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Setting the scene and objectives for the day:
What does good Musculoskeletal care
look like for whole populations? A local and national picture of MSK
services
Peter Kay National Clinical Director, Director for
MSK
#MSKNetworks
www.england.nhs.uk
What does good Musculoskeletal care look like for whole populations? A local and national picture of MSK services Peter Kay National Clinical Director Director for MSK Sue Brown Chief Executive ARMA
Setting the Scene
#MSKNetworks
"Whole System MSK Northern Region event”
What does good Musculoskeletal care look like for whole populations?
A local and national picture of MSK services.
Prof Peter Kay FRCS Hip and Knee Surgeon Wrightington National Clinical Director MSK NHS England
• More years lived with MSK disability than any other disease • 2nd cause of disability • More time off work • etc • Not Kids, Cancer, Cardiac • Is it a priority for payers?
• Under the Spot light
– Economy • Expensive • Variation • Waiting times • Social care
– Work • Benefits
MSK in the NHS England (£7 -10bn) 4th largest area of spend
GBD England 2013: deaths by cause - Not a major killer
MSK
Trauma Autoimmune Cardiac RA
GBD England 2013: Years lived with disability
MSK
30.9 million working
days lost
One third of all GP
appointments
Second poorest quality
of life Main cause of
physical disability
£5 billion of NHS spending
per year
Why is MSK Important? It affects more than 10 million adults and 150,000 children in the UK
200+ separate conditions OA, RA, AS, Back, Neck, Hip, Knee, traumatic degenerative, inflammatory, infective, neoplastic, pain, bone disease osteoporosis etc Associated with a large number of co-morbidities, including diabetes, depression and obesity
Accounts for over 25% of all
surgical interventions in
the NHS
• Ageing population, productive and independent • Increased emphasis on long-term conditions and
multimorbidity (MSK as part of this) • Self-management an patient empowerment SDM • Promoting and supporting wellbeing, not just
treating illness • Global Burden of Disease study: MSK main cause
of rising burden of disability. • Present system is not working well • New models of care VANGUARDS
Drivers of change - MSK
#msknetworks
Nicola Walsh Professor of Knowledge
Mobilisation & MSK Health
MSK Disorders: Societal and
healthcare impact
1
#msknetworks
2
Prevalence
Number of adults affected by MSKD in England
YLD attributed to MSKD Ranked 1st in GBD
South-West has highest YLD for MSK in England
30.5%
1st
~10m
(Data from Global Burden of Disease, 2014-17)
#msknetworks
3
YLD/100,000 3457 (2440-4600)
(Courtesy of BNSSG Public Health Teams)
#msknetworks
4
NHS Financial Impact
• 3rd largest area of NHS spend
£4.7billion
• Prescription spend
£223.6million
• GP appointments (~800 GP equivalent)
4.6million
• Hospital bed days
2.16million
(ARUK, 2017)
#msknetworks
5
Societal Impact
Work days lost in 2016
People receiving PIP with MSKD as primary disability
Own or partners work-life affected
34.6%
30.8m
(PIP, 2016; ARUK 2017)
43%
#msknetworks
6
Impact on Quality of Life
Experience pain on most days
Nuisance to family
Depression is four times more common in this group
(ARUK, 2017)
Patient Experience: Ehlers Danlos Syndrome
Laura Lewis
Dislocations Pain Fatigue
Stretchy skin
Digestion problems
Bruising
Hypermobile
Anaesthetic reduced effect
My journey to diagnosis
● Childhood – tiredness, bendy, “pain”, clumsy, bruising
● Teenager – pain, tiredness, hips and clavicles were not in the
right place
● 21 – diagnosis of HMS (after suggesting it myself and asking
for referral)
● 25 – had my son and my health took a nose dive + start of POTS
● 26/27 – EDS type 3 confirmed on paperwork
I have had good and bad experiences with medical professionals
Notable Experiences
BAD
● Cant possibly be dislocating
● I have seen someone with EDS before, they
didn’t experience that so…
● Oh hypermobility you mean? Its not that bad!
● Your too young/ look too well
● Your just a bit flexible dont worry about it
● You just need to exercise more
GOOD
There has been some amazing people, this is usually based on:
• Willing to listen and acknowledge my experiences as real • Believe I am in pain • Work with me to find treatment – manage not cure • Honesty • Research, talk with other Drs for advice • Being gentle and patient
Advice ● Don’t be afraid to say you don’t know or have never heard of EDS
● We don’t mind you googling – We would rather you go onto the EDS UK site and have access to current info than send us away without help (or worse still base treatment on hearsay and myths)
● Please understand we may be bitter and angry. We don’t mean to take it out on you, most of us have had years of being made to feel like we are crazy or making it up. - All we want is empathy and understanding.
● Accept that we may know more about EDS than you. We learn to be the experts of our bodies
● We don’t want to keep doing “party tricks”. If we have a diagnosis accept it, don’t make us prove our bendiness as you are curious (if its necessary that’s of course different). It can hurt us to show how bendy we are and it comes with risks of damage.
● Don’t be afraid to ask us to rebook an appointment so you have time to do more research. You can say you don’t know what to do but I will find out (I cried with joy when someone said this to me)
Research data
Lets debunk some myths
● You must have stretchy skin to have EDS ● Its all about dislocating joints ● You have to be tall and thin in order to be diagnosed with
Ehlers-Danlos Syndrome ● (for children) – its just growing pains ● Can grow out of it ● Pain is not associated with EDS ● Sufferers are comparable and treated in the same way
Thank you
For more info on EDS please visit:
www.ehlers-danlos.org
Musculoskeletal Health and Care across the Pathway: A regional priority NHS RightCare overview Piers Glen NHS RightCare Delivery Partner [email protected]
2
What is RightCare? NHS RightCare is a programme committed to reducing unwarranted variation to improve people’s health and outcomes. It ensures that the right person has the right care, in the right place, at the right time, making the best use of available resources. NHS RightCare ensures local health economies….. • make the best use of resources to give better value – better value for patients, the population and the tax payer. • understand how they are doing – by identifying variation with demographically similar populations • get talking about the same stuff - about population healthcare rather than organisations • focus on the areas of greatest opportunity by identifying priority programmes which offer the best opportunities to improve healthcare for populations • use tried and tested processes to make sustainable change to care pathways to reduce unwarranted variation
3
• NHS RightCare works with a wide range of stakeholders, national programmes and partner organisations to develop and test new concepts and influence policy.
• Examples of NHS RightCare’s current work related to MSK include: • Collaborating with Getting It Right First Time Programme • Working with the Arthritis Research UK MSK Health Data Group • Developing networks and Optimal Value Solutions with national
organisations such as Public Health England, National Osteoporosis Society & Chartered Society of Physiotherapy
• Developing national thinking on Medicines Optimisation with the National Institute for Clinical Excellence and the Care Quality Commission
• Testing and proving concepts around patient and clinician Shared Decision Making and Supported Self-Management
4
5
6
NHS RightCare Principles
What’s there to help? RightCare materials include insight packs for each CCG; online tools; in-depth focus packs; practice level analysis packs; casebooks.
