Paediatric Orthopaedic MSK Pathways Pamela Holland

Background 3000 referrals each year to Paediatric Orthopaedic Services Prolonged wait of up to 16 weeks for orthopaedic assessment In 2013 -2014 - 249 patients were assessed at Spire as 'NHS See and Treat' 249 patients resulted in a total 375 consultations at an additional cost of £33 979 If patients require onward referral to other MSK services such as physiotherapy a further wait of 10 -12 weeks for initiation of treatment

Aim Reduce patients length of wait for treatment reducing chronicity Reduce duplication of referrals Reduce inappropriate referrals to Orthopaedic Services which in time will reduce demand on the service To improve patient experience and journey by ensuring each patient is seen by the right person at the right

Initial Planning Funding secured from Scottish Government following successful bid to Pump Prime Funding 6 month audit of NP Orthopaedic Clinics to determine focus for pathway development Knee pathway Back pathway Gait pathway Patient satisfaction of original pathway Audit: excluded fracture clinic and patients with an underlying neuromuscular diagnosis 278 NP March to August 2015, 155 (56%) of these patients were discharged after assessment with advice, 48 (17%) were referred to physiotherapy 20 (7%) to orthotics16 (6% ) specialist onward referral 12 (4%) surgery, 27 (10%) had ortho follow up appointment Working diagnosis: 75 gait assessment, 62 joint pain (knee, ankle, hip, shoulder) 32 back pain, 18 pes planus Patient satisfaction survey using paediatric care measure with additional 2 question regarding their length of wait. A small sample of 15 patients patients were surveyed. All were found to be happy with the care they received (good, very good or excellent). Length of wait however varied considerably with average length of wait for treatment 18 weeks, (min 13 weeks and max wait 22). Many patients rated this either poor or fair.

Engaging Stakeholders NHSL Orthopaedic Consultants Radiology Consultants Orthopaedic Spinal Consultant Rheumatology Consultant RHSC Assistant Service Manager Medical Record Staff Patient Information Leaflet Group E-health team / AHP Informatics Lead

Pathway Development All pathways developed collaboratively by the multi disciplinary team K:\Paediatric Msk ESP\Pamela\MSK Pathway Re-design\Knee Pathway\Paediatric Orthopaedic Musculoskeletal Knee Pathway.doc Pathway aim: Orthopaedic referral received at RHSC – triaged by orthopaedic consultant using pathway flow chart: details urgent and routine orthopaedic patient other MSK specialities such as rheumatology, orthotics etc physiotherapy If referral triaged to physiotherapy, further triaged as urgent or routine and added to MSK waiting list Each patient has detailed MSK assessment – agreed by the MDT team To reduce risk detailed red and yellow flags with a specific plan for each clinical finding with onward referral to appropriate service as required Continue with physiotherapy until discharge

Risk Management Detailed competencies within each pathway Completed IRMER training and competencies Regular peer review with Orthopaedic Consultant Ongoing discussion with Orthopaedic consultant when required Highly experienced physiotherapist

Self Management Developed patient information leaflets Secured opportunity to work jointly with the NHSL Communications Team to develop physiotherapy website Working with Scottish Government AHP CYP National Lead to develop information for musculoskeletal conditions between the age of 12-16 for NHS Inform Rapid access to physiotherapy following changes to self referral

Embedding Pathways Small audit of knee and back pathway 37 orthopaedic referrals triaged to physiotherapy All patients have been assessed with a maximum wait of 10 weeks 6 patients required further investigations of which 4 continued with physiotherapy and 2 have had onward referral to spinal service due to confirmed scoliosis 25 patients have been discharged, 10 ongoing with physiotherapy treatment Patient satisfaction: Patient satisfaction: using paediatric care measure – rated as very good or excellent, no concerns raised about not being assessed by an Orthopaedic Consultant Length of wait rated much better: either good, very good or excellent For those patients who waited longer than 6 weeks : wait found to be fair or poor.

Savings Enabled 37 NP Orthopaedic Clinic Appointments to be allocated to other patients Cost saving £1790 of NHS Consultant time Additional saving of potential waiting list breaches of £3360 Totalling £5150 during the 19 week audit period Annually minimum saving of £14,100. Calculated on 1 consultant session annually costing 10000/year There for on a weekly session £238.

Moving forwards Continue to develop and embed musculoskeletal pathways throughout NHS Lothian Investigate if reduced waiting time leads to reduced number of appointment, aim for 6 week maximum physiotherapy wait Expand collaborative working to include Rheumatology services Single musculoskeletal referral and triage process for all MSK referrals Age appropriate care 14 – 16, quantify additional resources required with increasing age range Secure further funding to enable physiotherapy services to manage increased demand Increased demand to all services (additional 3000 Orthopaedic outpatient episodes, - over outpatient 700 physiotherapy episodes) Increased orthopaedic surgery estimated at 3 – 4 cases/week

In Conclusion Pathway development improved MDT working Streamlined patient journey Reduced patient waiting times for treatment Avoided duplication of workload Reduced inappropriate demand on overstretched Orthopaedic services Enabled the development of advanced practice in physiotherapy Ensured each patient is seen by the right person at the right time striving to achieve the Scottish Governments vision of ‘Getting it Right for Every Child’