Transcript Document

Relieving the Orthopaedic
Outpatients Bottleneck
Damian Armour
General Manager Surgical Services
Barwon Health
[email protected]
Department of Human Services
Introduction
• Victorian Travelling Fellowship Program
– Relieving the Orthopaedic Outpatients
Bottleneck
• NHS Initiatives
– Overview of the Orthopaedic Assessment
Service.
• Barwon Health
– Improving Access to Orthopaedics
• State-wide focus
The Challenge –
Access to Ortho Outpatients
Routine Orthopaedic Outpatient Waiting list patients
<1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11 11-12
> 12
Month Months Months Months Months Months Months Months Months Months Months Months Months
54
85
45
64
60
57
52
45
42
81
34
58
342
Total
1,019
Orthopaedic Outpatients Waiting List
Patients Awaiting their 1st Appointment
1 - Urgent
2 - Semi Urgent
3 - Routine
1200
1000
Patients
800
600
400
200
0
2003
12
2004
01
2004
02
2004
03
2004
04
2004
05
2004
06
2004
07
2004
08
2004
09
2004
10
2004
11
2004
12
Victorian Travelling Fellowship
• Awarded in Aug 04
• Travel to 9 NHS sites in Nov 04
• Intended Learning
– New models of Outpatient Care
• use of Primary Care to ease demand on Secondary Care.
– Referral Pathways for GP’s.
– Consultant Physiotherapists (ESP’s) & GPwSI
– Change Management.
• How did they engage the Consultants?
– Funding Models.
Victorian Travelling Fellowship
2
1
3
4
5
9
6
7
8
1
Stockport NHS
2
Aintree Hospitals
3
Whiston Hospital
4
Royal Liverpool
Hospital
5
University Hospital of
North Staffordshire
6
Somerset Coast PCT
7
Royal Bournemouth
Hospital
8
Southampton Health
Community
9
Modernisation Agency
Fellowship Summary
•
•
Multiprofessional Triage Team / Orthopaedic
Assessment Service (OAS)
Benefits
–
–
–
–
More timely access for patients referred with
musculoskeletal problems.
Orthopaedic Consultants see a higher ratio of new patients
in their clinic who are likely to require surgery.
A clear and documented framework is developed for
patients with musculoskeletal disease.
Physiotherapy and other allied health professionals are
provided with a significantly enhanced career path.
Fellowship Summary
• Risks
– Downstream impact on the capacity of the referral
alternatives.
•
•
Physiotherapy, Podiatry, Pain Clinic etc
Elective Surgery
– GP resentment
– Seen as solution for all musculoskeletal issues.
OAS Overview
Stage 1 – GP Referral
GP sees patient with an Orthopaedic/musculo-skeletal condition and ‘refers’ them into the OAS.
Specialist physiotherapists review all referral letters to identify the appropriate care pathway
Appropriate treatment not clear from referral
Appropriate treatment clear/unambiguous from referral
Patient referred directly to Orthopaedic consultant
Patient referred directly to pain management
Patient referred directly to physio for treatment
Patient referred directly to Orthotics
Patient referred directly to podiatry, rheumatology
Patient referred directly back to GP
Stage 2 – Face to face physiotherapy triage assessment
Patient has an assessment in a locality based clinic by a specialist physiotherapist to identify appropriate care pathway.
Patient referred directly to Orthopaedic consultant
Patient referred directly to pain management
Patient referred directly to physio for treatment
Patient referred directly to Orthotics
Patient referred directly to podiatry, rheumatology
Patient referred directly back to GP
GP Referral
• Standardised GP referral template.
• Desirable for ease of triage but not a prerequisite for
success.
• Barwon Health already has a generic Medical Director
referral template with a high take up rate.
• GP Communication Plan crucial to implementation.
– Prevent backlash “Expect to see a Surgeon”
– Prevent all musculoskeletal issues being referred.
Triaging
• There are varying levels of GP referral triage
undertaken:
• Referral Management
– NHS - implementing a centralised referral management system
– a precursor to the implementation of the “Patient Choice” system
• Paper Triage
–
–
–
–
Generally by an experienced Physiotherapist.
Some sites still had Consultants triaging
Allocated to non-consultant resources after a “transition phase”.
Undertaken in conjunction with agreed guidelines (include ‘red
flags’).
• Clinic Assessment
– Undertaken if paper assessment not adequate for decision
– A face-to-face assessment by Primary Care resources.
– Communication is made with the GPs about the ongoing care.
Clinic Structures
• Multidisciplinary
– Physiotherapists are the core resource
– General Practitioner with a special interest in
Ortho.
– Other resources would include Podiatrists, OTs,
Rheumatologists etc.
• Timeframe
– Assessments run for a period of 30 minutes
– 20 min patient consultation / 10 min
multidisciplinary discussion.
• Patient Numbers
– Each clinician sees 6 new or 5 new/2 review.
Clinic Structures
• Themed Clinics
– Mixture of approaches
• Themes/specialities vs generic in nature.
– Types:
• Lower Limb, Upper Limb, Spinal, Injection clinics
– Some sites also ran a mixture of specialised and
generic clinics.
• Location
– Primary care or secondary care settings.
– Dependant upon responsibility for the service.
– Logistical matters (e.g clinic space, access to
diagnostic services).
