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Sport & Exercise Medicine A Fresh Approach in Practice A National Health Service Information Document


Contents Foreword

Page 04

Introduction

Page 05

Six Key Points for Commissioners

Page 06

Summary Table

Page 07

Models of Care – Primary 1) Schopwick Surgery Musculoskeletal Service, Elstree, Herts

Page 11

2) Gedling Soft Tissue Clinic, The Calverton Practice, Nottinghamshire

Page 17

3) Newcastle West Community Musculoskeletal Service, Newcastle upon Tyne

Page 21

4) Physiotherapy and Orthopaedic Medicine Service, Staffordshire and Stoke-on-Trent Partnership NHS Trust

Page 29

Models of Care – Secondary 1) Nottingham Sport and Exercise Medicine Service, Nottingham University Hospitals Trust

Page 35

2) Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust

Page 41

3) Oxsport, Oxford University Hospitals NHS Trust Newcastle upon Tyne

Page 49

Models of Care – Intermediate 1) Oxfordshire Musculoskeletal Hub Oxford

Page 53


The diverse range of sport and exercise services in this document highlights the opportunities to commission new services to positively improve health and health economics in the NHS.

Foreword – A Fresh Approach in Practice The burden of musculoskeletal (MSK) problems and physical inactivity in the UK is now significant and we need a fresh approach to this health problem. Without an increase in Sport and Exercise Medicine consultant lead services, working in multidisciplinary teams, the NHS is not meeting one of the key health threats to the UK population. This document gives the reader the ‘how to’ and the ‘top tips’ for NHS commissioners in considering such services, the clinical successes and ‘lessons learnt’ in a frank and analytical way. The reader will quickly appreciate the diversity of different services constructed to meet the needs of the local populations, at the centre of which, in each example, sits a consultant in sport and exercise medicine (SEM). The SEM consultant, following a formal medical training and then higher specialist experience, is the key to ensuring that musculoskeletal and physical inactivity problems are correctly assessed in the multidisciplinary team, whilst ensuring that ‘red flag’ patients are identified and managed appropriately. Thank you for taking the time to read this document which puts forward the experiences of a number of Sport and Exercise Medicine consultants, providing musculoskeletal and physical activity initiatives in the NHS over the last 20 years. Dr Roderick Jaques President Faculty of Sport and Exercise Medicine (UK)

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Forward – A Fresh Approach in Practice

‘A Fresh Approach in Practice’ is the second NHS Sport and Exercise Medicine services document. Focusing on musculoskeletal care and exercise medicine, it provides useful working examples of the benefits of Sport and Exercise Medicine services to patients and the NHS. It includes 6 key points for Commissioners when considering services across both primary and secondary care and working examples of how sport and exercise medicine services can reduce costs and referrals. Physical inactivity is now endemic in the UK and we need to look at how we can develop sustainable prevention and treatment models for chronic disease, conditions related to inactivity and common musculoskeletal conditions. A must read for all NHS Commissioners. Mike Farrar Independent Management Consultant NHS Confederation


Introduction - A Fresh Approach in Practice: Sport and Exercise Medicine Services in the NHS A Fresh Approach in Practice follows Sport and Exercise Medicine: A Fresh Approach (published September 2011), providing working examples of the benefits of Sport and Exercise Medicine (SEM) services to patients and the NHS. The diverse range of these services highlights the opportunities to commission new SEM services to positively improve health and health economies in the NHS. The Faculty of Sport and Exercise Medicine was established in 2006 and is responsible for the standards of SEM, training and higher specialist examination. There are now over 60 Doctors on the GMC specialist register in SEM. SEM doctors are trained to holistically diagnose and treat musculoskeletal conditions and sports injuries and effectively promote physical activity, especially for those with chronic noncommunicable disease, through physical activity interventions, prescription, rehabilitation, clinical exercise testing and risk assessment. Why is it important to involve SEM Consultants in Primary Care clinics to treat musculoskeletal (MSK) conditions and prevent MSK problems? Physical inactivity is endemic, strongly associated to chronic disease and MSK problems, and costs the UK economy roughly £8.2 billion a year1. Increasing activity levels can inexpensively treat chronic disease, MSK conditions and sports injuries. It can also decrease chronic disease risk by 30 - 50%1, preventing co-morbidity and aiding recovery, function and improving quality of life, in those who do suffer from chronic disease. Sport and Exercise Medicine doctors also offer alternative non-surgical pathways in managing musculoskeletal (MSK) conditions and ensure rapid diagnosis. MSK disorders account for up to 30%1 of all primary care consultations and affect most individuals at some point in their lives. However, the vast majority (up to 82%2) of these

cases do not convert to surgery, and so patients typically re-present to GPs, which is neither time nor cost effective. SEM consultants, in multi-disciplinary teams, can deliver non-surgical MSK services and rapid diagnosis in primary care, allowing for considerable savings and efficient pathways. They can also provide exercise interventions in tackling chronic pain syndromes i.e. the creation of chronic back pain pathways1. The examples of SEM services found in this document include that of the pilot Newcastle West Community MSK Service, which saw a reduction in costs of £42,000 in 6 months of 2012 compared to 2010, despite 62% more referrals. The Schopwick Surgery Musculoskeletal Service, Elstree reported orthopaedic referrals halving, on average, over a 5 month period. The service saw physiotherapy waiting times reduced by 2 weeks and reduced requested number of direct-access MRI scans by 80%. The service made conservative estimated total savings via MSK service of £10,400 (not accounting for follow up appointment and operation tariffs saved). This introduction includes ‘Six Key Points for Commissioners’. The SEM services already in existence in the NHS demonstrate a high demand and proven level of success. Commissioners will see that SEM services are delivered across primary and secondary care, providing both musculoskeletal and exercise promotion services. It is clear that SEM doctors provide opportunities to improve NHS outpatient musculoskeletal services and promote better health through exercise. On reading this document I question the reader to consider just one thing: can you afford not to provide this service to your patients?

Introduction

05


Six Key Points for Commissioners 1. Sport and Exercise Medicine (SEM) consultants offer unique and specific skills in the diagnosis, treatment and rehabilitation of musculoskeletal, soft tissue and sport injuries. 14 2. SEM services may be situated in both community and secondary care settings and tailored to meet local pressures and needs. 14 3. Globally physical inactivity causes 9% of premature deaths, 5.3 million of the 57 million deaths that occurred in 2008.6 4. Maintaining physical activity at recommend levels can equate to 3 to 4 years in additional life expectancy, with risk reductions in the order of 20-40% for over 22 non-communicable diseases.7 5. Current costs of providing healthcare cover for a physically inactive aging population are not sustainable. 10 11 6. The NHS needs to invest proportionately to the burden of physical inactivity to develop sustainable prevention and treatment models for chronic disease.12

Footnotes 3. 4. 5. 1. 2.

6.

7.

8.

9.

10

11

12

15 13 14

06

Combined direct and indirect costs of physical inactivity. CMO report 2005 Weiler R, Jones N et al. NHS. Sports and Exercise Medicine: A Fresh Approach. Ibid Ibid The cost of chronic back pain to the economy stands at £12.3 billion yearly. Maniadakis N, and Gray A., The Economic Burden of Back Pain in the UK. Pain 2000; 84 (1) Lee I-M, Shiroma EJ, Lobelo F, Puska P, Blair SN Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380: 219-29 Wen CP, Pui Man Wai J, Tsai MK. Yang YC, Cheng TYD, Lee M-G, Chan HT, Tsao CK, Tsai SP, Wu X. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study Lancet 2011; 378 (9798):1244-1253 Jarret J et al., Effect of increasing active travel in urban England and Wales on costs to the National Health Service. Lancet 2012, 379 (9832):2198-2205 Physical Activity: brief advice for adults in primary care. NICE PH44 24th May 2013 www.nice.org.uk/nicemedia/live/14176/63945/63945.pdf Anderson LH, Martinson BC, Crain AL et al. Healthcare charges associated with physical inactivity, overweight and obesity. Prev Chronic Dis 2005;2(4):A09 Nazmi S. Physical inactivity and its impact on healthcare utilisation. Health Economics 2009;18(8):885–901. Moore G. The role of exercise prescription in chronic disease. Br J Sports Med 2004;38:6–7, Jarret J et al. op. cit, Nazmi S. op.cit. Ibid, p.6-7 Weiler R, Jones N., op.cit. Pedersen BK, Saltin B. Evidence for prescribing exercise as a therapy in chronic disease. Scand J Med Sci Sports2006;16(Suppl 1):3–63.

