NHSL 18 weeks RTT MSK Event

Janie ThomsonConsultant Physiotherapist NHSL

NHS LANARKSHIRE MSK PATHWAY

PATIENT GP

PATIENT ASSESSED AT 1:1 PHYSIOTHERAPY

APPOINTMENTACUTE

PATIENT ASSESSED AT 1:1 PHYSIOTHERAPY

APPOINTMENTPRIMARY CARE

ORTHOPAEDICSESP VET

ESP:· General (3)· Spinal (3) - 2784· Podiatry (1)· Appliance

Consultant

5,712

17,000

22,712

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

992

426

689

212

828

386

0100200300400500600700800900

1000

lumbar spinexray GP

lumbar spinexray ortho

MRI lumbarspine ortho

Diagnostic Tests carried out

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

LOW BACK PAIN PATHWAY

GP Direct AccessPhone Line

A & ERed Flags

Selfmanage

Surgical Opinion

Urgent Ortho 1:1 physioAx + Rx 4/52

Self ManageRing Back 3/52 WHSS

Settling signpost to Active

Health

Not Settling Escalate to Senior

Pain Association

Scotland

ESPInvestigate if indicated

Back Pain Clinic

ESP / Associate

Pain ClinicSelf Manage

Self Manage

Back Pain Pathway

Impact

Back pain referrals to orthopaedics

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4 5 6 7 8 9 10 11 12

jan - dec

2010

2009

Impact

Month Ortho/GP PAL Total Post MRIStonehouse

Refer to Surgeo

n

October 2010

343 243 612

November 2010

387 228 615

December 2010

313 148 461

January 2011

382 281 663 51 18

February 2011

425 281 706 40 15

March 2011

427 390 817 52 11

April 2011

307 280 587 22 4

May 2011

383 383 766 45 7

June 2011

378 387 765 42 7

July 2011

336 279 615 31 10

August 2011

415 334 749 52 19

Pathway Stages

Patients seen at Stonehouse Clinic

5%

Referral onward for surgical opinion

1%

Total No. Back Pain Patients

94%

Total No. Back Pain Patients

Patients seen at StonehouseClinic

Referral onward for surgicalopinion

Pathway Stage Percentages

Physiotherapy MSK Pathway Summary

Assessment + Intervention

PatientPresents

MSK issue

PhysiotherapyAssessment

Line

GP

Cauda Equina

Red Flags

Physiotherapy 1:1

treatment

ESP Complex caseDiagnostics if required

A&E

Self Management

Ortho clinic

Pain Services

Vocational Rehab

Leisure Services

Rheumatology

Spinal Clinic

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)

Injury / Knee Problem

Self-Referral Telephone Triage

PhysiotherapyOutcome Measures

Clinical AlgorithmsOA – Appendix BMeniscal - AppendixCAKP - AppendixD

Refer to NHSL knee module guide in Education Folder

Orthopaedics Referral

Consultant

Physio

ESP

Pain ClinicSurgery Pain Association

Scotland

Phase 4WHSSPain Association

Scotland

Discuss with ESP

AppendixE

Self Manage

GP

History, exam and working diagnosis

Apply Knee Guidelines AppendixA

+/- MRI

x-ray

+/- WHSS

Discharge

Primary Care

Acute Services

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