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Good Practice Framework

MSK

Greater Manchester Health and Social Care Partnership

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Overview of MSK Interventions . . . . . . . . . . . . . . . . . . . . 4

Descriptions of the MSK Interventions . . . . . . . . . . . . . . 6

Further Information per Intervention . . . . . . . . . . . . . . . . 9

Supporting Case Studies . . . . . . . . . . . . . . . . . . . . . . . 15

1

Good Practice Framework MSK

This Good Practice Framework outlines elective care interventions for MSK that Localities should consider implementing locally in collaboration (commissioners and providers and other organisations) to effectively manage the increased demand for elective care services. Interventions outlined in this document should inform the Locality planning and prioritisation process for 2019/2020.

The document forms part of the following suite of inter-related documents, but also can be used as a standalone document:

1. Overview and Introduction to the Elective Care Good Practice Frameworks and Interventions

2. GM Elective Care System Wide Interventions (non-specialty specific)

3. Implementation Considerations – A Stepped Approach

4. Evidence Document – from national/local information, good practice and impact data emerging from NHS England Specialty Based Transformation pilots from across England, and/or actual integrated service offers in place in GM

Further information pertaining to our vision for Elective Care in Greater Manchester, our GM Elective Care Outcomes and Standards, and our approach to the development of Good Practice Frameworks can be found in the Overview and Introduction document.

Further information regarding approaches to implementation are detailed in the Implementation considerations document.

This Good Practice Framework for MSK covers:

●● Overview of MSK Interventions and alignment with GM Elective Care Standards

●● MSK Interventions – details on what is required to be implemented

●● Further Information – Supporting examples, benefits, resources

●● Supporting Case Studies – from Localities across GM and from National elective care pilot sites 100 Day Challenge Teams.

Introduction

2


Introduction continued

The interventions broadly fall into three main areas:

We have also included public health interventions, which are consistent with the GM Population Health Plan and gives a ‘whole system approach’ to commissioning MSK elective care services. Interventions regarding workforce/education and training for dermatology are featured in the GM Elective Care System wide interventions.

Supported Self Management & Shared Decision Making

Rethinking Referrals

Transforming Out-Patients

3


Overview of MSK Interventions and Alignment with GM Elective Care Standards

Overview of MSK Elective Care Interventions

Public Health

Self Management & Shared Decision Making


Transforming Outpatients

Patient screening/stratification

Community based MSK Assessment (triage) and treatment clinics

Community/web based readily accessible patient information

Self-referral pathways

Patient education videos/tech to support patients to self-manage

Virtual reporting and follow up (default position)

Social prescribing

Primary Care MSK Management Guide

Falls Prevention programme/Facture Liaison Service

Standardised imaging pre-referral

Exercise programmes

Standardised referral template/with MDS e.g. fit for surgery

4


Overview of MSK Interventions and Alignment with GM Elective Care Standards

How they Align with Elective Care Standards

The public should have access to well-publicised resources which enable self care at all stages of the elective care pathway

Mechanisms should be in place to support clinicians to make the right referral decision

People should be able to obtain advice through a variety of mechanisms including self referral, social prescribing and community options

Referring clinicians should have access to specialist advice without the need for the patient to visit a hospital setting

Patients should be involved in shared decision making throughout the elective care pathway and feel in control of their care

All referrals should be triaged to ensure patients arrive in the right place with the right information

Wherever possible follow up should be virtual and undertaken by the most appropriate member of staff


5

MSK Interventions

Community/web based readily accessible patient information - prevention, SDM and EUR

Exercise programmes (at scale) in non-clinical settings

Social prescribing

Falls Prevention programme/FLS

Readily accessible information should be made available to support prevention, support early detection and treatment of MSK conditions, this should be made available in a range of formats including the use of online portals.

A range of standardised exercise programmes should be available in non-clinical settings which patients should be able to self refer into. This should include EscapePain for knee OA, and exercise programmes for back and neck pain. These programmes should integrate virtually with local physiotherapy services for support and include referral criteria for clinical assessment if and when required

Neighbourhood models should be in place to support delivery, including use of LA services e.g. leisure/VSC for location of community based services.