Clinic Structures
• Clinic Outcomes
– Not just Assessment
– One Stop Shop
• Assessment / Advice / Discharge
Downstream Impact
• OAS clinics will result in an improvement in
waiting times for initial assessment.
• However implications are …
– Waits for treatment clinics (e.g Physiotherapy,
Podiatry and Pain Clinic) will increase.
– Increased listing rates result in an increase to the
elective surgery waiting list.
• Patients receiving immediate assessment,
advice and discharge within the OAS clinic will
benefit without impacting on downstream
resources.
Downstream Impact
• A study within one of the sites indicated
approximately:
– 33% of GP referrals would receive
immediate treatment and discharge.
– 33% requiring a Consultant opinion.
– remainder requiring other non-invasive
therapy.
• Other sites found that only 20%
required a consultant opinion.
Workforce Issues Orthopaedic Consultants
• In NHS - full time with about 7 clinical
sessions per week for their Trust.
• High degree of subspecialisation.
• Role in the OAS …
– need to be willing reallocate traditional
consultant tasks to other clinical resources.
– flexible in relation to the management of
their allocated time (swap clinics for
theatre sessions).
Workforce Issues –
GP’s
• Play a key part in the OAS
– as a referrer
– as a participant in the clinics themselves
• Utilisation of GPwSI’s was mixed.
• Integration of a GP within the clinics assists in
the relationship building with GP community.
• The availability of a medically trained
resource within the clinic provides a required
level of clinical expertise.
Workforce Issues –
Physiotherapists
• Success depends on the ability of the
organisation to successfully enhance the role.
• Extended Scope Physiotherapist (ESP)
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–
–
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Injection Therapy
Ordering of X-Rays and Blood Tests
Ordering of MRIs
Listing for surgery
• Competency development
– Documented guidelines outlining the core
competencies of ESP.
– Orthopaedic Consultant Signoff
– Society of Orthopaedic Medicine training course
Workforce Issues –
Other
• Other Allied Health Professionals
– Podiatrist
– Rheumatologist
• Administrative Staff
– Crucial in managing patient expectations
• HMO’s
– Reduced the need to work in clinic
– Safe working hours.
Change Management
• Ensure all stakeholders (esp. Surgeons and
GPs) embrace the concept of the OAS.
• Start the OAS small (e.g. with a particular
body part) and expanding gradually.
• Many sites started with new referrals as
opposed to going back through the waiting
list.
• Documented procedures and protocols in
addition to the continuing education of staff is
critical.
Government Influences
• Advances would not have been achieved without a
comprehensive focus on the matter by NHS.
• Outpatient Targets. No one waiting greater than…...
– 21 weeks by April 2003,
– 17 weeks by 2004,
– 13 weeks by 2005.
• Underpinned by a national outpatient service
improvement collaborative and modernisation
program.
• Many of the sites visited recognised the evolving
problem well before the targets were set.
Measurement
• Patients by service type (e.g. back/spine,
lower limb, upper limb)
• Conversion rates for Surgery
• Waiting Number and Waiting Times
• Service Outcomes
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Referral to Physiotherapy (Primary or Secondary)
Referral to Orthopaedic Consultant
Assessment, Advice & Discharge
Investigation (including type) and further review
Other Referral (Pain Clinic, Podiatry, Rheum)
DNAs
Outcomes
• Patients
– Improved Access:17 weeks for all referrals.
– Patients satisfied with care.
– Lower DNA / FTA Rates (6%)
• Surgeons
– Higher listing rates, better time utilisation.
– 20 to 30% of referrals require a consultant opinion
– Many now rely on OAS.
• Physio’s/Allied Health
– Enhanced Career Path
Barwon Health’s Strategy
Improving Access to Orthopaedics Steering Group
Orthopaedic Spokesperson
Orthopaedic Surgeon
BM Surgical Services
GM Surgical Services
DND Surgical Services
Project Manager
Project Leaders (3)
Chief Physiotherapist
ESAC
Project Manager (PT)
Outpatient Access
Project Lead - Physio
Exec Sponsor - GMSS
Surgeon
Deb Schulz (Chief Physio)
Lisa Adair (NUM OPD)
Jeff Urquart (GP)
Focus Areas
OP Waiting Numbers
OP Waiting Times
Physio led services
Better use of consultant
time.
Theatre
Inpatient Access
Focus Areas
Focus Areas
Project Lead - R Cockayne
Exec Sponsor - DNDSS
Surgeon – Mr Willams
Anos Representative
Lee Rendle (ANUM Ortho)
Haydn Lowe (ESAC)
Audrey Williams (CSSD)
Turn around times
Start times
Equipment Issues
Consumables
Project Lead - L Coleman
Exec Sponsor - BMSS
Surgeon
Haydn Lowe (ESAC)
Mick O’Donnell (NUM Ward)
Rehab Rep
Length of Stay
Rehab Predictor
Patient Education
Bed Management in Ward
State-wide Focus
1. Awareness of the Outpatient issue
– “Can’t manage what you don’t measure”
2. Identify existing initiatives.
– National & International
3. Coordinated/Consolidated focus
– NHS Modernisation Agency
– DHS Collaborative
References
• Chartered Society of Physiotherapists (UK)
– www.csp.org.uk/download/sep/pdf/csp_sep_ocos.pdf
• NHS Modernisation Agency
– www.modern.nhs.uk/serviceimprovement/1339/1990/7700/Orthopaedics
GuidevFinal.pdf
Questions
?