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Orthopaedic and Rheumatology Services Consolidation Report May 2015
Orthopaedic and Rheumatology Services
Consolidation Report
May 2015
Contents1.0 Introduction...................................................................................................................................4
2. Summary and Conclusions.............................................................................................................6
3. The Engagement Process and Outcomes.......................................................................................8
3.1 Who and how many people were engaged...........................................................................8
4.0 Which option do patients think would offer a better service?....................................................12
4.2 Respondent Group – MCAS and RCAS Service Users. (PRAXIS)............................................13
4.3 Respondent Group – Vulnerable Older People. (AGE CONCERN)........................................14
4.4 Respondent Group – Muscular Dystrophy (NEURO MUSCULAR CENTRE)...........................14
4.5 Respondent Group – Attendees at International Women’s Day Event - WHISC..................15
4.6 Respondent Group – online survey......................................................................................15
4.7 Respondent Group– VOICE of NATIONS..............................................................................16
5.0 Usage and Experience of NHS MCAS/Physiotherapy Services (Orthopaedics)............................17
6.0 Usage and Experience of NHS RCAS/Physiotherapy Services (Rheumatology)...........................19
7.0 Usage and Experience of NHS Neck and Back Pain Services........................................................21
8.0 Usage and Experience of Osteopaths and Chiropractors.............................................................23
9.0 Travel...........................................................................................................................................24
10.0 Patient Information.....................................................................................................................26
11.0 Findings specific to particular groups or communities................................................................29
12.0 Were there were conflicting viewpoints?....................................................................................29
13.0 Other feedback/comments not included in the findings above..................................................29
14.0 Unplanned outcomes and unexpected learning as a result of this engagement.........................30
15.0 Understanding the Engagement Approach..................................................................................31
15.1 What worked well about this engagement method:.......................................................31
15.2. What should be done differently next time when engaging with these communities/individuals:................................................................................................................32
Appendix 1 Free-text Comments.........................................................................................................34
Comments Relating to Option 1......................................................................................................34
Comments Relating to Option 2......................................................................................................35
Comments Relating to Option 3......................................................................................................36
Appendix 2: Orthopaedic & Rheumatology Services – Briefing Paper.................................................41
Appendix 3: Who was engaged, where and how:................................................................................57
Appendix 4: A note on the statistics used in the Orthopaedic and Rheumatology services consolidation report............................................................................................................................58
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1.0 Introduction1.1. This report consolidates the findings of six separate engagement exercises reviewing
the views and opinions of patients and public to proposed changes to Orthopaedic and Rheumatology Services. The specific services being considered were Musculoskeletal Clinical Assessment Services (MCAS), Rheumatology Clinical Assessment Service (RCAS) and Neck and Back Pain Services.
1.2. The six engagement exercises were:
i. Praxis: A face to face survey of 277 patients attending MCAS, RCAS, secondary care and neck and back pain clinics across Liverpool, using a structured questionnaire.
ii. Age Concern: Group explanation and one to one interviews with 25 respondents at Age Concern Liverpool and Sefton Poppy Centre.
iii. Neuro Muscular Centre: Three face to face interviews and three phone interviews conducted with patients aged 16+ with muscular dystrophy and associated neuromuscular conditions.
iv. WHISC: 68 female respondents from diverse communities and service users interviewed in focus discussion sessions together with a structured questionnaire applied at the end of the event.
v. Online Survey: 41 respondents completed the on-line structured questionnaire. Respondents profile includes ‘communities of interest’, ‘members of the public’ and ‘existing service users’.
vi. Voice of Nations: 32 respondents made up of service users and members of the public attending events at LA Health & Wellbeing Clinic and Pentecost Baptist Church.
1.3. In total 449 people took part in the Orthopaedic and Rheumatology Services engagement exercise. The methodologies employed in each of these engagement exercises appear in Table 3.1. A copy of the structured questionnaire is included in Appendix 2 together with the background document explaining the proposed change. All interviews took place between 9th and 27th March 2015.
1.4. Throughout this project, researchers had been mindful of the unique circumstances of individual respondents and the need to adjust their approach and methodology accordingly. This poses a challenge in consolidating findings into one overall perspective but equally it is vital that the findings pertaining to particular ‘sub-populations’ are preserved in their entirety – such is the uniqueness of their experiences, opinions and concerns.
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1.5. Finally, this consolidation report is based solely on the final reports submitted by the different agencies/organisations. We did not have access to the original data sets and, as a consequence, this defines the limits of analysis such as our ability to combine and compare results on a ‘sub-group’ within the overall sampling population e.g. by gender or ethnicity. We would also add that there was no consistency in the way the structured questionnaire was analysed. (The reader is directed to Appendix 4 for a more detailed commentary on the analysis of the structured questionnaire.)
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2. Summary and Conclusions
I.II.
II.1. The most popular option for improving Orthopaedic and Rheumatology Services was Option 3 (“the one service that combines MCAS, Neck and Back Pain and RCAS). The evidence to support this conclusion is as follows:
53% of service users favoured this option (Praxis) 84% of vulnerable elderly people favoured this option (Age Concern) 33% of patients with muscular dystrophy favoured this option (NMC) 49% of attendees at Women’s International Day favoured this option
(WHISC) 28% of members of Voice of Nations favoured this option. 34% of online respondents favoured this optionThe combined result across the six organisations was that 50% of respondents favoured Option 3, 23% favoured Option 1 and 19% favoured Option 2. The balance of 8% was made of respondents who had ‘no opinion’ or who didn’t fully understand the implications of what was being offered.
II.2. The main reason for favouring Option 3 was the potential for a more effective and efficient service – quicker and more accurate diagnosis leading to speedier and effective treatment.
II.3. It is clear from the findings that not all respondents were in favour of Option3. Option 1 was the next preferred alternative with 23% reluctant to change the current situation.
II.4. Support for Option 3 was consistent across age and gender groups. The qualitative evidence showed that support was weakest for Option 3 amongst patients with muscular dystrophy who were very critical of the knowledge, competence and empathy of staff to deal with patients with muscular dystrophy, members of the BME community who were generally critical of the levels of support and treatment on offer and those who were concerned about the potential of the new service to threaten the GP/patient relationship. There were also those respondents who found it difficult to grasp the exact nature of the change being proposed and therefore preferred to stick with what was familiar.
II.5. 82% of NHS MCAS Physiotherapy service users rated their experience as “Excellent” or “Good”.
II.6. 85% of NHS RCAS Physiotherapy service users rated their experience as “Excellent” or “Good”.
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II.7. 77% of NHS Neck and Back pain service users rated their experience as “Excellent” or “Good”.
II.8. 77% of Osteopath users rated their experience as “Excellent” or “Good”.
II.9. 69% of Chiropractor users rated their experience as “Excellent” or “Good”.
II.10. There were patients who were dissatisfied with services due largely to the ineffectiveness of the treatment they had received to alleviate their condition.
II.11. As a general overview most patients felt they had been involved in the development of their care plan(s).
II.12. 80%+ of respondents who had used the services of an Osteopath or Chiropractor agreed it would be beneficial to include those services in any new service provision.
II.13. Most patients (86%) would want to receive appropriate information relating to their medical condition from a ‘professional’ at all stages of their treatment pathway i.e. at initial GP appointment, at first appointment with a professional and during the treatment.
II.14. Based on the statistical evidence 58% of respondents would travel to their medical appointment by car. 30% would travel by bus and 13% by taxi. (This was a multiple choice question so some respondents would use more than one mode of transport). Mode of transport did vary and according to the qualitative evidence provided by Age Concern the most likely methods to attend appointments is by taxi, sometimes accompanied by family and by ambulance.
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3. The Engagement Process and OutcomesThis section summarises how and where the engagement took place and the outcomes in terms of who took part and the numbers involved in each activity. The following table shows which engagement partner was responsible for the different designated activities:
Table 1: engagement activities
The next table on the following page describes who was engaged by each engagement partner as well as giving the numbers of people who were engaged. Following on from this chart one presents the combined demographic profile of those respondents participating in the engagement exercises and chart two a summary of previous and current service users. Appendix 3 provides further detail on who was engaged, where and when this happened and the different methods used.
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Name
Activity A - In depth feedback from members of relevant communities - likely to be gained from face to face discussion in either one to one or group settings (Qualitative data from smaller numbers of people).
