Page 60 The Community Musculoskeletal Service Cathy Lennox FRCS(Orth)Ed, Consultant Orthopaedic Surgeon Atle Karstad MBA, BSc Hons, MCSP, HPC, Consultant Physiotherapist Improving the After retirement from a full-time Consultant post in Trauma and Orthopaedics, I have spent the past 5 years in what has been, for me, an entirely new venture: as Clinical Lead/Adviser in a community MSK service. Working with a batch of enthusiastic, competent and highly professional nonmedical professionals has been a privilege and an eye-opener. I recognise the potential for the huge benefit it offers to the patients, the GPs and most of all to the Orthopaedic secondary care teams, in addressing the overwhelming work-load, by sharing that load and ensuring the patient is seen by the right person, at the right time, in the right place. Cathy Lennox pathway for Orthopaedic patients: A model of care developed in the North Tees and Hartlepool NHS FT Background The term Musculoskeletal (MSK) entered common parlance only recently, and represents the wide spectrum of conditions affecting the soft tissues, skeleton and joints; all age groups and causes; and includes systemic diseases. The percentage of MSK cases on GPs workload is 30% (and 50% in over 75 year olds). 1 Until the introduction of multiprofessional services, GPs had little alternative other than to refer all of this wide spectrum to the Orthopaedic Service, which was therefore overloaded; cases who were most in need of Orthopaedic specialist attention were often significantly delayed. A framework for the delivery of Musculoskeletal Services was published by the Department of Health in 2006. 2 It described the extensive and multi professional (and often disparate) provision of care across primary and secondary care. Specifically, it acknowledged the problem of access to specialist Orthopaedic and Rheumatology services, in providing timely assessment, investigation and treatment for appropriate cases, within this ever-increasing spectrum of MSK conditions. Since its publication, demand for MSK services has continued to increase; therefore the need for reliable, robust, consistent, and effective referral patterns and clinical pathways is now all the more pressing to ensure that patients are directed to the most appropriate professional without a lengthy wait and without duplication of effort. Professor Briggs recent report Getting it right first time (2012) emphasises the fact that low priority is afforded to training at Medical School in musculoskeletal conditions (maybe as little as 5 weeks during under-graduate training), and indeed this is also true of junior doctor Foundation Training. 1 Consequently, in General Practice, there has been a reliance on referral into secondary care for all manner of MSK problems, both surgical and non-surgical. As a result, a large number of such referrals to a specialist Orthopaedic clinic are considered of low value (43%) in terms of their suitability for specialist (including surgical) involvement. 2 As a consequence, the secondary care Orthopaedic out-patient service is heavily over-subscribed; patients and their referring GPs have become resigned to lengthy waits for first appointment, which is then often rushed, with inadequate time for explanation and discussion. Then there is a further wait for imaging investigations and frequently only then a forward referral; and yet another wait for those who need a more appropriate professional e.g. physiotherapist, podiatrist, pain management team etc. It is frequently impossible to achieve the 18 week referral-totreatment target.