Six Key Points for Commissioners


Summary Table Service

No. patients treated yearly

No. years in operation

Schopwick Surgery Musculoskeletal Service, Elstree

168 (7 per session, 2 sessions per month)

Pilot service – established Sept 2011

Main trends and clinic outcomes Downward trend, orthopaedic referrals halved

Improvements and patient satisfaction Total savings via MSK service of £10,488 - £62 saving per patient using service (not including follow up appointment and operation costs) Waiting time for physiotherapy reduced by 2 weeks Reduced requested number of direct access MRI scans by 80% Over 90% “very good” or “excellent” response to all PSQ parameters

Newcastle West Community Musculoskeletal Service

Approx. 3125 patients treated in the pilot in 2012

Pilot service (2 years, beginning 2011)

Secondary Care Orthopaedic referrals reduced by 40% Improved efficiency of Orthopaedic outpatient conversion to surgery rises to 82% Rheumatology referrals down 8% Neurosurgery referrals down 44%

Reduction in costs of £42,000 in 6 months of 2012 compared to 2010, despite 62% more referrals = more patients seen for less money 79% rated their access to Orthopaedics compared to patients attending hospital outpatients for MSK problem as ‘much better’ 83% rated the performance of the pilot as ‘much better’ compared to previous Community Physiotherapy Service Access to physiotherapist by telephone in 48 hours and face to face in 3 weeks. More specialist service (i.e. SEM consultant) within 4 weeks

Physiotherapy and Orthopaedic Medicine Service (Staffordshire and Stoke-on-Trent Partnership NHS Trust)

Circa10,000

Gedling Soft Tissue Clinic

6 new patients per week, 276 patients treated yearly

Since 2005

Only 10% referred on After triage 21% seen outside service

Savings of 20% of overall MSK budget 82% said service met most or almost all of their needs in 3 month period 72% said service was ‘much better’ than other outpatient appointments

Pilot period 2002-3. Clinic ran until end of 2009

32% of over 500 general orthopaedic referrals were triaged away from hospital setting

Acute Trust waiting times were over 6 months when the STC was delivering 59% in less than 8 weeks

59% patients seen in less than 8 weeks at Soft Tissue Clinic

86% reported successful treatment outcome

Less than 3% triaged into Soft Tissue Clinic discharged back into secondary care

98% patients highly satisfied

In initial year, no patient referred back to secondary care with same orthopaedic problem

Summary Table

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Service

Nottingham Sport and Exercise Medicine Service

No. patients treated yearly 1,488 patients between period of February 2009 – March 2010

No. years in operation

NHS funded since 1996

Main trends and clinic outcomes Just 6.4% required referral, of which 3.2% referred to Orthopaedics, with the remaining referred to surgical or Osteopath Of the 1,250 patients requiring treatment:

Improvements and patient satisfaction 93% of patients ‘very satisfied’ with service

• 62% managed with advice • 42% required NHS physiotherapy, • 13% given home exercise • 8% referred to other specialties Of the 1,488 patients audited: • 47% had an ‘open’ outcome • 39% required follow-up • 6% discharged SEM department, Circa 3700 University of patients Leicester NHS Trust per year (1100 new referrals per year)

20 years (established 1993)

Oxsport, Oxford University Hospitals NHS Trust

2005

1000 new referrals per year

Over last 5 years of activity, for new patients rates of investigations: MRI (18%), USS (5%), X-ray (7%), blood tests (3%), EMG (1%)

Surplus of income over expenditure of about 20% turnover

Over last 5 years 30% of new patients seen, treated & discharged at 1st appointment

Very high levels of patient satisfaction across multiple surveys – from latest survey 99.5% would recommend service to family/ friend

69% patients discharged at first appointment 29% discharged at follow-up Very low onward referral to orthopaedics - 2.4%.

Excellent commissioner feedback with on-going commissioning Consistently excellent patient feedback for face to face service and email follow-up service 100% of GP rate service as good or excellent Average wait for new appointment 2 weeks

Improved efficiency of Orthopaedic outpatient conversion to surgery rises to 98% Email follow-up Investigation referral rates • None-46% • MRI- 18% • Ultrasound on day 24% Joint clinics with hip and knee surgical teams

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Summary Table

Typical waiting time 2-4 weeks for first appointment


Service Oxfordshire Musculoskeletal (MSK) Hub, Oxford

No. patients treated yearly

No. years in operation

All MSK 2006 referrals across Oxfordshire including orthopaedic, rheumatology, metabolic bone, sports, paediatrics, spinal

Main trends and clinic Improvements and patient outcomes satisfaction Reduction in orthopaedic secondary care referral rate by 27% Reduction in rheumatology referral rates to secondary care by 35%

Service recently re-commissioned in competitive bid for next 5 years High patient satisfaction rates Adherence to 18 week pathway

Improvement in surgical conversion rates for hip (11% increase) and knee (36% increase) in 2 year period Tier 1 paper triage service led by SEM consultants and senior and consultant physiotherapists Tier 2 face to face service staffed by SEM consultants, podiatrists, orthopaedic fellows and senior physiotherapists

Summary Table

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Models of Care – Primary


Models of Care – Primary 1) Schopwick Surgery Musculoskeletal Service, Elstree, Herts

Service Details Name of Service

Schopwick Surgery Musculoskeletal Service

Location of Service

Schopwick Surgery GP, Elstree, Herts

Service Type

Primary care musculoskeletal clinic and triage service for access to secondary care

Number of Sessions per week

2 sessions per month

Average consultation time (mins) 30 Length of session (mins)

240 mins

Please list staff numbers

2x Sport and Exercise Medicine (SEM) Speciality Training Registar (StR), 1x Physiotherapist

Background Pilot musculoskeletal service, led by two Sport and Exercise Medicine (SEM) Specialty Training Registrars (StRs), with evening clinics based in consulting rooms at a General Practice (Schopwick Surgery) in Elstree. GPs identify appropriate patients and refer directly to the service using guidelines drawn up by SEM clinicians; patients are instructed to book an appointment at reception at their convenience. The SEM clinician has access to ‘same week’ priority physiotherapy slots (two per week) in order to allow fast-track treatment of patients. Ultrasound (US) scanning is utilised to facilitate diagnosis and image-guided injections are administered where appropriate. Exercise prescription is undertaken for common conditions, facilitated by instructional videos emailed to patients. Negotiations were made with a local private podiatrist for reduced rates (20%) on podiatric assessment and custom made orthotics, utilising a voucher system.

Models of Care – Primary

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The primary aims of the pilot were to: • Provide a ‘one-stop’ triage clinic to reduce the number and improve the quality of secondary care orthopaedic referrals and instigate definitive treatment for musculoskeletal (MSK) conditions in patients not requiring onward secondary-care referral • Reduce the number of inappropriate referrals to ‘in-house’ physiotherapy and reduce first appointment physiotherapy waiting times

Follow up appointments were not routine, but at the discretion of the clinician (e.g. for injection). The majority of follow up was undertaken by telephone consultation and / or by email. This included:

to below a certain threshold, the practice was awarded a lump sum (£12,000) by the Practice Based Commissioning Local Enhanced Service (PBC LES). This money is used to fund the service in advance on a sessional basis.

• Discussion and feedback of scan / x-ray results ordered by the clinician

As SEM StRs were running the service, provision was made to ensure supervision and accountability pathways were in place; formal StR trainee GP placement was extended at the practice with the London Deanery’s approval and GP partners took on a supervisory role. Medical indemnity was negotiated and approved with respective organisations.

• Monitoring compliance and response to clinician guided exercise / rehabilitation prescription • Clinical response to therapeutic injections Mechanisms were also put in place to ensure feedback from physiotherapist and podiatrist by telephone or email. This allowed patients who had failed conservative measures to be flagged and referred to secondary care promptly without the need for an MSK clinic appointment.

What was Implemented? Following the completion of SEM training placement at the practice, negotiations were made at a practice level with GP partners and the Practice Manager to develop a pilot MSK service for the local population with the aim of achieving the goals detailed above. By reducing referrals

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Models of Care – Primary

Achievements and Impact The following is a result of data derived from a MSK service audit at five months (6/9/2011 to 7/2/2012 inclusive): • No. of clinic sessions: 11 • No. of patients attending in audit period: 74


Schopwick Surgery Musculoskeletal Service Figure 1: Clinical Presentations

4%

Figure 2: Outcome Summary

7%

5%

8% 5%

15%

8%

4% 2%

5%

7% 9%

15%

34%

1%

9% 3% 7%

26%

26%

Ankle

Neck

Referred to NHS secondary care

Direct access hospital USS

Elbow

Other

Physiotherapy

“In house” USS

Foot

Other Spinal

Clinician directed rehab

Therapeutic / diagnostic injection

Hand

Shoulder

Podiatry

Hip / groin

Wrist

Direct access MRI

Knee

Xray

Figure 3: Monthly orthopaedic first referrals from Schopwick Surgery Feb - Nov 2011 (2011/12 HIDAS website data) 30

Patient feedback 62% response rate randomly selected patients completed a Patient Satisfaction Questionnaire (PSQ) and MSK service questionnaire. These were submitted anonymously.

