Relieving the Orthopaedic Outpatients Bottleneck

1. Relieving the Orthopaedic Outpatients Bottleneck Damian Armour General Manager Surgical Services Barwon Health damiana@barwonhealth.org.au

2. Introduction • Victorian Travelling Fellowship Program • Relieving the Orthopaedic Outpatients Bottleneck • NHS Initiatives • Overview of the Orthopaedic Assessment Service. • Barwon Health • Improving Access to Orthopaedics • State-wide focus

3. The Challenge – Access to Ortho Outpatients

4. Victorian Travelling Fellowship • Awarded in Aug 04 • Travel to 9 NHS sites in Nov 04 • Intended Learning • New models of Outpatient Care • use of Primary Care to ease demand on Secondary Care. • Referral Pathways for GP’s. • Consultant Physiotherapists (ESP’s) & GPwSI • Change Management. • How did they engage the Consultants? • Funding Models.

5. Victorian Travelling Fellowship • Stockport NHS • Aintree Hospitals • Whiston Hospital • Royal Liverpool Hospital • University Hospital of North Staffordshire • Somerset Coast PCT • Royal Bournemouth Hospital • Southampton Health Community • Modernisation Agency 2 1 3 4 5 9 6 7 8

6. Fellowship Summary • Multiprofessional Triage Team / Orthopaedic Assessment Service (OAS) • Benefits • More timely access for patients referred with musculoskeletal problems. • Orthopaedic Consultants see a higher ratio of new patients in their clinic who are likely to require surgery. • A clear and documented framework is developed for patients with musculoskeletal disease. • Physiotherapy and other allied health professionals are provided with a significantly enhanced career path.

7. Fellowship Summary • Risks • Downstream impact on the capacity of the referral alternatives. • Physiotherapy, Podiatry, Pain Clinic etc • Elective Surgery • GP resentment • Seen as solution for all musculoskeletal issues.

8. Stage 1 – GP Referral GP sees patient with an Orthopaedic/musculo-skeletal condition and ‘refers’ them into the OAS. Specialist physiotherapists review all referral letters to identify the appropriate care pathway Appropriate treatment not clear from referral Appropriate treatment clear/unambiguous from referral Patient referred directly to Orthopaedic consultant Patient referred directly to pain management Patient referred directly to physio for treatment Patient referred directly to Orthotics Patient referred directly to podiatry, rheumatology Patient referred directly back to GP Stage 2 – Face to face physiotherapy triage assessment Patient has an assessment in a locality based clinic by a specialist physiotherapist to identify appropriate care pathway. Patient referred directly to Orthopaedic consultant Patient referred directly to pain management Patient referred directly to physio for treatment Patient referred directly to Orthotics Patient referred directly to podiatry, rheumatology Patient referred directly back to GP OAS Overview

9. GP Referral • Standardised GP referral template. • Desirable for ease of triage but not a prerequisite for success. • Barwon Health already has a generic Medical Director referral template with a high take up rate. • GP Communication Plan crucial to implementation. • Prevent backlash “Expect to see a Surgeon” • Prevent all musculoskeletal issues being referred.

10. Triaging • There are varying levels of GP referral triage undertaken: • Referral Management • NHS - implementing a centralised referral management system • a precursor to the implementation of the “Patient Choice” system • Paper Triage  • Generally by an experienced Physiotherapist. • Some sites still had Consultants triaging • Allocated to non-consultant resources after a “transition phase”. • Undertaken in conjunction with agreed guidelines (include ‘red flags’). • Clinic Assessment  • Undertaken if paper assessment not adequate for decision • A face-to-face assessment by Primary Care resources. • Communication is made with the GPs about the ongoing care.

11. Clinic Structures • Multidisciplinary • Physiotherapists are the core resource • General Practitioner with a special interest in Ortho. • Other resources would include Podiatrists, OTs, Rheumatologists etc. • Timeframe • Assessments run for a period of 30 minutes • 20 min patient consultation / 10 min multidisciplinary discussion. • Patient Numbers • Each clinician sees 6 new or 5 new/2 review.

12. Clinic Structures • Themed Clinics • Mixture of approaches • Themes/specialities vs generic in nature. • Types: • Lower Limb, Upper Limb, Spinal, Injection clinics • Some sites also ran a mixture of specialised and generic clinics. • Location • Primary care or secondary care settings. • Dependant upon responsibility for the service. • Logistical matters (e.g clinic space, access to diagnostic services).

13. Clinic Structures • Clinic Outcomes • Not just Assessment • One Stop Shop • Assessment / Advice / Discharge

14. Downstream Impact • OAS clinics will result in an improvement in waiting times for initial assessment.  • However implications are … • Waits for treatment clinics (e.g Physiotherapy, Podiatry and Pain Clinic) will increase. • Increased listing rates result in an increase to the elective surgery waiting list. • Patients receiving immediate assessment, advice and discharge within the OAS clinic will benefit without impacting on downstream resources.