Page 62 Therefore, the process may be considered of low value by the secondary care team, but even more so by the patient and GP! A majority of such cases are managed far more effectively by Allied Health Professionals and so the design of a comprehensive MSK service ought to centre on a community-based hub for referrals, where triage is applied, and the patient is allocated to see the most appropriate professional, in a multidisciplinary team and, where indicated, referred to specialist secondary care. This ensures that the expertise of the Orthopaedic Surgeon is accessible to the most appropriate cases, i.e. those for whom experienced assessment, diagnostic skills and surgical input are indicated. It is also important that we in the Orthopaedic Surgery profession accept that it is not necessary for us to see all MSK referrals but to recognise and acknowledge the skills and experience of other professions. Referral pathways Many attempts have been made to design referral pathways which would be seen as user-friendly by the referring GP clinician, and therefore likely to be adopted nationally. The fact that there are no universally-accepted MSK referral pathways is a reflection of many factors: lack of consensus amongst clinicians, and the involvement of so many sub-specialty teams who require their own pathways. Not the least of the factors is the demand on GPs time, overwhelmed as they are with requirements relating to targets, preventive medicine and of course referral pathways produced by every other secondary care specialty! Thus, in order to bridge the divide between Primary Care and achieving timely advice, treatment and forward referral as required, there is a strong case for harnessing the skills and experience of senior physiotherapists and other allied professionals in a Communitybased MSK service. Nevertheless, it is still of vital importance to continue to develop such formal pathways and to integrate them into seamless clinical pathways from primary to secondary care. Hopefully the introduction of Clinical Commissioning Guidance will prove useful in that respect. The Development of a Community MSK Service Several models of a community MSK service have emerged in the UK, with the aim of improving the quality of those referrals into secondary care: The role of the GP with a special interest (GPSI) was developed as a means of providing MSK expertise in the community, and it has been very successful in some areas, especially in areas of large population density, where patients can travel a short distance to an MSK service staffed by GPSIs. The role was also intended to provide credibility to the MSK service and attract other practices to refer. There are obviously training and cost issues. 3 Some General Practices have been able to allocate responsibility for MSK patients to one GP per practice (some of whom have completed formal GPSI training). Employing a physiotherapist within a practice is a popular move with GPs and with patients but has proven difficult to sustain. A musculoskeletal triage service (MTS) may be staffed by physiotherapists and/ or GPSIs, and their main role is to decide on the most appropriate forward referral. Others CAS, CATS, ITC etc. All of these options have training and cost-effectiveness issues and may delay the forward referral for those needing specialist care. 2 The Community Musculoskeletal Triage, Assessment and Treatment Service North Tees and Hartlepool NHS FT serves a population of 360,000. This MSK service was initiated as a small pilot in a GP surgery nine years ago and has developed into its present form, which is a multiprofessional service located centrally in Community Health Centres (on two sites to serve the two towns of Stockton and Hartlepool). The service developed in The North Tees and Hartlepool Community Directorate of the FT differs from other models in several important respects: The harnessing of the skills and experience of senior physiotherapists and other allied professionals is the key to its success. The members of the team were all already employed within the Trust and have now re-located centrally within the Community Health Centres. This is an ideal scenario to allow interprofessional working. These existing Physiotherapy and Podiatry staff were recruited onto the preceptorship programmes to take on the extended role. Their role is far more than simply triage. The following is a description of the process of referral into the service from the GP: GPs are offered the option of referral directly to the Community MSK service rather than to Orthopaedics in Secondary Care. All referrals (most of which are now made electronically) from GPs to the Community MSK service are read immediately by one of a team of Extended Scope Practitioners (ESP Physiotherapists Band 7, and Highly Specialised Podiatrists, HSP, Band 7) and depending on the content of the referring information, the patient is allocated to one of the triage options below (if referral information is inadequate then direct contact is made with the referring GP to request more specific information). Of critical importance is that these professionals are very well able to recognise a red flag and that they should refer such cases immediately to secondary care by direct communication.