25 20 15 10 5 0

Feb

Mar

Apr

May June

July

Aug

Sept

Oct

Nov

Service Started July 2011 Models of Care – Primary

13


Patient Satisfaction Questionnaire – % of patients responding “very good”, “excellent” or “outstanding” Figure 4: PSQ results Making a plan of action with you

4%

86%

7%

Helping you take control

76%

15% Explaining things clearly

90%

Being positive

90%

Showing care and compassion

90%

Fully understanding your concerns Being interested in you as a whole person 15% Really listening

90%

Letting you tell your story

90%

95% 95%

Making you feel at ease

7%

95%

26%

0%

25%

50%

75%

100%

Musculoskeletal (MSK) Service Questionnaire – % of patients answering either “agree” or “strongly agree” to the questions... Figure 5: MSK service questionnaire results You feel that your referral to the Musculoskeletal Service clinic today by your GP was appropriate

95%

You preferred visiting your GP practice rather than having to visit a hospital clinic

90%

The waiting time to see the Sport & Exercise Medicine doctor today at the practice was less than the time you have experienced before waiting to see a hospital-based specialist

81%

You felt more comfortable / at ease in the consultation with the Sport & Exercise Medicine doctor today than you have done before with a hospital-based orthopaedic specialist

76%

After your consultation today, you are confident in the Sport & Exercise Medicine doctor’s knowledge and skills with respect to your musculoskeletal complaint

76%

You are confident that the Sport & Exercise Medicine doctor would refer you for a surgical opinion at hospital if they felt it was appropriate / necessary

95%

The musculoskeletal service you attend today is a useful and important part of the overall medical service Schopwick Surgery provides to it’s patients

95%

Should this service be permanent?

95%

0% 14

Models of Care – Primary

25%

50%

75%

100%


Improvements and Efficiencies See Figure 3 • First appointment waiting time for physiotherapy has reduced from approximately eight weeks to six weeks, despite number of physiotherapy sessions per week being reduced due to funding cuts • Reduced number of direct access MRI scans ordered by GPs at the surgery over an equivalent time period prior to the MSK service starting (see below)

Table 1: Potential savings via MSK service

Savings to Practice Based Commissioning (PBC) over 5 month period (11 clinic sessions)

Orthopeadic referral tariff

Diagnostic Ultrasound tariff

Injection tariff

Physiotherapy sessions

Total

£9,135

£440

£400

£513

£10,488

Benefits to patients Shorter waiting time for access to musculoskeletal specialist assessment and treatment • Balanced, informed holistic care • Diagnostic ultrasound and therapeutic injections at point of care, rather than waiting for a subsequent secondary care hospital appointment • Care close to home and easy access for patients e.g. parking • Familiar, welcoming GP environment • Clinician led exercise prescription to start immediate rehabilitation and priority/rapid access physiotherapy • Reduced cost of private podiatry treatment • Appropriate sign-posting to appropriate orthopaedic departments/consultants with sub-speciality interests (NHS or private) with respect to specific MSK conditions

Models of Care – Primary

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Top Tips What did you do well? • Flexibility - prepared to adapt as the service evolved. Ensured follow up and monitoring of patient progress in some capacity; patients grateful for personal touch

• Some reception staff not aware of service provision – patients double booked back into clinic rather than into priority physiotherapy slots

• Liaison with the Commissioning Group to advertise SEM skills and promote service expansion

• Delay in imaging results – difficult to flag point at which reports are returned to the practice so occasionally delay in feeding back to patients. Can’t see the images yourself so reliant on hospital radiologist. Clinical question sometimes not answered directly

• Audit and regular feedback to GPs optimised referral behaviour and ensured efficient use of clinic appointments

What would you advise others who wish to replicate this piece of work?

What didn’t go so well?

• Ensure mechanism for regular feedback from physiotherapist – e.g. monthly case meetings

• Non attendance rates were high initially. Systems were put in place for reminders by telephone and text message. This improved attendance rates significantly

• Keep detailed records in addition to the practice consultation manager database • A strong relationship with the practice manager, primary care staff and the administrators is invaluable

Sustainability Demand has increased since the clinic was started. We have monitored average waiting times for access to the clinic and altered the clinic frequency accordingly, as well as providing additional sessions. On going audit of orthopaedic referrals made whilst the service has been in operation is important; this information has been fed back to GPs to inform better referral practice. Regular feedback is also provided at monthly GP partner meetings. Liaise with physiotherapist to ensure that the priority slots are being used efficiently. Due to the success of the musculoskeletal (MSK) pilot service a commissioning proposal has been approved to expand the service to other practices. A Consultant in SEM will be responsible for leading the service in each practice. Ultimately it is our aim as SEM clinicians to be formally commissioned as a MSK service provider for the whole Hertsmere locality.

Contact Details

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Name

Dr James Noake, Specialist in MSK Sports and Exercise Medicine Dr Stephen Chew, Consultant Physician in Sport and Exercise Medicine

Telephone

07973 138720

Oganisation

Schopwick Surgery, Elstree

Email

jamesnoake@hotmail.com, stevechew@me.com

Commissioning PCT/Org

Schopwick Surgery

Models of Care – Primary


2) Gedling Soft Tissue Clinic, The Calverton Practice, Nottinghamshire

Service Details Name of Service

Gedling Soft Tissue Clinic

Location of Service

The Calverton Practice, 2A St Wilfrid’s Square, Calverton, Nottinghamshire

Service Type

Community Musculoskeletal Triage and Treatment Service

Number of Sessions per week

1

Average consultation time (mins) 30 mins new / 15 mins f/up Length of session (mins)

3 hours

Please list staff numbers

1 Doctor + 1 Specialist Physiotherapist

Background Over a number of years there has been an increasingly high demand for orthopaedic services across the Nottingham Acute Trusts. Gedling Primary Care Trust (PCT) needed to make its own contribution to faster access for patients, greater choice, and the opportunity for patients to access services closer to their home, avoiding the need to go into hospital for outpatient assessment or further treatment. In September 2003, Gedling PCT designed a local service to manage this increasing demand whilst at the same time providing opportunities for local clinicians to develop special interest skills. The key objectives were to: • Set up a community based, multi-disciplinary orthopaedic triage system and clinic in a variety of orthopaedic areas from referral to discharge • Manage a reduction in demand for hospital appointments by 10% in the first twelve months Models of Care – Primary

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What was Implemented? Working in partnership with a local GP with Special Interest (GPwSI), specialist physiotherapist, local practice and local orthopaedic consultants, the PCT developed a pilot service to provide a multi-disciplinary Soft Tissue Clinic based in a local practice. The objectives of the initial 8-month pilot from August 2003 to March 2004 were to: • Establish a GPwSI clinic in Gedling Primary Care Trust (PCT) supported by a physiotherapist for all patients aged sixteen or over suffering from sub-acute musculoskeletal/soft tissue problems • Reduce demand for orthopaedic services in Gedling by at least 10%. It was proposed that the clinic would see approximately 100 patients over the 8-month pilot, between 6 and 8 patients per week • Establish a clear GP referral triage service integrated with local orthopaedic consultants • Improve GP understanding and referral behaviour for Soft Tissue conditions

To initiate the pilot, the PCT had to: • Recruit a high class GPwSI, establish a location and make this known throughout the GP community • Establish good working relationships with the local orthopaedic consultants including establishing a fourth-week rotational clinic within secondary care where more difficult cases would be followed up • Develop and distribute a local referral protocol and practice toolkit for the service • Visit local GPs and practices to clarify and reassure them • Identify PCT management support for a referral triaging service and audit mechanisms to monitor and evaluate the pilot The service was supported by adopting change management techniques, including process mapping and matching capacity with demand. 18

Models of Care – Primary

This also included ensuring variation in demand could be dealt with by both the primary care and secondary care clinicians. All patients were involved in preliminary evaluations of the original service design, the quality of the service, and their individual patient outcomes.

Achievements and Impact Less than 3% of all those triaged into the Soft Tissue Clinic have been discharged back into the secondary care system. Over 98% of patients were highly satisfied with the level of access to the community service (based at a local GP practice not necessarily their own) as well as the professionalism of staff involved and the quality of the service. 86% of patients reported a successful treatment outcome as measured by the degree of shared treatment plan goals achieved after six weeks of being discharged. Patients consistently reported high scores on access and quality of care through ‘before and after’ patient satisfaction surveys.

Improvements and Efficiencies Results were measured in terms of access, patient outcome and patient satisfaction as described above. Historic data over a year revealed 32% of over 500 general orthopaedic referrals were triaged away from a hospital setting, with over 150 appropriate patients being offered an appointment in the community based Soft Tissue Clinic. In terms of improved access in comparison with waiting list times, 59% of patients were seen in Soft Tissue Clinic in less than eight weeks (no patient obtains a first appointment in more than 12 weeks). In the initial 12 months, no patient was referred back to secondary care with the same orthopaedic problem.


Benefits to patients Patients were able to access the service in a local setting without the need to be referred into the hospital setting. The proposed changes to the referral and care pathway aimed to give patients an accurate diagnosis and earlier access to treatment. At the same time, the pilot had a positive effect on staff and services in both primary and secondary care. Patients would be treated by a qualified GPwSI and supported by a highly trained specialist physiotherapist.

Top Tips What did you do well? • Doing things differently in primary care • Shifting an established GP culture • Changing GP behaviour in a short time frame

The Soft Tissue Clinic was presented at local GP evening meetings, with regular communication via practice letters, regular updates at the Professional Executive Committee and local GP Board meetings. The service and its results were also showcased at the district wide Musculoskeletal Forum with other community practitioners.

• Developing the role of the GPwSI

What didn’t go so well?

• Regular communication and reinforcement at GP practice level

We could have made an even bigger impact by delivering three times the volume, but limited by time and budget. We were also limited as the service ran with only 1 x GPwSi and 1 x Physio.