15. Downstream Impact • A study within one of the sites indicated approximately: • 33% of GP referrals would receive immediate treatment and discharge. • 33% requiring a Consultant opinion. • remainder requiring other non-invasive therapy. • Other sites found that only 20% required a consultant opinion.

16. Workforce Issues - Orthopaedic Consultants • In NHS - full time with about 7 clinical sessions per week for their Trust. • High degree of subspecialisation. • Role in the OAS … • need to be willing reallocate traditional consultant tasks to other clinical resources. • flexible in relation to the management of their allocated time (swap clinics for theatre sessions).

17. Workforce Issues – GP’s • Play a key part in the OAS • as a referrer • as a participant in the clinics themselves • Utilisation of GPwSI’s was mixed. • Integration of a GP within the clinics assists in the relationship building with GP community. • The availability of a medically trained resource within the clinic provides a required level of clinical expertise.

18. Workforce Issues – Physiotherapists • Success depends on the ability of the organisation to successfully enhance the role. • Extended Scope Physiotherapist (ESP) • Injection Therapy • Ordering of X-Rays and Blood Tests • Ordering of MRIs • Listing for surgery • Competency development • Documented guidelines outlining the core competencies of ESP. • Orthopaedic Consultant Signoff • Society of Orthopaedic Medicine training course

19. Workforce Issues – Other • Other Allied Health Professionals • Podiatrist • Rheumatologist • Administrative Staff • Crucial in managing patient expectations • HMO’s • Reduced the need to work in clinic • Safe working hours.

20. Change Management • Ensure all stakeholders (esp. Surgeons and GPs) embrace the concept of the OAS. • Start the OAS small (e.g. with a particular body part) and expanding gradually. • Many sites started with new referrals as opposed to going back through the waiting list. • Documented procedures and protocols in addition to the continuing education of staff is critical.

21. Government Influences • Advances would not have been achieved without a comprehensive focus on the matter by NHS. • Outpatient Targets. No one waiting greater than…... • 21 weeks by April 2003, • 17 weeks by 2004, • 13 weeks by 2005. • Underpinned by a national outpatient service improvement collaborative and modernisation program. • Many of the sites visited recognised the evolving problem well before the targets were set.

22. Measurement • Patients by service type (e.g. back/spine, lower limb, upper limb) • Conversion rates for Surgery • Waiting Number and Waiting Times • Service Outcomes • Referral to Physiotherapy (Primary or Secondary) • Referral to Orthopaedic Consultant • Assessment, Advice & Discharge • Investigation (including type) and further review • Other Referral (Pain Clinic, Podiatry, Rheum) • DNAs

23. Outcomes • Patients • Improved Access:17 weeks for all referrals. • Patients satisfied with care. • Lower DNA / FTA Rates (6%) • Surgeons • Higher listing rates, better time utilisation. • 20 to 30% of referrals require a consultant opinion • Many now rely on OAS. • Physio’s/Allied Health • Enhanced Career Path

24. Barwon Health’s Strategy Improving Access to Orthopaedics Steering Group Orthopaedic Spokesperson GM Surgical Services Project Leaders (3) Orthopaedic Surgeon DND Surgical Services Chief Physiotherapist BM Surgical Services Project Manager ESAC Project Manager (PT) Outpatient Access Project Lead - Physio Exec Sponsor - GMSS Surgeon Deb Schulz (Chief Physio) Lisa Adair (NUM OPD) Jeff Urquart (GP) Theatre Project Lead - R Cockayne Exec Sponsor - DNDSS Surgeon – Mr Willams Anos Representative Lee Rendle (ANUM Ortho) Haydn Lowe (ESAC) Audrey Williams (CSSD) Inpatient Access Project Lead - L Coleman Exec Sponsor - BMSS Surgeon Haydn Lowe (ESAC) Mick O’Donnell (NUM Ward) Rehab Rep Focus Areas Turn around times Start times Equipment Issues Consumables Focus Areas OP Waiting Numbers OP Waiting Times Physio led services Better use of consultant time. Focus Areas Length of Stay Rehab Predictor Patient Education Bed Management in Ward

25. State-wide Focus • Awareness of the Outpatient issue • “Can’t manage what you don’t measure” • Identify existing initiatives. • National & International • Coordinated/Consolidated focus • NHS Modernisation Agency • DHS Collaborative

26. References • Chartered Society of Physiotherapists (UK) • www.csp.org.uk/download/sep/pdf/csp_sep_ocos.pdf • NHS Modernisation Agency • www.modern.nhs.uk/serviceimprovement/1339/1990/7700/Orthopaedics GuidevFinal.pdf

27. Questions ?