High level analysis compares a CCG with its 10 most similar CCGs using demographic factors, showing where it’s an outlier and highlighting opportunities for improvement.
8
Commissioning For Value Where to Look Packs – January 2017
Commissioning For Value Where to Look Packs – January 2017
10
Pathways on a page
11
Variation compared to most similar 10 CCGs
12
Commissioning For Value Long Term Conditions (LTC) Pack December 2016
• Population prevalence of risk factors • Smoking • Overweight and obese • Eating 5-a-day • Inactivity
• Estimate prevalence of hip and knee OA
• Preoperative Oxford hip and knee scores
13
Prevention - % physically inactive adults
Source: RightCare Long Term Conditions Focus Pack
14
Estimated Prevalence Knee OA
Source: RightCare Long Term Conditions Focus Pack
15
Commissioning For Value – Focus Packs
Musculoskeletal Conditions & Trauma & Injuries May 2016 (update due July 2017)
The focus pack breaks MSK down into five pathways: • Back, neck and MSK pain; • Rheumatoid and inflammatory
arthritis; • Osteoporosis and fragility
fractures; • Osteoarthritis; • Trauma and injuries Key indicators are presented along the pathway to help commissioners understand how performance in one part of the pathway may affect outcomes further along the pathway. For example a higher prevalence of osteoarthritis may explain higher spend on elective activity.
16
MSK Focus packs
17
MSK Focus packs
Practice level packs • Each GP practice within a CCG has been grouped on the basis
of demographic data into one of 15 national clusters based on: • Deprivation (practice level) • Age profile • Ethnicity • Practice population size
• Practice level analysis and opportunities calculated by
comparing to other demographically similar practices. MSK pack due July/Aug 2017
19
RightCare pathways
20
Shared decision aids
NHS RightCare Shared Decision Making aids are available for osteoarthritis of both the hip and knee
21
Case studies
Ashford CCG introduced a successful MSK triage service, delivering a 30% reduction in acute MSK demand and a 7% reduction in MSK spend through introduction of a triage service. Effective Shared Decision Making and a triage service in Bedfordshire showed 20% of referrals changing from the initial route and the proportion of MSK activity happening in secondary care falling from 68% in 2012 to 52% now.
22
RightCare scenarios
23
“Susan’s story”
24
Awareness is the first step
If the existence of clinical and financial variation is unknown, the debate about whether it is unwarranted cannot take place.
25
Think about whole populations….
Need to avoid the trap of improving value for those that use a service and ignoring those with a condition that don’t use the service
I For more information and support about how to use the NHS RightCare approach to get best value for your population, go to www.rightcare.nhs.uk or email us at [email protected]
NHS RightCare is a programme of NHS England
RightCare Delivery Partners currently working in South Region: Bruce Pollington [email protected] 07710 152763
Mary O’Brien mary.o’[email protected] 07710 152781
Steve Sparks [email protected] 07970 949469
Piers Glen [email protected] 07710 152804
Siân Jones, Primary Care Programme Lead,
West of England Academic Health Science Network
MSK: commissioning
services that work
2
3
Evidence and healthcare • Evidence based medicine (EBM) • 20 years • Individual decisions
• Health & Social Care Act 2012 ‘… embed research as a core function of the NHS’ CCGs: ‘…need to demonstrate that they have in place systems and processes to promote patients' recruitment to research, participation in research; and systems and processes for funding the treatment costs of patients taking part in research.’
• Decisions based on population needs
• Commissioners are responsible for 2/3 NHS budget (£72bn 2016-17)
• MSK: third largest area of NHS spend • Commissioning decisions impact on whole populations
Get it right first time!
4
Responsibility
‘…lots of commissioning work goes on, but we don’t use much evidence about what works, not much analysis, so there’s little real improvement in services.’
An NHS Commissioner:
‘73% of CCGs studied by the Royal College of Surgeons do not follow NICE and clinical guidelines on referral for hip replacement’
Arthritis & Musculoskeletal Alliance (ARMA)
6
Hip replacement
• Evidence • Difficult to use • Timeliness • Gaps • Relevance
• Individual
• Skills • Confidence • Time
• Organisational
• Capacity • Culture
8
Healthcare commissioning ‘most challenging context for use of evidence and best practice’ (Checkland et al 2011)
Checkland http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1808-240_V01.pdf
Evidence informed commissioning
Strategic decision making – populations Spring, B. & Hitchcock, K. (2009) Evidence-based practice in psychology. In I.B. Weiner & W.E. Craighead (Eds.) Corsini’s Encyclopedia of Psychology, 4th edition (pp. 603-607). New York:Wiley
Population needs/
demands
Finite resources
• Solutions • Toolkits • Training • GP Evidence Fellows
• Buddy up • CLAHRC West • APCRC
• Expertise • Public Health • Library & Knowledge Services • Academia
10
Help is out there!
11
A call to action!
Getting It Right First Time (GIRFT) Clinical Quality, Efficiency and Productivity Programme
Andy Brown Governance and Procurement for GIRFT 14th July 2017
#msknetworks
GIRFT Pilot on orthopaedics The first ‘Getting it right first time’ (GIRFT) report - published by Professor
Tim Briggs in 2012 suggested that changes could be made to improve pathways of care, patient experience, and outcomes - with significant cost savings.
The Secretary of State and NHS England funded the GIRFT project as a national professional pilot across England.
Project was hosted on behalf of the British Orthopaedic Association, at the Royal National Orthopaedic Hospital in Stanmore.
#msknetworks
GIRFT Pilot on orthopaedics
Supporting the following in elective orthopaedic care: Improved patient experience - Quality Re-empowering clinicians Improved patient safety Better outcomes in terms of joint longevity, infection – SSI and acquired,
complications, readmissions and mortality Significant taxpayer savings from reduced complications; infections;
readmissions; length of stay and litigation; better directed care pathways; reduction in loan kit costs; and introduction of evidence based procurement and procedure selection.