WHISCAge ConcernOnline SurveyVoice of Nations
Activity B - Wider feedback from a broader range of relevant communities - likely to be through questionnaire (Quantitative data from larger numbers of people)
WHISCOnline SurveyVoice of Nations
Activity C - Feedback from existing service users - likely to be through questionnaire with patients as they attend pain services for their appointment.
WHISCPraxisNeuro MuscularOnline SurveyVoice of Nations
Activity D - Research synthesis and reporting are also required to bring the reports from each engagement Organisation together to producing an overall engagement report.
Praxis
3.1 Who and how many people were engagedPopulation PRAXIS Age
ConcernNeuro
MuscularWhisc Online
SurveyVoice ofNations
BME communities 23 0 10 4 (32)People with Learning Disabilities
3 1
People with disabilities / sensory impairments
29 13
People with Long Term health conditions
(277) (6) 14 3 4
People with mental health issues
9 11 3 10
Older People (65+) 82 (25) 11Children and Young People (Under 18)
1 0 0 0
Children & Young People in care/other vulnerable groups- please listReligion/belief groups – please listChristianHinduJehovah WitnessJewishMuslimOther
1972117
17
12
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Men 104 2 20 12Women 167 4 (68) 18 20LGBTIQ people 9 0 7Pregnant womenMothers of young childrenVeteransVictims of abusePeople with addiction issuesHomeless peopleRefugees and Asylum seekers
10
People experiencing poverty
20
People experiencing social isolation
68 30
Traveller communities 10Single parentsCarers 68 10TOTAL NUMBER OF PEOPLE*
277 25 6 68 41 32
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Table 2: engagement demographics
Chart one: The combined demographic profile of those respondents participating in the engagement exercise
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Chart two: summary of previous and current service users
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4.0 Which option do patients think would offer a better service?
4.1 OptionsThree options were considered as to how orthopaedic , rheumatology and neck and back pain services might be provided in the future. The three options were as follows:
Option 1. Continue with the current scenario with three separate services that GPs can refer to according to whichever service they think best. Musculoskeletal Clinical Assessment Service (MCAS) Rheumatology Clinical Assess and Treatment Service (RCAS) Neck and Back Pain. Same clinic locations as now. Patients have a choice of where to be assessed and
treated and some choice of appointment time.
Option 2. Combine some of the services so GPs refer to MCAS or RCAS and the patient is then assessed. Combine MCAS and Neck and Back pain. Keep RCAS separate – may not be in the same place as the MCAS clinic. Patients have a wider choice of appointment times. Less likely to be returned to GP to then be referred to a different service if tests,
e.g. x-rays, are needed. Patients have a choice of where to be assessed and treated but at a reduced
number of places.
Option 3. To have one service that combines MCAS, Neck and Back pain and RCAS. GPs refer patients to this one community service for assessment, treatment or
referral. MCAS, RCAS and Neck and Back pain clinics would be combined in the same
service and patients could be referred directly between the services without returning to their GP for the additional referral; which is the current system.
Patients have a wider choice of appointment times. Patients are less likely to be returned to their GP to then be referred to a
different service if tests, e.g. x-rays, are needed. Patients have a choice of where to be assessed and treated but a reduced
number of places.(See Appendix 2 for the detailed background to the proposed changes.)
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The following table shows preferences in respect of the different options that it was felt offered patients a better service as a percentage of the number of responses. Chart three then gives the combined results:
Options Praxis
N=277
AgeConcern
N=25
NeuroMuscular
N=6
WHISC
N=68
OnlineSurveyN=41
Voice of Nations
N=32
Overall %
1 – Maintaining separate services 29% 4% - 9% 20% 25% 23%2 – Joining up some services 13% 8% 33.33% 36% 29% 28% 18%3 – Joining up all services 53% 84% 33.33% 49% 34% 28% 51%4 – Don’t know 5% 4% 33.33% 6% 17% 19% 8%
Table 3: option responses
Chart three: preferred options
The reasons given are categorised both by option and respondent group. Sample verbatim are shown below but the full list of comments for each option and respondent group are shown in Appendix 2.
4.2 Respondent Group – MCAS and RCAS Service Users. (PRAXIS)Option One
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“Assessed immediately to correct clinic” “Because better to have diagnosis and treatment in one place” “Because I think you know where you are up to, I’m happy with the way it is now
- if I have other problems they will just refer me”
Option Two “Be easier for the hospital, they will know where everyone is, they will have team
all in one place except for the RCAS, because RCAS is dealing with different process of the body”
“Because it seems easier to have another choice of clinic - neck and back if necessary”
“Because may save time, more direct and GP still refers so GP still in control”
Option Three “All in one place and wider choice of times” “All in one service, less referrals and messing about” “All in the one building and it would be quicker and easier as well if they are in
the one place”
4.3 Respondent Group – Vulnerable Older People. (AGE CONCERN)Option One
‘Each service has specialism’s and this would be lost if services were joined up’Option Two
‘Having all services in one place would result in patients having to travel further’Option Three
‘All services would be in one place’ ‘More efficient’ ‘Better treatment can take place in one place’
4.4 Respondent Group – Muscular Dystrophy (NEURO MUSCULAR
CENTRE)
Option One No responses.
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Option Two
Two people thought joining up services would reduce travel and multiple appointments.
Option Three
Two people thought joining up services would reduce travel and multiple appointments
Don’t Know
Two younger males responded due to being disaffected – one patient had been through MCAS and Rehab and no-one understood his condition and he didn’t receive positive outcomes or actions.
4.5 Respondent Group – Attendees at International Women’s Day Event - WHISCService users were in favour of localised pain relief clinics, seeing them as being a useful resource where skills can be concentrated while costs are reduced. There was also a welcome for the fact that these services would mean patients would not have to continue going back to their GPs for treatment. These are a sample of unclassified comments relating to the three options:
‘They’re all linked and people often suffer from more than one condition’ ‘One massive department all connected’ ‘Professional reasons – it doesn’t offer as wide a range of services’
4.6 Respondent Group – online survey This group consisted of communities of interest, members of the public and service users.Option One ‘Would speed up services, and improve diagnosis, especially for patients with
more complex problems’ ‘One-to-one service’ ‘Doing on-to-one consultation with a professional person’
Option Two ‘By joining up some community services resources can be better managed for
those services which have to be provided in a certain location accessible to all.’ ‘Because people suffer different pain i.e. arthritis, nerve pain, osteoporosis’ ‘Rheumatology requires more time and different/ additional knowledge for staff’
Option Three ‘If all the services are joined together , or better still run from the same site it
would cut down the time from being diagnosed to treatment, it would give patients the opportunity to meet and talk to other sufferers about their experiences and how other patients manages their pain, Plus if there is an
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ambulance or mini bus service it would make it easier for pain sufferers to travel to and from therapy sessions with people they will get to know so the sharing part of the therapy will start on the way to the venue.’
‘They all will be equal, nobody's different’ ‘Because it is hard to diagnose the cause of pain. GPs have a long wait and going
back to GP for a re referral is a waste of time and money. Makes sense to get all the treatment through specialised services’
4.7 Respondent Group– VOICE of NATIONS
This group predominantly consisted of members of BME Communities
Option One
The view was that you would be referred exactly where you will need treatment and which could also be close to home.
Option Two
More flexibility of options in the same centre, as more often than not more than one service will be required and service users will benefit from this.
Option Three
Some patients had been misdiagnosed in the past (option 1) which resulted in longer waiting times and displacement.
The benefit of this option is the ability to have all services in one place. The counter argument was that as most patients either walked or took buses they will have only single option/destination to attend appointments and receive treatments. There was also the fear that this would increase waiting times for appointments.
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5.0 Usage and Experience of NHS MCAS/Physiotherapy Services (Orthopaedics)
5.1 The following table presents the percentage number of people engaged using NHS MCAS/Physiotherapy Services (Orthopaedic) by each of the engagement partners: Usage of Service Praxis
N=277Age ConcernN=25
NeuroMuscularN=6
WHISCN= 68
OnlineSurveyN=41
VoiceOf NationsN=32
Currently using NHS MCAS/Physiotherapy Services
49% NS NR 12% 15% (31%)
Have previously used NHS MCAS/Physiotherapy Services
18% NS NR 24% 34% (31%)
Have not used this service/no answer
33% NS NR 64% 51% 69%
Table 4: Use of servicesNS = No Statistics NR = No Response. Voice of Nation statistics have been combined.
