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