary care has an occupational health physiotherapy and podiatry service which treats staff with MSK problems at specific sites across the city. angela.price[email protected]
NHS Greater Glasgow AHP activities in Scottish MSK services
23 WORK IN PROGRESS
Acute care Northern Division (north/east sector)
Stobhill Musculoskeletal Unit. Patients are triaged by senior nursing staff and assessed and managed by 4 physiotherapists (20 sessions) and a
podiatrist with orthopaedic training. Approximately 80% of referrals are
managed in this way. In 8 months at Glasgow Royal Infirmary (GRI) 1,228
new patients were managed; 27% were discharged, 22% were placed on
surgical waiting lists, 13% were referred for investigation and 30% referred
for physiotherapy. Patient satisfaction was high with 76% happy to be seen
by a physiotherapist instead of a consultant and 94% were satisfied or very
satisfied with the service. This service is being further developed. The aim to
have eight ESPs working up to 40 sessions over the next six months following
training. The team includes a consultant surgeon and clinical nurse manager.
Through team working, communication and accurate information much has
been achieved. Including decreased waiting time, increased surgical capacity
and subspecialisation for the consultants and other team members.
Podiatry one stop triage clinics – In Stobhill, podiatrists have been triaging orthopaedic referrals for foot, ankle and gait problems since 1998.
Onestop clinics are in place whereby patients receive an assessment,
diagnosis and specially manufactured insoles, if required at the initial visit.
Therefore, treatment begins immediately, with only a review appointment
required. Only 6% of the referrals required to be referred onwards to the
orthopaedic surgeons for surgery (750 patients assessed per annum.
However, since the establishment of the designated orthopaedic podiatrist
post at GRI (July 2003), referrals for surgery can be triaged by the
orthopaedic podiatrist depending on the condition. A PGD for the
administration of steroid injections has been in place since November 03, and
training is being rolled out to all the podiatrists in the Acute Sector.
The podiatrist sees foot and ankle patients. (Primary forefoot, toes, hallux
valgus and heel pain. People are triaged and options include minor Surgical
sessions and steroid injections. Continuity is ensured and patients have pre
operative, surgical and postoperative follow up.
Joint podiatrist / orthotist clinics are in place to assess footwear requirements / splints – previously seen by orthopaedic consultants.
Podiatrists are part of the Rheumatology Team within Stobhill Hospital and Glasgow Royal Infirmary. [email protected]
West Glasgow
Orthopaedic Clinics – Extended Scope Practitioner Physiotherapist in Orthopaedics. In the West a physiotherapist with an extended scope of
practice effectively triages and manages care of referrals to the Orthopaedic
NHS Greater Glasgow AHP activities in Scottish MSK services
24 WORK IN PROGRESS
Department. The physiotherapist has the capacity to arrange any further
haematological or radiological investigation required and can refer directly
onto other specialists, including Rheumatology and Pain Clinic and can list
directly for Surgery. This service was developed initially to work with two
Orthopaedic Surgeons and effectively decreased waiting time to Out Patient
Appointment while maintaining high levels of patient satisfaction. This has
developed over the past five years and is now supplemented by the
appointment of three extended scope physiotherapists to assist in the
management of all Orthopaedic referrals.
Rheumatology – An Extended Scope Practitioner Physiotherapist in Rheumatology at Gartnavel General Hospital, triages and manages care of
patients referred to OutPatient Clinic carries out joint injection and sees also
inpatients.
Direct Access pilot in the acute setting run April – June 2004 at the Western Infirmary, incorporating joint working with Primary Care.
West Glasgow due to go full Direct Access (selfreferral) for all GP practices accessing both Primary Care and Hospital sites. Western Infirmary,
Gartnavel General Hospital. [email protected]
Southern Division
Southern General and Victoria Infirmary There is orthopaedic surgery and trauma on both sites, with the same
Integrated Care Pathways (ICPs) for all upper and lower limb arthroplasty
patients.
• Lower limb arthroplasty. OT in preassessment for all lower limb arthroplasty patients. Routine patients are seen by TI3 on both sites.
DARTeam is available to orthopaedic patients. Effectively hospital to home.
• Geriatric Orthopaedic Rehabilitation Unit GORU unit officially open late from October 2004.
• Victoria Infirmary. National Brachial Plexus service. Other services ESP in Rheumatology, who is also involved in GP injection training.