Page 64 Triage options 1. Consultant Physiotherapist Mr Atle Karstad: who has an overseeing and mentorship role, and also has his own clinical workload within MSK. Cases with a more complex history are often triaged to his clinic. He has responsibility for the education programme within the service and has been involved in research at the University of Teesside. He is also responsible for the selection of senior professionals to undertake the preceptorship programme for the ESP role. 2. ESP physiotherapist (band 7): for assessment, investigations, treatment plan including injection techniques and subsequent forward referral to Orthopaedics or Rheumatology if and when required and without delay. There are core physiotherapy staff on site to whom the ESPs can refer patients for specific courses of treatment. 3. ESP physiotherapist Joint Replacement: These ESPs assess potential THR/TKR patients, and for those who meet the criteria, liaise with a Senior Sister from the secondary care team who does a clinic in the Community Clinic weekly and who does the initial pre-assessment work and then allocates that patient to an appropriate lower-limb arthroplasty clinic in Secondary Care. 4. HSP Podiatrist: including biomechanics, gait analysis, treatment plan including injection techniques, orthotics made on site. 5. ESP Paediatric Physiotherapists who work with infants and up to 16 years old, for advice, reassurance and treatment as required and, where indicated, liaise directly with Paediatric Orthopaedic teams at the specialist centres in the North East. 6. HSP Paediatric Podiatrists have their own patients from the triage process, and also share the care of many cases with the ESP Paediatric Physiotherapist. They have access to the orthotics laboratory on site for simple inserts and appliances; and to the Orthotist who has a clinic within the service once weekly for more elaborate work and for bespoke footwear. 7. ESP Hand Physiotherapists. 8. Consultant Hand Surgeon (weekly clinic held in conjunction with the Hand ESPs who also have their own clinics). 9. Triage may refer directly to secondary care if indicated by referring information. 10. Counselling Psychologists are part of the team and available to take referrals from the ESP/ HSP staff. 11. Orthotist who has a clinic once a week and takes referrals from the Podiatry or ESP teams for bespoke shoes and supports (adults and children). 12. Podiatric Surgeon: a full team of Podiatric Surgeons, Senior Podiatrists with access to a fully equipped and staffed Community Operating Theatre is well established on site; receiving referrals directly from GPs as well as from the MSK Podiatry team. Immediately after triage, the patient is contacted and offered an appointment within 2-4 weeks (on a date agreed between patient and clinician). The initial appointment of 40 minutes involves history, assessment, clinical examination and a treatment plan outlined. X-Rays are performed on site at the first attendance and can be viewed by the ESP electronically (a subsequent Radiologist s report is viewed as soon as it becomes available). Further imaging e.g. Ultrasound and MRI scanning, can be arranged by the ESP and the reports are shared with the patient at a review appointment shortly after. If haematology, biochemistry and immunology blood tests are ordered by the ESP/HSP, bloods are taken by trained HCAs and results available for ESP to review electronically within few days. If the treatment plan includes a course of physiotherapy treatment, this is provided on site by the core physiotherapy team (Band 5). Injection techniques into joints/soft tissues are performed as required by suitably trained ESPs/HSPs either at the first appointment or in a designated injection clinic within the MSK service. A strict protocol for consent and aseptic technique is followed. Review by the same ESP/HSP is arranged to discuss test and X-ray results and reports and to assess progress. Internal referral to other ESPs is common e.g. ESP Physiotherapist to Biomechanics; ESP Paediatric Physiotherapist to HSP paediatric podiatrist; ESP to Clinical Psychologist, etc. Some of the ESP Physiotherapists have a regular contribution to Specialist Orthopaedic clinics in Secondary Care (e.g. joint replacement, knee injury, shoulder and spine); an excellent mutual learning experience; and an opportunity for the ESPs to discuss with Orthopaedic staff any unusual cases they have seen in the Community setting. This also allows Orthopaedic surgeons to update the ESPs but also to appreciate the skills and techniques that the physiotherapy/ podiatry staff offer. Other members of the team Podiatric technicians who are trained in the manufacture of custom-made orthotics, made in a laboratory on site. HCAs who act as phlebotomists, chaperones, clinic support and assistants in injection techniques and theatre assistants. Administration staff (12 team members) Clinical Governance There are regular clinical audits performed, some in conjunction with the Secondary Care teams. These include: Infection control issues Injection technique training and audit Consent audit Patient satisfaction surveys regularly performed; results discussed and acted upon Case notes audits (there are no paper case notes, records are kept electronically)