5.2 Patients who are currently using or have previously used NHS MCAS Physiotherapy (Orthopaedic) services were asked to rate their experience of using this service. Results were as follows:
Rating of MCAS/Physiotherapy Services
PraxisN=183
AgeConcernN=25
NeuroMuscular
WHISCN=25
OnlineSurveyN=20
VoiceofNationsN=10
Excellent 49% (80%) NR 28% 35% 30%Good 39% (80%) NR 52% 25% -Average 8% NS NR 12% 25% 70%Disappointing 3% NS NR 4% 10% -Poor 1% NS NR 4% 5% -
Table 5: Rating of MCAS ServicesNR = No Response. For Age Concern statistics have been combined – base number
not available.
Chart four shows the combined experiences of those who are currently using or have previously used MCAS Physiotherapy Services.
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Chart Four : satisfaction with NHS MCAS Physiotherapy Services5.3 Those rating the service as ‘excellent’ or ‘good’ were asked to state why? These are
some illustrative comments: “All the treatments I have had from all the physiotherapy sessions and
department have been excellent, have never had a problem” “Always had good service and pain relieved” “Am always seen on my appointment on time, everything is explained clearly
so I know where I’m up to” “Appointment and treatment brilliant” “Out of the people who had used the MCAS service 80% had rated it as
excellent or good with the majority of those stating that they did feel involved in their care plan.” (Age Concern)
5.4 By contrast the small number of patients who were unhappy or dissatisfied with the service made these comments or similar: “At that time which was some years ago nothing was explained and my
condition did not really improve” “Disjointed services, I have multiple joint problems, so have been unable to be
treated realistically under the current service” “Because they never found out what was wrong with me”
5.5 Approximately 80% of those currently using or have previously used NHS MCAS Physiotherapy services said ‘they felt involved in the development of their care plan(s)’, (Based on responses from Praxis, Age Concern, IWD and Survey Monkey). 60% of users from Voice of Nations said ‘they felt involved in the development of their care plan(s)’.
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6.0 Usage and Experience of NHS RCAS/Physiotherapy Services (Rheumatology)
6.1 Overview of the number of patients using NHS RCAS/Physiotherapy Services (Rheumatology) is shown below:
Usage of Service PraxisN=277
Age ConcernN=25
NeuroMuscularN=6
WHISCN= 68
OnlineSurveyN=41
VoiceOf NationsN=32
Currently using NHS RCAS/Physiotherapy Services
17% NS NS 6% 12% NS
Have previously used NHS RCAS/Physiotherapy Services
14% NS NS 16% 15% NS
Have not used this service/no answer
69% NS NS 78% 73% NS
Table 6: usage of RCAS ServicesNS = No Statistics.
6.2 The patients who are currently using or have previously used NHS RCAS Physiotherapy (Rheumatology) services were asked to rate their experience of using the service. Results were as follows:
Rating of RCAS/Physiotherapy Services
PraxisN=86
AgeConcern
NeuroMuscular
WHISCN=15
OnlineSurveyN=11
VoiceOf NationsN=?
Excellent 49% NS NS 7% 37% -
Good 40% NS NS 65% 27% 60%
Average 5% NS NS 7% 9% -
Disappointing 6% NS NS 21% 18% -
Poor - NS NS - 9% 20%
Table 7: rating of RCAS Services NS = No Statistics See Chart Five for the combined experiences of those who are currently or have previously used RCAS Physiotherapy services.
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0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Excellent Good Average Disspointing Poor
43%42%
5%
9%
1%
Experience of NHS RCAS Physiotherapy Services (total number 112)
Chart Five: satisfaction with NHS RCAS Physiotherapy Services
6.3 Those rating the service as ‘excellent’ or ‘good’ were asked to state why? These are some illustrative comments: “Appointment system great, good standard of care” “Found that they help you as much as they can” “I didn’t have to wait long, doctor very efficient” “I have confidence in the specialists, it’s a well-run clinic, I feel comfortable here” “In the fact that the lady explained to me and she was patient with me” “The majority of participants had used or were using RCAS service however the
rating of the service ranged equally between ‘excellent’ and ‘average’ with the following comments noted:
- ‘not enough time spent with patients’- ‘felt rushed’- ‘waited a long time for the appointment’- ‘treatment not effective’- ‘felt involved throughout treatment’ (Age Concern)
6.4 Other patients who were unhappy or dissatisfied with the service made these comments or similar: “Didn’t help much overall” “Doctor was disappointing, he put me on the wrong medication which made me
ill” “It’s always the waiting times that gets to me”
6.5 88% of those currently using or have previously used NHS RCAS Physiotherapy services surveyed by Praxis said ‘they felt involved in the development of their care
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plan(s)’. This compares with 58% surveyed by WHISC, 64% using the Online Survey and 40% by Voice of Nations.
7.0 Usage and Experience of NHS Neck and Back Pain Services.
Usage of Service
PraxisN=277
AgeConcern
N=25
NeuroMuscular
WHISCN=68
OnlineSurveyN=41
Voice ofNations
Currently using Neck and Back
Pain Services
13% (68%) NS 4% 7% NS
Previously used Neck and Back
Pain Services
17% (68%) NS 10% 20% NS
Have not used
service/ No answer
70% 32% NS 86% 73% NS
Total 100% 100% NS 100% 100% NSTable 8: usage of neck and back pain servicesNS = No Statistics. For Age Concern statistics have been combined.
7.1 Patients who are currently using or have previously used NHS Neck and Back pain services were asked to rate their experience of using this service. Results were as follows:
Rating of Neck and Back Pain Services
PraxisN=83
AgeConcernN=17
NeuroMuscular
WHISCN=10
OnlineSurveyN=11
VoiceOf Nations
Excellent 52% (52%) NS 10% 30% NS
Good 29% (52%) NS 40% 30% NS
Average 13% NS NS 10% 30% NS
Disappointing 5% NS NS 30% - NS
Poor 1% NS NS 10% 10% NS
Total 100% NS NS 100% 100% NS
Table 9: rating of neck and back pain services NS = No Statistics. For Age Concern statistics have been combined.See Chart Six for the combined experiences of those who are currently or have previously used Neck and Back pain services.
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0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Excellent Good Average Disspointing Poor
46%
31%
13%
6%4%
Experience of NHS Neck and Back Pain Services (total number 112)
Chart Six : Satisfaction with neck and back pain services7.2 Those rating the service as ‘excellent’ or ‘good’ were asked to state why? These are
some illustrative comments: “Because they sort out my problem” “Everything was perfect, 100%” “He explained everything properly, he doesn’t give you things that are impossible
to do, he gives you advice on what to do that you can fit in easily with your daily life”
“I don’t have to wait around for hours, its good” “I feel as though finally I am getting my back sorted out” “Of those users, 52% rated it as ‘excellent’ or ‘good’ with the following
comments:- ‘very efficient service’- ‘took pain management to my level’- ‘staff very good, very patient’ (Age Concern)
7.3 By contrast the small number of patients who were unhappy or dissatisfied with the service made these comments or similar: “After her operation the domestic cleaned and that dust was falling on her” “Because I am still suffering with back pain - it didn’t do me much good” “Didn’t solve problem” “It didn’t work for me, that’s all - so went private” “Not enough time with the doctor” “Didn’t consult with me about my pain”
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7.4 89% of those currently using or have previously used NHS Neck and Back Pain services surveyed by Praxis said ‘they felt involved in the development of their care plan(s)’. This compares with 56% for WHISC and 38% for the Online Survey.
8.0 Usage and Experience of Osteopaths and Chiropractors411 patients responded to the question asking if they had attended an osteopath or chiropractor. 110 people said they had used one or both services.
Table 10 use of osteopath or chiropractor serviceUsage of osteopath or chiropractor Service(% who had used service)
No of people
who had used the service
PraxisN=277
AgeConcern
N=25
WHISCN=68
OnlineSurveyN=41
% of people
who had used the service (411)
Osteopath 69 16% 24% 7% 34% 17%
Chiropractor 41 9% 20% 6% 18% 10%
Table 11: rating of osteopath and chiropractor services
Of the 110 people who had either used an osteopath or chiropractor, 54 thought it would be beneficial to include an osteopath (86%) and 29 thought it would be beneficial to include a chiropractor (82%).
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Of the 69 people who said they had used an osteopath, 53 of them rated the service as excellent or good , this equates to 76% of the people who had accessed the service.Of the 41 people who had used a chiropractor 30 rated the service as excellent or good which equates to 71% of the people who had accessed the service.
