1. A Musculoskeletal Pathway Sarah L Mitchell, Rehabilitation Programme Manager, Scottish Government June Wylie, AHP Professional Officer, Scottish Government

2. Related Policy Drivers Shifting the Balance of Care –  Extend scope of services provided by non medical practitioners outside acute hospital Extend scope of services provided by non medical practitioners outside acute hospital Extend scope of services provided by non medical practitioners outside acute hospital  Improve capacity and flow management for scheduled care Improve capacity and flow management for scheduled care Improve capacity and flow management for scheduled care  18 week referral to treatment standard  Delivery Framework For Adult Rehabilitation Equally Well Implementation Plan Task and Finish Group SGHD

3. Pathway Requirements Self referral into MSK services Community AHP led MSK model

4. The Evidence Is patient self referral to physiotherapy: – – feasible, appropriate, acceptable, safe, cost effective, have wider implications? Yes: national & international trials 10 publications (2 more in press), 73 presentations, 37 peer reviewed, 46 invited international 270,988 referrals to physio from GPs annum (90%MSK) £1,815016 (2004) based on 22.5% cost benefit

5. Top Ten conditions presenting to GP

6. What could it deliver – apart from known patient benefits? Improvement in waiting times Impact on wider system greater – –Less diagnostics – –Frees up GP and 2ndry time – –Maximises physio efficiency Why is it not mainstream in Scotland? (40%) Resources only where history of underprovision Needs clear policy steer and local accountability

7. Rationale for utilising NHS 24 as resource for self referral Single point of access into PT. Improving access to services (especially for remote and rural areas) Systems for self referral to physiotherapy need to be streamlined and utilised in a more cost effective manner. Part of a whole systems MSK pathway Onward electronic referral management systems Self management advice Websites as support for self management

8. A Model For Accessing Ortho Services A Community Based Multiprofessional Triage Team / Orthopaedic Assessment Service (OAS) – PT’s and Gpwsi A centralised referral management system – NHS 24 physiotherapy telehealth service All AHP musculoskeletal services to be delivered within a single system All return clinic appts following surgery seen by AHP MSK team

9. Why re-design? UK figures show that in some centres conversion to surgery between 20-38%. In Scotland figures much the same Scotland – 30,000 even with 40% conversion still leaves 18,000 people who are having no active management and do not require surgery Stockport – implementation of musculoskeletal pathway in primary care altered conversions to 75% Glasgow Back Pain Service – Internationally acclaimed model!

10. Requirements for 18 week delivery The delivery of 18 weeks requires fundamental service transformation and re-design - doing the same faster will not achieve the 18 week target. Access to services needs changing– planning strategy Demand management for orthopaedic services in primary care is key to meeting access targets AHP’s given opportunity to deliver on improving access and the necessary referral management process

11. Service transformation Service transformation will require not only the ability to influence processes, but to change mindsets, cultures, activities, and organisational power bases. Quote – Albert Einstein Insanity: doing the same thing over and over again and expecting different results.

12. Community AHP MSK Services Integrated MSK Team Physiotherapy Podiatry OT Dietician Prosthetics Radiography Specialist nurse GPwsi Self Referral via NHS 24 Self management and advice (MKN, working backs etc) GP Referral Walk in Self Referral Electronic Referral Vocational Rehabilitation Services & Chronic Pain Services Orthopaedic waiting list Rheumatology services Other acute services Electronic Referral GP Referral Electronic Referral

13. Referral Management electronic and appointment given to patient at time of call. In future a reminder text message will be sent to the person one day prior to appointment. Appropriate interventions will be delivered or sign posted by AHP team including discharge and onward referral to; vocational rehabilitation teams, self management programmes, leisure facilities the community based advanced practitioner multi- professional triage team for a specific orthopaedic assessment. This team will screen to identify whether surgical opinion is necessary or any other secondary care service required.

14. Benefits of this change in service delivery Improve access to diagnosis and treatment Reduce waiting times Improve conversion rates to surgery in secondary care Provide greater efficiency and productivity Support shifting the balance of care and other Government policies (rehab framework, patient experience etc) Develop and enable a self management culture for patients in Scotland Promote health and well being Facilitate early return to work and avoid long term absence and long term dependency on benefits

15. Critical success factors A single system MSK service Scoping work to identify the most accessible locations where services can be provided– utilising leisure facilities as well as well CHP facilities. A system of in-reach into acute hospitals to allow AHP staff work with Orthopaedic Consultants in secondary care, while remaining primarily based outside acute hospitals Training to be undertaken to develop advanced practitioner skills. Detailed evaluation plan and baseline data set to be developed before the start of the change so that the impact can be fully understood.

16. The future of MSK pathways requires ……. NHS Boards to think radically about new solutions to MSK services The need to overcome professional barriers to explore more productive and effective options Using lessons learnt and available evidence to design services Support to fully explore greater productivity and efficiency in delivering MSK services