#msknetworks
Future challenges Breakdown of the Estimated 22bn Efficiency Challenges by 2020/21
Carter work is key to delivering the acute sectors share of this challenge
#msknetworks
Improving NHS productivity: mapping providers’ cost per Weighted Activity Unit against their surplus/deficit as a percentage of operating expenditure
• Dots: 136 non specialist trusts • Size of dot: Standardised clinical
output (WAU) • Colour of dot: CQC rating • Cost per WAU: is from Reference
Cost 15/16 • Surplus deficit: from trusts accounts,
figure excludes impact of impairments and transfers by absorption and charities
BETTER PRODUCTIVITY, SUSTAINABLE FINANCES
BETTER PRODUCTIVITY, UNSUSTAINABLE FINANCES
WEAKER PRODUCTIVITY, SUSTAINABLE FINANCES
WEAKER PRODUCTIVITY, UNSUSTAINABLE FINANCES
Trusts with a lower cost per WAU (more productive) tend to have a smaller deficit and more sustainable finances
Inadequate trusts tend to have weaker productivity and unsustainable finances
Outstanding trusts have higher productivity and more sustainable finances
Direction of Improvement
#msknetworks
Data sources – 12 sets of data for each trust A comprehensive orthopaedic dashboard has been created for each provider. Data sources include:
NJR (disappointingly not all data is available by provider – e.g. Longevity/revision rate by different prosthesis/weight bearing surface etc)
HES HSCIC NHS Comparators NHS Indicators Productivity Metrics PROMS National data sources – waiting times etc National Hip Fracture Database NHS Litigation Authority NHS Atlas of Variation Arthritis Research UK Musculoskeletal Calculator
UNIQUE Data Set For Each Trust #msknetworks
What a GIRFT discussion involves – Peer to peer review
Clinicians within a specialty meet with the GIRFT senior clinical lead to examine and discuss : clinical outcomes processes (including revisions) patient experience patient pathways network arrangements financial impacts waiting times ….to help confirm a reasonable and legitimate interpretation and agree implications for practice
#msknetworks
Pilot in England and beyond
Project began in May ‘13 Report published March 2015 Over 98% of all trusts visited, voluntary - one refusal only >130 GIRFT visits 211 hospitals completed in England Team have travelled 18,000+ miles, met 1708 surgeons, met 435 managers Wales, NI and Scotland Also Reviewed Total Hospital Visits - 265
#msknetworks
What did the GIRFT pilot in Orthopaedics tell us
Huge variations in practice and outcomes in terms of device and procedure selection, clinical costs, infection rates, readmission rates, and litigation rates.
Scope to tackle many of these variations and drive short, medium and longer- term improvements in quality of delivery (through adopting best practice), reducing supplier costs (for example of implants) and generating savings, for example from reduced readmission and re-operation rates.
Many of the answers are already out there There is no consensus as to what constitutes best practice in
areas of activity where there is no NICE or formal guidance from the BOA or other professional sub-specialty association. This provides a significant opportunity to drive efficiency.
#msknetworks
Examples of variation
• Fixation cemented versus uncemented
• 10A rated implants • Choice and selection of implants • Procurement:
– Cost of implants – Use and cost of loan kits
• Litigation costs • Revision rates • Infection rates • Cost of procedure • Replacement within 1 year of
Knee Arthroscopy • No’s of procedures per surgeon
#msknetworks
Key findings of GIRFT Orthopaedics
#msknetworks
Variation in specialist activity Average 11 shoulder replacements
per trust (increased by 5 higher volume specialist centres – generally less than 5 at most trusts so far)
Average 4 elbow replacements (increased by 2 higher volume centre – generally less than 2 at most trusts)
Average 6 ankle replacements (increased by 4 higher volume specialist centres – generally less than 2 at most trusts)
Average 35 spinal fusions (increased by 6 higher volume specialist centres)
6
1
2
31
1
3 2
Example - Elbow replacements and revision across trusts in Manchester
Trust 1
Trust 2
Trust 3
Trust 4
Trust 5
Trust 6
Trust 7
Trust 8
Trust 9
Trust 10
#msknetworks
Orthopaedic surgery: debunking myths?
Examination of data has confirmed: • No strong relationship between numbers of procedures
undertaken and length of stay • Cost data skews reflect the efficiency of trusts in
reclaiming income, more than clinical effectiveness • Arthroscopy may not always represent Value For Money • Readmission rates –more revealing than LOS about
problems in quality of intervention and /or care
#msknetworks
What has happened since the pilot? Two key changes have been:
• A step change in the method of fixation for primary hip replacement in
the over 65 year old cohort with a jump from just under 45% of activity to over 55% between 2012/13 and 2013/14, reversing a long term trend. This alone is worth an estimated £4.4 million per year.
• Reductions in length of stay for primary hip and knee replacements of
half a day, creating over 50,000 bed days in released capacity.
#msknetworks
Getting It Right First Time
Update Increased funding announced – very positive coverage 20 new clinical lead roles advertised Team scaling up Savings methodology using HES data established and dashboard in development Collaboration with Model Hospital being formalized Support for NCIP agreed First new specialist report imminent 11 workstreams underway Trackable changes in orthopaedic practice and cost
Impact
Reversal of hip fixation trend in the over 65s
30 day readmissions on all orthopaedics
#msknetworks
Progress to date in MSK
Orthopaedic surgery 2015-17 • Trust visits by Tim Briggs 2014/15 and publication of national
report • Orthopaedic Vanguard • Revisits 2017 to refresh data and assess progress Spinal surgery 2016 • Deep dive visits in progress • National report due later in 2017
Expansion of GIRFT programme 2017-19 will include neurology and rheumatology, as well as reviews of services of relevance to MSK such as outpatients and pathology services
#msknetworks
Orthopaedic surgery dashboard
Hip replacement fixation method Patients 65+ years. HES Apr 2014 – Mar 2015
Estimates of case-mix complexity ASA – NJR 2015.. Other – HES Apr13 – Mar15.
Total knee replacement within 1 year of arthroscopy Patients 60+ years. HES Apr12 – Mar15.
General statistics
Hip prosthesis ODEP 10A rating - % of all acetabular /femoral prostheses
NJR 2015.
Annual average procedures per surgeon . NJR 2015. .
Activity (admissions) . HES 2014/15 data .
PROMS average health gain – Oxford score HSCIC – Apr15 – Dec15
ProviderPrimary Revision Primary Primary Revision Primary Elective Non-EL Injections
procs procs LoS (days) procs procs LoS (days) procs LoS (days) procs LoS (days) procs LoS (days) procs LoS (days) procs LoS (days) procs LoS (days) procs procs % EL % NEL LoS (days)Hospital 1 275 35 5.98 242 27 7.46 12 4.37 7 5.35 149 17.26 387 5.98 57 5.98 87 5.98 2,912 425 59.4% 85.6% 5.67Hospital 2 419 40 5.19 591 31 5.49 10 6.29 --- --- 558 19.52 107 5.19 11 5.19 29 5.19 2,611 695 81.5% 92.5% 7.88Hospital 3 96 8 4.67 145 7 5.06 --- --- --- --- 271 17.80 --- 4.67 --- 4.67 --- 4.67 390 257 65.6% 97.3% 6.54Hospital 4 138 14 4.70 156 14 5.17 --- --- --- --- 128 17.02 29 4.70 32 4.70 16 4.70 1,046 312 48.1% 96.8% 5.67Hospital 5 365 163 8.04 400 136 10.45 25 3.87 13 4.23 --- --- 74 8.04 12 8.04 124 8.04 1,901 9 67.1% 66.7% 7.44England median 4.02 4.01 4.67 5.22 18.10 4.02 5.51 4.51 74.0% 97.5% 6.05
Non-elec & No procBack painHip Knee Primary shoulder
replacementPosterior lumbar procedures - level 1 & 2 only
Decompression Discectomy FusionPrimary ankle replacement
Fractured neck of femur
ProviderAverage per
surgeonNo. surgeons
<5 per yearAverage per
surgeonNo. surgeons
<5 per yearAverage per
surgeonNo. surgeons
<5 per yearAverage per
surgeonNo. surgeons
<5 per yearHospital 1 36.9 7 10.8 2 60.8 1 7.0 2Hospital 2 26.1 4 5.9 3 29.7 2 4.6 4Hospital 3 17.1 1 5.3 1 12.4 2 4.0 1Hospital 4 26.8 3 8.7 1 24.9 2 4.0 3Hospital 5 50.1 0 21.0 1 46.8 2 18.9 2England median 42.1 10.5 48.0 5.7
Primary hip replacement Hip revision Primary knee replacement Knee revision
Provider ASA rating
Hospital 1 15.4% 2.10 0.75 25.36Hospital 2 7.9% 2.25 0.81 20.74Hospital 3 8.2% 2.40 0.91 33.16Hospital 4 7.4% 2.00 0.69 27.39Hospital 5 32.4% 2.00 0.83 18.35England median 7.0% 2.17 0.63 18.40Note: Higher ASA and Charlson value indicates patients with more comorbiditiesNote: Higher deprivation value indicates patients with greater deprivation
% specialist Charlson score Deprivation (IMD2015)
Ring-fenced elective orthopaedic beds Prototype data ony.