Rating of osteopath or chiropractor service as Excellent or Good(% who had used service)
No of people
who rated service good or
excellent
Praxis
N=36
AgeConcern
N= 5
WHISC
N=1
OnlineSurvey
N = 11
% of people
who rated
service good or
excellentOsteopath (69 people) 53 81% 80% 25% 79% 76%Chiropractor (41 people)
30 72% 90%(Est.) 50% 71% 71%
Agreeing it would be beneficial to include as part of new service(% who had used service) based on 110 people
No of people who thought it would beneficial to include in service
Praxis AgeConcern
WHISC OnlineSurvey
% of people who thought it would beneficial to include in service
Osteopath (69) 54 86% NR 80% 86% 86%
Chiropractor (41) 29 84% NR 88% 71% 82%
Table 12: benefits of specialist services
9.0 Travel
9.1 Patients/respondents were asked ‘How would/do you travel to medical appointments’?’ This was a multiple choice question and the results were as follows:
Mode of Transport Used/% of All Journeys Undertaken
Praxis(n=271)
AgeConcern
NeuroMuscular
WHISCN=68
OnlineSurveyN=41
Voice of Nations
Walk 6% NS NS 40% 26% NS
Bus 20% NS NS 57% 50% NS
Car 62% NS NS 40% 61% NS
Train - NS NS 14% 8% NS
Taxi 11% NS NS 14% 26% NS
Bicycle 1% NS NS - 13% NS
Other (Ambulance, Mobility Scooter)
1% NS NS - - NS
Table 13: mode of transport (This is a multi-response question)
9.2 Age Concern commented “the most likely methods to attend medical appointments is by taxi, sometime accompanied by family or by ambulance.”
9.3 Based on patients home postcode, the starting point of journeys were as follows (only 3 organisations collected this information):
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Patients Home Postcode Praxis(n=277)
WHISC(n=68)
OnlineSurvey (n=41)
L1 1% 2% -L2 - - -L3 1% 2% -L4 7% - -L5 1% - -L6 7% 7% 8%L7 6% 2% 8%L8 3% 10% 5%L9 3% 2% 14%
L10 2% - -L11 7% - 3%L12 5% - 5%L13 5% 10% 3%L14 4% 2% 11%L15 4% 2% 3%L16 4% - 8%L17 5% 12% 5%L18 4% 5% 11%L19 4% 2% 5%L20 4% 2% -L21 3% - -L22 - 5% -L24 1% - -L25 4% 5% 3%L26 1% 2% -L27 1% - -L30 3% - -L31 4% - -L32 1% - -L33 1% - -L34 - - -L35 1% 2% -L36 3% - -L39 - 2% -
Other Non-Liverpool 2% 9% 5%Total
Table 14: patients postcodes %’s Rounded to nearest whole number and due to ‘rounding errors’ column percentages may not add to 100.
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10.0 Patient Information
10.1 Finally, patients were asked ‘how they would like to receive information about how they can manage their condition or injury. The alternatives and responses are shown below:
How they would like to receive information
Praxis(n=277)
WHISC(n=68)
OnlineSurvey(n=41)
From a professional 91% 93% 42%From a leaflet 32% 50% 3%Training/education support 20% 48% 5%Through peer support 8% 38% 16%Personalised tools 5% 5% 5%Websites 25% 26% 8%Email 20% 12% 13%Social media 11% 10% 3%Smartphone Apps 13% 5% -Other 6% 2% 5%Not interested in taking personal action.
2% - -
Table 15: receiving informationSee Chart Eight for combined responses regarding receipt of information.
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0 50 100 150 200 250 300 350
From a Professional
From a Leaflet
Training/Educational Support
Websites
Peer Support
Smartphone Apps
Social Media
Personalised Tools
Combined Results of Preferred Method of Recieving Information (total number 386)
Chart Eight : preferred method of receiving information
10.2 Respondents were asked to indicate when they would prefer to receive information.
Preferred time to receive this information
Praxis(n=277)
WHISC(n=68)
OnlineSurvey(n=41)-
At your first GP appointment 46% 76% 74%At first appointment with specialist service
64% 64% 66%
During treatment 52% 52% 53%On discharge 45% 29% 37%Not at all - - 3%Don’t know 1% - 3%
Table 15: receiving information
See Chart Nine for combined responses regarding timing of information
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At First Appointment with Specialist Service
At Your First GP Appointment
During Treatment
On Discharge
Not at All
Don't Know
0 50 100 150 200 250
248
209
201
158
1
4
Combined Results for Preferred Time for Recieving Information (total number 386)
Chart Nine : preferred time for receiving information
10.3 Age Concern found that most of the older people engaged with wanted information on how to manage their condition from a professional and/or leaflet and they generally wanted to receive this information at all trigger points i.e. at GP appointment, first specialist appointment, during treatment and on discharge.
10.4 The vast majority of patients (90%+) would like to be able to contact the service (discussed above) after a period of treatment if the same condition recurred within a specified time period. 48% of patients added a comment about the issues raised through the interview. Most of these comments were positive or supportive in nature. Some illustrative examples include: “All the issues we have raised are very helpful, gives me more knowledge and
insight into what’s happening - that’s ok” “Can’t think of any that I don’t think you should have to wait months between
appointments, it’s too long to wait” “Good to have help directly from department if condition reoccurs”
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11.0 Findings specific to particular groups or communities
All the people with muscular dystrophy who suffer long term pain specific to their neuromuscular condition felt that chronic pain specialists and MCAS physiotherapists did not understand the impact muscular dystrophy has on posture and joints. Patients with muscular dystrophy who live in CCG catchment area are reluctant and anxious to access mainstream MCAS services. If members of the MCAS team had knowledge of pain and muscle power in patients with muscular dystrophy it is likely patients would attend MCAS services locally. (The Neuromuscular Centre)
Age Concern reported that the majority of the vulnerable older people they engaged with felt that Option 3 was the best option
WHISC reported that Option 3 was supported by the majority of women attending the International Women’s Day Event including members of the BME community, those with long term health conditions, those experiencing social isolation and some with mental health issues
Praxis found that Option 3 was supported across age and gender classifications
Voice of Nations reported that six patients suffering one of the conditions say they have never experienced any involvement or concern towards their situation by their GPs. They reported no communication about the services available to them and suffer negative consequences to their lifestyle and social skills because of their condition. Members of the BME community felt culture and language/communication was a huge barrier. Too often, they felt they were not properly understood, or their situation was misinterpreted and under-estimated.
12.0 Were there were conflicting viewpoints?
Conflicting opinions were expressed through respondent explanations as to why they chose a specific option. These opinions are fully documented above in 4.1 above and Appendix 1.
13.0 Other feedback/comments not included in the findings above
Praxis reported that the existing structure already delivers high levels of patient satisfaction. Whilst there is significant support for Option 3, together with the integration of all related services such as Osteopaths and Chiropractors, there is some concern amongst one third of patients that the new structure risks losing some of the close personal relationship that currently exists between patient and GP. This concern is felt most amongst female and elderly patients
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The Neuro Muscular Centre suggested there should be education of medical professionals re muscular dystrophy if they are to be expected to work with muscular dystrophy patients. Patients with muscular dystrophy tend to see orthopaedic surgeons associated with tertiary neuromuscular clinics e.g. Oswestry and the Walton Centre rather general orthopaedic surgeons
Voice of Nations recorded that some patients complained that the time GPs devoted to them was so brief and that professionals were more engaged with writing, ticking boxes and taking notes. They often failed to look and connect with them as a person – who sometimes just needed reassurance and feeling of been unheard and understood
Voice on Nations also recorded comments that there was much repetition in the assessment exercise by every professional involved. They felt there should be a proper communication system within the NHS, to reassure patients that they are being listened to.
14.0 Unplanned outcomes and unexpected learning as a result of this engagement
WHISC recorded three comments of relevance to this issue:
Users of current services often find that it is very difficult to obtain an appointment and this has led to a large percentage of them welcoming the idea of pain relief clinics that they can return to without having to be referred again
Some participants would welcome inclusion of holistic pain management therapies within an NHS service as they are too expensive privately.
Some participants felt that they did not receive enough follow up from current services and that not enough information was given.
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15.0 Understanding the Engagement Approach
A number of observations were made about the engagement method and issues to be aware of when speaking with particular communities again:
The Neuro Muscular Centre commented that patients with long term conditions do not feel that any mainstream MCAS or rehab services understand their condition and how it affects them. These services are concerned with treating people in a very stereotypical way which acts as a barrier for patients with muscular dystrophy.