Social prescribing should be embedded within all pathways - approaches include incorporation of community networks and ‘expert patient’ support into the elective pathway

Localities should facilitate provision of a Falls Prevention Programme including Fracture Liaison Service (FLS)

Intervention

Public Health

Descriptor

6


MSK Interventions continued

Intervention

Self-Management & Shared Decision Making


Descriptor

Patient screening/stratificationStratified care approaches aim to improve the management of patients by offering a more systematic and tailored approach to management decisions.


Pt education videos/tech to support patients to self-manage

Primary Care MSK Management Guide

Standardised imaging pre-referral

Patients with lower back pain should be screened/stratified for self care before the patient enters a medicalised model.

Patients should be offered more specialist opinion at the outset, such as access to First Contact Practitioner type roles, with direct access through General Practice appointment booking.

Patients should be offered a range of educational materials (in a range of formats such as video/other tech) to support the patient to self manage.

A standardised primary care MSK condition management guide should be produced collaboratively between GPs, Physiotherapists, Orthopaedic Surgeons and Rheumatologists.

Standardised imaging should be conducted pre referral, with mechanisms in place to ensure that acute providers are not re-doing the test unless they can prove that it is clinically required.

7


MSK Interventions continued

Standardised referral template/with MDS e.g. fit for surgery

Virtual reporting and follow up (default position) supported with online support materials

Standard referral template (as part of eRS) for routine referrals, including a pre-referral checks (including peer review and administrative checking for up to date information), with minimum dataset included. This could be a minimum criteria checklist for referral which would reduce the risk of discharge before surgery.

Virtual reporting and remote/virtual follow up should be made the default position with face to face appointments offered only when clinically needed or for those patients where virtual follow up would not be appropriate. Follow up should be by the most appropriate clinician who may not be the consultant.

Management plans should be in place for all patients being discharged to ensure that they understand their management plan. This reduces the need for ongoing regular follow up, unless problems arise.

Intervention


Descriptor

Transforming Out-patients

Community based MSK Assessment (triage) and treatment clinicsMSK triage services provide a single point of access for local MSK referrals. They provide specialist clinical review of incoming referrals and triage patients to the most appropriate setting for further treatment and/or diagnosis.

Interface community MSK services should be in place for assessment, and treatment including cognitive behavioural therapy, and a pain management programme.

8


Further InformationExamples, Benefits, Resources

Public Health

Examples Benefits References

Community Web-based Information

Online tools are freely available such as clinically approved websites and webinars, workshops to upskill patients and enable a better understanding of their condition eg Stockport Knee self management videos

●● Supports a population level focus

●● Increases quality and amount of information available to patients

●● Increases patient understanding of their condition

●● Increases patients ability to self manage

GM Population Health Plan

Social Prescribing

The VCSE should be part of the pathway and service offer to support self management education; peer support; health coaching; group activities and supporting wider asset based approaches

●● Supports a population level focus

Falls Prevention Programme

In the UK, Fracture Liaison Services have demonstrated significant cost savings over a 5 year period and upto 9 times higher rate of assessment and treatment for prevention of secondary fractures than other models of care in the UK.

GM Falls Prevention Specification

Exercise Programme

●● Webinars and self directed and group exercise programmes

●● Combined Physical and Psychological Programmes (CPPP)

●● Supports a preventative approach

National Lower Back Pain Pathway Guidance

9


Further Information continuedExamples, Benefits, Resources

Self Management and Shared Decision Making


Patient Stratification

The Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability and matches patients to treatments based on prognosis or risk of poor clinical outcome.

Salford Locality

STarT Back has the potentail improves clinical outcomes, reduces back pain disability, improves patient satisfaction and improves care pathways.

STarT Back reduces sickness absence, physiotherapy wait times, GP consultations, referrals to secondary care and referrals for imaging. Is cost-effective, saving £34 per patient and £675 in costs to the wider society.

https://www.keele.ac.uk/sbst/

National Lower Back Pain Pathway Guidance.

Patient Education

Literature to support community/self care provision could include ARUK leaflets.

Patient Passports help to educate and empower patients to self-manage their condition. The information they contain can help to ensure that patients have the correct expectations of the outcomes following surgery. If taken to appointments, patient passports can provide a written record of the steps patients are already taking to self-manage their condition and have the potential to support shared decision making about their care.