Acute and Chronic Pain Management Clinics – Glasgow Royal Infirmary and Southern General (Pain Management in UK, Dr Foster). OT input is about
to be provided to all these clinics. [email protected]
Glasgowwide osteoporosis service, written up as part of the CSP project. http://www.csp.org.uk/effectivepractice/sepp/databasebyproject.cfm?id=32
Occupational Health and Injury prevention for all undertakers in Scotland – Margaret Revie (Independent Practice) –
NHS Greater Glasgow AHP activities in Scottish MSK services
25 WORK IN PROGRESS
New training post partfunded by the health board to look at the training and CPD requirements of leisure centre staff/instructors delivering physical
activity programmes with a health component.
Developments Greater Glasgow Foot and Ankle Triage Service aims to provide the 3000 patients traditionally referred to an orthopaedic surgeon. The service will
be lead by specialist podiatry practitioners and start with a primary care based
MSK service for assessment and treatment as required.
[email protected] (CCI supported).
Saturday orthopaedic OT service (in the Southern division).
NHS Highland AHP activities in Scottish MSK services
26 WORK IN PROGRESS
NHS Highland
NHS Highland serves a population of some 208,000 residents and sees a
proportion of its patients from the influx of tourists to the Highlands, which at
certain times of the year can double or even triple the local population. NHS
Highland’s catchment area comprises the largest and most sparsely populated
part of the UK with all the attendant issues of a difficult terrain and a limited
internal transport and communications infrastructure. The area covers almost
25,784 km² (10,000 square miles), which represents approximately one third
of the Scottish land surface. The geographical nature of the region presents
particular challenges for the efficient and effective delivery of health care
services.
Primary care Patient Selfreferral to Physiotherapy. Raigmore Hospital provides physiotherapy services within Inverness GP Practices. A patient selfreferral
clinic is currently being piloted within two GP Practices. This pilot is part of the
National Survey.
A Physiotherapy Musculoskeletal Triage is based in GP practices within Inverness. Patients are assessed by a senior physiotherapist and given
appropriate advice and exercise. 3 sessions of treatment is offered within the
practice. Some patients only require advice and discharge, others may be
inappropriate for physiotherapy.
An injection therapy service is provided by trained physiotherapists within GP practices in Inverness. Referrals are accepted from physiotherapists, GPs
and consultants. This has reduced patients waiting times for this treatment by
xxx weeks. In the absence of this service X nos. of patients would be
managed by the Orthopaedic Department at Raigmore Hospital. It is
anticipated that this service will be expanded in the near future.
East Highland
Primary Care [email protected]
The MSK physiotherapy service – The outpatient service consists of an established MSK service in nine GP practices and health centres plus provision
to two Community Hospitals outpatient departments. Direct access (self
referral) has been introduced to six practices. This will be rolled out to all the
other practices once impact is established.
Informal physiotherapy screening service prior to referral to secondary care.
Physiotherapyled injection therapy service based in the community and community hospital. Referrals are accepted from all GP’s, physiotherapists
and consultants. Although we do not have accurate figures, this has had an
impact on the number of referrals to secondary care. Patient group directives
being reviewed to cover all physiotherapists in NHS Highland.
NHS Highland AHP activities in Scottish MSK services
27 WORK IN PROGRESS
An open access community wide podiatry service (Biomechanics is un resourced) – many practitioners have acupuncture skills and one assistant
practitioner undergoing training. A central functioning old electronic diary and
appointments system keeps good data which demonstrates consistent growth
over the past 10 years. Personal footcare is discontinued and patients are
assessed and graded High Risk, Medium Risk and Low Risk.
Acute care AHP lead clinics have been piloted but these have been hampered by lack of
space.
Other services Highland Rheumatology Unit. This is an ARMA standards of care good practice entry. Lynn Forbes [email protected]. There is also a
physiotherapy led injection clinic, multiprofessional case management, a
weekly National Ankylosising Spondylitis Class and a telephone help line.
Other developments are self medication audit, dedicated computer software
and education programmes.
Musculoskeletal clinical specialist post based in Town and County Hospital – Nairn.
Developments AHP Orthopaedic Referral Facilitator. CCI supported. This post aims to improve appropriateness of referral and reduce orthopaedic waiting times the
impact of this role will be audited and evaluated. The postholder will work
closely with orthopaedic consultants, GPs and community staff to ensure
orthopaedic referrals are sent to the most appropriate team member. Other
activities would include devising protocols, educating GPs and community
staff (physios), identifying staff with an interest in developing their
orthopaedic skills and possibly developing orthopaedic specialist roles within
the community.
Patient Selfreferral to Physiotherapy (Badenoch and Strathspey) is currently being piloted in Grantown on Spey GP practice. This pilot is part of
the National Survey.
Back Pain Project. Plans to develop a back pain project, in practices and to extend to leisure centre based class/group work for chronic back pain.
