NHSL 18 weeks RTT MSK Event

1. NHSL 18 weeks RTT MSK Event Janie Thomson Consultant Physiotherapist NHSL

3. The direction ?

5. 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

7. 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

8. 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

10. LOW BACK PAIN PATHWAY Back Pain Pathway Direct Access Phone Line GP A & E Red Flags 1:1 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

12. Impact

13. Impact

14. Pathway Stages

15. Pathway Stage Percentages

16. Physiotherapy MSK Pathway Summary Assessment + Intervention A&E Patient Presents MSK issue Physiotherapy Assessment Line Cauda Equina Red Flags Ortho clinic GP ESP Complex case Diagnostics if required Physiotherapy 1:1 treatment Spinal Clinic Pain Services Vocational Rehab Leisure Services Rheumatology Self Management

17. 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)

19. Primary Care Injury / Knee Problem Acute Services GP Self-Referral Telephone Triage +/- 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 +/- MRI x-ray ESP Phase 4 Pain Association Scotland Surgery WHSS Pain Association Scotland Discharge Physio Pain Clinic

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

22. 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

24. 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