VofN commented that language, faith and cultural barriers must be considered. Engaging someone from a similar background/culture or faith group makes an engagement activity more fruitful/engaging. Empowering a particular group must be an integral part, or even better, the first step towards any engagement activity.
Age Concern made a number of points: The terminology needs to be appropriate i.e. everyday language and to be as
concise as possible.
Some older people may have a disability such as sight or hearing impairment therefore you need to ensure that they have fully taken in what the engagement is about
Some older people have difficulties with dexterity and therefore cannot hold a pen for any length of time to answer a questionnaire
The need to be able to focus an older person on the issues being engaged about.
WHISC said they would welcome a longer lead time in order for them to publicise any future events to all of our service users and contacts. Many marginalised communities rely on word of mouth for information, and this takes time.
15.1 What worked well about this engagement method:
WHISC suggested combining the consultation with holistic therapies and classes meant that the day proved popular. It also encouraged participants to consider the alternative forms of pain relief. Aromatherapy and Yoga yielded appreciative feedback.
Age Concern found the following aspects of the engagement process worked well: The one to one approach with staff members helped to focus the older person
on the engagement activity
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Older people can become anxious so by having one to one support to go through the questions really helps them understand the issues and draw out their points of view
Older people often have problems writing down answers or completing a questionnaire on their own due to things like poor eyesight or difficulty holding a pen due to mobility issues. This method allowed one to one support to do this
As it was a one to one environment they were able to express their own views and experience around sensitive medical issues.
VofN reported that the Community Health Empowerment day was very successful, and also the one to one sessions that gave individuals the chance not only to be educated and empowered, but also to work on their specific health conditions. It also enabled them to set goals necessary to manage their conditions and improve their overall health, wellbeing and lifestyle.
The Neuro Muscular Centre (NMC) commented that it gave their patients from Liverpool CCG area the opportunity to comment on local services. This informed NMC as to why they attend NMC for specialist physiotherapy services. NMC was able to hold detailed, in-depth conversations with a sample of patients from Liverpool CCG area explaining why NMC had been selected to carry out the engagement and the relationship between NMC and CCG – highlighting NMC is a trusted provider. Not all patients understand who pays for their treatment, how NMC interacts with the CCG and that patients can have a say on the services they access.
Praxis found the questionnaire worked well. Patients entered into the exercise with enthusiasm and the questions were easily understood by all categories of respondents. They did not keep a record of those who refused or were unable to take part.
15.2. What should be done differently next time when engaging with these communities/individuals:
WHISC suggested that they could improve attendance from diverse and marginalised communities through a longer lead time. They also suggested that with certain communities such as the Somali community they might attract more attendees if a venue is hired within the community.
VofN suggested that more time and detailed explanations were needed to allow participants to begin to grasp and better understand their conditions. They recommended more face to face engagement activities with patients who share similar background and values. They were critical of structured questionnaires particularly for respondents whose first language is not English – they have the potential to leave participants disengaged.
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Praxis offered four suggestions: A structured questionnaire should always be piloted even if it is to eliminate
simple design flaws or routing problems. The questionnaire could have been more efficiently designed
Thought should be given to a more appropriate method of classifying patients and not simply relying on the standard ‘diversity’ classification. The degree of patient disability and mobility might have provided some relevant insights that could have influenced service design and delivery
The idea of using a video to describe the three options was not tested but it could be useful in future engagement exercises. It would ensure a standard description was given to each patient removing the possibility of some unintended influence/bias by the interviewer
The printed brochure offered no obvious advantage over the printed card used by interviewers to communicate details of the three options.
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Appendix 1 Free-text Comments
Comments Relating to Option 1
Theme One – Impact on Waiting Times“As it is, no messing, I think other option will increase waiting times”“Because I think the others would cause more delay”“I think if you combine them then it would be a longer process, longer waiting times, that would be my concern”“If they put all of them together the appointment times would be longer. The clinics would be packed out, taking longer times to be seen”“It just keeps it all separate, it will avoid backlogs”“More likely to get to the right clinic without waiting, less assessments”“Options may disrupt referral, put barriers in way treatment is assessed in clinic before allocating appointment”“To put all these clinics together would create a lot of people waiting, that's the main problem - time consuming, waiting around”“That’s the one I go to - most of them are all grouped together, it would be a longer wait to be seen to” “You have a choice of where to be assessed and treated as it is, no missing, I think after option will increase waiting times”
Theme Two – Satisfied With Current Situation/Don’t Want Change/Trust in GP“Because I think you know where you are up to, I’m happy with the way it is now if I have other problems they will just refer me”“Because that’s the one I have now and I have nothing to complain about, it's fine for me”“Easier to trust GP than to trust person assessing me in clinic”“Easier to visit GP and to be directed from there”“Fine as it is, I trust my GP”“Fine as is, no need to change, I trust my GP”“Happy to have GP make choice”“Happy with my GP to choose service, I would trust him more”“I am happy with things as they are”“I am not bothered as long as I get seen to I think it would get muddled with it altogether, appointments turn up late now”“I am old fashioned and like to stick to how it's always been”“I am quite happy as it is”“I can pick where I want to go, I don’t like it when GP tells me where to go, I would like to say myself”“I don’t understand other options, happy with GP to allocate clinic”“I found it worked for me, they put the problem right which saved return visits to the GP”“I have a lot of faith with the GP here so I prefer to see him”“I have been to MCAS in another area, they haven’t been as good as the chiropractor”“I know where to come and it's convenient”“I like it the way it is, haven’t had any problems”“I like it the way it is, I have never come across any problems”“I like to see GP”
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“I prefer separate referral”“I prefer to be referred by GP I think if sent to central point to be assessed it may delay treatment”“I prefer to not have another assessment”“I prefer to see my GP and her decide” “I think its ok as it is, no need to change, very good sense, may cause delay if changed”“I trust my GP and feel he is able to make the right choice for me”“I trust my GP and feel he would put me to the correct clinic” “I’m used to this system and feel it works well” “It works for me, I got referred straight away from the NHS”“It works for me, my GP is good, I just go in and say I am due for a scan and she books it there and then”“It’s the service I’m used to and I’ve never had a problem with it”“It's a direct thing, right to the appropriate department”“It’s been brilliant and the referral was very quick if the service has been great, no complaints”“It’s easier, I live locally and this option suits me”“It’s more pertinent to what your problem is at the time, the treatment received was very good”“It’s mostly all round, it covers lots of aspects”“It's specific and my GP would know which is right for me”“It’s worked well for me and my GP referred me, I was seen very quickly”“Leave it as it is, I prefer to see my GP first” “Ok as is, why change? Seems good to me to have GP refer, he knows me well” “Prefer all separate clinics”“Prefer to go through GP, more personal treatments”“Prefer to have it as it is, I don’t know enough about option 2 and 3 to judge”“Probably because I don’t have a problem with the way things are at the moment”“So convenient as it is at present” “They deal with your complaint only, will be more specialised”“This seems to be working well and I’m sure the GP knows what he is doing” “Well he knows about my medical records, I would rather go back to the doctor, that’s all”“Well you know the way it works now, my parents wouldn’t adapt to change if that happened”“When it's all under one there could be confusion, I feel if one clinic is dealing with just one thing it can be more specialised”“Why change? It’s simple as it is, more confusion and extra layers as more examinations and tests within option 1 or 2”“You can see when you are going and which clinic you need for your condition”
Comments Relating to Option 2
Theme Three – Greater Efficiency and More Effective Treatment“Be easier for the hospital, they will know where everyone is, they will have team all in one place except for the RCAS, because RCAS is dealing with different process of the body”“Because may save time, more direct and GP still refers so GP still in control”
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“Combines the whole services so get right treatment eventually”“Easier for assessment”“Every person has their own needs but I feel the clinic that dealt with bones should be together and the one dealing with muscles etc. should be separate”“I think Rheumatology and bone pain are probably needing to be treated separately and differently”“If you have a certain problem and you need to be referred to one clinic, but if you have just rheumatology that's kept separately, that can be the whole of the body”“I have been trying to get my doctor reported to see someone at the hospital it’s a problem getting referred”“It combines the MCAS with neck and back pains”“It seems to get to my problems better - it says I wouldn’t have to go back to my GP”“It’s easier for me to understand what’s wrong with me; it could be neck/back/or other that needs treating”“It just appeals more to my GP - I just think that would be better”“More appropriate for me”“More individual diagnosis and more specific”“The last time I asked my GP he sent me to the neck and back pain clinic, I think it’s better for patients, it makes it easier”
Theme Four – More Choice“Because it seems easier to have another choice of clinic - neck and back if necessary”“It just seems that you have a choice where you’ve treated”“Don’t know really, it just looks better. You have a choice where you can get treated also a choice of appointment times” “Gives you more options”“Just seems the best, patients have the choice where to be assessed”“There seems to be more choice”“There’s a wide choice of services”
Theme Five – More Convenient “Better appointment times, especially if you are working, I wouldn’t need to take a day off work”“Better for the appointments and times, that’s all”“Less waiting around as MCAS and neck and back are related” “They can combine them together. There's a wider choice of appointment times”“To define exactly what treatment I need, I don’t think I need RCAS”“You are less likely to be referred back to your GP, wider choice of appointment times”“You’re less likely to be returned back to you GP, wider choice of appointment times as well”