• Provided educational sessions to GPs • Improved referral letter details written by GPs • Improved working relationships between local clinicians and Gedling PCT management • Significant influence on demand management over what was originally expected • Improving patient access

What would you advise others who wish to replicate this piece of work? • Be approachable • Treat people like people • Make sure patients can access the service to make changes to appointments etc • Make it easy for patients to speak with you

• Reducing chronic disease in patients with soft tissue problems in Gedling

Lessons Learnt One feature of the service was the strength of the GP/Manager partnership, which had designed and implemented the service, provided regular evaluation to all parties and continued to drive it forward. This is coupled with the valuable commitment of the specialist physiotherapy and administrative staff at the front end of the clinic. This all made for a secure team effort which was sustainable, and produced a high quality service for local patients. Coupled with this, one key component part of the success for the service was being part of the triage system which enabled the team to see appropriate patients in the right setting.

Models of Care – Primary

19


Sustainability The Primary Care Trust (PCT) continued to monitor the Soft Tissue Clinic pilot carefully and the service became mainstream and fully funded after the pilot. The Soft Tissue Clinic model has since been used to help develop a large scale Integrated Clinical Assessment and Treatment Service (ICATs) which is currently going through a procurement process for Nottingham.

Evaluation The service underwent continual evaluation by the PCT. It was also highly commended at the Trent Celebrating Success event 2004, category “New Ways of Working”.

Contact Details

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Name

Dr James Hopkinson

Job Title

Consultant in Sport and Exercise Medicine

Telephone

0115 9657801

Oganisation

The Calverton Practice, 2A St Wilfrid’s Square Calverton, Nottinghamshire

Email

james@sportsdoc.co.uk

Commissioning PCT/Org

Gedling PCT / Notts County Teaching PCT

Models of Care – Primary


3) Newcastle West Community Musculoskeletal Service, Newcastle upon Tyne

Service Details Name of Service

Newcastle West Community Musculoskeletal Service

Location of Service

Newcastle upon Tyne, west of city. The clinics are all community-based including Community Assessment Triage Services (CATs) based in five sites and Community Physiotherapy based in nine sites. Most venues are GP practices

Service Type

Full Community Musculoskeletal service

Number of Sessions per week

Consultant in SEM- 3 sessions Consultant Orthopaedic Surgeon-1 session GPwSI -1 session Extended Scope Physiotherapy (ESP)-15 sessions Physioline telephone sessions -7 sessions Community Physiotherapy - 30 sessions

Average consultation time (mins) Physiotherapy: new 30mins; review 20mins CATs : new 40mins; review 20mins Length of session (mins)

210 or 240 mins

Please list staff numbers

SEM Consultant 1 / GPwSI 1/ Orthopaedic Consultant 2 / ESP 6 / Physiotherapist 12

Models of Care – Primary

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Background

GP

Physioline Telephone Consultation

Referral Management Centre

Exclusions Community Physiotherapy

MSK CATs Service ESP, GPwSI, SEM Consultant Orthopaedic Surgeon – direct waiting list

Secondary Care

Newcastle West GPs have had access to a musculoskeletal (MSK) Community Assessment Triage Service (CATs) for several years provided by Connect Physical Health. Utilisation of this service was good, but many GPs still sent a significant number of patients direct to secondary care that could have been managed in the community service. In addition, waits for physiotherapy in the community had been felt by GPs to be excessive for many years. Following discussions between Newcastle West GP Commissioning Group, North of Tyne Primary Care Trust (PCT), Connect Physical Health and Newcastle upon Tyne Hospitals Trust, a pilot was commissioned to test a whole community pathway which GPs would agree to use as a single point of entry other than defined exclusions. The pilot was to run for two years from the start of 2011, with evaluation within 2011, to see if it was effective and continue into year two. When GPs need help with a patient with musculoskeletal problems, they decide in their consultation whether to refer to community physiotherapy or to MSK CATs. For physiotherapy they simply supply the patient with a card documenting the telephone number for Physioline which is a well established telephone assessment and advice service. The patient contacts the service and will be assessed by a senior physiotherapist by telephone within 48 hours. Most patients will be booked in for face-toface assessment as a result but a proportion are given advice and sent details for exercises and do not require to be seen face-to-face. This early professional advice ensures that patients are doing the correct thing for their condition at the earliest stage. Face-to-face community physiotherapy consists of a standard model of care. This is provided within 1-3 weeks of referral, having all had initial advice from Physioline unless unable to use the telephone.

22

Models of Care – Primary


For the MSK CATs service, GPs refer on a proforma via Choose and Book. All referrals are triaged by Extended Scope Practitioners’ (ESPs) and appropriate action taken according to the information supplied. This can include direct immediate referral to secondary care or an appointment with the most appropriate clinician in the MSK CATs team. ESPs choose from appointment with ESP/Consultant in SEM GPwSI or Orthopaedic Consultant. GPs are asked on the proforma to indicate whether the problem involves a Sport and Exercise issue to aid this decision. Patients are seen in MSK CATs within four weeks following triage. Consultant Orthopaedic surgeons will see patients direct from triage if the need for surgery is clear, otherwise on cross-referral within the service once a possible need for surgery is identified by an ESP or SEM Consultant. The SEM Consultant will see a mix of SEM problems and general musculoskeletal patients. The service has access to the full range of diagnostic investigations. The SEM Consultant uses portable ultrasound for diagnosis and guidance of injection, particularly where unguided injections by GPs or CATs colleagues have failed. MRI scan is available within two weeks at a local independent sector provider and standard radiology at the local NHS Trust. Most patients are managed within the service, but where secondary care facilities and expertise are required; patients are referred having been offered the choice of a secondary care provider. The Orthopaedic Surgeons in the service place patients directly on their waiting-list thus removing the need to attend outpatients at the hospital. The whole service is administered on SystmOne, a web-based paperless system allowing patient data to be handled securely between the numerous venues and the Referral Management Centre where all the administration occurs.

What was Implemented? This commissioning group already had an MSK CATs service, but without Orthopaedic involvement, which was included as part of the pilot. The physiotherapy service was paid for from a non-recurring budget but equates with the existing physiotherapy budget. The pre-existing provider has invested the saved income in services in other parts of the city not subject to the pilot service. The results of the pilot suggest that the increased costs of this service, related to higher referrals, were outweighed by reduced costs in referral to secondary care. Hence, the balance is an overall saving for the commissioners of these GP initiated referrals.

Achievements and Impact The success of the service has been measured with GP and patient satisfaction, EQ5D (EuroQol) Group Health Questionnaire) clinical outcome measures and cost analysis.

Models of Care – Primary

23


GP and patient satisfaction Anecdotally, the feedback from GPs and the Clinical Commissioning Group (CCG) managers has been excellent. Formal assessments have confirmed this:

Your overall confidence in the Musculoskeletal (MSK) Service 14%

Table 3: GP Questionnaire re Community Physiotherapy – 29 responses:

3%

“Compared to your previous Community Physiotherapy Service, please rate the performance of the Pilot Service delivered by Connect Physical Health?”

83%

Much Better

Worse

Better

Can’t Comment

Same

Access for Patients 10%

Table 4: GP Questionnaire – 29 responses:

3%

“In the pilot the pre-existing CATs service has been augmented by the inclusion of Newcastle Hospital Trust Orthopaedic Surgeons. How do you rate this access to Orthopaedics compared to patients attending hospital outpatients for MSK problems?”

7%

79%

24

Models of Care – Primary

Much Better

Worse

Better

Can’t Comment

Same


Clinical Outcomes EQ5D-5L data was used for the first time to try to measure clinical outcomes. The numbers of postal returns from patients at three month follow-up were very poor. The returned responses demonstrated a clear improvement in the physiotherapy cohort and a small improvement in the MSK CATs cohort – additional surgical and physiotherapy outcomes were excluded from the assessment. Mechanisms and pathways for the collection of these clinical outcomes is being reviewed. There is little published data on the use of these outcomes in services such as this to compare with.

Financial Implications A full assessment of the financial implications of this service was made by comparing data for a control period of 6 months of secondary care referrals in April - October 2010 (pre-pilot) with the same period during the pilot in 2012. Referrals to Orthopaedics reduced by 40%, into Neurosurgery by 44% and into Rheumatology by 8%. There was a consequent increase in referrals into the community services consisting of an

81% increase in attendance in the Community CATs service and 174% increase in community physiotherapy attendances. Overall there was a 62% increase in patient consultations in the pathway across all services. A value was attached to each change in referrals and community attendances based on national Tariff for secondary care including an assumed 1:2 follow-up rate in secondary care for Orthopaedics and Rheumatology referrals. The absolute costs of the community pilot service were easily calculated using SystmOne data and local agreed tariffs for these services.   Comparing total costs for the 6 months covering April to October 2010 (pre-pilot) and April to October 2012, demonstrated a saving of £42,000 for a practice population of 77,000 over 6 months. This equates to a £1.09 per head of population saving per year for this pilot despite the overall activity increase. Savings could be significantly higher where no baseline CATs service exists.