NHS Lanarkshire AHP activities in Scottish MSK services
28 WORK IN PROGRESS
NHS Lanarkshire
Lanarkshire has a declining and ageing population in common with Scotland
as a whole. The population of Lanarkshire in 2003 was 555,440. In 2003,
8.6% of the population was aged 6574 and 6.1% aged 75 and over. These
proportions have risen over the past 15 years from 7.5% and 4.7%
respectively. Over the next 15 years they will continue to rise to 10.6% and
8.6% respectively.
AHP services managed separately at each site. An existing ESP service is
currently in place on each acute hospital site with a total annual capacity of
2500 patients. The aim is to establish a single Lanarkshire wide resource.
Historically, crosssite working and multiprofessional working has not been
strong.
Primary care A podiatryled biomechanical service. The public and General Practitioners have had access to this for over seven years. Previously these
patients would have been referred to an orthopaedic department at one of
the three acute sites within NHS Lanarkshire.
A service for homeless people which has recently started includes podiatry input for those with musculoskeletal foot deformity.
Back Pain Classes in the community On 2 sites physiotherapy staff take back pain classes in the community. Hunter Hails, East Kilbride this started in
2001. [email protected] and Coatbridge Health
Centre where classes using the Klabber Moffat approach are taken in the
‘Time Capsule’ sports centre. Patients are then encouraged to join the ‘Get
Active’ scheme and continue classes at a reduced rate.
Direct Access Pilot Site Motherwell. [email protected]
Electronic data collection. 2 pilot sites using PIMS.
Early Supported Discharge Team based in Primary Care. This is not specifically an MSK service but does cover a high proportion of these cases. It
offers a home based time limited (6 weeks) rehabilitation service following
discharge. With a team of 3 Physiotherapists, 3 Occupational Therapists, 3
Rehab Support , 1 social work assistant, 1 clerical worker, 1 speech therapist,
1 team leader. Based at Cleland Hospital. Covering
Motherwell/Wishaw/Clydesdale areas. Acute hospital covered is Wishaw
General.
Clydesdale LHCC – Occupational Therapy does not have a specific MSK service
but in covering the 3 GP hospitals in the area deals with a high proportion of
these cases.
NHS Lanarkshire AHP activities in Scottish MSK services
29 WORK IN PROGRESS
Acute Care Monklands Hospital
Orthopaedic Specialist Physiotherapist (Sept 2003).
Low Back Pain Screening Service commenced June 2004. Four sessions per week. Early to judge impact on outpatient consultant waiting times.
However, no consultants in Lanarkshire undertake spinal surgery so this
service will not affect waiting times for surgery.
Occupational Therapy Hand Injury Clinics for both trauma and elective hand surgery. Treatments include scar and oedema management,
thermoplastic and lycra splinting and a wide variety of therapeutic treatment
media to improve functional work and leisure skills
Supported Discharge teams; Rapid response (prevention of admission, 1 PT, 1 OT 1 TI III ) and an early supported discharge team (1.9 PT, 2 OT,3
Ti111, 1 speech and language, 1, 1 social work assistant. ,3 discharge co
ordinators)
Hairmyres Hospital
Orthopaedic Outpatients – Extended scope physiotherapy practitioner (700 orthopaedic outpatients per year) [email protected]. Five
sessions working along side each of five consultants funded through the
orthopaedic budget. One new patient clinic (Dear Dr letters). “Consultants
triage waiting lists and put any patients who may not require surgery on this
list.” Service includes: joint injections, ability to order blood tests, Xrays for
arthoplasty review only and MRI via the consultant.
Triage clinic in Physiotherapy Outpatients. Nonurgent patients receive a 20 minute assessment by a senior Physiotherapist to establish their
treatment path. The appropriate course of treatment is then arranged. This
decreased the average
waiting time in our department from 6 weeks to less than 2 weeks.
Assistant led back pain classes with good links to leisure centres and ESP clinics.
Physiotherapy hand service, Margaret Merrill
Supported Discharge teams; Rapid response (prevention of admission, 1 PT, 1 OT) and an early supported discharge team (3 PT, 2 OT,2 Ti111, 1
speech and language, 1 CPN, 1 social worker,4 discharge coordinators)
NHS Lanarkshire AHP activities in Scottish MSK services
30 WORK IN PROGRESS
Wishaw Hospital
Orthopaedic Outpatients – Extended Scope Physiotherapy Practitioner – Tracey Coulton. ([email protected]). Service established in
May 2000. Patients are triaged by Orthopaedic Consultants. Three sessions
per week in Orthopaedic clinic assessing spinal patients. Access to all onward
investigations but MRI, XRay & blood tests are via consultant. No spinal
surgery is performed at Wishaw but ESP can refer directly to Neurosurgery at
Southern General.