Comments Relating to Option 3Theme Six – More Efficient and Effective Diagnosis and Treatment“Would prefer to be assessed in clinic, communication easier, to get correct treatment”“All combined would be better”“All in one place and wider choice of times”
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“All in one service, less referrals and messing about”“All in one, appears to be quicker”“All in the one building and it would be quicker and easier as well if they are in the one place”“All services are combined together in one place, saves you going back and forth to different places”“All under one umbrella, easier assessment, more choice for patients”“Assessed immediately to correct clinic”“Because GP has overview, but to see another more qualified person at clinic to direct to correct service is best”“Because better to have diagnosis and treatment in 1 place”“Because there is a choice in option 3, better diagnosis to be sent to correct clinic”“Because I have different problems so they could all be dealt with without referral to GP”“Because it will diagnose completely what is wrong with us at one appointment”“Because it will identify all problems at same time, save being referred again”“Because it will stop repeat referrals and find out what’s wrong with me at one appointment”“Because it's all together get it all done at once, save you going back and forward”“Because more options than 1 and 2, it would take pressure of GPs”“Because saves going for more referrals - probably would save time”“Because they are less likely to have to go back to their GP if they have a choice of where to go”“Because this option dealt with all conditions and gives diagnosis in clinic which is more likely to be right”“Because you are referred by the service, more choice”“Combining services could help make the service cash effective”“Common sense, save going back to the GP to be referred, save on time all round”“Easier if they’re altogether, it saves you travelling around to different places, it makes it harder”“Everything in one place, saves a couple of different journeys to different place, it must save on time as well and save on cost with all the letters they send out”“Everything in the one place, everything combined, that’s all”“Everything is combined you’re not backwards and forwards to the GP, they can sort it out in the clinic”“Everything is returned to GP and I am more likely to get information from my GP than the hospital”“Everything will be together; you will have a wider choice of appointments, but everything being together it saves you going backwards and forwards” “First time I've been but it looks as if getting the advice at the hospital would be easier to actually find out the treatment needed”“From experience for each appointment it takes too long, so you are going back to your doctor, it would be better to be assessed in one place”“Get to the right clinic and could get help for other problems”“Get to the right clinic instead of being re-referred”“Having one service under one roof, you do not have to go to several places and phone calls”“I am under Broadgreen, save on car parks, and better that all the clinics in one place”
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“I don’t want to be travelling to different places for appointments better all in the one place easier”“I have a lot of problems and I have to go to different clinics, so it would be easier if they’re all together in one place.“Prefer to deal with one department; there will be no messing about going back to GP and re-referrals”“I suffer from neck and back problems and also I have rheumatology so I was at 2 clinics for treatment”“I suffer with back pain and if it’s all in one place they can refer you to save you going back to the GP”“I think it sounds better, saves you going from one place to another if you need to see a different doctor”“I think it would be easier rather than going to 3 separate places its better if all combined to the one clinic”“I think it’s more likely to get correct treatment of 3 clinics offered”“I think that would work best if it would cut across appointments to see your doctor”“I will be directed to correct clinic first time”“I wouldn’t have to go back to the doctors they would do it themselves”“It appears to give more options on place and time”“It covers everything; everything is done in one place, wider choice of appointments, patients won’t have to keep returning to GP to be re-referred”“It gives more flexibility in referral, more benefits for patient”“It is better to be assessed in clinic which condition applies to”“It just seems easier instead of going back and forward to different places and their GP”“It just seems to be more practical to have more than one service in the one place. It’s better for patients care. Won't be confusing for the elderly, less having to go to one place, its more practical for the staff”“It keeps them all together; you’re not coming from one clinic to the other”“It means that you can get sorted in the one clinic; you don’t have to wait for appointment you can get it sorted there”“It might be better altogether if we’re not going to different clinics and hospitals”“It seems more extensive and more involved, some clinics are combined and they can communicate better. Patients can choose which clinic to go to, you are given the choice”“It sounds better if there all together, it saves on time going back to GPs and my time as well”“It will be easier to find right clinic, one stop shop is fine”“It will save people having to travel all over the area. It makes sense to have one place accessible for people”“It would be a way of finding out exactly what is wrong”“It would be all in the one clinic, I wouldn’t have to go to different ones”“It would be better to have all three clinics together; you wouldn’t have to travel to different clinics”“It would be easier all together at the one clinic, if I needed to see someone one they will do it for me”“It would be easier to go if there altogether”“It would mean more precise diagnosis than now”“It would save going backward and forward to different clinics in the hospital”
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“It would save me running round to different places”“It would save time and going back and forth to your GP”“It would save time making another appointment with the GP”“It’s all a smaller clinic and conditions, I don’t have to go back to the GP because I need a scan to see what it is, it all sounds brilliant”“It’s all combined, choice of appointment times, it does sound a lot better, you don’t have to go to different hospitals”“It’s all in one, assessment and referral is all in one place instead of being sent backwards and forwards all the time, you can pick which appointment is better for you which is good for me because I work”“It’s all in one building; it would be easier all round altogether. You wouldn’t have to go to different places if you had more than one complaint”“It’s all in one, you do not have to go back and forward to your doctor to go and see another specialist, it would all happen in one place, the doctor in the hospital would have all the information at hand rather than my GP”“It’s all together. I got referred to the wrong one for my last appointment and it got cancelled but they didn’t say why and I had taken the day off for the appointment”“It’s combining everything together, wider choice of appointment times, you are less likely to be returned to your GP”“It's easier it would save you travelling too far, its better if it’s all under the one roof because you have a number of different problems”“It’s easier on time and energy and travelling time and saves stress”“It’s got everything in it, everything you need. Patients have a better choice where to be assessed and treated”“It’s just like the range of different options it offers”“It’s more concise this way, you’re not being sent here there and everywhere”“It’s only one community service for assessment, wider choice of appointment times, you have choice of where you can be assessed and treated”“It’s under one roof, you can’t get through to the doctor by phone so if it was altogether it would be easier - no going back to the doctors”“Just dealing with 1 department is better, no messing about re: referrals”“Just looks the best out of them all. I just think it’s better”“Looks like best option, convenient for everyone concerned”“Makes it easier if you have more than one complaint you can take it all up on the one visit”“Maybe it would save time if you might not have to see the GP doctor as much”“Maybe quicker to get seen with option 3”“More chance of getting correct treatment, more options”“More chance of getting seen by right person”“More choice and would look at different conditions at the same time”“More choice to find out what could or couldn’t be wrong more choice of clinics”“More direct - easier to access proper treatment”“More flexible times”“More likely to get better diagnosis and treatment”“More options, but person assessing which clinic to go to must be professional, doctor etc.”“Offers most flexibility in clinics and availability of appointments”“One service will assess and patients also have the choice of time and venue”“Only 1 referral so time saving and simpler”
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“Patients have a choice of where there assessed. A lot of people don’t have transport. There are more points for it than against it. I wouldn’t want to go back to the GP”“Patients have more choice”“Prefer to using different places, assessment in one place at hospital where services are”“Save time and I would probably be seen to quicker you don’t have to keep going back to the doctor”“Seems a lot easier - to go to the clinic to see where to go is easier than being passed around and re-referred”“Seems to be an easier option than going back to GP”“Seems to be more flexible to find correct treatments”“Seems to be quicker appointments and sent to correct department saves referrals in future”“Seems to make sense, seem a lot more efficient to have it all in one place”“Seems to offer more choice and first time placement in correct clinic”“So I’m not backwards and forwards for different appointments all the time, and not have to travel to different hospitals that would be so much easier for me if everything was in the one hospital in one place”“Sometimes you are referred to wrong clinic, so if they are all t the same place you can just get passed on instead of going back to GP and having to go through the system again”“The assessment by GPs is not so precise, better diagnosis at merged clinics”“The assessment would be done by the right people all under one department”“The GP is referring you, if you are always going to your GP first”“The hospital knows best and would be quicker in getting you to the right department”“They are all in one department”“They are all under one roof”“Wider choice of appointment times” “Wider choice of appointment times and less likely to have to go back to your GP choice in where to go”“Wider choice of appointment times, any treatments”“Wider choice of appointments times because of my work pattern, combining the services because I need lots of treatments”“Wider choice of times and venues”“You do not have to go back to your GP to be referred to see someone else at another clinic, that all takes time”“You are getting more services with that one”“You can be dealt with easier if you’re not at the right department they will put you through or if you need to see someone else”“You could get it done in peace, leaves time going to different clinics”“You should be referred from the clinic you don’t have to keep going back to the GP, quicker lists” “You would be able to be treated at the one place”“You would have had to do back to the doctor to be redirected to another clinic if needed”“Your notes would all be there together, so would be easier for them to access notes in case you needed referring to another clinic”
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Appendix 2: Orthopaedic & Rheumatology Services – Briefing Paper
Who are we?NHS Liverpool Clinical Commissioning Group is made up of all the GP Practices in Liverpool. We are responsible for planning and buying local health services - this includes hospital and community services.