Models of Care – Primary

25


Improvements, Efficiencies and Benefits to Patients • Short waiting times for assessment, including access to a physiotherapist by telephone in 48 hours and face to face within three weeks • Ability to see a more specialist service in the community within four weeks, including Consultants in Sport and Exercise Medicine and Orthopaedic Surgeons • High patient and GP satisfaction with the service • A whole service administered and clinically recorded on a web based system, providing maximum efficiency of patient handling, allowing clinics to be based at any available community site • Physioline telephone service has reduced GP administration of referral and provided early access to sensible advice and exercises at an early stage of the problem, thus potentially reducing chronicity • Early access to face to face physiotherapy, which easily and rapidly links into the MSK CATs service being in the same pathway and on the same IT system, allowing direct booking

26

Models of Care – Primary

• Access to a Consultant in Sport and Exercise Medicine able to assess patients with sports injuries and guide management alongside experienced ESP physiotherapists • Access to ultrasound guided interventions in the community, with significantly shorter wait than has been available in secondary care via an SEM Consultant • A multidisciplinary team used efficiently for patient benefit, with appropriate triage decision, to try to get the patient to the correct practitioner first time • High conversion to surgery rates of patients seen by the Orthopaedic Surgeons of 79% • Financial saving based on direct comparison with previous year amounting to £1.09 per head of population. This may be a conservative estimate, based on the fact a pre-existing CATs service was present in the control year of 2010 In summary the service in 2011 was highly regarded as having been more efficient for patients, was cheaper and gave rapid access to a range of skilled professionals.


Top Tips What did you do well? • Used Sport and Exercise Medicine (SEM) Consultant and Senior Extended Scope Physiotherapists at the heart of the assessment of patients, working together to inform on the best course of action for each individual problem. This is the model that works well in elite sport applied to the NHS • Allowed the Community Physiotherapy service to work efficiently and take on problems early and prevent those problems becoming chronic. Where needed, the physiotherapy aspect of the service could access MSK CATs multi-disciplinary team including an SEM Consultant

What would you advise others who wish to replicate this piece of work? • The operation of this service since January 2011 is based on Connect Physical Health’s experience of such services across the UK since 2007. The development of efficient IT systems and the administrative centre has taken several years to reach maximal efficiency, which is vital to the success in operating such a service efficiently • The clinical staff need to be well supported in their work • Clinical Governance needs to be well developed to support such a service

• Placed Orthopaedic Surgeons in the Community pathway assessing not all patients but those considered by the rest of the team to be at a stage possibly requiring surgery, hence the high conversion rates suggesting efficiency in using the surgical skills available

• Initial triage by experienced physiotherapists is vital in sending the patient to the right person first time

• One stop shops, especially with SEM Consultant, who possesses excellent clinical skills alongside expert ultrasound assessment and guided interventions to deal with issues at first appointment

• Orthopaedic Surgeons have to buy into the philosophy of allowing other clinicians to manage most of the referrals without their input, but adding to the efficiency by applying their expertise to a cohort of selected patients who will have a high conversion rate to surgery

• Team leadership and educational opportunities provided by an SEM Consultant and a senior Extended Scope Practitioner (ESP) physiotherapists • Saved money whilst increasing quality

What didn’t go so well? Clinical Outcome assessment using EQ5D as a tool didn’t give many returns which was disappointing. The results for Community Physiotherapy were good, although there were low numbers. The lack of significant improvement in MSK CATs may reflect the nature of the patients in the sample (non-surgical, not suitable for physiotherapy) as well as low numbers.

• GPs have to buy into the system and not bypass the service and over use secondary care

• SEM Consultants work well alongside Physiotherapists and can provide support and leadership to the whole team alongside Senior Physiotherapists • SEM Consultants provide a high level of clinical expertise to complement Physiotherapists and Surgeons

Models of Care – Primary

27


Sustainability The Clinical Commissioning Group (CCG) has extended the pilot into 2013 to preserve the service whilst considering commissioning intentions for the future.

Evaluation This pilot is being submitted for publication

Contact Details

28

Name

Dr Graeme Wilkes

Job Title

Consultant in Sports & Exercise Medicine

Telephone

0191 2504991

Oganisation

Connect Physical Health

Email

graeme.wilkes@connectphc.co.uk

Commissioning PCT/Org

North of Tyne PCT/Newcastle West CCG

Models of Care – Primary


4) Physiotherapy and Orthopaedic Medicine Service, Staffordshire and Stoke-on-Trent Partnership NHS Trust Service Details Name of Service

Physiotherapy and Orthopaedic Medicine Service (POMS)

Location of Service

Tamworth and Lichfield

Service Type

Integrated, multidisciplinary, GP commissioned service

Number of Sessions per week

See organisational sheet below 2.3 Doctor Clinical sessions and 2 support/development sessions 1 Sport and Exercise Medicine Physician 3 sessions per week 1 GP with Special Interest (GPwSI)                             1 session/week 1 Senior Sport and Exercise Medicine (SEM) Trainee ESP Clinical Lead                        Clinical team (Band 3-7 physiotherapists)    Administration team (Band 2-5)     Sonographer Podiatrist

Average consultation time (mins) Sport and Exercise Medicine Physicians 30mins Physiotherapy 45 and 15mins Length of session (mins)

3-4 hours

Please list staff numbers

1 Sport and Exercise Medicine Physician      1 GPwSI                                 1 Senior Sport and Exercise Medicine (SEM) Trainee Extended Scope Practitioners (ESP) Clinical Lead                       

Background The community we serve: 150,000 population 70 GPs 2 Community Hospitals 2 District General Hospitals Community Physiotherapy Chronic Pain management service is being commissioned and to be managed by our service Budget £1.14 million (for POMS and Back Pain Service) plus budget for Chronic Pain Management

GP referrals via referral management centre. Triaged by senior therapists to: • Physiotherapist at Band 4,5, 6 and 7 • Podiatrist • GPwSI • ESP/Clinical Leads • SEM Physician • Orthopaedic Surgeon

Models of Care – Primary

29


As a result patient flows are: Number triaged Triaged elsewhere New referrals New patients seen New patients non attendance Follow-up patients Doctor appointments

12,805 2,062 (16%) 10,739 8,676 6% 21,279 370

Outcome of patients seen in the Service were: Injections Referred on MRIs X-rays Ultrasound Bloods Nerve conduction studies

660 (8%) 860 (10%) 689 (8%) 192 (2%) 127 (1%) 24 22

What was Implemented? When the service was commenced, we offered Tamworth, Lichfield and Burntwood Primary Care Trust (PCT) to manage the majority of Musculoskeletal (MSK) patients in the population of 150,000 and reduce the number of referral steps along the way. Patients are slotted into the most appropriate clinician with the ability to investigate using protocols and with the flexibility to move patients to wherever necessary in order to ensure prompt recovery. This started with about 50% of total ‘orthopaedic’ referrals and has grown to over 70%. Since then we have incorporated diagnostic ultrasound, to allow one-stop diagnostic/treatment clinics and guided injections. Back pain is managed from within the service with close liaison with the tertiary back units in Birmingham and Derby. This allows prompt intervention when these are required. The same principles are used to ensure a high standard of care with all staff being required to do 30

Models of Care – Primary

appropriate training and pass competencies based on their band level. All clinicians are taught to manage patients and to understand the pathways, to be aware of treatment limitations and to pass on realistic expectations to the patients they are treating. In the beginning the service was run separately from the physiotherapy department, but in the last five years the services have been integrated to allow an economy of scale and a more streamlined service. Throughout we have met the GPs regularly to discuss resources, waiting lists and service development and so we feel well established and relatively safe now that GP commissioning has taken over commissioning decisions. We are currently looking at incorporating the locality Chronic Pain Management Service which is presently being commissioned and a more cost effective assessment and management service for carpal tunnel syndrome.


Achievements and Impact

Benefits to Patients

• Over three months from October 2011 to January 2012, a survey of patient outcomes demonstrates on average patients are extremely or very satisfied with the service

Pathways ensure patients have all appropriate treatment/interventions prior to consideration of operative intervention unless this is indicated as a primary treatment. This includes new evidence based treatments e.g. eccentric exercises and the trial of novel treatments, including dry needling and autologous blood. By fully utilising the skills of physiotherapists and training them to understand the agreed pathways and by supporting them with appropriately trained doctors; we believe we are proving a quality service.

• Use of new treatments for resistant conditions e.g. tendinopathy, medial and lateral epicondylar pain • Ongoing systematic review and service/ pathway development including competency training e.g. back pain, knee pain, shoulder pain (for 2012) • Recurrent requests to host medical students, sports physicians in training and physiotherapy students

Improvements and Efficiencies

With reducing resources in the NHS, our next job will be to decide realistically what we can and cannot provide with our limited resources, and provide better advice for patients who would benefit from interventions elsewhere i.e. in the private sector.

When the service was set up it aimed to save about 20% of the total budget traditionally spent on musculoskeletal (MSK) problems in the communities of Tamworth, Lichfield and Burntwood. This was achieved by giving more responsibility to the physiotherapist and for them to actively manage patients supported by doctors with sports medicine training. Patients were booked with the most appropriate clinician (Physio bands 4, 5 or 7, ESP or Doctor) based on the referral letter. We built in treatments e.g. management of tendinopathy which had been championed in the sporting world. We agreed with the GPs that we would not refer back to them but would follow, when appropriate, an agreed on-going pathway. Within the pathway we agreed surgical indications with our surgical colleagues and have experimented with direct referrals onto the waiting list.