Podiatrist Led Surgical Footwear Clinic has reduced waiting times for patients requiring orthopaedic or surgical footwear. This has also released
appointments) within the consultants new patients clinics resulting in a much
more efficient service. A protocol, which was developed in conjunction with
the consultant orthopaedic surgeons, establishes whether adaptation to the
patient's existing footwear is required, if stock footwear can be supplied or if
there is a need for bespoke footwear.
A one stop foot clinic has been established where patients are seen jointly by a podiatrist and an orthopaedic surgeon.
[email protected] Patients with common foot
conditions are triaged (annual capacity 516). This has reduced numbers of
patient appointments and orthopaedic waiting times). Following CCI funding
this service is about to be piloted at Hairmyres Hospital. Ultimately it is
planned that this service will be available in all three acute hospital sites.
Supported Discharge teams; Rapid response (prevention of admission, 1 PT, 1 OT OTA 0.50 ) for ECU and A/E and an early supported discharge team
(2 PT, 3 OT, 3 Ti111, 1 speech and language, 1 social worker, 1 discharge co
ordinators)
NB The management and funding is split between Acute and Primary Care in
a variety of different ways – not consistent across Lanarkshire. Also MSK patients may be seen as part of the general occupational therapy caseloads in
both Primary and Acute settings
Occupational Therapy Rheumatology Service patients are offered group joint protection education, activities of daily living assessment thermoplastic
splinting, relaxation therapies for pain management
Other services A limited rheumatology podiatry service also operates with podiatrists working directly with rheumatologists.
The Health Return Project. – Last year Kate Rouband was seconded to this [email protected]. The clinical director for this is
[email protected] and covers the West of Scotland. This is one
pilot site of a project with 8 sites across the UK funded by the department of
work and pensions.
NHS Lanarkshire AHP activities in Scottish MSK services
31 WORK IN PROGRESS
Lanarkshire Workplace Assessment Service aims to assist small and medium sized enterprises to: Prevent an increase in workplace related
accidents, protect the health and safety of employees, in the industrial
community and provide a comprehensive assessment of health and safety. A
team of two specialists in Health & Safety and Health Promotion will visit
workplaces and conduct a comprehensive assessment of its’ safety and health
status then write a confidential report prioritising any suggested action.
The HOPE Project Healthcare Occupational and Primary for Employees – The project has been in operation since May 2000. The aim of the project is to provide occupational health advice to employees who present
to their General Practitioners, Accident & Emergency Departments, or
Physiotherapy Departments in Lanarkshire with workrelated ill health.
Developments of this project are based on the findings and include sessions
on Stress Management, Back Care, Upper Limb Disorders and Skin care.
Developments Lanarkshirewide scoping for a unified Back Pain Pathway.
An additional 1500 patients seen by redesigning physiotherapy and podiatry
services, including extending the scope of podiatry to include requests and
investigations (xray scans, blood tests), using the results and investigations
to assist clinical diagnosis, cortisone and steroid injections, listing patients for
minor foot surgery.
Consider ESP clinics running in primary care.
Build on existing electronic referral systems.
To roll out the one stop foot clinics at all sites across Lanarkshire (part CCI
funded). [email protected]
NHS Lothian AHP activities in Scottish MSK services
32 WORK IN PROGRESS
NHS Lothian
The Lothian population of 778,500 is projected to grow to 793,244 (+1.8%)
in the next five years, as against the rest of Scotland where the population is,
in general, declining. Lothian also has an ageing population, but with different
demographic trends in different areas.
Edinburgh is predicted to have a slight decrease in the over 70s which are
predicted to grow in East, Mid and West Lothian.
It has been accepted by the health board redesign committee that there will
be an external review of all aspects of MSK services (including trauma,
orthopaedics, surgery, theatres and rheumatology) Lothian wide.
[email protected] is on the core group and steering group.
Primary & Community Division
East & Midlothian
The OutPatient Physiotherapy Service consists of two Community Hospital Departments and seven Health Centre based ones: four in East
Lothian and three in Midlothian. All areas take Consultant & GP referrals &
cater for all musculoskeletal conditions across a large spectrum of age groups.
One centre is participating with the Direct Access (selfreferral RCT).
Midlothian Back Pain Project – large scale project to look at LBP pathways, implement screening protocols and set in place the most
appropriate treatment at the most appropriate time by the most appropriate
individual. Included leisure centre based class/group work for 'yellow flag'
patients. This has led onto the Chronic Pain Service, which identifies
individuals with chronic pain and seeks to manage this within established
systems developed from the Astley Ainslie model.
