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Christopher Creaghan

Responsible Area: Approval Information:

Patient care and Professions Date Approved: July 2007 Committee:Committee - PEC

Lead Director:

Sheila Dilks Version No. Approved:


Review Date:

June 2009

Reference to Standards for Better Health Domain

Department of Health 2004: Standards for Better Health. Second domain: Clinical & cost effectiveness Fifth domain: Accessible & responsive care

Core/Development standard

Core Standard C5 C19

Performance indicators

1. Reduction of inappropriate referrals to secondary care.

History of Document

Version 1: May 2007

CONTENTS Section No.

Page No’s 3

1. 0


2. 0

Associated Policies and Procedures


3. 0

Aims & Objectives


4. 0

Purpose and Scope


5. 0

Roles and Responsibilities


6. 0

Training and Development


7. 0

Radiology referral agreement


8. 0

Referral Process


9. 0

Clinical Indications for referral


Audit and evaluation




10. 0

Appendices 1) Delegation agreement 2) Individual referrer agreement 3) Audit tool NICE Guidance Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. However, NICE Guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.

Approval Committee: Version No: Date Approved:





The Musculoskeletal Service (MSK) is a new initiative operating at the interface between primary and secondary care. Its role is to ensure patients identified with musculoskeletal dysfunction are assessed and diagnosed, making either treatment or onward referrals appropriate by putting the patient on the right pathway of care for their condition.


Patients are referred to the service by any of the General Practitioners operating within North Kirklees. Referrals are typically patients for whom diagnosis is unclear and / or a secondary care referral is a possibility.


The MSK Service has developed a working partnership between both GP’s and the Orthopaedic team at Dewsbury and District Hospital. In order for the MSK team to make appropriate referrals, diagnosis is essential, as too is recognising which service provider is the most effective at resolving the presenting condition. Should a patient’s condition require an Orthopaedic referral it again is essential that this is supported with the appropriate diagnostic imaging.


The MSK service employs both advanced and extended scope physiotherapists (Musculoskeletal Practitioners), along with a part-time general practitioner with specialist interest in musculoskeletal medicine and an orthopaedic consultant, also part-time.


For the purpose of this policy it is the Musculoskeletal Practitioners who require access to diagnostic radiology. They will provide the mainstay of clinical assessment and patient care plans. For a time efficient patient focused service, continuity would be lost if each patient had to be referred back to their respective GP in order that radiology be accessed.


Associated Policies and Procedures




This policy should be read in conjunction with the Mid Yorkshire Hospitals Trust ‘Guidance for medical staff who refers patients to Diagnostic Radiology’. This policy should be read in conjunction with the Kirklees PCT Policy (2007) Non Medical referral to radiology at The Mid Yorkshire Hospitals NHS Trust or Calderdale and Huddersfield NHS Foundation Trust.

Aims & Objectives


To ensure that patients who are referred to the MSK Service and attend an appointment with the Musculoskeletal Practitioner and who require further investigation at the radiology department receive a timely and safe service.


To maximise MSK service efficiency by making a prompt and accurate diagnosis, thereby allowing for appropriate treatment or referral to be made.

Approval Committee: Version No: Date Approved:



Purpose and Scope



This document sets out the guidelines for Musculoskeletal Practitioners employed by Kirklees PCT to refer patients for examinations performed by the radiology departments at The Mid Yorkshire NHS Hospital Trust or Huddersfield and Calderdale Foundation NHS Trust This includes acknowledgement of the employer of the responsibility to ensure the individual Musculoskeletal Practitioner is competent to undertake referral.

Roles and responsibilities


Musculoskeletal Practitioners in primary care •

The Musculoskeletal Practitioner must ensure they undertake tasks that they are competent to perform.

The Musculoskeletal Practitioner role is an enhanced role and as such they must have additional qualifications in courses recognised by the Health Professionals Council and Chartered Society for Physiotherapist in the study of Orthopaedics.

