NHSL 18 weeks RTT MSK Event

Janie Thomson Consultant Physiotherapist NHSL

PATIENT GP

NHS LANARKSHIRE MSK PATHWAY

PATIENT ASSESSED AT 1:1 PHYSIOTHERAPY APPOINTMENT ACUTE PATIENT ASSESSED AT 1:1 PHYSIOTHERAPY APPOINTMENT PRIMARY CARE

22,712

ORTHOPAEDICS ESP VET

5,712

ESP: · General (3) · Spinal (3) -

2784

· · Podiatry (1) Appliance

17,000

Consultant

The direction ?

The Back Pain Challenge

 30,000 referral to physio per annum  33% back pain  7500 referrals to orthopaedic ESP  48% back pain  Work already completed on MRI and x-ray  NHSL Low back pain pathway implemented July 2010

Diagnostic Tests carried out

1000 900 800 700 600 500 400 300 200 100 0 992 426 lumbar spine xray GP 689 212 lumbar spine xray ortho 828 386 MRI lumbar spine ortho 2005 2009

Problem Statement Pre Redesign

      Multiple access routes/assessments/opinions Variance in physiotherapy management and clinical skill set Appropriateness of MRI and x ray requests Significant number of low back pain referred for orthopaedic opinion despite no identified surgical target / low conversion to surgery Demand outweighs capacity Variable (or no) measurement of outcome/impact

Service Improvements

 Need to examine and address whole system      Ortho, GP, AHP, Leisure, WHSS Introduction of self referral Drive for clinical excellence and reduction in variance     Complex case clinics Learning resource file On job learning Online modules Clinical pathway development Establish exit routes

Self manage GP Direct Access Phone Line A & E Red Flags Urgent Ortho Settling

signpost to Active Health Self Manage Self Manage

1:1 physio Ax + Rx 4/52 ESP

Investigate if indicated

Back Pain Clinic

ESP / Associate

Surgical Opinion Self Manage

Ring Back 3/52

Not Settling

Escalate to Senior

WHSS Pain Association Scotland Pain Clinic

Impact

Back pain referrals to orthopaedics

200 180 160 140 120 100 80 60 40 20 0 1 2 3 4 5 6 7

jan - dec

8 9 10 11 12 2010 2009

Impact

Pathway Stages

Month

October 2010 November 2010 December 2010 January 2011 February 2011 March 2011 April 2011 May 2011 June 2011 July 2011 August 2011

Ortho/GP

427 307 383 378 336 415 343 387 313 382 425

PAL

390 280 383 387 279 334 243 228 148 281 281

Total

817 587 766 765 615 749 612 615 461 663 706

Post MRI Stonehouse Refer to Surgeon

51 40 52 22 45 42 31 52 18 15 11 4 7 7 10 19

Pathway Stage Percentages

Referral onward for surgical opinion 1% Patients seen at Stonehouse Clinic 5% Total No. Back Pain Patients Patients seen at Stonehouse Clinic Referral onward for surgical opinion Total No. Back Pain Patients 94%

Patient Presents MSK issue

Physiotherapy MSK Pathway

Summary

Assessment + Intervention Physiotherapy Assessment Line GP Cauda Equina Red Flags Physiotherapy 1:1 treatment ESP Complex case Diagnostics if required A&E Ortho clinic Spinal Clinic Pain Services Vocational Rehab Leisure Services Rheumatology Self Management

Preparation & Support

     Clinical training – reduce variance in practice Sign off for AHP investigation requests (monitoring systems agreement) Clinical support and mentorship (on the job) Complex cases / clinical reasoning sessions (by whom & where) Clinical escalation policies (by clinical signs or timing)

Primary Care Acute Services GP

History, exam and working diagnosis Apply Knee Guidelines

AppendixA

Consultant Orthopaedics Referral +/- MRI x-ray ESP

Injury / Knee Problem Self Manage

Discuss with ESP

AppendixE

Self-Referral Telephone Triage

+/- WHSS

Physiotherapy

Outcome Measures OA –

Clinical Algorithms

Appendix B

Meniscal -

AppendixC

AKP -

AppendixD

Refer to NHSL knee module guide in Education Folder Surgery Physio WHSS Pain Association Scotland Pain Clinic Phase 4 Pain Association Scotland Discharge

Other pathways

 Foot & Ankle  Hand  Both of these pathways are in the consultation phase.

Benefits

      Primary care management enhanced by supporting AHPs to manage episodes of care autonomously Reduction in handoffs = reduced waits, reduced chronicity, reduced workplace absence Investigations pre referral, within physio episode, collapses RTT Physio refers directly to ESP (ortho) via internal referral (Trak) Increased conversion rate to surgery within acute services Outcome measures monitor quality and effectiveness of services

Pathway design considerations

   Stakeholder engagement re: onward referral / exit routes (consider workforce & capacity issues) Monitoring flow for capacity planning (eg flow to ESP changing from GP to AHP referral) Anticipate resource issues