East Lothian Musculoskeletal Service at Roodlands Hospital – Initially a GP led project, a physiotherapy ESP is doing five sessions as an integral
member of the team that now includes an Orthopaedic Medicine Consultant,
Rheumatologist and Orthopaedic Surgeon. This involves triage of referrals,
clinical management of cases, injection, onward referrals to surgery,
treatment of highly complex patients in conjunction with local physiotherapy
departments, chronic pain management, ENT patients and quick access to
orthopaedist and podiatrist. There is also dedicated administration and
nursing staff. The post includes a teaching and audit/research commitment.
NHS Lothian AHP activities in Scottish MSK services
33 WORK IN PROGRESS
Edinburgh Community Physiotherapy Service.
Physiotherapy outpatient services at 13 sites across the city. Pilot studies include Direct Access (2 sites), Telephone Triage and Triage screening
clinics piloting at two sites. Three (2wte) clinical specialists/ESP have direct
access to xray and ultrasound scanning. Injection therapy is provided by the
Lead physiotherapist at Tollcross Health Centre.
Community Back Pain Classes. This pilot is due to run until 2005 with Edinburgh City Council and was funded by Primary Care Development Fund.
The classes are “sports coach led”. [email protected]
A Chronic Pain Management satellite service is held in City Centre clinics, accessible to all patients within our service.
Staff injuries Physiotherapy service – based within Occupational Health Service for all Primary and Community division.
Astley Ainslie Hospital
Out patient physiotherapy treatment principally for patients with musculo
skeletal problems. [email protected]
Acute care All trauma patients are seen in the Royal Infirmary Edinburgh (RIE). West
Lothian patients are returned to St Johns on average at 72 hours post
surgery.
• The service has been reconfigured so that Medical Consultants and other clinicians work in specialist teams, e.g. Soft tissue, knee, arthroplasty, foot
and ankle.
• Combined Rheumatology and Orthopaedic clinics . • City wide Low Back Pain physiotherapy pathway group working. • It envisaged that a “pan Lothian” approach to services should follow the health board review.
University Hospitals Division
Royal Infirmary of Edinburgh
The orthopaedic service is divided into subspeciality teams. Extended scope orthopaedic physiotherapists have worked in the service since
1995. Their clinics run concurrently with the orthopaedic consultants. There
are three orthopaedic physiotherapy practitioners (knee 1 wte, spine 1 wte,
upper limb .98wte) doing a total of 10 sessions per week. They are able to
inject, order any investigations (including MRI) and, in certain circumstances,
add patients to the surgical waiting lists. These sessions are funded by the
orthopaedic department. [email protected]
NHS Lothian AHP activities in Scottish MSK services
34 WORK IN PROGRESS
Foot and ankle service. This consultant led service includes a specialist podiatrist, orthotist and nurse led follow up. The consultant allocates all
referrals to the relevant practitioner. Appointments are given within 6 weeks.
The new service has helped reduced waiting times for the foot and ankle
orthopaedic consultant from 45 weeks (May 2003) to 9 weeks.
[email protected] / [email protected]
Arthroplasty practitioners (two physiotherapists and a nurse) see all the postarthroplasty lists. Consultant involvement with these patients finishes
after discharge from the ward unless there are problems. There is a patient
helpline and patients can ask to be reviewed. Practitioners take blood, order
Xrays and in certain circumstances can list for surgery.
[email protected] and [email protected]
Preadmission. All patients listed for THR are seen by OTs at preadmission clinics. Patients are sent a pro forma and asked to measure certain things to
enable equipment provision. [email protected]
Assistant caseload. All occupational therapy and physiotherapy assistants are Tec 3’s. Physiotherapy assistants have own case load, work weekends and
see all primary THRs within set protocols and OT assistants see the primary
total knees protocols [email protected]
Predischarge class for all patients who have had elective hip surgery run by OT’s allows consistency of information and good use of time, 8 patients: 1
hour.
MultiDisciplinary Supported Discharge Team. [email protected] This team is for Orthopaedic patients aged 70
and over admitted with orthopaedic trauma to RIE. It is assumed that all
patients will need the team until proven otherwise, therefore discharge
planning starts at admission. The hospital based team is led by a Consultant
Geriatrician. 2 domiciliary physios and 1 TI3 are based at McLeod St. Clinic.
Discharge is supported by home OT assessment, timely equipment provision,
domiciliary physiotherapy, telephone followup, liaison nurses and provision of
private homecare up to three times per day, over 7 days for the first 3 weeks
following discharge.
Western General Hospital
Minor injury clinic with extended scope physiotherapist [email protected] working alongside nurse practitioners.