Health education videos play an important role in getting patients engaged and activated in their care.

When patients are engaged, they become more actively involved in their own healthcare, leading to lower costs and better outcomes.

NHSE Transforming musculoskeletal and orthopaedic elective care services Handbook.

10








First Contact Practitioner/physios (FCPs) are qualified autonomous clinical practitioners embedded within primary care who can assess, diagnose, treat and discharge – and refer back to the GP or to secondary care as appropriate. FCPs see many low risk MSK presentations who may require self help or require specific interventions in primary care e.g. intra-articular joint injection.

First Contact Practitioner/physios usually work within GP/neighbourhood settings - staff would be likely to come from other parts of the system rather than training up a whole new cohort of staff.

Self referral should be offered at the same point a patient would be booking a GP appointment.

●● Patients are empowered to take control of their own condition while reducing demand on general practice.

●● FCP physiotherapists could see up to half of all patients attending practices for help with an MSK problem – around 10% of all patients visiting practices.

●● Pilots and research suggest that up to 70% of patients can be discharged after the first or second appointment.

●● Self-referral into physiotherapy can cut costs by £33 per patient.

●● Enables a broader system benefit – enabling more GP access for acute medical problems and LTC, for instance, thereby reducing the burden on urgent care.

●● Reduces demand on primary care and enable team development and support the education of clinicians in primary care setting.

Royal College of General Practitioners.


Bolton & Stockport Localities are part of the current National pilot.

11





Primary Care Management Guide

●● Supported by a rolling education and training programme.

●● Supported by advice and guidance.

●● Supporting primary care education and training.

●● Contributes to reduction in referral.

Standardised Imaging Pre-referral

●● E.g standardised tests such as MRSA swabs, blood tests, x-rays and other tests that could be provided in a community setting.

●● Over time this contribute to supporting a continued programme of education and training.

Standardised referral template/with MDS

●● Stockport MSK Template. ●● Improves the speed and quality of the referral.

●● The person in receipt of the referral should be able to triage appropriately and ensure the patient arrives in the right clinic first time and with the right information.

●● Only patients who have a condition that requires surgery, has engaged in a shared decision making process that ensures as far as possible they believe that surgery is right option for them at this time and are also physically able to undergo surgery.


12





●● One stop clinics - Face to face appointments with hospital specialists should be reserved for those patients who will benefit from this encounter, either because there is a need for delivery of significant diagnoses / management discussions that would not be appropriate to be discussed by other means or because there are procedures/diagnostics which need to be undertaken.

●● A triage of the ASA status and fitness to proceed to surgery could be considered within either primary care or a community MSK service.

●● Consideration should be given as to how best FCP services can be integrated in with MSK triage services.

●● Improves the accuracy of referral destination.

●● Clinical triage can be successful in diverting referrals to alternative out-of-hospital services.

●● Avoids inappropriate referrals.

●● Improves the quality of referrals and ensures that patients are directed to the right setting first time.



13




Virtual Reporting and follow up

Alternatives to traditional face-to-face clinics include:

●● virtual clinics - over email, skype or telephone;

●● group consultations - more than one patient or clinician;

●● nurse or other healthcare professional led consultations e.g. Stockport nurse led follow up.

Eg virtual fracture clinics which are hot clinics - patient comes back when they need to and are discharged with an open appointment.

The range of consultation types will be most effective at managing demand and improving experience, when combined with mechanisms to allow patients to choose when and how they will receive care.

One-stop clinics, where patients may receive tests, diagnostics and in some cases treatment within a single appointment in one location, reducing the total number of appointments required.

●● Strengthens MSK assessment and care in primary care.

●● Virtual interactions have the potential to free up clinician time and appointment slots, by reducing the time and space required for patient interactions and reducing DNA rates.



14


Supporting Case Studies

Stockport Orthopaedic Service – 100 Day Challenge Team

Patient Self-Management Workshops

What was the idea?The introduction of local knee workshops to help educate and empower patients to self-manage their condition, promote early intervention and support shared decision making about treatment options.