Provider Number Annual elective occupied bed days per bed
Hospital 1 14 256.34Hospital 2 11 302.11Hospital 3 5 284.23Hospital 4 6 312.03Hospital 5 28 234.56England mean 295.23
#msknetworks
5 year hip standardised revision ratio Revision of primary replacement. NJR. 2014 calendar year.
90 day hip standardised mortality ratio Following primary replacement. NJR. 2014 calendar year.
5 year knee standardised revision ratio Revision of primary replacement. NJR. 2014 calendar year.
90 day knee standardised mortality ratio Following primary replacement. NJR. 2014 calendar year.
Quality and outcomes
Posterior lumbar decompression (level 1 & 2) emergency readmission in 30 days
HES Apr2012-Mar2015.
Posterior lumbar fusion (level 1 & 2) emergency readmission in 30 days
HES Apr2012-Mar2015.
Epidural or nerve root block for back/radicular pain – % of patients receiving 3 or more per year
HES Apr2012-Mar2015.
Facet joint injection for back/radicular pain – % of patients receiving 3 or more per year
HES Apr2012-Mar2015.
Primary hip replacement - emergency readmission in 30 days
HES Apr2012-Mar2015.
Primary knee replacement - emergency readmission in 30 days
HES Apr2012-Mar2015.
Deep wound infection within 1 year of surgery Prototype data only
Provider
Decompression FusionHospital 1 4.48% 0.16% 5.48% 8.35% 3.30% 7.25%Hospital 2 0.65% 8.65% 1.88% 0.10% 4.22% 9.04%Hospital 3 5.76% 7.81% 8.59% 6.98% 6.10% 9.60%Hospital 4 6.76% 2.78% 6.25% 4.10% 3.53% 2.74%Hospital 5 3.68% 2.98% 0.19% 6.25% 6.98% 2.77%England median 4.27% 4.48% 4.48% 5.16% 4.83% 6.28%
Primary hip replacement
Primary knee replacement
Primary shoulder
replacement
Primary ankle replacement
Posterior lumbar surgery (level 1 & 2)
#msknetworks
Cost of return admission for additional procedure on same body site within 1 year, per original procedure (£) HES data. Apr 2012 – Mar 2015.
Loan kit cost(£) Prototype data only
Cost
Achievement of best practice tariff . primary hip and knee replacement .
NJR, PROMs. .
Fail to achieve best practice tariff criteria National Hip Fracture Database – Blue Book standards .
Achievement of best practice tariff – fragility hip fracture . 2014 calendar year (2015 NHFD Annual report). .
Average cost per spell .
Reference cost submissions 2014/15.. . Pro v id e r
HN12D HN12E HN12F HN22C HN22D HN22E Major Minor No complic Major Minor Major Minor Major Minor No complic
Hospital 1 £9,665 £9,080 £7,455 £7,883 £9,166 £6,388 £14,749 £9,480 £7,347 £9,524 £6,039 £9,777 £6,292 £8,098 £7,513 £5,888Hospital 2 £3,082 £2,906 £2,645 £6,100 £4,024 £3,694 £9,733 £7,180 £6,391 --- --- £2,739 £2,845 £3,650 £3,474 £3,213Hospital 3 £7,502 £6,833 £6,542 £8,426 £9,239 £8,064 £12,530 £8,618 £6,201 --- --- --- --- £5,935 £5,266 £4,975Hospital 4 £1,610 £1,610 £1,610 --- --- --- --- £1,509 --- --- --- --- £1,916 £2,178 £2,178 £2,178Hospital 5 £13,114 £10,386 £8,401 £17,910 £16,021 £12,212 --- £16,123 £27,294 £14,833 £8,114 £15,486 £8,767 £11,547 £8,819 £6,834England average £7,207 £6,617 £6,029 £6,860 £6,156 £5,719 £13,156 £9,319 £6,962 £7,919 £5,741 £7,752 £5,574 £5,640 £5,050 £4,462* Major complications (HT12A, HT12B, HT13A, HT13B), Minor complications (HT12C, HT12D, HT13C, HT13D), No complications (HT12E, HT13E)** Major complications (HC51D), Minor or no complications (HC51E). *** Major complications (HC51A/B), Minor or no complications (HC51C). *** Major complications (HC64A), Minor complications (HC64B), No complications (HC64C).
Sing le -le ve l d isce cto my o r d e co mp re ss io n (e le c tive )****
Fra cture d ne ck o f fe mur*Prima ry hip re p la ce me nt Prima ry kne e re p la ce me nt
(e le c tive ) (e le c tive ) (no n-e le c tive )
De fo rmity co rre c tio n surg e ry (child re n)**
De fo rmity co rre c tio n surg e ry (a d ults )***
Provider
Hip Knee Hip Knee Hip Knee Hip KneeHospital 1 93% 112% 27% 17% 82% 96%Hospital 2 85% 89% 18% 15% 72% 79%Hospital 3 87% 92% 0% 0% 91% 80% Negative outlier (95%)Hospital 4 97% 107% 6% 3% 76% 102%Hospital 5 85% 80% 9% 10% 55% 63%BPT criteria (16/17) 85% 85% 15% 15% 50% 50% Neg. (98%) - 3 SD outlier
NJR compliance NJR unknown consent PROMs participation PROMs aver health gainJan15 - Dec15 Jan15 - Dec15 Apr15 - Dec15 Apr15 - Dec15
ProviderStd 1 Std 2 Std 3 Std 4 Std 5 Std 6
A&E to orthopaedic
ward in 4 hrs
Surgery within 36 hours of
admission
Pre-op assessment by
Geriatrician
Development of pressure
ulcers
Bone health assessment at
discharge
Specialist falls assessment
Mental Health Assessment
% admissions that meet all 9
criteria
Hospital 1 74% 79% 93% 2% 99% 99% 95% 72%Hospital 2 46% 67% 98% 5% 98% 99% 94% 62%Hospital 3 47% 81% 98% 3% 100% 100% 100% 75%Hospital 4 18% 90% 94% 2% 100% 100% 86% 70%Hospital 5 --- --- --- --- --- --- --- ---England median 47% 75% 92% 2% 99% 100% 98% 66%
BPT attainment
Blue Book Standards
Prosthesis cost per procedure (£) Prototype data only
Litigation cost (£) NHS Litigation Authority & HES online.