Combined Occupational Therapy, Physiotherapy and Rheumatology Clinic (WGH). These started in August 2003 and offer patients a choice of appointment time, a common assessment and patients and staff spend less
time. To date the number of nonattenders has reduced, 56 hours of therapy
time has been saved and the waiting list is reduced.
NHS Lothian AHP activities in Scottish MSK services
35 WORK IN PROGRESS
West Lothian Healthcare Division
St Johns Hospital, Livingston
MSK Physiotherapy Clinic Session – One extended scope physiotherapist [email protected] is doing 3 clinic sessions one knee, one general
musculoskeletal and one general musculoskeletal primary care clinic.
Developments Primary & Community Division East Lothian
Back Pain Project – similar to that in Midlothian, the physiotherapist in Dunbar is preparing a self referral service for people with back pain, It will
have departmental & leisure centre components. If successful, this will be
rolled out across the whole county with the intention of having a fully open
access system for all conditions.
Ebooking of appointments. Our services use TIARA for clinical information. A pilot is set to begin to prove the concept of ebooking of
physiotherapy appointments by GP/GP staff for patients at the time of
consultation, followed by ereferrals.
Primary & Community Division West Lothian
Ultrasound scanning (pilot) and direct access to orthopaedic waiting lists in secondary care for named AHP clinical specialists. (Possibly in Edin
Community Physio – not St Johns)
Establish central booking office for Lothian for all MSK referrals.
Develop protocol based referral systems.
Enhanced services underdevelopment. GPwSI, ESPs to see new and follow up
patients. Expand the numbers of specialist practitioners to support equity of
service across Lothian.
Lothian Primary and Community Division
Foot and Ankle Service. By 2005 it is hoped that this service will be expanded and run in health centres across the Lothians.
[email protected] / [email protected]
An "Eaccess" Internetbased physiotherapy knee clinic based at the University Health Centre. Funded from Lothian Change and Innovation Fund
2004/05. [email protected]
Injection therapy – Patient group directives. (PGD). Working closely with pharmacy, two PGDs (Kenalog and Lignocaine) for injection therapy are
almost signed off. [email protected]
Website – Edinburgh Community Physiotherapy Service is developing a Website to be available on SHOW and NHS Lothian Intranet for both patient
and GP access detailing Service, wait times, new developments and literature
downloads. Aim to “go live” April 2005. [email protected]
NHS Lothian AHP activities in Scottish MSK services
36 WORK IN PROGRESS
Rapid Response. Funding from Sutherland implementation monies is allowing us to expand the Rapid Response service across the whole of
Edinburgh. Each locality will have a Rapid Response service (consisting
primarily of Physiotherapists and Occupational Therapists) working to
common criteria and service standards to provide an urgent multidisciplinary
assessment to begin an immediate programme of rehabilitation, thus avoiding
unnecessary hospital admission.
University Hospitals Division
Awaiting results of the service review.
Rapid recovery arthroplasty service aimed at reducing length of stay is under
discussion. [email protected]
NHS Orkney AHP activities in Scottish MSK services
37 WORK IN PROGRESS
NHS Orkney
NHS Orkeney is the smallest health board in Scotland. The total population of
Orkney is just under 20,000 with most people live on Mainland, the main
island. Kirkwall, the capital, with a population of 7,500, is the administrative
centre of Orkney with a good mix of shops, supermarkets and small local
businesses.
NHS Shetland
Shetland NHS Board is responsible for purchasing health care for a population
of 23,000. Local Hospital and Community Services are provided from the
Gilbert Bain and Montfield Hospitals. In addition, visiting consultants from
Grampian University Hospitals NHS Trust and Grampian Primary Care NHS
Trust provide outpatient clinics as well as inpatient and daycase surgery to
supplement the service provided by our locallybased Consultants in General
Medicine, General Surgery, Paediatrics and Psychiatry.
NHS Tayside AHP activities in Scottish MSK services
WORK IN PROGRESS 38
NHS Tayside
NHS Tayside provides primary care and secondary care services across
Tayside with full supporting services to a population of approximately
400,000. A number of NHS Tayside services are provided in partnership with
other statutory and voluntary organisations, and has close links and provides
teaching facilities for the two Universities in Dundee. NHS Tayside has a
workforce of approximately 14,000 and a budget of £562million.
The Tayside/NE Fife Orthopaedic Service provides specialist care for 480,000
population and delivers both outpatient and inpatient services in all three
acute hospital settings: Ninewells hospital, [email protected]
Perth Royal Infirmary [email protected] and Strathcathro
Ambulatory Diagnostic and Treatment Centre
[email protected] In addition, outpatient services are currently
delivered in peripheral clinics close to the patients own communities, across
Angus (4 sites) and Perth and Kinross (5 sites) and Kings Cross Hospital,
Dundee. There are links established with the leisure centres in Dundee for
‘fitness for life’ referrals and Biodex isokinetic facilities are available at Perth
Royal Infirmary and Ninewells Hospital.