Why here, and why now?Why Here? - Stockport’s orthopaedics service were seeing a high number of patients with knee osteoarthritis (OA) who could benefit from self-management support.

Why now? - Timing was right to test out through the 100 day challenge.

Headlines achievements/impactThree workshops were piloted, with more than 100 participants.

From the 83 feedback questionnaires received, the event increased the number of patients who felt very confident managing their OA by more than 650% (increase from 8 to 61 patients). About 90% of participants responded that they were likely or extremely likely to recommend the event.

How did you do it?●● The workshops were delivered by a multi-disciplinary team including a

GP, pharmacist, pre-op nurse, physios and allied health and social care organisations.

●● Individuals were referred by local orthopaedic services and GP practices.

●● Three 90 minute workshops aimed at patients over the age of 50, who have been diagnosed with osteoarthritis (OA) and who have not yet been referred to secondary care.

●● The workshops were also advertised in the community to attract self-referral, including in libraries, pharmacies, golf and leisure clubs and GP practices

15



Patient Passport

What was the idea?Patient passport - A patient passport is a document that supports people with MSK conditions to take an active role in their care, self-manage effectively and access support when they need it. The passport informs patients about their condition, local support available and actions that they can take to self-manage their condition. The guide also includes fields where patients can set their own health goals and measure their progress towards them, to be used as a shared decision making tool.

Why here, and why now?Why here? - Under the current system, patients often expect a surgical solution to achieve full pain relief and full joint mobility. This leads to patients’ medicalisation and demand for elective care. In cases where the surgery does not yield the results they expected, patients then attend multiple follow-up appointments, trying to regain joint function and mobility that is not realistic to expect. The passport aims to shift this expectation.


Headlines achievements/impact●● Patient passports help to educate and empower patients to self-manage

their condition. The information they contain can help to ensure that patients have the correct expectations of the outcomes following surgery. If taken to appointments, patient passports can provide a written record of the steps patients are already taking to self-manage their condition and have the potential to support shared decision making about their care.

How did you do it?The booklet was handed out at patient knee workshops and distributed by the local orthopaedic assessment service, GPs and physios.

The development was led by MSK consultants and MSK service support lead. ●● Local authorities also contributed, providing a list of public health services

available across the CCGs’ footprints. ●● Some of the self-management and self check content is inspired by online

Arthritis Research UK materials.●● Overall, the guide avoids using clinical language, consistently encouraging

patients to help relieve their joint pains themselves. This highlights the message of de-medicalisation and self care.

Supporting Case Studies continued

16


West Cheshire – 100 Day Challenge Team(Source – NHSE Orthopaedic Elective Care Handbook)

First Contact Practitioner

What was the idea?The introduction of a GP physiotherapy service (FCP)

Why here, and why now?Why here? - Traditional GP referrals to MSK services require patients to attend a GP appointment before being put on a waiting list to see a specialist. This lead to delays in access to treatment, increased GP workload and inappropriate referrals to secondary care.


Headlines achievements/impact●● 60% of self-referred patients were discharged after the first appointment. 3%

of self-referred patients needed to see the GP for reasons such as medication reviews or non-MSK conditions.

●● 99% of patients rated the service as good or excellent and were happy to use it again. 91% rated the service 8+ for benefit to their practice. 45% rated the service 10/10.

●● There were 20% fewer referrals to MSK physio therapy services (after 5 years of an annual 12% increase) resulting in a reduction in waiting times.

●● Annual savings: 84% patients would have seen the GP saving £540k, 4% less MSK imaging saving £11,495, 5.9% fewer X-rays saving £28k, 2% fewer orthopaedic referrals saving £70k.

How did you do it?A GP physiotherapy service was piloted across 36 practices and was then expanded to evening appointments. The capacity of the service stands at 11,000 patients per year, which is 25% of total GPs’ MSK caseload. Quick access to advice provided rapid return to function and no need for further treatment. There is scope to increase the capacity of the service further. The service was developed with a successful clinical triage assessment and treatment service already in place. Outcomes were positive, with high satisfaction with the service from both GPs and patients.


17


Salford MSK Service


What was the idea?Interface MSK assessment and treatment service, including shared decision making, integrated public health (health checks) and health champions employed.