Apr 2010 – Mar 2015. All orthopaedic & spinal services.
#msknetworks
#msknetworks
GIRFT beyond orthopaedics
#msknetworks
GIRFT expansion
• SofS announcing expansion on 8th November.
• Expansion from 11 to 29 specialties additions highlighted blue.
• Avoiding and preventing £1bn of wasted costs, unnecessary treatment and patient suffering every year.
• Establishment of regional architecture, with regional clinical directors to hold Trusts to account and drive implementation of the recommendations using the metrics.
• Procurement resources established regionally to drive transparency, evidence-based product rationalisation and better procurement – linked to Category Towers
• Inclusion and focus on Productivity, including job planning.
• Directly link best practice on Nursing and Allied Health Professionals.
• Deep dive visits with all Trust rather than a sample within each specialty.
• Implementation of Lord Carter recommendations.
1. Elective orthopaedics (including spinal) 15. Acute & General medicine 2. General surgery 16. Emergency medicine 3. Urology 17. Intensive & critical care 4. Obstetrics & gynaecology 18. Imaging & radiology 5. Ear, nose & throat 19. Cardiology 6. Cardiothoracic surgery 20. Geriatric medicine 7. Oral & maxillofacial 21. Outpatients 8. Hospital Dentistry 22. Respiratory 9. Neurosurgery 23. Dermatology 10. Breast surgery 24. Neurology 11. Paediatric surgery 25. Rheumatology 12. Vascular 26. Gastroenterology 13. Ophthalmology 27. Diabetes & endocrinology 14. Plastic surgery and burns 28. Pathology
29. Renal 30. Anaesthetics and Perioperative care 31. Stroke 32. Mental Health
#msknetworks
Where Next :Expansion of GIRFT programme
Support from All Royal Colleges All Specialist societies DH NHSI NHSE
Specialty Spend
£m WAUs
(thousands) PPO
% Programme status
Spinal surgery and spinal injuries
£571 166 10.1% ▪ 45 visits have been completed, with a further 44 due in the next few months ▪ First national report in preparation
General Surgery £2,346 672 7.9%
▪ 50 deep dive visits completed ▪ A draft national report is imminent ▪ Visits to approximately 100 further general surgery trusts are planned for 2017
Vascular Surgery £471 134 10.2% ▪ 70 deep dive visits have been completed ▪ First national draft report in preparation
Neurosurgery £521 147 8.6% ▪ 23 visits have already taken place; final visit is scheduled for early March ▪ Draft report in preparation
ENT £775 222 10.0% ▪ Nine trust visits complete ▪ 32 booked in for next three months, and a further 20 to follow
Cardiothoracic Surgery
£477 138 8.6% ▪ Pilot visit scheduled for March ▪ Deep dives due to start in May
Urology £1,175 336 8.6% ▪ 56 visits conducted so far ▪ 23 more in pipeline
Paediatrics £2,857 819 10.7% ▪ Pilots starting in March ▪ Full programme of visits will commence in May
Obstetrics and Gynaecology
£4,124 1,168 11.4% ▪ Pilot visit planned for 23rd March ▪ Report produced ahead of full programme of visits to be conducted from May
Ophthalmology £1,112 323 10.9% ▪ Pilot visits completed in November/December 2016 ▪ Deep dive visits commencing at the end of February 2017, with 20 more to follow
Dental £655 184 15.3% ▪ Pilot visit conducted in January 2017 ▪ Deep dives following from April
The GIRFT programme is gathering pace and extending across 30 clinical specialties. Pilot visits, report drafting and comprehensive site visits are all underway as part of a phased rollout.
Potential Productivity Opportunity (PPO) is based on analysis of positive variance within Reference Cost data. It highlights where a trust's costs for like for like activity exceeds the national average, and quantifies the potential cost savings that could be realised by the trust if above average unit costs were reduced to the national average without increasing costs elsewhere. The percentages in the table are the PPO divided by the total trust expenditure reported in Reference Costs.
#msknetworks
Early examples of the scale of variation
Only 15% of spinal surgical data inputted into the BSR in last 5 years
Bowel cancer - variation in stoma retention rates at 18 months in colorectal cancer have been identified at between 0% and 78%. This means that 15,303 patients a year still have a stoma 18 months after surgery. 2014 data from the 2015 National Bowel Cancer Audit annual report appendix
Blood perfusion during cardiac surgery – the cost of blood products for perfusion during heart bypass procedures vary from £500 to £2,500 per operation. The total national annual perfusion cost is estimated at £47,416,454 and there is the potential to halve this. Estimation data source: 2015 National Cardiac Benchmarking Collaborative Annual data report.
Primary cranial tumour – re-operation rates in neuro surgery within 1 year vary between 5% and 17%. Reducing the average return rate to 5% could save £1,638,090 per year. Estimation data source: 2012/13 to 2014/15 HES – cost calculated using national tariff.
#msknetworks
Early examples of the scale of variation
Head & neck cancer (oral & maxillofacial) – following oral and maxillofacial cancer surgery the rate of return for another procedure within 90 days varies from 8.33% to 80.56%. Reducing the return rate to 8.33% could save £5,475,907 per year. Estimation data source: 2012/13 to 2014/15 HES – cost calculated using national tariff.
Tonsillectomy – following a tonsillectomy the rate of emergency readmission within 30 days varies from 3.68% to 24.77%. Reducing the readmission rate to 4% could save £2,501,450 per year. Estimation data source: 2012/13 to 2014/15 HES – cost calculated using national tariff.
Specialist urological procedure (Cystectomy, Prostatectomy, Nephrectomy, PCNL) – following a specialist urological procedure the rate of return for an emergency readmission within 30 days varies from 5.32% to 28.21%. Reducing the readmission rate to 5% could save £3,732,937. Estimation data source: 2012/13 to 2014/15 HES – cost calculated using national tariff.
Surgery for Abdominal Aortic Aneurysm – following surgery for abdominal aortic aneurysm the rate of emergency readmission within 30 days varies from 4.35% to 21.74%. Reducing the readmission rate to 4% could save £1,490,207 per year. Estimation data source: 2012/13 to 2014/15 HES – cost calculated using national tariff.
