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Wednesday 26 October 2016
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Sharing the work

The multidisciplinary team is becoming central to some practice’s plans to better meet the demand of patients and ease the pressure on GPs and secondary care

Musculoskeletal practitioners are an emerging model of care designed to deliver a streamlined patient-centred service while addressing the growing demands on general practice and secondary care.
The service creates capacity in general practitioners’ clinics, improves relevant referral and conversion rate to surgery for secondary care, and provides an efficient care pathway with direct access to a specialist service for musculoskeletal problems. It provides value for money across the heath service, and is shown to be effective and efficient, allowing the best care in the right place at the right time.

A new way of working
Feeling the constraints and ever changing demands on primary care, Windermere Health Centre in Windermere, Cumbria took the initiative to look at a different way to manage their patient load.1
Musculoskeletal related problems make up almost a quarter of a GP’s caseload,2,3 taking up significant consultation time.  Musculoskeletal conditions were pinpointed as something that could be more effectively streamlined to ensure the best care for this patient group, with the vision to create capacity for GP consultation for other medical conditions. The practice funded a three-month pilot before integrating it into the practice as a permanent role, having considered capacity, outcomes from referral, source of referral, patient satisfaction and the impact on the orthopaedic service.
The aims of the post were:

  • To develop, refine and enhance the model of service delivery for musculoskeletal consultations based on patient and other stakeholder perspectives.
  • To provide direct access to a specialised musculoskeletal service for patients.
  • To free-up GPs to focus on other medical conditions, and to provide greater accessibly to see a GP within a shorter waiting time.
  • To ensure relevant musculoskeletal referral into secondary care.
  • To evaluate the impact of the musculoskeletal practitioner post regarding: accessibility, patient satisfaction, safety, efficiency of the care pathway, cost effectiveness and the impact on the wider health system.
  • To enhance musculoskeletal knowledge within the multidisciplinary team (MDT).

To deliver on these aims, the role would require:

  • A clinical musculoskeletal physiotherapist with extended scope skills such as injection therapy, ordering and interpretation of X-rays/ultrasound scans/MRI scans and bloods, and non-medical prescribing.
  • The provision of highly specialised assessment and diagnostic triage to determine the basis for referral, investigations and further management into secondary care.
  • Musculoskeletal education and advice for the MDT.
  • Audit/research on the outcomes from the service.

The hours were worked out on the basis that the average number of musculoskeletal patients in the practice was around 20%. The length of consultation is 20 minutes with a 20-minute admin break in a session (four hours).
All patients presenting to the surgery with a musculoskeletal problem or rheumatological condition are eligible for the service. They gain access by booking directly at reception or via a GP, nurse practitioner or the onsite physiotherapist.

Outcomes from the service
Data collected over an 11-month audit period, May 2014 to March 2015 determined that the service had achieved some very positive results.

The total referrals in this time period were 710. All of these were appropriate for the service, 557 were first referrals, and 153 follow-ups.
Of these, 79% of the overall number would normally have seen a GP as a first contact, so saving 560 GP appointments over 11 months.
Source of referral
The main source of referral is from direct referal at reception, with the GPs utilising the service as the second main source (Figure 1).

Outcome from referral
The most common outcome of referral is exercises and advice regarding the condition, followed by injection, referral to physiotherapy, referral to secondary care and further investigations (Figure 2).

Impact on secondary care
Looking at the referral rate into secondary care between May 2013 to February 2014 prior to the new post (169 patients) and May 2014 to February 2015 since the new post (136 patients), 33 fewer patents (19.5%) had a first initial contact with secondary care. Looking at the patients referred from the musculoskeletal practitioner into secondary care, only one patient was not converted into an operative procedure in that timeframe, giving a 99% conversion rate. This rate was calculated from consultants’ letters confirming listing for surgery.

Steroid injections
The number of injections given within the practice between May 2013 to February 2014 were at 98. However, between May 2014 to February 2015, 190 injections (124 from the practice physiotherapist) were delivered – a 93% increase.
The implications of this are potentially:
Patients are no longer being sent to secondary care for injections (other than spinal/hip under image intensifier).
Patients are being kept away for longer/or preventing cold operative procedures as they are managed for their symptoms locally.
More income from injecting for the practice.
Looking at statistics from secondary care, there is a direct correlation between the number of injections performed in primary care and the reduction of pheripheral joint injections in clinic.

Patient satisfaction survey
The musculoskeletal practitioner role has proven to be a very popular addition to the primary care service. A survey was handed out to all patients for a month and 50% were returned.
Overall patient satisfaction of the service showed 90% ‘excellent’, 9% ‘very good’ and 1% ‘good’. Each category tested (time given for consultation, thoroughness of examination, explanation given for the complaint, advice for the condition, outcome from consultation and approach the consultation) showed results of between 88% and 96% for excellent, 4% and 12% for very good and 4% for good.
A model for the future
Establishing a musculoskeletal practitioner into primary care has had positive implications for the patient, primary care, secondary care, and NHS finances.
The patients are now able to directly access a highly specialised service without a long wait to get to the right person at the right time, streamlining their care pathway.
It has had a significant impact on capacity for the general practitioners to focus on medical conditions, improving throughout and creating an opportunity to broaden their experience in musculoskeletal care.
It is a cost-efficient role that saves money by streamlining a service and eliminating unnecessary appointments with other healthcare professionals.
For primary care it is slightly cheaper to employ at a band 8a on the agenda for change payscale, and attracts income into the practice from performing steroid injections previously done in secondary care.
The role is currently being looked at nationally to be extended into ultrasonic diagnostics for musculoskeletal problems to further reduce the number of visits a patient has to make to secondary care, and to shorten the length of time between diagnosis and treatment.
Since the role has been established, several pilots have been taken up nationally and a number of practices have now employed physiotherapists as part of their primary care team.
The Chartered Society of Physiotherapy in response to the popularity of the new role has been collecting data from around Britain to demonstrate its effectiveness to consolidate the evidence base on a larger scale.
It is an exciting and innovative opportunity for physiotherapy, and for primary and secondary care as it sits in a prime position to be able to play a central role in delivering the kind of patient-centered care that the NHS is seeking to establish.

Amanda Hensman-Crook, musculoskeletal practitioner.

1 McElduff P, Lyratzopoulos G, Edwards R, Heller R, Shekelle P and Roland M. Will changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK. Quality and Safety in health care. 2004; 13(3): 191-197. Do1: 10.1136/qshc.2003.007401
2 Mäntyselkä P, Kumpusalo E, Ahonen R, Kumpusalo A, Kauhanen J, Viinamäki H, Halonen P, Takala J. Pain as a reason to visit the Doctor: a study in Finnish primary care. Quality Health Care. 2000; 89(2-3): 175-80.
3 Rekola KE, Keinänen-Kiukaanniemi S, Takala J. Use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultation with a physician. J Epidemiol Community Health. 1993; 47(2):153-157.