Headlines achievements/impact

●● Reduction in A&E attendances

●● Impact on MRI activity

How did you do it?

●● Blended public health, CAT and physio service

●● Healthy life styles approach - health checks taken at the same time as wider assessments. These are taken first before the patient goes on to see the consultant.

●● National back pain pathway implemented with FCP complementing delivery of it.

●● Investment in motivational interviewing technique


18


Pennine MSK Service

Community based MSK Assessment (triage) and treatment clinic

What was the idea?The provision of holistic community based clinical assessment and treatment service for those patients presenting with musculoskeletal conditions and related chronic pain that cannot be treated adequately within primary care by the patient’s GP or by Outpatient Physiotherapy, and who may need access to an appropriate skill set that will deliver the best outcomes for non-surgical musculoskeletal conditions.

Why here, and why now?The need to reduce the number of referrals to the orthopaedic and rheumatology services in secondary care.

Headlines achievements/impact

Provision:●● >95% of Rheumatology care of the Oldham registered population. Consultant led

but Nurse driven pathways.●● >95% of elective MSK care referrals●● c75% of elective MSK delivered without the need to see an Orthopaedic

Consultant

How did you do it?Intermediate care clinic based in the Primary Care environment using GPs with special interest (GPwSI), specialist nurses and Extended Scope Practitioners (ESPs) from physiotherapy, podiatry and occupational therapy.

Referrals in from GPs and clinicians in physiotherapy and the DVT services. Directly employed workforce with SLAs in place with secondary care providers and independent practitioners.

Multidisciplinary triaging of referrals to determine the appropriate pathway for the patient which may be within the MSK service or achieved by referring outside of the service.

Direct referral to the orthopaedic team who offer patients a choice of secondary care provider. If there are consultant clinics for the chosen provider within the MSK service, the appointment is made directly. If not referrals are forwarded to that provider’s booking service.

Patients assessed as requiring surgery can be directly listed for surgery within the community.


19



Telephone Follow Up

What was the idea?Telephone follow up appointments for hip, knee, shoulder and hand clinic patients to limit the time spent on routine post-intervention or post diagnostics follow ups and eliminate the need for patients to come to hospital with the aim to create a virtual fracture clinic in the future.

Why here, and why now?Why here? - Stockport’s orthopaedics service was facing high clinic waiting times and staff were keen to utilise their clinic time more effectively.


Headlines achievements/impactOf 58 telephone follow ups:

●● 97% did not require a face to face appointment.

●● 34% of patients were discharged following the telephone appointment

●● 47% were listed/referred for another procedure/investigation

How did you do it?

●● Existing clinic lists were used to select the specialties that the service would focus on.

●● Suitable patients booked into face-to-face clinic appointments were rescheduled for a telephone review.

●● Specialist nurses and ESPs run weekly telephone clinics. The telephone follow up processes are similar to face-to face follow ups and are as follows:

• Send out the feedback form within a week of the appointment.

• Patients receive a letter noting the time of their appointment. The same rules apply regarding cancellations and DNAs.

• Staff complete RTT forms for each telephone review and each consultation generates a dictation and clinic letter.


20


Salford Orthopaedic Service

Salford virtual fracture follow-up clinic

What was the idea?

Physiotherapy led virtual fracture follow up clinic.

Why here, and why now?

●● The goals of the fracture clinic redesign process are to ensure that:

●● Simple, stable injuries that do not require specialist review are managed quickly and efficiently

●● Injuries that require specialist review are assessed rapidly by a consultant

●● Face-to-face review is timely, by the correct team: no wasted encounters

●● Early imaging for diagnostic uncertainty

●● Adequate time for both telephone and face-to-face consultations

●● Consistently meet BOAST standards for fracture care

●● Promote consistent patient care

●● Improve patient satisfaction

●● Training and support of junior medical staff is enhanced

Headlines achievements/impactReduction of 40% of patients who would have had a face to face follow up appointment.

How did you do it?Physiotherapy telephone fracture follow up service, providing advice, supported by a helpline.

Patients put on to evidence based exercise programme.

App currently being developed to facilitate a supported self-care approach.

Patients can self refer back into a physiotherapy service if required.


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