Models of Care – Primary

31


Top Tips

• Evaluation after the pilot stage

What did you do well?

• Patient involvement

• Integrate physiotherapy service with physicians with Sport and Exercise Medicine training

• Persuading physiotherapy management to include Sport and Exercise Medicine in the name of the service

• To provide training, competencies and competency assessments for therapist on care pathways in order for them to fully understand the conditions they are treating • Maintain good relationships with commissioners, GPs and orthopaedic surgeons • Use of evidence based and novel treatments etc. championed in Sport and Exercise Medicine, so that surgery is used at an appropriate stage • Involvement with training Physiotherapists, Sport and Exercise Medics and Medical Students

What didn’t go so well? • Some difficulty persuading physiotherapy hierarchy to accept doctors in a joint department

• Get out and tell other health authorities what we were doing

What would you advise others who wish to replicate this piece of work? • Integrate existing physiotherapy service with doctors trained in Sport and Exercise Medicine • Decide realistically what you can and cannot achieve and so be honest with patients and, where necessary, help them find effective treatment elsewhere • Get away from the title of triage clinics we are a comprehensive treatment service which offers holistic management by using medical and physiotherapy treatments, and appropriate timing of surgical opinions and interventions

Sustainability • Regular meeting with GP commissioning group • Attempting to employ younger Sport and Exercise Medicine Physician who could take over from medical director on retirement in six years’ time • To present our model as the most logical way forward in these times of austerity

Evaluation Our Service has received a Health and Social Care Award

Contact Details

32

Name

Dr Roger Hawkes

Job Title

Medical Director

Telephone

07836657389

Oganisation

Staffordshire & Stoke-on-Trent Partnership NHS Trust

Email

RAH@wkes.co.uk

Commissioning PCT/Org

South East Staffs CCG

Models of Care – Primary


Models of Care – Primary

33


34

Models of Care – Secondary


Models of Care – Secondary 1) Nottingham Sport and Exercise Medicine Service, Nottingham University Hospitals Trust

Service Details Name of Service

Nottingham Sport and Exercise Medicine Service

Location of Service

Nottingham Treatment Centre and Queens Medical Centre Campus, Nottingham University Hospitals NHS Trust

Service Type

Secondary/tertiary care service with GP/secondary care referral.

Number of Sessions per week

6 x Adult Sport and Exercise Medicine (SEM) clinics 1 x Paediatrics/Adolescent clinic 3 x SEM Consultants servicing clinics:

Average consultation time (mins) 20 mins new, 10 mins follow-up Length of session (mins)

240 mins

Please list staff numbers

3 x SEM Consultants/Specialists physicians 1 x GP with Special Interest (GPwSI) in MSK/SEM 1 x Extended Scope Practitioner (ESP): Physiotherapist 1 x Physiotherapist 1 x Orthotist 1 x Osteopath

Background Outpatient based secondary-tertiary care service, utilising clinic-based ultrasound with access to gait clinic and compartment pressure measurements. Working in close proximity with orthopaedics, rheumatology and radiology.

What was Implemented? Secondary/tertiary service with GP referral: Original service commenced in 1995 operating as a private clinic once a week on a Monday evening. In 1996 became NHS funded. The service now operates with three consultants (two part-time) each on NHS contracts. We have now expanded to seven clinics per week funded by the NHS.

We help train and mentor our Sport and Exercise Medicine (SEM) registrars nationally. There are six trainees in the East Midlands, and approximately three trainees are supporting our Nottingham clinics at any one time.

Achievements and Impact We have conducted patient satisfaction surveys, have a comprehensive audit of over 10 years’ worth of patient data and have trialled new patient pathways. All of our Patient Satisfaction Surveys have similar results to those below.

Models of Care – Secondary

35


Patient Satisfaction Survey 1 (example 2011) A cohort of 28 patients completed one of the patient satisfaction forms over a period of approximately one month in the year; August 2010 to August 2011 with one Consultant. The Directorates Clinical Audit Officer designed a scanable data collection tool. Patients leaving clinic were asked, by clinic admin staff, to complete a questionnaire and place into a box over a period of one month in order to maintain patient confidentiality.

Overall how satisfied were you with the doctor that you saw today? (Sample size 28) Figure 1: Patient Survey 100% 80%

26/28 “Very satisfied” (93%) 2/28 “Fairly satisfied” (7%)

60% 40%

Free Text Comments made by patients

20%

“Lovely Doctor.” “Everyone friendly and efficient.” “I was delighted with the consultation.” “1st class service.” “Thoroughly satisfied.” “Fantastic experience throughout.” “Very clear, well explained.”

0%

Very Satisfied

Fairly Satisfied

Figure 2: Patient Survey Was the Doctor polite and considerate? Did the Doctor listen to what you had to say? Did you have enough opportunity to ask questions? Did the Doctor answer all of your questions to your satisfaction? Did the Doctor explain things to you in a way that you could understand? Were you involved as much as you would like in the decisions about your care or treatment Did you have confidence in the Doctor who saw you? Did the Doctor respect your views?

If the Doctor examined you, did he or she: (a) Ask you permission? (b) Respect your privacy and dignity? Did you feel better able to understand and/or manage your condition Should you have questions or concerns would you know who to contact?

0% 36

Models of Care – Secondary

20%

40%

60%

80%

100%


Improvements and Efficiencies For new patients, same day ultrasound/MRI available: There is a big efficiency drive on reducing follow up appointments, with some follow-ups achieved by telephone or e-mail. We presently have a 50% open appointment rate following initial visit permitting flexibility for return. We also have the use of splints and orthotic services in clinic, and a senior physiotherapist is always available to see patients.

Benefits to patients The service was originally commissioned in 1995 operating as a private clinic once a week on a Monday evening for adults only. In 1996 we were successful in becoming NHS funded, and the service was rolled out to include paediatric patients in 1997. The service now operates with three consultants (two part-time) each on NHS contracts. We have now expanded to seven clinics per week funded by the NHS. We have undertaken a ‘one-stop’ clinic approach for our patients, offering holistic care of the entire spectrum of the physically active. We have also conducted an ongoing prospective audit of new patient presentations to NUH Sport and Exercise Medicine clinics. Now approaching its 10th year, it has proven vital in service description for commissioners – locally and nationally.

NICE Compliant Audit Audit sample size was 1,488 patients between February 2009 and March 2010 Figure 3: NICE Compliant Audit continued—Mechanism of Injury (other than sport) 50%

Mechanism (Sample size 1488) 2

40% Mechanism of injury • Almost half of the injuries (47%) were sporting injuries (704) • 517 (35%) were insidious • 111 injuries occurred at work (7%)

30%

20%

10%

0%

Sport

Work

Insidious

Other

Models of Care – Secondary

37


Figure 4: NICE Compliant Audit continued – Investigations performed: of those investigated Bone scan Dexa

Investigations performed: of those investigated: • 396 patients (44%) had an MRI • 378 (42%) had an X-ray • 212 (24%) had an ultrasound in clinic • 79 patients (9%) had an ultrasound but not in clinic • 40 patients required blood tests (4%)

Microbiology CT Diagnostic inj

(899 Investigations)

NCS/EMG Other Gait clinic Blood Test Ultrasound Clinic Ultrasound X-ray MRI

0%

10%

20%

30%

40%

50%

Figure 5: NICE Compliant Audit continued – Management of the Patient HA inj

Management of the patient There were 1250 patients identified as requiring management • 62% of these patients were managed with advice (776) • 42% (527) required NHS physiotherapy

Physio (private) Medication Steroids

(1250 Patients)

Other Referral Further lx

• 13% (157) were given home exercise

Splint/orthotics

• 95 patients (8%) were referred to other specialities

Home Exercise Physio (NHS) Advise 0% 10% 20% 30% 40% 50% 60% 70%

38

Models of Care – Secondary


Figure 6: NICE Compliant Audit continued - Patient Referrals

Medical

Patient referrals • There were only 95 (6.4%) patients who required referral • 47 (3.2%) were referred to Orthopaedics

Vascular

(95 Patient Referrals)

Other Osteopath

• 18 to surgical • 15 to an Osteopath

Surgical

Ortho

0%

10%

20%

30%

40%

50%

Figure 7: NICE Compliant Audit continued - Orchard Classification

S

Orchard Classification

T

The most common injury site was:

S

• K: Knee 505 patients (34%)

F

• A: Ankle 172 patients (12%) • G: Groin/Hip 163 (11%) • Lower leg 119 (8%) • L: Lumbar back 103 (7%)

Top 10 Orchard 2nd Characters (Sample size 1488)

Not Recorded L Q G A K 0% 5%

10% 20% 25% 30% 35% 40% Models of Care – Secondary

39


Top Tips What did you do well? Communication and collaborative working was critical to setting up the service. We regularly talked with GPs, radiologists, orthopaedics and rheumatologists.

Also be aware of the number of appointments in clinic versus financial viability. Some patients need 30 minutes, but we can only provide 20 minute slots. If we only provided 30 minute slots our financial viability may be challenged. Thus you must always demonstrate viability in this modern world.

Lessons Learnt

What didn’t go so well?