Standardised Assessment forms throughout Tayside
Musculoskeletal assessment forms have been standardised throughout
Tayside to enable ease of audit. Patient information leaflets are standardised
and available on the intranet.
Primary care Selfreferral to physiotherapy has been ongoing in Carnoustie for many years. The Arbroath site is involved in the Scotland wide direct access pilot.
It is planned to introduce selfreferral to all outpatient Physiotherapy
departments in Angus. Self referral at KXH has reduced the waiting list by 8
weeks [email protected]
Injection Therapy is currently available within Carnoustie HC and there are plans for training and implementation in all areas in Angus – seeking funding
for this. Injection therapy also available at KXH with 7 physiotherapists
completing inhouse training – PGDs agreed [email protected]
Musculoskeletal outpatient clinics are run from 6 sites in Angus based locally in the towns – Arbroath, Brechin, Carnoustie, Forfar (2) and Montrose.
Early Supported Discharge/Prevention of Admission. There is a limited community service available across Angus both for direct GP/consultant/other
health profession referral for this service.
Orthopaedic Screening – Stracathro Hospital: 1 WTE clinical specialist physiotherapist screens back referrals coming into the orthopaedic
department, provides assessment, diagnosis and treatment of patients
referred to the clinic by Angus GPs. There are 6 clinics per month across the
NHS Tayside AHP activities in Scottish MSK services
WORK IN PROGRESS 39
two sites. ESP’s can request xrays, but not other investigations.
Redesign of podiatry in Perth and Kinross Local Healthcare Co operative. This was previously a demand led service, where many patients expected a certain level of service based on their age alone. In 2003 there
were waiting times, averaging 30 months for low risk patients. Baseline
criteria were introduced, selfhelp was encouraged and greater use was made
of the podiatry assistant. By January 2004, the wait had reduced to 69
months; 15% of the old case load was discharged. The proportion of patients
suitable for treatment by a podiatry assistant increased from 7% to 17%.
[email protected]. (This relates to the podiatry service as a
whole not just MSK services).
Rheumatology patients are treated by a dedicated clinical specialist
physiotherapist in Kings Cross Hospital Dundee who links into the
rheumatology clinic at Ninewells. [email protected]
The Community Pain Management Clinic was originally started as a bio psychosocial multidisciplinary Primary Care Initiative in 2002 to address the
need for a community based service that could reduce the pressure on the
Acute Pain Service while satisfying the needs of patients who suffer from less
complex pain syndromes. It includes Physiotherapy, Pharmacology and
Cognitive Behavioural Therapy input, and is designed to improve the
management of patients who suffer nonmalignant musculoskeletal pain by
addressing the effects that pain has on their lives and empowering them to
develop self management skills. Initially available to 10 GP Practices it is now
available to all GP Practices in Dundee and will be provided 4 sessions a week,
with increased input from Pharmacists and Cognitive Behavioural Therapists,
to accommodate 200 referrals a year. This service is a community adjunct to
the Consultant led Pain Service in Ninewells and as the only Physiotherapyled
pain management service in Scotland. An audit of the impact of this Clinic
demonstrated an annual saving in drugs costs of £136.59 per patient. The
wider health economic impact of this Clinic remain to be evaluated in terms of
reduced GP visits and reduced hospital costs.
To date it has not been possible to secure recurring funding for this initiative
which continues to survive on nonrecurring funding.
Occupational Therapy Rheumatology services are provided by three locality hospitals, Pitlochry, Crieff and Blairgowrie. Patients are provided with
core Occupational Therapy input including education, support, pre and post
operative assessment, ADL assessment, joint protection and splinting. Waiting
times are approximately 6 weeks. A limited, needs led community
rehabilitation service is also available. [email protected] or
NHS Tayside AHP activities in Scottish MSK services
WORK IN PROGRESS 40
Acute Care The Tayside Back Pain Pathway. This was developed and includes the long established spinal service with ESPs now present in Dundee, Angus and
Perth. Patients are either triaged to a physiotherapist with extended skills who
will assess, diagnose, treat and discharge independently, or to a Consultant
with subspecialist expertise as appropriate.
• Approx 70% of patients referred to secondary care are discharged directly by the physiotherapy service without requiring a consultant opinion.
• It is estimated that this physiotherapy screening service takes the equivalent of 17 months of patients off the orthopaedic waiting lists.