#msknetworks
Implementing GIRFT
Will improve patient outcomes Will reduce unwarranted variation Will create transparency across all providers with regards to
outcomes and costs of prostheses including spinal implants
We will ALL have to work differently and look at all our departments in the provider sector
Working together
Thank You
#msknetworks
Musculoskeletal Health : A public health approach
Benjamin EllisSenior clinical policy [email protected]
Musculoskeletal healthA public health issue
• The pain and disability of musculoskeletal conditions limits independence and the ability to participate in family, social, working life
• Nearly three-quarters of people with osteoarthritis report constant pain; one in eight describes their pain as ‘often unbearable’
• Musculoskeletal conditions are the largest contributor to the UK burden of disability, accounting for 30.5% of years lost due to disability in 2010
• Only 59.4% of people of working age with a musculoskeletal condition are in work
• Around one in five people with arthritis has depression• Musculoskeletal conditions account for the third largest area
of NHS spending, programme budget of £4.7 billion in 2013/14
• Poor musculoskeletal health coverage in JSNAs:- Osteoarthritis in 36%; Back pain in 38%
• MSK Calculator – local prevalence estimates for:- Osteoarthritis (knee, hip)- Back pain (total, severe)- Rheumatoid arthritis- High risk of fragility fracture
• Worked with PHE to created public health bulletins- Osteoarthritis, back pain now available
• Estimates now live at LG Inform tool
Musculoskeletal healthEstimating local prevalence
http://www.arthritisresearchuk.org/policy-and-public-affairs/reports-and-resources/jsna-report.aspxhttp://www.arthritisresearchuk.org/arthritis-information/data-and-statistics/musculoskeletal-calculator.aspxhttp://www.arthritisresearchuk.org/arthritis-information/data-and-statistics/data-by-region.aspx
Musculoskeletal Health Musculoskeletal Recommended Indicator Set
Overall objective:Agree and define a concise set of indicators that could populate a musculoskeletal dashboard that will be of use and interest to people with a musculoskeletal condition, commissioners, clinicians and policymakers while supporting the work of the musculoskeletal clinical networks. Aims:Balanced indicator set, reflecting needs of people with a musculoskeletal
condition, commissioners, clinicians and policymakers;Mixture of process and outcome, specific and generic measures;Meaningful and practical metrics, using existing data where possible;Indicators highlighting variation that can help service improvement.
www.arthritisresearchuk.org/policy-and-public-affairs/msk-indicators.aspx
Musculoskeletal healthAssessing musculoskeletal health status
http://www.arthritisresearchuk.org/msk-hqHill JC et al. BMJ Open. 2016 Aug 5;6(8)
Musculoskeletal healthTaking a public health approach
• Shift focus from end stages of musculoskeletal disease to promotion of lifelong musculoskeletal health.
• Everyone, at every age can do something to improve and maintain the health of their muscles, bones and joints.
• Particularly promote physical activity and a healthy weight.
Clark PM, Ellis BM. A public health approach to musculoskeletal health. Best Pract Res Clin Rheumatol. 2014 Jun;28(3):517-32.www.arthritisresearchuk.org/policy-and-public-affairs/public-health.aspx
Musculoskeletal Health Providing physical activity for people with MSK conditions
http://www.arthritisresearchuk.org/policy-and-public-affairs/reports-and-resources/reports/physical-activity-report.aspx
Research evidence shows that ESCAPE-pain:
Reduces pain Improves physical function Improves mental wellbeing Reduces healthcare and utilisation costs (estimated
annual saving of £1,417 per person) Creates benefits that can be sustained for up to 30
months after the end of the programme
A group rehabilitation programme for chronic hip or knee pain,integrating:
✓ Patient informationTailored advice on their condition, self- management, pain coping strategies, weight control;
✓ Personalised Exercise regimenIndividualised, progressive, challenging
• 10 -12 sessions • Supervised by physiotherapist, fitness instructor• Clinically and cost-effective• Requires a large room and simple equipment
Enabling Self-management and Coping with Arthritic Pain using exercise
Endorsed by the National Institute for Health and Care Excellence, British Society of Rheumatology and Royal Society of Public Health.
Research evidence shows that YHLB resulted in: 30% improvement in general daily functioning 70% reduction in work absenteeism over 12 months
(average 3.8 days off sick compared to 12.3 for control) Most maintained exercises 9 months after course Cost effective from NHS, societal perspective
A self-care group programme for chronic/recurrent low back pain:
✓ Physical activity (beginner-friendly)Strengthening, Stretching, Mobility, Posture
✓ Education and behaviour changePain-relief, Spinal health education, Positive mental outlook, Home practice
✓ Holistic approachBreathing, Mindfulness, Relaxation
Delivering the programme• Course of 12 classes x75 mins, max. 12 people• Taught by qualified yoga teachers with additional
specialised training• Educational resources: Manual (book), Relaxation
CD, Practice Sheets• Cost £300 per person attending
Tilbrook HE et al. Ann Intern Med. 2011 Nov 1;155(9):569-78.Chuang LH et al. Spine (Phila Pa 1976). 2012 Aug 15;37(18):1593-601.
www.yogaforbacks.co.uk
Musculoskeletal Health Mobilising community assets, health trainers
Set up ‘Managing Your Joint Pain’ clinics
Referral routes
Hip, knee and back pain
4 appointments over 6 months
Collect clinical outcome data
Focus on physical activity and self-management
Signpost to local partnersHarris J et al. Using health trainers to promote self-management of chronic pain: can it work? Br J Pain. 2014 Feb;8(1):27-33.
https://youtu.be/OVbpHFyUmR4
• Free service for people living with persistent pain. • Chronic pain health trainers are based in a
number of GP practices, community and leisure buildings across the city.
• Five to seven one-hour sessions of one-to-one support
• Encourage individuals to identify, to focus and to achieve their health and wellbeing goals.
Musculoskeletal Health Maximising existing programmes
“My sciatica has not returned and I have not required any medication or prescriptions for any aches or pains in my body. I am sure this is due to the Active for Health programme”Stuart Ellershaw (Participant)
First 12 months• 327 MSK referrals• 47% take up from referrals• 59% continue from step 2 to 3• 95% patient satisfaction
• Maintain local tier-by-tier lists of physical activity opportunities
• Promote physical activity as a way to improve MSK symptoms
• Develop local services to signpost people to services
• Engage local authority and clinical commissioners
• Implement ESCAPE-pain locally
Musculoskeletal Health What can we do?
Introduction to musculoskeletal care in the South West
Carl Davies
Associate Director of iMSK & Trauma Services
Ashford & St Peter’s Hospital
Former MSK Transformation
Programme Manager Gloucestershire CCG
Problems?