Management within the Treatment Centre was sometimes obstructive. Be aware how helpful management can be, but also bear in mind the reverse. Some services and pathways have suffered.

A good Practice Manager is critical for the number of clinics/service.

What would you advise others who wish to replicate this piece of work? Talk to other secondary/tertiary care providers and understand your market.

Sustainability The service is fully commissioned and funded. Thoroughly embedded in the Trust service provision. Service is also listed on Choose and Book. Demand has been maintained.

Contact Details

40

Name

Prof Mark Batt

Job Title

Consultant Sport and Exercise Medicine

Telephone

0115 924 9924 ext 65143

Oganisation

Centre for Sports Medicine C Floor West Block Queen’s Medical Centre Nottingham NG7 2UH

Email

mark.batt@nottingham.ac.uk

Commissioning PCT/Org

Nottingham City/Nottingham County

Models of Care – Secondary


2) Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust

Service Details Name of Service

Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust

Location of Service

Leicester General Hospital, University Hospitals of Leicester NHS Trust

Service Type

Secondary / Tertiary referral service Accepting referrals from General Practitioners, as well as Orthopaedic Surgeons, Rheumatologists, Pain Clinic, Occupational Health, Emergency Medicine, General Surgery and tertiary referrals from other hospitals

Number of Sessions per week

7 Consultant-led clinics per week in total 1 Dedicated Consultant operating list per week

Average consultation time (mins) New patient = 30 minutes Follow-up patient = 15 minutes Length of session (mins)

240 mins

Please list staff numbers

Consultant, Sport and Exercise Medicine and Consultant, Orthopaedic Surgeon with an Interest in Sports Injuries 4 Sport and Exercise Medicine Specialist Registrars 1 Nurse Practitioner 3 Extended Scope Practitioners Physiotherapists (p/t) 1 Podiatrist (p/t) 1 Qualified Nurse (p/t) 1 Healthcare Assistant (p/t) 1 Clinical Scientist (p/t) 1 Personal Assistant 4 Clinic Coordinators/Secretaries (p/t)

Models of Care – Secondary

41


Background We run a multi-disciplinary Sport and Exercise Medicine (SEM) clinic, based within Secondary Care. Within the service we employ SEM physicians, an Orthopaedic Surgeon with an Interest in sports injuries, Extended Scope Physiotherapists, a Nurse Practitioner, a Podiatrist and a Clinical Scientist. We hold close links with Orthopaedic Surgeons within the Hospital Trust, as well as Musculoskeletal Radiologists, Rheumatologists and the pain management service. We maintain a short waiting time, typically of only a few weeks for NHS patients ensuring that high-level of care is available as soon as possible following referral. Within the clinical service, we are able to offer both ultrasound and fluoroscopic guided injections including a range of novel therapies, as well as being able to perform gait analysis and dynamic compartment pressure testing. We utilise clinic-based ultrasound to aid diagnosis at first presentation within the clinic, and have ready access to a range of formal diagnostic

42

Models of Care – Secondary

investigations. In addition, within the Sports Medicine clinic footprint, we have two operating theatre spaces used for minor hand procedures and local anaesthetic arthroscopies as well as guided procedures. As we employ both physicians and surgeons, we are able to offer a complete package of conservative and surgical management options for a wide range of musculoskeletal problems. In addition, the range of experience of our staff in working with elite and professional athletes brings with it wide scope of practice in dealing with a range of medical problems associated with physical activity. We have a significant role in training Sport and Exercise Medicine Specialist Registrars, with four registrars currently working within the Leicester Sports Medicine Department. We also host undergraduate medical students from Leicester University during their musculoskeletal training. In addition post-graduate doctors and physiotherapists often spend some observation time based within the clinics and our consultants regularly teach at both undergraduate and postgraduate levels.


What was Implemented? The Leicester Sports Medicine Department was set up in 1993. It was the first NHS Sports Medicine clinic in the East Midlands region and one of the earliest in the UK. It is an established service valued by our local GPs who can access the service directly or through Choose and Book referrals. The clinic has continued to grow and now hosts a total of seven Consultant-led clinics per week, supported by a full complement of multidisciplinary staff. We treat in the order of 1200 new referrals and 2500 follow-up consultations each year, with the service continuing to grow year on year. The service, both clinics and surgery, is commissioned by our two local Primary Care Trusts (PCTs) with smaller contracts from neighbouring PCTs. Funding is by the current tariff charges and has continued to run at an operating profit for the NHS Trust. Tertiary

referrals are funded independently. We continue to offer 30 minutes as a routine new appointment length giving time to explore patients concerns about their symptoms and initiate appropriate first-line management options. Patients rate this length of time for their appointments very highly.

Achievements and Impact We conduct an annual patient feedback process amongst all of the clinical staff within the department. The last year’s process involved collating 195 replies over a period of six weeks. The following table highlights the responses that we achieved (with 100% representing all patients being fully satisfied) – figures shown above 90%.

Leicester Sport and Exercise Medicine Department 2011 patient feedback (195 responses received) Was the doctor/physio polite and considerate? Did the doctor/physio listen to what you had to say? did the doctor/physio give you enough... Did the doctor/physio answer all your questions? did the doctor/physio explain things in a way you... Are you involved as much as you want to be in the... Did you have confidence in the doctor/physio? Did the doctor/physio respect your views?

If the doctor/physio examined you, did he respect... By the end of the consultation did you feel better... Overall, how satisfied were you with the...

90%

92%

94%

96%

98%

100%

Models of Care – Secondary

43


Free text comments are also gathered in this survey. Some anonymous comments from this year’s survey include: “A very patient Doctor who has put me at ease. He explained everything and asked me if I understood before he started to explain something else. Thank you.” “Everyone friendly and efficient” “This was the first time that I have seen a specialist, previous appointments were with physiotherapists. I now know what is wrong with my spine and was reassured I am no longer alone.” “The Doctor is a very reasonable, polite and empathetic man!” “I have found all the staff who have dealt with me to be very helpful and professional. They have made me feel involved in the care and the discussions. They have always explained what they are doing and intend to do, and they are doing it.” “I would find it difficult to identify any way that the treatment / experience could have been improved.” Overall 99.5% of patients surveyed would recommend the service to a family member or friend. These numbers are similar to previous years’ responses and demonstrate very high levels of patient satisfaction. From a financial perspective, the Leicester Sport and Exercise Medicine service generates a surplus of income over expenditure of about 20% of turnover. This currently ensures its financial security within the Hospital Trust and makes the department ripe for expansion into further areas.

44

Models of Care – Secondary


Improvements and Efficiencies We have driven down our waiting times for initial consultations which currently stand at 1-2 weeks. We utilise virtual clinics for reporting of investigations, which speeds feedback to patients and limits the need for additional follow-up appointments. The use of an open appointment system gives our patients a ready avenue back to specialist advice should their symptoms return. We have very close links with our physiotherapy service and utilise a number of senior physiotherapists in our clinics, in an Extended Scope role. This allows patients to commence appropriate and specialised physiotherapy on their first attendance. Patients who have failed non-operative measures or who need surgery are listed directly for operations by the referring physician or therapist, reducing the wait for a surgical opinion and intervention. The presence of a sports injury surgeon within the department means all practitioners become aware of the surgical interfaces and post-operative management. The increasing dependence on image guidance for injections and novel treatment modalities has been addressed by our own intervention

service, utilising ultrasound and fluoroscopy, and so relieving pressures on our musculoskeletal imaging department. Our hospital’s overheads are minimised by delivering clinical work within our departments own footprint, rather than utilising the outpatient departments. We employ specialists e.g. podiatry and clinical science on a sessional basis to support our clinical workload. This close working arrangement allows us to ensure optimum treatment for our patients. We offer a multidisciplinary lower limb assessment clinic which allows us to undertake intracompartmental pressure testing on a first appointment.

Benefits to Patients Our patients have rapid access to a multidisciplinary specialist service and patient satisfaction levels are very high. We treat in the region of 1200 new patients every year with a wide range of musculoskeletal and other problems. The following table highlights the wide range of anatomical problems that we treat, and covers the last 4200 patients seen by one of the Consultants in clinic.

Models of Care – Secondary

45


New and follow-up Patients seen at Leicester Sport and Exercise Medicine Department (4127 patients total) 25.00% 20.00% 15.00% 10.00% 5.00%

s on

es

iti

Co

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s O

th

er

Sy

nd

ro

m

on

s

iti

nd n

Co ro

ni

c

og ol

Ch

Rh

eu

m

at

Follow-up (F/U)

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We endeavour to utilise investigations appropriately within the department to maximise patient benefit in delivering both clinically-effective and cost-effective care. The following table demonstrates the use of investigations within the clinic of one of our consultants, from the last 3,050 consultations.

Blood tests Bacterial swab X-ray (distension) Arthrogram Ultrasound MRI MRI Arthrogram Nerve Conduction Studies / EMG DEXA Compartment Pressure Testing 46

Models of Care – Secondary

New Patients

F/U Patients

All Patients

3.0% 0.0% 7.1% 0.2%

1.9% 0.1% 1.4% 0.1%

2.4% 0.0% 3.7% 0.2%

4.4% 16.9% 1.0% 1.2% 0.0% 0.2%

1.9% 3.4% 0.3% 0.4% 0.1% 0.2%

3.0% 9.0% 0.6% 0.7% 0.1% 0.2%


The following table demonstrates the use of interventions within the clinic itself.

