1. T&O

2. ICATS Worcestershire an outlier on spend on orthopedics in the West Midlands ICATS now saves 2 Million (includes total cost of extra physio and the ICATS service) Being reprocured currently

3. Previous ICATS Audit Around 30% could have not been referred Top 4 reasons - Try conservative treatment for longer - Try injecting the joint - Try physiotherapy - Ask patients opinion on possible treatment options

4. INDICATED DIAGNOSIS CONSERVATIVE MANAGEMENT OUTCOME Please insert name of GP providing Injection in each red GP Name box HIP PATHWAY OA Analgesia/NSAIDS Physio XRay Better Discharge Failed conservative Treatment + suitable for THR Complete Oxford Score Oxford score <30 clinically Oxford score >30 clinically If suitable for surgery Refer To ICATS Self Management Trochanteric Bursitis Analgesia/NSAIDS Physio ? Injection GP Name Better Discharge Failed conservative Treatment i.e. failed up to 3 injections Refer To ICATS ICATS Ax

5. HAND / WRIST/ ELBOW PATHWAY Please insert name of GP providing Injection in each red GP Name box INDICATED DIAGNOSIS CONSERVATIVE MANAGEMENT OUTCOME CTS Dupytren’s Trigger finger Ganglia Mild/ Moderate or patient not fit for operation Analgesia / NSAIDS Splint Injection GP Name Nerve conduction studies (NCS) performed if diagnostic doubt orr before referral to ICATS for surgery Severe NCS +ve-ve Re-assess Refer To ICATS Physio not indicated Analgesia / NSAIDS Injection GP Name Reassurance + Leave for 3 – 6 months Neurovascular compromise Significant pain— ganglia at base of digit Mucoid cyts at DIP joint Better Discharge Refer To ICATS Referral to secondary care Better Discharge No better + Fixed deformity Refer To ICATS Referral to secondary care Contracture causing functional compromise or progression of contracture Referral to secondary care Refer To ICATS No better Symptoms >6/12, patient would consider surgery Better Discharge NCS +ve-ve Re-assess Refer To ICATS

6. QP orthopedic Audit GP referral to 1 st consultant outpatient 592 referrals audited

7. Could anything else be done in primary care?

8. Interventions that might have allowed management in primary care

9. Possible interventions by area of the body

10. Interventions following seeing a consultant where the GP audit suggested no alternatives

11. Improving the orthopedic pathways 1) How could you help more patients manage their condition conservatively? 2) How could you make a more appropriate selection of patients for physio? 3) How could you perform more/ a wider selection of joint injections? 4) How could you ensure all of the doctors working in your practice are aware of the above?