• Aging population
• Increasing morbidity
• GP & Primary Care capacity issues
• Plans to shift demand out of secondary care into primary care
• Lack of true ‘integration’
• MSK is a Complex Adaptive System
Solution
• Transform the current MSK models into true ‘systems’:
• Structure secondary care to work as
truly integrated model
• Install MSK specialist as ‘first point of contact practitioners’
• Facilitate improved relationships & connectivity between Primary & Secondary Care
Example of
Current Model
What happens when we don’t
think in systems?
• Unintended consequences
• Failure to engage partners
• Conflict
• Failure to deliver benefits
• Pressure in already pressured services (chasing)
Systems Shared Vision
The Good
• CCG & Providers are working towards collaborative visions (STP’s etc)
• Partners are aiming for ‘integration’
• MSK practitioners have proved concept
• Secondary Care integration has proved concept
• Understanding of the need for change has improved
Future model
Gloucestershire CCG
Investment Costs
• Integration & collaboration costs nothing (remove perverse incentives)
• First Point of Contact MSK Practitioners
• Anticipated provider costs (to include 1 WTE, on-costs, consumables, admin support, overheads) = circa £105,000 per clinician (at Band 8a)
• Capacity per clinician (to include AL, sick-leave, CPD and DNA) 42 weeks x 8 sessions per week = 3024 new patients, 1008 follow-ups (based on clinic template of 20 min new, 20 f/u) per annum.
• Suggested tariffs for payment = £35 for new, £20 for follow-up
• Commissioner costs at suggested tariffs (3024 x 35) + (1008 x 20) = £126,000 per clinician
Impact?
What does this mean? Patients will get early specialist MSK care, GPs would see a reduction in demand and the average CCG would see a net saving of between £2.5m-£4.6m (sensitivity analysis of 30%) by improving system integration and having specialist physiotherapists provide early specialist MSK.
The not so good
• Lack of change management skills & experience
• Lack of evaluation
• A failure to stop and assess when not working as planned
• Allowing anecdotal fears to get in way of evidence
Conclusion
• The current pressures are significant
• Transforming the MSK model is possible, and is happening
• Systems thinking and Physiotherapists as a first point of contact offer a solution that provide benefit for Patient, GP, Provider and Commissioner
• Invest to save option represents as much as 240% saving across the healthcare system
• We must allow people who understand how to truly manage change to lead
Friday 14 July 2017 Exeter Racecourse
National Elective Care Transformation
Programme MSK Triage
Siân Hopkinson
• Demand for elective care services is continuing to grow and more patients are being referred for treatment than hospitals are able to treat.
• Patients are therefore waiting longer to see consultants and start treatment
• There is evidence that suggests that, for some referrals, patients could be managed differently without having to be referred to a hospital for treatment.
• The High Impact Interventions are part of the elective care transformation programme and they are evidence based initiatives that are designed to spread good practice
• The underpinning principles are: patients should be seen by the right person, in the right place,
first time, and; patients should be seen as quickly as possible in line with their
constitutional rights.
2
Introduction
• Clinical triage services provide specialist clinical review of referrals after a GP has made a referral for a musculoskeletal condition.
• Patients and/or their referrals are reviewed by physiotherapists, advanced physiotherapy practitioners, or GPwSIs who will ensure that patients are directed to the right place for further treatment and/or diagnosis.
• MSK conditions affect 1 in 4 of the adult population, approximately 9.6 million adults in the UK. By ensuring that patients are seen in the most appropriate setting, triage services ensure that patients who need to be seen by a hospital consultant are seen as quickly as possible.
• They also reduce demand on secondary care services. Triage schemes can reduce MSK referrals by 20-30% which is equivalent to 2-3% of all GP referrals.
• The RightCare programme identified that 31% of total elective opportunities involve musculoskeletal pathways. During Wave 1 of the RightCare programme (c.70 CCGs) MSK was the most frequently chosen pathway (46 CCGs).
3
MSK clinical review and triage – what is it and why do it?
The MSK Triage High Impact Specification has drawn on published evidence from a number of sources including The Musculoskeletal Services Framework. Input was also received from our national clinical advisers and we have drawn learning from front line services The Surrey Integrated Musculoskeletal Service (iMSK) patient pathway is included as an example here:
4
Musculoskeletal Triage
• CCGs have to ensure MSK triage services are put in place during 2017/18.
• CCGs must have clear referral criteria for MSK services including conditions covered and clinical indications for referral which are communicated to all GPs.
• There should be a suite of standardised referral forms (requiring a minimum data-set), to ensure inclusion of all key clinical information and enable rapid assessment.
• Referrals should be assessed in a timely manner. Good practice dictates that services should be able to contact the patient within 48 hours to discuss the outcomes and offer choice.
• CCGs should ensure they have access to relevant data to monitor and manage the impact of the service.
• Close collaboration between clinicians in both primary and secondary care is required to ensure robust clinical governance systems with strong leadership and clear accountability are developed.
5
MSK clinical review and triage – what action is needed?
The MSK Triage High Impact Specification draws upon the MSK Service Framework to identify key elements to drive success, including: Organise meetings of key stakeholders: consultants in
orthopaedics, rheumatology, pain; key GPs; physiotherapists and other allied health professionals; nurses; chiropractors; osteopaths; diagnostic services; managers; patient representatives Agree what is and isn’t in scope i.e. exclusion of red flag conditions Develop referral pathways; referral forms based on GP views, GP
training sessions and secondary care specialists Ensure appropriate arms of service available e.g. pain
management services; back pain functional restoration programmes Agree outcome measures, referring to agreed protocols and
standards of care. These should include patient satisfaction measures. 6
MSK clinical review and triage – how to achieve success
• We would expect all GP practices to be utilising a clinician-led MSK triage by 31 December 2017.
• Primary and secondary care clinicians should jointly agree referral protocols, thresholds and clinical pathways
• The MSK Triage service should be able to refer to a range of community, hospital and if appropriate social care services that have capacity to meet demand
• The service should use standardised referral forms and data sets to support accurate decision making and work to a 48 hour turnaround.
• There should be appropriate governance and oversight measures in place and systems to track agreed outcome measures.
• The triage should also support he wider NHS agenda and align with the requirement for all referrals to be sent via the NHS e-referral service by October 2018. 7
MSK clinical review and triage – what does this mean?
• Heat map data based on distribution of 4 different MSK sub-specialisms including Orthopaedics, Spinal/Back, Rheumatology and Pain.
• Orthopaedics was the most common service.
8
MSK Triage: Coverage (June 2017)
• Contact us at [email protected]
• https://www.england.nhs.uk/ourwork/ltc-op-eolc/ltc-eolc/si-areas/musculoskeletal/
How do we keep in touch?
