Transforming musculoskeletal (MSK) services Dr Tom Aslan Hampstead Group Practice GP and Camden CCG MSK clinical lead Working with the people of Camden to achieve the best health for all
Problems with the current MSK system Musculoskeletal (MSK) services see patients with injuries or conditions related to their muscles, bones or joints. Common conditions include arthritis, sports injuries, gout, osteoporosis, carpal tunnel syndrome and shoulder, back or ankle pain. In Camden, different providers deliver different parts of our MSK service. Depending on their condition, and its severity, patients may need to be seen in different settings (for example, some patients will need to see a physiotherapist in the community, some will then need to go to hospital appointments, and some may need an operation.) These services are not always joined up, and the system can be confusing for patients to navigate. At present, the success of services is not always measured by what is important to patients. GPs and providers say it s ineffective and leads to tests being duplicated, poor use of consultant appointments and too much administration for GPs. Patients say system is complex, waiting times too long and referral process inefficient. 2
Problems with the current MSK system Through a survey and focus groups, MSK patients have told us: They want to be more involved in their care I explained that I had tried orthotics years ago and that it had not worked. This was ignored and orthotics were recommended. They want care to be holistic, supportive, and personalised to their needs They make you leave and give you no after-care except a routine visit so long after the op that complications... can cause severe problems. They want timely and responsive services It is also very, very slow to get ultrasound and steroid injections through the hospital, leaving me in pain and restricted mobility for weeks and months at end. They want a coordinated, seamless experience I had to be re-referred by my GP to access another part of the MSK service, this is a waste of my time and GP s time. 3
How will we transform MSK services? To tackle these issues, in March our Governing Body approved a proposal to commission an integrated MSK service through a single contract. This means one provider will be responsible for managing the MSK system, and coordinating care for patients. Existing services which are valued by patients will continue to be available. We aim to appoint a service provider by late 2016 and launch the new service in spring 2017. The proposal was developed with Camden MSK patients, GPs and specialist clinicians. 4
What will the new MSK service look like? A full range of MSK services will be provided and integrated with each other, including imaging and specialist inpatient and outpatient services Patients, carers and referrers will have a single contact for access, triage, referral and case management (this includes self-referral for patients) Patient choice will be available for specialist services, including those outside our MSK service. Information, such as waiting times, will be available to patients so they can make informed choices Where appropriate and with patient consent, a patient s information can be shared with relevant health services outside MSK, such as psychology or weight management Patient self-management and education resources will be available. 5
Typical patient journey in current MSK service Sue is experiencing back pains. She: is 51 years old is obese does minimum exercise has a desk job Experiences low moods Service type Treatment Diagnosis Assessment 1 Weeks 1 & 2: Sue selfmanages her pain Self-help information is not easily or readily available 3 weeks wait 2 3 Week 3: Week 8: Sue visits Sue returns her GP to see her Sue s GP: GP with Completes continued pain assessment refers her Sue s GP Write a for physiotherapy prescription for pain Gives some leaflets 4 Weeks 11-17: Sue completes 6 physiotherapy sessions ~10.5 months 2 weeks wait 5 7 Week 18: Sue returns to her GP with 6 continued Week 20: pain. Sue has her Sue s GP MRI scan refers her Her results for an MRI are sent to scan her GP Patients get no direct advice from providers, resulting in less informed decision Week 22: Sue returns to see her GP for her MRI results Sue s GP refers her to neurosurgery 4.5 months 1 wait Reliance on a single expert (GP) with no direct communication between providers results in an increased chance of incorrect referrals and unnecessary interventions 8 Week 41: At neurosurgery, Sue has: Another MRI scan Additional tests Neurosurgery refers Sue back to her GP Long referral wait times 9 Week 45: Sue returns to see her GP Sue s GP refers her back for additional courses of physiotherapy and lifestyle services 10 Patient issues 1 Based on historic range between 3 and 6 months Multiple unsuccessful referrals from GP Only ~18% of time spent in treatment After almost one year in the system, the patient is still in pain and referred back to an early treatment 6
Typical patient journey in future MSK service Service type 3 months Assessment 1 Week 1: Sue completes a MSK service self-assessment online She self-refers 2 weeks wait 4 Week 11: Sue calls her appointed care coordinator, still experiencing some pain Sue is experiencing back pains. She: is 51 years old is obese does minimum exercise has a desk job Experiences low moods Diagnosis With the right information, Sue is able to identify a need to contact to her GP sooner 2 48 hours later (Week 1) service contacts Sue to: Arrange her physio appointment Discuss and set up her personalised treatment plan Signpost her to lifestyle services 5 within 48 hours (Week 11): Sue s coordinator: Contacts her GP, physiotherapist, and a neurosurgeon to better understand her options and get their recommendations Contacts Sue to discuss her progress, options and expected outcome (e.g. success rates, wait-times, recovery time, etc.) Sue makes an informed decision to continue with physio and lifestyle services Treatment A single integrated service has the right range of expertise to provide holistic, coordinated care 3 Week 3-9: Sue completes 6 physio sessions, as well as psychological therapies and weight management classes Her care coordinator monitors her progress Better informed, personalised decisions can be made with input from experts Service improvements experienced Significantly shorter length of time 3 months vs. 2 years due to reduced waiting times Majority of time (55%) spent in treatment Unnecessary interventions avoided Quicker recovery due to more holistic care (e.g. exercise) 7
How will patients benefit? The new service will make it easier for care to be focused on individual patient needs. We will measure the success of MSK services using factors that are important to local patients and clinicians (called outcomes). Work has been undertaken with patient focus groups to understand which areas are most important to patients. There will be further workshops and a survey to build on this. Patients will benefit from: a convenient, single point of contact who will manage their whole journey through MSK services resulting in no need to repeat patient history or duplicate tests. shorter waiting times better and more personalised information, delivered at the right time, so they can make informed decisions IT systems that work together, so they won t need to keep repeating their patient history when they see a new service or clinician improved integration between care providers, so they can seamlessly move between their chosen providers and types of care. 8
How have patients shaped the proposal so far? Focus groups With Camden MSK patients in September 2014 and November 2015 Highlighted waiting times, a need for joined-up services and desire for incorporating self-help into system. Patient survey With Camden MSK patients in 2015 53% rated community management of condition as poor or very poor Highlighted lack of involvement in care, lack of joined up care and waiting times. More positive feedback received on hospital-based care. Patient input led to priority being given to: providing joined up care for patients through a single point of contact and consistent case management minimising causes of delays and waiting times through access to advice over the phone, quick referrals into the system and a requirement for triage within one working day providing patient information to help patients make informed decisions at every stage of care, including self-assessment, surgical decisions and choice of providers. 9
What happens next? Future patient involvement: Two MSK patient leads to join evaluation panel for assessing provider bids Online survey to further understand patient views on desired outcomes Focus group to look at areas raised in survey and past focus groups in more detail Focus group members will have the opportunity to listen to a presentation from shortlisted bidders, and support the evaluation process Regular updates at CPPEG meetings and in PPG newsletters. Key dates: Provider bidding and assessments: April to September 2016 Contract awarded: September 2016 Service preparation: October 2016 to April 2017 Service launched: April 2017. 10