Volume 01 / Issue 02 / September 2013 Page 65 boa.ac.uk 2013 British Orthopaedic Association Basic Life Support training and updates for all staff and Intermediate Life Support training with regular updates for staff involved in any invasive techniques, e.g. injection work. Teaching sessions with clinical presentation and Case reviews Performance data The success and efficacy of this model can be demonstrated by monitoring throughput numbers, the numbers seen treated and discharged from the MSK service, and the numbers referred on to secondary care. Future Developments There are obviously teaching opportunities within this service For GPs For undergraduate medical students and FY doctors. The Band 7 Physiotherapy and Podiatry staff are very experienced in doing a thorough assessment at the initial visit. Their history-taking and clinical examination skills are very competently done and present an opportunity for students to refresh and/ or learn those skills in an unhurried situation. Conclusion This model of care addresses the issue of service provision by acknowledging the competence and potential of senior AHPs. It effectively identifies which cases are unlikely to need a surgical opinion or intervention and allows those to be assessed, investigated and treated within the MSK service. The benefit to the GP is the provision of an option for referral of those cases where it is unclear whether Orthopaedic Surgical opinion is necessary or for chronic and long-term conditions, or where there is no useful referral pathway. The GP will still refer directly to Orthopaedics those cases where the diagnosis is clearer. The benefit for the patient is that it provides timely access (four weeks) to an appropriate professional competent in assessment, examination, investigations and arrangement of a treatment plan, including followup. Patient satisfaction levels are very high, particularly as their care pathway starts within four weeks; they see the same professional at each subsequent visit. The benefit to the secondary care Orthopaedic Service is very significant, ensuring that cases sent on to Orthopaedics (after initial assessment and investigation in the MSK service) are appropriate, as evidenced by the high conversion rate to surgery. Since the patient has had imaging and other investigations already done in the MSK service, the Orthopaedic Surgeon may be in a position to make a treatment plan at the first visit, including a surgical procedure if appropriate, so the patient s name may be entered onto the waiting list without delay. There are fewer steps in the care pathway, and referral-to-treat times are improved. Advice for others considering setting up such a service is that it requires the existing staff of allied health professionals to be re-located to work in a team and that may take some time to set up, as well as suitable premises, and that gradually the critical mass of staff to meet the demand will be assembled. The extended role of the AHPs is of great importance and a preceptorship programme with University backing will be needed. Strong clinical leadership will ensure support and guidance for the staff and credibility amongst the referring GPs. An essential requirement is to have the support and clinical advice provided by members of the Consultant Orthopaedic staff from secondary care to ensure good liaison and contribute to the teaching programmes. The cost of setting up such a service is minimal in terms of staff costs other than the training for the extended role and appropriate re-banding. In terms of cost effectiveness, the MSK service is well-supported by the Clinical Commissioning teams, based on GPs confidence in the service and outcomes but, also the comparison of the salary of a Senior Physiotherapist with that of a Consultant Surgeon. The recently published Clinical Commissioning guidelines emphasise the need for commissioners to expect an integrated service. This service represents a reliable and costeffective means of achieving that, and will provide commissioners with confidence in recommending the use of the Community MSK service. Figure 1 - Referral patterns from GPs in the North Tees and Hartlepool catchment area to Orthopaedics and into MSK - 3 year trend
Page 66 The proportion of GP referrals to Orthopaedics and to MSK is shown, with some annual variation, but the latter service may see an increase in referrals as it attracts more confidence from GPs in its present format. Of the numbers referred from GPs to MSK, those subsequently referred to Orthopaedics for specialist attention is an average of 16.6%. Therefore, the other 83.4% are seen within 4 weeks of referral, investigated and treated in MSK, and discharged from there. These are cases which would otherwise have added to the numbers waiting for an initial Orthopaedic assessment. Figures 2 to 4 show the referral and surgery rates for GPs and the MSK service. There is a higher conversion (average 76%) amongst those who had been referred initially for MSK assessment before referral to Orthopaedics. Those referred directly to Orthopaedics have a conversion rate to surgery of 55%. A large proportion of those referred directly from GP to Orthopaedics are not subsequently selected for a surgical procedure, i.e. many could have been more appropriate for initial assessment by the MSK team. Figure 2 - The numbers of patients referred by GPs to Orthopaedics and the numbers converting to surgery. Figure 3 - The numbers of patients referred by MSK to Orthopaedics, and the numbers converting to surgery. References 1. Getting it right first time - Prof T.W.R. Briggs 2012 2. A Framework for the delivery of Musculoskeletal Service - Department of Health 2006 3. Department of Health Briefing Paper An assessment of the clinical effectiveness, cost and viability of NHS General Practitioners with Specialist Interest (GPSI) services. Department of Health 2006 Figure 4 - The comparison between conversion rates to surgery in the 2 groups Correspondence: Ms C M E Lennox Email: JMCMEL@aol.com