New Patients

F/U Patients

All Patients

10.1% 0.0% 0.0% 1.4% 0.5% 60.6% 46.3% 27.1% 1.4% 3.7% 0.4% 1.3%

3.9% 0.1% 0.0% 1.2% 0.5% 43.6% 11.4% 6.6% 0.4% 4.2% 0.6% 2.4%

6.4% 0.0% 0.0% 1.3% 0.5% 50.5% 25.7% 15.0% 0.9% 4.0% 0.5% 2.0%

Diagnostic ultrasound used in clinic Lower limb compartment pressure test Upper limb compartment pressure test Prescription Medical certification (MED3/MED5) Home exercise programme Physiotherapy referral Podiatry referral Orthotics department referral (unguided) Injection performed in clinic Guided injection performed in clinic Arrange guided injection (X-ray/US)

Top Tips What did you do well? We continue to develop the Sport and Exercise Medicine service in Leicester which in 2013 will have been going for 20 years. By close working and mutual respect between physicians, surgeons, physiotherapists and podiatrists we are able to offer a true multidisciplinary service to patients that we treat. We maintain close links with radiologists, orthopaedic surgeons and rheumatologists within the hospital trust as well as regular contact with our local General Practitioner referrers. We are involved in mentoring and inter-professional education opportunities. We have developed a business model which, even within the current financial limitation of the health economic market, shows on-going profitability.

We have embraced the development of Sport and Exercise Medicine as a specialty and aim to offer more opportunities for Consultants in the future.

What didn’t go so well? We are poor at self-promotion both within and outside the Trust. Our focus is delivering to our patients who value the service that we offer very highly. Opportunities to undertake research is much needed but the speciality remains limited.

What would you advise others who wish to replicate this piece of work? There are examples around the country of good practice. We recognise that there is no onesize fits all answer to the development of a Sport and Exercise Medicine service, and our service has been twenty years in evolution. We have benefited from the support of our local GPs who now know what kind of service we deliver. Opportunities for service development and improvement should be based on need and should compliment existing practices, rather than setting something up from scratch. Models of Care – Secondary

47


Sustainability The Leicester Sport and Exercise Medicine service is lean and sees a relatively large number of patients for its Consultant workforce. We have accommodated the increased workload we have been asked to deliver. All local clinical services have been subject to close financial scrutiny and we have been able to demonstrate financial security over the years. We are heavily involved in the training of Sport and Exercise Medicine (SEM) Doctors for the future, therefore we are preparing them to join us within the NHS specialty. We are also providing skills needed by the NHS now and in the future.

Evaluation The service has been robustly examined by our hospital management and business teams. All services need to demonstrate their clinical worth and value for money. Our staff undergo regular appraisal by both the Trust and the Faculty of Sport and Exercise Medicine. There is no formal national recognition process for Sport and Exercise Medicine. Our local and national referrals partners continue to refer their patents to us.

Other Comments This service is increasing from January 2013 taking on two new part-time consultants, Dr James Hopkinson and Dr Tham Wedatilake, both of whom will offer another two clinics per week. This increase in service provision will allow an expansion of our adult service, and allow us to restart the former children’s and adolescent service that we previously ran until a few years ago.

Contact Details

48

Name

Dr Patrick Wheeler

Job Title

Consultant, Sport and Exercise Medicine

Telephone

0116 2588101

Oganisation

University Hospitals of Leicester NHS Trust

Email

patrick.wheeler@uhl-tr.nhs.uk

Commissioning PCT/Org

Clinic based within University Hospitals of Leicester NHS Trust Clinic commissioned by Leicester City PCT and Leicestershire County and Rutland PCT

Models of Care – Secondary


3) Oxsport, Oxford University Hospitals NHS Trust

Service Details Name of Service

Oxsport

Location of Service

Secondary Care

Service Type

Secondary Care Sports and Exercise Medicine Clinic

Number of Sessions per week

8

Average consultation time (mins) 30 mins Length of session (mins)

-

Please list staff numbers

2 Consultants, 2 Specialist Registrars, 2 Clinical Assistants

Background Oxsport is a secondary care service accepting referrals from across Oxfordshire and beyond, for sport and exercise related injuries and medical problems related to sport or exercise. It is now eight years old. Oxsport sits within the rheumatology directorate but has also forged close links with orthopaedic colleagues. The Oxsport team comprises a specialist physiotherapist, two Sport and Exercise Medicine (SEM) consultants and a variable number of specialist registrars. All our referrals are filtered through a musculoskeletal (MSK) intermediate care service that adhere to patient pathways for common MSK conditions, ensuring all our referrals have already received appropriate physiotherapy.

Oxsport offers a one stop shop approach to patient care with on the day Ultrasound Services by specialist MSK radiologists, on the day orthotics assessment and rapid access to MRI. This approach combined with email follow-up has enabled us to maintain a consistently high new to follow-up ratio, rapid access and high patient and commissioner satisfaction. Oxsport also offers compartment pressure testing and a range of interventional treatments for common MSK conditions. We also offer biomechanical assessment for running, cycling and rowing. Our service is supported by a range of patient information leaflets and an informative website. We run joint hip clinics with the orthopaedic teams. We have a weekly Multidisciplinary Team radiology meeting and combine this with orthopaedic radiology meetings allowing us to offer direct booking onto surgical lists where appropriate.

Models of Care – Secondary

49


50

Models of Care – Secondary


What was Implemented?

Top Tips

Oxsport was originally supported by a charitable grant but has now been fully commissioned for 8 years. The service is expanding to include an academic department supported by a centre of excellence grant.

What did you do well?

Achievements and Impact Patient and GP feedback is consistently excellent. We undertake regular audit and clinical effectiveness work and regularly review our pathways in light of current best evidence.

Collaboration with other specialties, maintenance of excellent links with commissioners and keeping our patients at the centre of everything we do. Our recent collaboration with the university and establishment of a centre of excellence for sport and Osteoarthritis has been essential in the development of our service and our role in translational research so essential in this area.

Benefits to Patients Oxsport offers a rapid access service to patients which is essential for this population. We see a range of people, from elite athletes to active pensioners.

Sustainability Development of an Academic Department is essential.

Evaluation Departmental clinical audit, clinical effectiveness and key performance indicators

Contact Details Name

Natasha Jones

Job Title

Consultant in Sport and Exercise Medicine

Telephone

01865738109

Oganisation

Oxford University Hospitals NHS trust

Email

Natasha.jones@ouh.nhs.uk

Commissioning PCT/Org

Oxfordshire PCT

Models of Care – Secondary

51


52

Models of Care – Intermediate


Models of Care – Intermediate 1) Oxfordshire Musculoskeletal Hub, Oxford

Service Details Name of Service

Oxfordshire Musculoskeletal Hub

Location of Service

Intermediate care

Service Type

Musculoskeletal (MSK) triage and treatment centre

Number of Sessions per week

-

Average consultation time (mins) 30 mins Length of session (mins)

-

Please list staff numbers

14 Extended Scope Practitioner Physiotherapists 3 Consultant MSK Physiotherapists Sport and Exercise Medicine (SEM) Consultant Specialties at consultant level Rheumatology Associate Specialist Expertise from orthopaedic teams, metabolic bone and paediatric rheumatology and orthopaedics. Administration Team IT support

Models of Care – Intermediate

53


Background

What was Implemented?

• Central triage of all musculoskeletal (MSK) referrals by a team of clinicians including SEM consultants, Orthopaedic consultants, consultant physiotherapists and specialist physiotherapists and a surgical podiatrist

The service was commissioned after a competitive procurement process

• Email advice and support line for GPs • Face to face consultations for a proportion of patients by a team of clinicians including SEM consultants, specialist registrars, specialist physiotherapists and band 6-7 physiotherapists and a podiatrist • On the day investigation where appropriate • Referral for further investigation in order to inform a care pathway • Referral to appropriate care pathway or discharge • Programme of GP education • Patient care pathways designed by medical and surgical teams for all common MSK conditions • Patient self-care and management classes

Achievements and Impact Reduction in orthopaedic secondary care referral rate of 27% • Reduction in rheumatology referral rates to secondary care of 35% • Improvement in surgical conversion rates for both hip (11% increase) and knee (36% increase) in two years • The service has recently been recommissioned with a greater role for medical consultant staff and additions of on-the-day investigations and an email advice line for GPs • High patient satisfaction • Meeting of all key performance indicators • Adherence to 18 week pathway

Evaluation Departmental clinical audit, clinical effectiveness and key performance indicators

Contact Details

54

Name

Natasha Jones

Job Title

Consultant in Sport and Exercise Medicine

Telephone

01865738109

Oganisation

Oxford University Hospitals NHS trust

Email

Natasha.jones@ouh.nhs.uk

Commissioning PCT/Org

Oxfordshire PCT

Models of Care – Intermediate


To find out more about Sport and Exercise Medicine NHS Services, please contact: enquiries@fsem.ac.uk 0131 527 3404 www.fsem.co.uk

A fresh approach in practice  
A fresh approach in practice