What do we want to know?We are interested in your views about changes to how and where these services operate.
What will we do with the information?All of the information that you provide will be kept confidential. It will not be shared with your GP, hospital or anyone else involved in your care. The information will be used to help improve patients’ experience of services and how efficiently they are delivered.
Summary of changes being considered We are reviewing the way people with Orthopaedic and Rheumatology conditions can best be supported in Liverpool. Orthopaedics covers injuries and diseases of the body's muscles, skeleton and related tissues including the spine, joints, tendons and nerves. Rheumatology also affects joints and muscles but is usually connected with the immune system and includes conditions such as inflammatory arthritis.
We are reviewing How GPs can refer patients for specialist treatment. Referrals, assessment and treatment for patients that don’t require surgery or complex
treatment. Waiting times for patients that do require surgery or complex treatment. Inclusion of Chiropractor and Osteopath treatments in services Location of services.
There are currently three separate services providing treatment including advice, physiotherapy, group exercise classes, testing (eg x-rays) and referral to the hospital consultant if it is a complex case / needs surgery. These three services are being reviewed:
A. Orthopaedic Musculoskeletal Clinical Assessment Services (MCAS) in hospitals & community clinics (delivered in 8 places across Liverpool)
B. Rheumatology Clinical Assessment Services (RCAS) in hospitals & community clinics (delivered in 3 places across Liverpool)
C. Neck and Back Pain clinics in GP/health centres and hospitals (delivered in 19 places across Liverpool)
Patients can choose where to be treated and some places are seeing very few patients.
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Currently a GP has to choose which service to refer a patient to without having information such as test results. Knowing which service is best for a patient requires specialist knowledge and assessment, for example pain in the neck can be caused by a shoulder problem, or pain in the back by a hip problem. Across the three services there are many different referral, assessment and treatment steps which can make the patient’s journey to getting the best care complex. A trial was carried out with some services to see if streamlining these steps and combining services would improve patient’s experience and improve efficiency.
Summary of Implications of Possible Changes
The trial of GPs referring all patients with orthopaedic conditions via MCAS has reduced waiting times for people with complex or surgical cases needing to see hospital consultants. Waiting times for non-complex and non-surgical cases is stable.
92% of patients surveyed rated the care they received from the MCAS service during the trial as excellent or good
92% of GPs responding to the survey rated the performance of the piloted service as very good or good for their patients.
Joining up services would mean fewer referral steps and appointments for patients Joining up services would make access to tests (eg x-ray/blood tests) easier – they
may be available on the same day and no need to return to the GP for another referral
The benefits seen from joining up orthopaedic services could apply to combining rheumatology and neck and back pain services as well
Joining up services means a wider choice of appointment times would be available for all patients, as appointments are not divided up between separate services.
If services are being joined up, the locations are likely to change. They can still be based in both hospital and community venues for ease of access but locations would need to be decided
Financial savings would be realised for the CCG which could be reinvested in orthopaedic/rheumatology clinic locations or other services.
There are three options being reviewed about the way these services might be provided in future and your views on these would be really welcome.
Option 1Continue with the current scenario with three separate services that GPs can refer to according to whichever specialty they think is best. Musculoskeletal Clinical Assessment Service (MCAS) Rheumatology Clinical Assess and Treatment Service (RCAS) Neck & Back Pain
Same locations, patients have a choice of where/when to be assessed and treated.
Option 2Combine some of the services so GPs refer to MCAS or RCAS and the patient is then
assessed Combine MCAS and Neck and Back Pain
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Keep RCAS separate Review location of services to ensure good access. Patients have a choice of where to be assessed and treated and a wider choice of
appointment times.
Option 3To have one service that combines MCAS, Neck and Back Pain and RCAS. GPs refer patients to this one community service for assessment, treatment or referral. We review location of services . Patients have a choice of where to be assessed and treated and a wider choice of appointment times.
FAQs1. Why are these services being reviewed?
The contracts for most of the services A, B and C are held by different organisations working on behalf of NHS Liverpool CCG and are due for renewal. At present there are many different referral routes which can make the patient’s journey complex. A different way of working would be to bring the services together to act as one joined up service. A trial was carried out with some services to see if changing the referral, assessment and treatment steps for a patient improves their experience and improves efficiency. The pilot has shown the following benefits:-
Reduced waiting times for those needing complex treatment / surgery. Reduced backwards steps in the treatment journey eg exiting the system and having
to go back to the GP for a different referral Reducing re-referrals to different services Reducing costs
Based on this, three options have been prepared for how services might be delivered in future. Previous engagement found that patients felt the quality of services was good and this will be maintained across any of the delivery options.
2. Why are we asking for your views?NHS Liverpool CCG wants now to look at these services in the round and get a wider set of views about delivery. The aims of seeking the views of patients and members of the public are to influence the way the services are designed so as to:-
a. Improve patients experience of using the servicesb. Maintain high quality servicesc. Improve efficiency in service delivery
We are particularly trying to explore the following:a. To gather knowledge, experience, information and perspectives from local
communities to help improve the redesign of these servicesb. To find out people’s views about the steps they will go through in being referred for
these services, assessed and treated.c. To find out people’s views about the location of these services.d. To find out whether information and support for patients about how they can
manage their condition/injury themselves is wanted and if so, what is helpful and when in the assessment, treatment and recovery journey it needs to be available.
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e. To understand people’s experiences on any aspect of these services that will help improvement.
f. To find out which of the three options for delivery are preferred by people – maintaining separate services, joining up some services, joining up all services.
g. To understand whether people want osteopathy to be included in the service.h. To understand whether people want chiropractors to be included in the service.i. To ensure community members are aware of and understand how their input has
been considered and used to shape the redesign of the services.Each of these elements can be influenced by this engagement process and views will be used to help shape the final service.
3. Whose views are we seeking?We are interested in the views of everyone who may have used the services in the past, or be currently receiving treatment, people who may use the service in future or benefit from prevention/self-care measures and those who have relevant issues but have not used the services. We are also interested in the views of carers and friends/family members.
4. What are the Current assessment & treatment steps for Orthopaedic and Rheumatology services?
GP decides to refer patient to a specialist and can refer directly to any of the following services:
Orthopaedic Consultant in hospital Rheumatology Consultant in hospital Musculoskeletal clinical Assessment Service (MCAS)(staffed by Physiotherapists, Extended Scope Physiotherapists and GP with Special Interest in orthopaedic conditions) Rheumatology Clinical Assessment Service (RCAS)(staffed by GP with Special Interest in rheumatic conditions and Physiotherapists) Neck and Back Pain clinic (staffed by Physiotherapists, Chiropractors and/or
Osteopaths)
MCAS, RCAS and Neck and Back Pain clinics are in both hospitals and community locations.
The patient is seen by the service chosen by the GP. If that specialist decides the patient requires a different specialty, the patient is referred on to another service. This can involve additional appointments and sometimes returning to a GP to start the referral process again.