• Orthopaedic clinics • The Ninewells site for Physiotherapy has two main clinical specialist physiotherapy clinics for spinal and knee orthopaedic patients. The Spinal
Service (possibly the first in Scotland) was started in 1992 and
[email protected] has been in post for four years. Referrals are
taken off the consultant list and Xrays (not MRI’s) can be requested.
• In Strathcathro Hospital a clinical specialist physiotherapist screens the back referrals coming into the orthopaedic department and provides
assessment, diagnosis and treatment of patients referred to the clinic by
Angus GPs. There are 6 clinics per month across the two sites. ESP’s can
request xrays, but not other investigations. [email protected].
• The shoulder screening service has demonstrated that up to 57% of patients can be successfully assessed, treated and discharged without the
need for a consultant appointment. [email protected]
Trauma and elective hand clinics; Ninewells are covered weekly by OT and PT. Patients are immediately assessed and treated appropriately. Both PT
and OT are able to discharge patients without Consultant follow up, so
reducing the Consultant waiting lists and ultimately improving patient care.
[email protected] (0T) [email protected] (PT)
Early supported discharge scheme Early orthopaedic discharge scheme provides OT + Homecare services/Rehab with access to Physio via referral to
community rehab team. [email protected].
Ninewells Hospital; OT Technical Instructor 2 covers all total hip and knee arthroplasties ,intervention as well as preadmission clinics for total hip
arthroplasties [email protected].
Specialised services at KXH include Back pain, rheumatology, upper limbs, pain management, community rehabilitation and biomechanical assessment.
Biomechanical clinic involves assessment by both podiatrist and
physiotherapist.
NHS Tayside AHP activities in Scottish MSK services
WORK IN PROGRESS 41
Occupational Therapy Rheumatology services are based in Perth Royal Infirmary. Patients are provided with core Occupational therapy services such
as education, splinting, ADL assessment and joint protection as well as pre
and post operative assessment, treatment and support. Waiting times for this
service are approximately 912 months. A limited, needs led community
rehabilitation service is also available. [email protected] and
Developments CCI bid includes mention the development of – A patient referral tool based on the patient’s selfassessment with objective markers for prioritisation which will enhance triage decision making. All screened referrals
will be directed hereafter to the most appropriate practitioner
CCI bids have enabled development of hip and knee screening clinics in Perth,
Dundee and Angus and hand screening clinics in Dundee. Hand ESP can
request EMG studies
Ninewells hospital Joint Health and Social Care approach to patient management, in particular elective hip replacements:
This aims to reduce length of stay in hospital. To include:
• Planned access and care to community aids when a patient is placed on consultant’s waiting list.
• Preadmission pilot with hospital OT visiting patient at home 34 weeks prior to admission re preparation, education, exercise and to ensure
necessary equipment is in situ.
NHS Western Isles AHP activities in Scottish MSK services
WORK IN PROGRESS 42
NHS Western Isles
NHS Western Isles Board integrated health organisation providing Primary,
Secondary and Community Health Services. It serves a population of 29,000
residents, which increases in the summer months due to an influx of tourists
from all over the world. The board works closely with other organisations such
as representatives of the public, voluntary bodies and local authority in a
multiagency approach to the improvement of health on the Western Isles
and the promotion of healthy lifestyles.
The main hospital in the islands is based in the north in Stornoway, Isle of
Lewis, with a small hospital in the South on the Isle of Barra, and a new
hospital on the Isle of Benbecula (opened in March 2001) in the centre of the
Western Isles. On the Primary Care side we have 15 practices across the
islands.
Orthopaedic and rheumatology services are currently under review.
The consultant rheumatologist is retiring and the current orthopaedic
consultant is a locum.
Physiotherapy
The Physiotherapy Department is based at two main sites, however we
provide physiotherapy to a number of outlying surgeries, clinics, patients
homes, schools, Residential Homes and Hostel, Hydrotherapy pool etc. The
Physiotherapists travel significant distances in order to provide their services,
including a twice weekly visit by a Physiotherapist to the Isle of Barra,
involving a long drive and then a ferry journey of one hour each way! There
are currently no clinical specialists or ESPs. [email protected]
Junior physiotherapy rotation – Four month joint physiotherapy junior rotation with North Glasgow NHS Trust. This has proved very successful and
resulted in two permanent recruitments. “This gives a new impetus to staff”
and challenges their thinking with the latest research. Junior staff who have
all done four year degrees give regular presentations – one about their
student project.
Podiatry [email protected]
Radiology [email protected]
Two radiographers undertake and report on MSK ultrasound scans. Close
working relations with physiotherapy have developed. It is thought that with
the use of ultrasound arthogram and arthoscope numbers have been reduced.
Malcolm is also reporting on CT brain scans.
Developments Teleradiological reporting is under discussion