integrated musculo skeletal service (imsk) · silo service delivery with little/no integration...
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Integrated Musculo Skeletal Service (iMSK)
Realising Benefits of Right Care: North West Surrey System MSK Experience
Tuesday 7th February 2017
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Background • In 2013/14 the North West Surrey (NWS) CCG spent
circa £33m on musculoskeletal (MSK) services. • The commissioning for value indicators identified
that best value was not being derived from this budget and that NWS was an outlier when compared with other similar CCGs.
• Patients and GPs expressed concerns that the services were disjointed.
• Patients received poor outcomes.
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£4.4m is ~25-30% of our total elective orthopaedic
spend
Right Care
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Programme Budget Comparison The ‘Right Care’ analysis showed the CCG MSK spend was significantly higher than peer CCG’s in 12/13 with a gap of £3.3m compared to all peers in comparative group
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Selected CCG Code: 09Y 99H 07Q 06Q 12A 10H 99E 12D 09X 10J 09L
NH
S N
orth
Wes
t Su
rrey
CCG
NH
S Su
rrey
Dow
ns
CCG
NH
S Br
omle
y CC
G
NH
S M
id E
ssex
CCG
NH
S So
uth
Glo
uces
ters
hire
CC
G
NH
S Ch
ilter
n CC
G
NH
S Ba
sild
on a
nd
Bren
twoo
d CC
G
NH
S Sw
indo
n CC
G
NH
S H
orsh
am a
nd
Mid
Sus
sex
CCG
NH
S N
orth
H
amps
hire
CCG
NH
S Ea
st S
urre
y CC
G
Value Value Value Value Value Value Value Value Value Value Value
Programme Budget - Musculo Skeleta l - Tota l admiss ions per 1000 population across secondary care - Cost 47439 40018 33342 37936 38872 30141 32542 39193 44065 42302 38323
11
Programme Budget - Musculo Skeleta l - Tota l elective (IP + DC) admiss ions per 1000 population across secondary care - Cost 44064 36739 30076 35520 36386 27180 29303 35552 41136 38796 35120
11
Programme Budget - Musculo Skeleta l - Non-elective (EM + ONEL) admiss ions per 1000 population across secondary care - Cost 3398 3287 3263 2398 2480 2960 3237 3641 2939 3494 3208
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Programme Budget - Musculo Skeleta l - Cost prescribed per 1000 ASTRO-PU population - Cost 4539 3944 4086 5135 5776 4133 5422 5569 4402 5535 4745
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Programme Budget - Musculo Skeleta l - Tota l admiss ions per 1000 population across secondary care - Activi ty 15.8 14.8 16.5 16.1 13.0 10.9 15.5 16.3 15.9 15.4 13.4
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Programme Budget - Musculo Skeleta l - Tota l elective (IP + DC) admiss ions per 1000 population across secondary care - Activi ty 14.5 13.1 14.3 14.7 11.8 9.4 14.0 14.3 14.4 13.7 11.6
10
Hip replacement, EQ-5D, Heal th Gain (Provis ional 2011/12)0.4 0.39 0.41 0.46 0.42 0.39 0.44 0.44 0.33 0.37 0.46
9
Knee replacement, EQ-5D, Heal th Gain (Provis ional 2011/12)0.3 0.25 0.24 0.37 0.23 0.31 0.33 0.30 0.28 0.27 0.22
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Hip replacement, Oxford score, Heal th Gain (Provis ional 2011/12) 19.0 19.5 21.1 22.1 21.3 20.1 21.2 21.3 17.2 20.0 21.7
10
Knee replacement, Oxford score, Heal th Gain (Provis ional 2011/12) 13.6 13.7 13.1 16.0 15.1 13.9 14.8 15.2 15.1 14.8 14.1
10
Similar 10 CCGs to the selected CCG:
Select Your CCG:
Rank of Selected CCG within similar
10 CCGs (where
11="worst", e.g. higher spending)
Indicator Name
Programme Budget Comparison The ‘Right Care’ analysis showed the CCG’s with a lower spend still had better outcomes
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Programme Budget Comparison: Health GainEQ-5D Index The ‘Right Care’ analysis 12/13 data continued to show the CCG had lower outcome scores than other CCG'
Health Gain EQ-5D Index - Hips
Health Gain EQ-5D Index - Knees
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From the clinical perspective…
Silo service delivery with little/no integration
Clinical Variability
No coherent pathways
Focussed entirely on physical medicine
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General Practice Workload
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No Coherent Pathways
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and the Patient Perspective…..
Long waiting times for MRIs/physiotherapy/to see orthopaedics/to see
the pain team/for everything
Siloed Practitioners in different hospitals I feel like pass the
parcel in terms of being referred back and forth
and went round the system
I have had numerous referrals, scans and
treatments over 5 years – nothing has alleviated
the pain and I have never had a definitive
diagnosis
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What did we do?
Stakeholder consultation
Set up an Interim MSK Service supported by CCG’s Referral Support Service (RSS)
Commenced procurement of a redesigned integrated MSK service
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Pain Management
Therapies Orthopaedics
Rheumatology
Conservative Treatments
Triage & Assessment
Inpatients & Surgery
Primary Prevention
Public Health Primary Care
iMSK
Patie
nt C
hoic
e
Shar
ed D
ecis
ion
Mak
ing
Our vision…. Biopsychosocial m
odel
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Coherent Clinical Pathway
Primary Care
Biopsychosocial Assessment
Referral for onward treatment
Diagnostics • Rheumatology • Orthopaedics • Pain Management • Therapies
Triage
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The iMSK service provided by Ashford and St Peter’s Hospital
Foundation Trust October 2016
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What the service provides
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New pathways: • Shared decision making:
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New pathways: • Pain Management:
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Summary patients and families
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General Practice
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Efficiency
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Scale of the change
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Culture change programme
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Components of integrated intervention – Personalised care plan including
Cognitive component
Impairment -based
component
Functional integration component
Lifestyle/ Physical activity
component
Focussed on specific maladaptive cognitions identified during Ax
Based on patients maladaptive movement factors
Patient adapts their previously painful activities and functional goals set around these Relate treatment to the functional needs/ goals of the patient
3-5 times per week Engage patient in regular physical activity Promote healthy living
Adjuncts
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