5. What is not being reviewed? GPs making initial assessments of patients Orthopaedic and Rheumatology Consultants delivering complex case and
surgical treatment services in hospitals
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Orthopaedic and Rheumatology Consultants treat patients in hospital including managing complex cases and surgery. In Liverpool the Royal Hospital, Aintree Hospital and Spire Hospital are the main providers of these services which include complex shoulder and spinal surgery, hand surgery, hip replacement, knee replacement and foot and ankle surgery.These parts of the process are not being reviewed.
6. What has been trialled as a new way of delivering the Service?Between 2013-2014 NHS Liverpool CCG worked with the three main providers of Orthopaedic services and agreed to trial changes to referral processes for a period of 9 months. Clinicians were of the opinion that 80% of all orthopaedic referrals would best be handled by MCAS. The trial saw GPs referring via MCAS only to see if this would improve the service.
Trial treatment steps were GP refers all orthopaedic patients to MCAS MCAS clinicians review the referral letter and use their specialist knowledge to
decide whether they can assess and treat the patient or if the patient should instead go to another clinic.
80% of patients are expected to then be kept in MCAS who see and treat the patient, including carrying out any tests e.g. x-rays and may refer to a hospital consultant if the cause is complex or requires surgery.
Most of the remaining 20% of patients will be booked directly into another clinic by MCAS but without needing an MCAS appointment first. A small number will be discharged back to their GP with a management plan to follow.
The ‘STarTBack’ tool was used by GPs to help identify the most appropriate service for patients with neck and back pain. This helps decide if the patient should be treated by their GP, at a Neck and Back Pain clinic, in MCAS, or sent direct to a hospital consultant.
If at any point the patient is referred to a hospital consultant clinic they were contacted by the NHS Liverpool CCG Choice Team to be offered choice of where to have treatment and in the majority of cases their appointment would be booked during that conversation.
7. What was the Learning from the Trial?Evaluation of the trail has shown that making all orthopaedic referrals via MCAS has reduced the number of referrals into hospital consultants which in turn, has reduced waiting times for people needing complex treatment or surgery.
Where a MCAS referral on to a consultant was needed, the MCAS clinicians were able to explain to the patient the possible result of the consultant appointment. For instance if it was hip replacement surgery, then they would discuss with the patient what would happen in the operation and what the expected outcome would be, such as a change in mobility or pain reduction. In this way, only patients who were prepared to consider an operation were referred to a consultant. The consultant can then review and treat an informed patient rather than starting from scratch and/or
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discovering the patient will not consider surgery. This makes better use of the consultants and patients time.
This process has also reduced the number of patients discharged from hospital consultants at their first appointment because they didn’t want the treatment options available to them. This means that only those patients who need to be seen by a consultant and are prepared to consider having the treatment available to them are seen by a consultant. This has also contributed to reducing waiting times for consultant appointments.
In the 12months before the trial there were 25.3 people in every 1000 attending a consultant appointment in Liverpool. In other cities it was 20.7 people in every 1000. After the pilot Liverpool had 20 people per 1000 population visiting a hospital consultant and was therefore more in line with other places.
Initially waiting times for MCAS did increase as more patients were being seen there, however additional staff were recruited and waiting times are now within the current target of within 20 working days.
During the course of the pilot there has been an increase in MCAS appointments and therefore costs, although overall the funding for orthopaedics has reduced as the increase in MCAS has been offset by the savings in consultant appointments.
Introduction of the STarTBack questionnaire by GPs has also reduced the number of patients with neck and back pain being referred to the separate Neck and Back pain clinics. More patients are being effectively supported by their GP. This results in some financial savings and improves patient experience as patients are being seen in the right place by the right clinician.
8. What did Patients and GPs think of the new approach?During the pilot we spoke with 750 service users and 92% of patients surveyed (695) rated the care they received from the MCAS service as excellent or good. A GP survey found 78% of the 48 GPs who took part stating they were very satisfied or satisfied with the piloted MCAS service and 92% rating the performance of the piloted service as very good or good for their patients. In light of the positive outcomes, the piloted referral model has been retained post pilot and is continuing to generate benefits. The Neck and Back Pain clinics and the Rheumatology Assessment clinics have remained separate however and we are looking at the benefit of joining these services up in the same system.
9. What about Neck and Back Pain Services?The separate Neck and Back Pain clinic divides The Royal and Aintree Hospitals MCAS service, as appointments have to be provided in both clinics. It is not always easy for referrers to decide which the most appropriate clinic is as pain in the neck can be caused by a shoulder problem, or pain in the back by a hip or knee problem. This is leading to patients being re-booked into alternative clinics, or not always being seen
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by the appropriate clinician and wasted clinic appointments. It is exacerbated by Neck and Back Pain clinics not having access to diagnostics, so the referrer has to decide prior to referral whether the patient is likely to need a diagnostic test. If they believe they may, then the referral should be sent to MCAS but this is not always clear in advance. If a patient attends a neck and back pain clinic and is then found to need a diagnostic test, then they have to be discharged back to the GP for re-referral.
The outcome of the review indicates that there may be benefits in not renewing the separate Neck & Back Pain contracts which are due to expire in September 2015 but joining the service into the MCAS process piloted and described above. The benefit suggested by the pilot is that this joined up service would streamline the referral and treatment process and ensure patients are seen by the most appropriate clinician first time. However most of these clinics are in GP practices so removal of these clinics would reduce access for patients. The locations for joined up services would therefore need to be reviewed. We are asking for views on all of these elements.In addition, the Neck & Back Pain clinics have recently included a chiropractor and an osteopath as part of the service. The chiropractor and osteopath have seen just over 100 patients between September and December 2014. We are keen to understand whether osteopath and chiropractor services are valued by patients and whether they should therefore be included in any of the service delivery options being considered.
10. Where do we need the services to be?The Orthopaedic and Rheumatology clinics which are part of this review are currently provided in the following locations. As part of the review we want to know if any changes are made to join up services where clinics need to be held to best meet patient needs.
Main Providers and Locations of Services for Liverpool Patients
Consultant led Orthopaedic Clinics
The Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP
Broadgreen Hospital, Thomas Dr, Liverpool. L14 3LB Aintree University Hospital, Longmoor Lane, Liverpool, L9
7AL Spire Liverpool, 57 Greenbank Road, Liverpool. L18 1HQ
Royal Hospital MCAS Clinic
The Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP
Broadgreen Hospital, Thomas Dr, Liverpool. L14 3LB South Liverpool Treatment Centre, 32 Church Road, Garston,
Liverpool. L19 2LWAintree Hospital MCAS Clinic
Aintree University Hospital, Longmoor Lane, Liverpool, L9 7AL
Mere Lane Neighbourhood Health Centre, 49-51 Mere Lane, Liverpool, L5 0QW
Ropewalks, 26 Argyle Street, Liverpool L1 5DL
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Litherland Health Centre, Hatton Hill Road, Litherland, Liverpool, L21 9JN
Yew Tree Health Centre, Berryford Road, Liverpool, L14Neck and Back Pain Clinics
The Injury Care Clinic (TICCS) Bousfield Health Centre, Westminster Road, Liverpool, L4
4PP Princess Park Health Centre, Bentley Road, Liverpool, L8 0SY Green Lane 15 Green Lane, Liverpool, L13 7DY Ellergreen, 24 Carr Lane, Liverpool, L11 2YA Baycliff Health Centre, 73 Baycliff Road, Liverpool, L12 6QX South Liverpool Treatment Centre, 32 Church Road, Garston,
Liverpool. L19 2LW Orrel Park Medical Centre, Orrell Lane, Liverpool, L9 8BU Netherley Health Centre, Middlemass Hey, Liverpool, L27
7AFBack2Health (Osteopath)
Aintree Osteopathic Clinic 225 Longmoor Lane Aintree, Liverpool L9 0ED
Firth (Chiropractor) Rocky Lane Medical Centre, 80 Rocky Lane, Liverpool L16 1JD
Aintree Aintree University Hospital, Longmoor Lane, Liverpool, L9
7AL Mere Lane Neighbourhood Health Centre, 49-51 Mere Lane,
Liverpool, L5 0QW Ropewalks, 26 Argyle Street, Liverpool L1 5DL Yew Tree Health Centre, Berryford Road, Liverpool, L14 4ED
The Royal The Royal Liverpool Hospital, Prescot Street, Liverpool, L7
8XP Broadgreen Hospital, Thomas Dr, Liverpool. L14 3LB South Liverpool Treatment Centre, 32 Church Road, Garston,
Liverpool. L19 2LW York Centre, