| Musculoskeletal Interface Clinic St George’s Hospital, London, are piloting an interface clinic for one locality within Wandsworth PCT, which originates from the fact that only one in 7 patients who see an orthopaedic surgeon goes on to have surgery. The idea is to triage referrals and send through patients with red flag symptoms to consultants and have other patients seen by consultant physiotherapist, extended scope practitioner or GPSI. Patients will be seen sooner through this approach whether they are red flag or not. One of the significant issues is the wait for MRIs. Background Musculoskeletal conditions are major reason for health care consultations. It has been estimated that 40% of those who attend UK walk-in centres and 20% of people consulting their GPs do so because of a musculoskeletal complaint. In Wandsworth between 2002 and 2003, the number of trauma and orthopaedic referrals to St George’s Hospital increased by 10% and by 2003-4 the numbers had increased again by 15%. Currently, the NHS provides a wide range of services for patients with musculoskeletal conditions, but the vision is that everyone with such a condition will be able to access effective, timely assessment, diagnoses, and advice and treatment to enable them to fulfil their optimum health potential and remain independent. In December 2004, a multi-agency group, spanning acute and primary care was established to oversee the strategic development of orthopaedic care pathways for patients in Wandsworth PCT. Reviewing the pathways for patients with musculoskeletal conditions fits into the government’s strategy for long-term conditions, and it is recognised that where possible these pathways should be evidenced based and involve a multi-disciplinary team. The steering group also recognised that in order for the PCT to achieve the target of a maximum waiting time of 13 weeks for first outpatients appointments by the end of December 2005, they needed the pursue the development of a musculoskeletal interface service to help the achievement of both aims. Progress on service development was slow for a number of reasons, including lack of dedicated project management time and difficulties in obtaining accurate data to support the development of a business case. To this end, and in order to ensure that the aims of the contract were met, plans were put in place to begin a pilot phase in November 2005. This phase of the project is intended to be cost neutral and allow time for a more detailed and robust plan and business case to be made. Pilot Project Plan Weekly interface clinics were launched in November 2005 at the Bolingbroke Hospital. Aims: • To provide a service to address the needs of the population of Wandle practices commissioning group and provide a specialist second opinion for patients with musculoskeletal disorders, referred by GPs within Wandle.
• To reduce the number of referrals to secondary care services, where a surgical opinion is not required, and the patient does not have a complex diagnosis. Staffing: • The lower limb interface clinic is run by a GP with a special interest (GPSI) and a physiotherapy extended scope practitioner. The spinal clinic is run by a consultant physiotherapist and extended scope practitioner. Support is available from the orthopaedic and rheumatology consultant at St George’s Hospital NHS Trust.
• Administrative support is available for the clinic. Investigations: • Investigations are requested as deemed appropriate by the assessing clinician, with diagnostic support from radiology and other specialist departments including xrays, MRI and blood tests.
• Patients are given a clinical diagnosis, where appropriate. Management: • Advice is given to patients regarding the self-management of their conditions.
• Cortico-steroid injections are offered where appropriate for lower limb patients.
• A short course of simple analgesia and other medications are also offered to patients, as necessary, in line with Trust policy on prescribing medication.
• Patients who require further treatment and management are referred on to the appropriate service, eg physiotherapy, rheumatology and orthopaedics. Follow Up: • Patients not discharged directly from the clinic or referred on to secondary care are followed up, if appropriate, either in the clinic or by telephone. Patient Pathway And Referral Process To Interface Clinic: • Patients follow a described pathway
• Protocols are followed for referral into the service. Paper or electronic referrals are accepted at St George’s call centre. These are reviewed and appointments are generated as appropriate. Referrals To Secondary Care: Patients who have been seen at the interface clinic, but who are assessed as requiring a secondary care referral, are discharged from the care of the clinic. Copies of all investigations and treatment are forwarded to the appropriate service. Primary/Secondary Care Services: Access to primary and secondary care services, including physiotherapy, podiatry and pain services are available, where appropriate to patients assessed in the clinic. These, during the pilot phase are provided by existing local services. Capacity: During the pilot phase, the interface clinic is able to accept referrals from GPs, who represent the Wandle practices commissioning group, approximately 42% of GPs within Wandsworth PCT. Conditions Included: During the pilot phase the following conditions are accepted for referral to the interface clinic: • Lower limb (excluding foot)
• Spine Clinics: The spine clinic is held bi monthly on Tuesday mornings and has about 16 patients a month; the lower limb clinic is held on Tuesday afternoons on a weekly basis and has approximately 57 patients per month. Performance Management In the pilot phase, the service’s performance is monitored against the indicators set out below. Demand and capacity are reviewed regularly to ensure the efficiency of the service. A lead person has been identified to take responsibility for ensuring performance management in the pilot phase. Key Performance Indicators: • Number of patients referred and seen at interface clinic
• Number of patients discharged after 1st appointment
• Number of consultant referrals into secondary care
• Number of referrals to other services eg physiotherapy
• Waiting times for trauma and orthopaedic outpatient appointments at St George;s hospitals
• Conversion rate for surgery fro patients referred from interface clinic to secondary care Key Quality Indicators • Patient satisfaction survey
• Staff satisfaction survey
• Number of complains/ positive patient comments Financial Framework: Revenue Costs: The pilot project was effectively the relocation of existing staff and was planned to be cost neutral. Administrative support during the pilot used staff within Bolingbroke Hospital, and there were not additional costs involved. The pilot is to identify the cost pressure of a sessional payment for a secondary care consultant to provided support, advice and review referrals on a once monthly basis. If additional secretarial support is found to be necessary, then this would be an additional cost pressure. Total cost of consultant sessions: £2K (Based on £400 per session, to included 5 sessions in the first five months to the end of March 2006). Capital Costs: No capital costs were identified for the pilot phase of the project. | 