NHSL 18 weeks RTT MSK Event

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NHSL 18 weeks RTT MSK Event

• Janie Thomson
• Consultant Physiotherapist NHSL

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The direction ?
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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

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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

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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

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LOW BACK PAIN PATHWAY
Back Pain Pathway
Direct Access Phone Line
GP
A E Red Flags
11 physio Ax Rx 4/52
Self Manage Ring Back 3/52
WHSS
Self manage
Urgent Ortho
Pain Association Scotland
Settling signpost to Active Health
Not Settling Escalate to Senior
Pain Clinic
ESP Investigate if indicated
Self Manage
Back Pain Clinic ESP / Associate
Self Manage
Surgical Opinion
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Impact
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Impact
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Pathway Stages
Month Ortho/GP PAL Total Post MRI Stonehouse Refer to Surgeon
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
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Pathway Stage Percentages
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Physiotherapy MSK Pathway Summary
Assessment Intervention
AE
Patient Presents MSK issue
Physiotherapy Assessment Line
Cauda Equina
Red Flags
Ortho clinic
GP
ESP Complex case Diagnostics if required
Physiotherapy 11 treatment
Spinal Clinic
Pain Services
Vocational Rehab
Leisure Services
Rheumatology
Self Management
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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)

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Primary Care
Injury / Knee Problem
Acute Services
Self-Referral Telephone Triage
GP
/- WHSS
Self Manage
History, exam and working diagnosis
Physiotherapy Outcome Measures Clinical
Algorithms OA Appendix B Meniscal -
AppendixC AKP - AppendixD Refer to NHSL knee
module guide in Education Folder
Apply Knee Guidelines AppendixA
Orthopaedics Referral
Discuss with ESP AppendixE
Consultant
ESP
/- MRI x-ray
Pain Association Scotland
Phase 4
Surgery
WHSS Pain Association Scotland
Discharge
Physio
Pain Clinic
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Other pathways

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

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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

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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

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