It is essential that a Musculoskeletal Practitioner continues to record in detail any clinical examination undertaken and history that may lead the Practitioner to request an investigation.

Prior to sending anyone for an investigation the Musculoskeletal Practitioner must ensure that the process will add to or alter the diagnosis and is beneficial and not detrimental to the patient.

The Musculoskeletal Practitioner must ensure: That the investigation will add to the consultation and management Does not investigate too often That any investigation is not unnecessary repeated That any request is supported by accurate and appropriate clinical information o That the request is the most appropriate investigation o o o o

(Royal College of Radiologists 1998) 5.2

PCT Service Manager •

It is the responsibility of the PCT Service Manager to ensure that a list of approved referrers in their service is maintained.

Changes or additions to the referrers must be submitted to the Primary Care Trust’s Clinical Governance Lead and Acute Trusts radiology department prior to referrals commencing.

• It is the responsibility of the PCT Service manager that appropriate education and training is undertaken by relevant staff. Approval Committee: Version No: Date Approved:



Training and development


The referring Musculoskeletal Practitioner should be working towards or should have completed a recognised Post graduate Diploma or MSc course in Orthopaedics.


The referring Musculoskeletal Practitioner must have received appropriate training in radiation protection as identified by the radiation protection advisor appointed by the Acute Trusts.

Radiology referral agreement


• A Radiology Referral Agreement must be completed. • This comprises 2 parts, a delegation agreement and individual referral agreement. • A copy of the certificate of competence in radiation awareness should also be sent with the completed agreements to the radiology departments. 7.1

Delegation agreement (appendix 1) • The delegation agreement is between radiology services and the Medical Director for the MSK Service. • The agreement will identify the scope of the practice i.e. the professional/ situation / examination / area etc. The delegator will be responsible for delegating the referral process.


Individual referrer agreement (appendix 2) • Confirmation must be given that the individual is working to approved clinical guidelines and has received supervised clinical training from the delegating clinician. • Confirmation must be given that the individual has received the radiology protection training session delivered within the Trust or other equivalent training on radiation awareness, if appropriate to the referral. • Responsibility as a referrer cannot be transferred between individuals and any new appointments must follow the guidelines in place for the speciality and an individual referrer agreement must be completed and submitted to the Clinical Governance Committee. This ensures all staff receives appropriate education and training relevant to their role.


The Radiology Departments can terminate referral rights at any time, either in whole or for any named individual, for any persistent abuse of the agreement.

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Referral process • Referrers will ensure correct demographical information is entered on the request form • Referrers will complete relevant clinical information and anatomical area to be viewed on the request card. • The request form is signed, the name written alongside in block capitals and is identifiable as sent by a Musculoskeletal Practitioner from MSK Service. • Pregnancy must be excluded in female patients and LMP documented on the request card. All referrals must be in line with the Mid Yorkshire or Calderdale and Huddersfield Hospitals’ Trust policy related to the irradiation of females of childbearing age.


Clinical indications for referral


Capsular Restriction • Any joint presenting with a restricted capsular pattern whereby underlying degeneration is suspected. • Clinical presentation of shoulder capsulitis as part of a screening process to eliminate alternative pathology.


Injury / acute dysfunction • Suspected bony lesion


Chronic Dysfunction • Clinical presentation suggestive of calcification / bone spur / stenosis / degenerative changes (joint space narrowing) • Suspected previously undiagnosed congenital abnormalities.


Pathology • To screen for pathology as and when clinical assessment does not eliminate practitioners concerns.

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Audit and evaluation


Practice will be audited and evaluated twelve months after the implementation of this guideline using the audit tool (appendix 3). The report and results will be presented by the Musculoskeletal Practitioners to the PCT Clinical Governance Group.


Any referrals regarded as inappropriate by the radiology department and therefore returned to the referring Musculoskeletal Practitioner will be discussed at the Musculoskeletal Service meetings.

References & Bibliography College of Radiographers (2002), Statements for Professional Conduct, College of Radiographers: London. Core Standards of Physiotherapy Practice (2005). CSP: London CSP Rules of Professional Conduct (2002). CSP: London Department of Health (2000), Ionising Radiation (Medical Exposure) Regulations, Department of Health: London. Department of Health (2000), NHS Plan – A plan for investment, A plan for reform, Department of Health: London. Department of health (2002) Making a difference: Reducing Burdens in Hospitals. Department of Health: London Department of Health (2003), 10 key roles for Allied Health Professionals, Department of Health: London. Mid Yorkshire Hospitals NHS Trust (2002), Guidelines for X-Ray Investigation of Females of Childbearing Age. Mid Yorkshire Hospitals NHS Trust (2003), Minimum Technique Protocol. Nursing and Midwifery Council (2004) Guidance for records and record keeping; London Royal College of Radiologists (2002), Risk Management in Clinical Radiology, Royal College of Radiologists: London. United Kingdom Association of Sonographers (1993) Guidelines for Professional Working Practice London: UKAS

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APPENDIX 1 (to be completed by Medical Director for PCT employed staff)

Non-Medical Radiology Referral Agreement for

Delegation agreement


This agreement is designed to clearly identify for the Mid Yorkshire NHS Trust or Calderdale and Huddersfield Foundation Trust the degree to which appropriately trained non-medical health professionals will refer patients for examinations. This agreement is recognised by the Trust as appropriate referral practice.

Scope of the agreement Health professional

Musculoskeletal Practitioner

Referring Practice or Team

Musculoskeletal Services

Examinations covered

Appendicular skeleton Axial skeleton (spine and pelvis)


Women of childbearing age. Guidelines for LMP Persons under the age of 16 years

Reason why agreement required:

To allow clinical impression to be confirmed / disputed by radiological investigation. Thereby helping to determine diagnosis and enabling the patient to access the most appropriate care for their condition in a timely manner.

Approval Committee: Version No: Date Approved:

Before an individual can participate they must have completed all appropriate training as stated in the individual referral protocol (Appendix 2). Radiation training will be provided for professionals and dates should be inserted in appendix 2 and signed off by the trainers when attended.

Only fully completed valid request forms will be accepted, showing the examination required, relevant clinical history and symptoms.

The cards must be signed and it should be made clear that the request is from a non medical referrer. In the future radiology will provide an area on the request for the signature of the non-medical referrer.

Signatories I, the undersigned, approve the implementation of this agreement as specified above. Clinical Director Radiology Services: ……………………………. Print name: Delegating GP or PCT Medical Director: Print name:

Agreement Date:

Approval Committee: Version No: Date Approved:


…………………………….. ……………………………..

APPENDIX 2 Individual referrer Non-Medical Radiology Referral Agreement for



This protocol is designed to clearly identify the individuals allowed to work within this referral agreement.

Part one. To confirm the suitability of the NHS professional with regard to experience and competence within their speciality. Name of referrer

1.Christopher Creaghan 2.Emma Jones

Job title

Musculoskeletal Practitioner

Referring Practice Team

Musculoskeletal Services

Signature of referrer:

1 2.

Signature of service manager or Practice Manager: ………………………………………………………

Print name:

Peter Horner



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Part two: Confirmation that the above named individual has attended the radiology services training session or alternative if appropriate. Date attended:



Signature of trainer: ……………………………………………… Print name:



Part three: Confirmation that the above named individual has been provided with specific clinical protocols to work to AND has received supervised training from the delegator or nominated alternative where appropriate. Copies of the training package and protocols are available within their workplace. Signature of delegator/nominated alternative: ……………………………….. Print name:


Position: …………………………………… Date: ……………………………….

Approval Committee: Version No: Date Approved:

APPENDIX 3 Musculoskeletal Practitioner Audit tool Musculoskeletal Practitioner…………………………………………… DATE

Approval Committee: Version No: Date Approved:






OUTCOME Clinical Diagnosis confirmed?

Approval Committee: Version No: Date Approved:

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