#MSKNetworks
Reducing the impact of fatigue in rheumatoid arthritis (RAFT): a randomised controlled trial
Emma Dures
Associate Professor
These slides are not currently available for sharing
For more information on the RAFT trial please contact Professor Sarah Hewlett at:
APP – What do we know, and who are the real winners? Fiona Robinson MSc MCSP
Background General Practice Physiotherapist / First Line Practitioner / Advanced Practice Physiotherapist Advanced Clinical Practice embodies the ability to manage complete clinical care in partnership with patients/carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance patient experience and improve outcomes.(HEE, 2017) An opportunity for physiotherapists to support GPs and build capacity and diversity in the primary care workforce (CSP, 2016)
Proposed Benefits
Patients • Quick access to expert MSK assessment,
diagnosis, treatment & advice • Improved patient experience • Longer appointment times in primary care,
meaning patients feel listened to, cared for and reassured
GPs • Release of GP time • Reduced prescription costs • In house MSk expertise
Local Economy • Reduced referrals to Interface or
secondary care services • Improved use of imaging? • Increased conversion rates to surgery?
Physiotherapists • Job prospects • Opportunity to develop and enhance
scope of practice
Traditional – Pathways – With APP Patient has an MSK problem
Patient visits GP who offers analgesia and advice
Patient returns to GP with unresolved problem
Patient referred to physiotherapy, 6 week wait. Then undertakes 4 weeks of treatment
Problem unresolved, patient referred to Interface service, 6 week waiting time.
Patient referred for diagnostic imaging and informed of results 5 weeks + 1 week
Referred for surgical opinion. Total waiting time for patient 22 weeks
Patient has an MSK problem
Patient contacts GP surgery who offer appointment with a general practice physiotherapist
Patient receives advice, analgesia, and 4 week exercise prescription. At the same time is referred for imaging and informed of results
Referred for surgical opinion. Total waiting time for patient 6 weeks
Current Pilots Location Length of Audit Banding Appt Times Service Provision No. of patients & % managed
without GP % referred to physio
Savings
Windemere, Cumbria
11 months 8a 20 Triage, injections 710 62% 27% 600 GP slots Incr revenue through injection £44 x 322 Reduced ortho referrals equiv to £4,356
New Forest, Hampshire
4 months 8a 20 Ix, CSIs, surgical referrals
162 74% £2922 APP vs £3529 GP
North West Wales
9 months ‘ESPs’ 2171
Ravenscourt, Cardiff
1 year 569 (6 months) 71% (24% had f/u)
16% Less analgesic prescriptions
Portsmouth
6 months 7 Telephone triage am / face to face pm
340 34% 27%
Darlington 7 months 7 20 Acute service 1147 74% 1128 GP appts £20k saving over 7 months 18% fewer referrals to secondary care
West Cheshire (36 GP practices)
3 months 7 & 8a if Independent prescribers
30 then 20 754 52% 34% Est £625k annual savings per year based on seeing 100MSK pts per month Reduction in orthopaedic referrals
Somerset 6 months 7 30mins (5 months) then 20mins (1 month)
CSIs in last month 434 / 153 86% (incl those requiring prescriptions)
28% £3782 5 months (30mins) £1802 1 month (20mins)
Local findings: activity • October to February, 434 appointments (30 minute appts) • 55% (237) were fully managed by the APP • 83% (365) had no GP involvement at all • When appointment slots were 20 minutes – little change
• In summary - 94% of patients had no GP appointment in the first
stage, compared to 92% in the second stage. And those with no involvement were 83% in the first stage and 77% in the second stage.
Local findings: patient feedback Patient feedback on APP consultation: • 85% (195) rated as excellent. • 83% (190) rated the advice and management plan as excellent. • 87% (201) rated the service as excellent. • 2 patients would have preferred to see the GP, 194 preferred to see the
MSk practitioner and 40 had no preference. A follow up survey at 4 weeks: • The speed of getting the appointment was rated as 4.7/5 • The assessment and explanation was rated as 4.6/5 • The advice and management was rated as 4.4/5 • Overall the service was rated as 4.5/5
Local findings: financial
* Based on all physio slots being fully utilised
Financial Review - March Pts seen 153
Cost If GP saw the pts instead: Hours of GP time 38 Cost per GP consulting 'hour' 109 Total cost 4173
Total cost of the work seen (Physio and doctor time)
140 just seen physio (35.70 per hour for physio plus £3.20 insurance) 1815 13 GP appts (10 mins) 355 22 GP tasks (5mins) 200 Saving Total cost 2370 -1803
Local findings: impact on services • Impact on MSk Physiotherapy and OAS services:
Referrals to MSk physio
Pre pilot During Pilot Difference %age increase/
decrease
Q1 238 334 86 36% increase
Q2 300 278 -22 7% decrease
Referrals to OAS
Q1 131 128 -3 2% decrease
Q2 140 103 -37 26% decrease
Who wins? • Most cost savings are in primary care (GP time, prescription
costs etc.) • No significant reduction in referrals to physiotherapy within
our study
• Local models need to be based on local populations/ demographics/service requirements/local intelligence etc.
• Funding for these posts???
Concerns • Are there enough suitably qualified physiotherapists with the knowledge
and skills to fill the void in GP practice who can request multiple diagnostic tests for multiple musculoskeletal conditions and more importantly interpret the results to make appropriate referrals on to surgical providers?
• If all of these highly skilled practitioners are located in primary care who is going to train and provide governance for the newly qualified physiotherapy staff to succession plan for these 'super' roles?
• Will Consultant colleagues feel uncomfortable receiving referrals from multiple APPs when they do not have a strong working relationship or links with these clinicians?
• Governance models - who is going to provide the training and ongoing clinical support for these post holders?
Supporting people in Dorset to lead healthier lives
Working at Scale (and Pace!)
Christian Verrinder GP
GPSI MSK Dorset CCG Clinical Lead MSK
Supporting people in Dorset to lead healthier lives
Dorset CCG
• 750000 population • Aligns with STP footprint • 1 CCG • 13 localities • 2 county councils
Supporting people in Dorset to lead healthier lives
Dorset MSK Commissioning History
• 2011-2014-MSK CCP Clinical Commissioning Programme • 2014/15-MSK 5 year vision: ARMA 7 • 2015/16-Clinical Services Review (Planned and Specialist) • 2016/17-Right care/GIRFT/Vanguard/STP • 2017-MSK stakeholder group • 2017-Flat cash contracts
Supporting people in Dorset to lead healthier lives
Initial projects
Spinal group
• Review current pathway • National low back pain
pathway sign up • Out of area peer challenge • Spinal Injection policy • START back implement • Single spinal triage and treat
team
Knees/Hips/Elective MSK
• Reviewed all MSK CBAP • Implemented patient decision
aid TKR • Developing patient decision
aid THR • CHAIN development • ESCAPE-PAIN
Supporting people in Dorset to lead healthier lives
Next projects
• Virtual fracture clinics • MSK triage service (NHSE mandated) • Community LA hand surgery service • Peri-operative lifestyle intervention • Prehabilitation pilot
Supporting people in Dorset to lead healthier lives
Summary (what seems to work)
• A group with all stakeholders involved • Enough seniority (clinical and management) to make decisions • Peer challenge • Network - don’t reinvent the wheel! • Trust • Flat cash contracting
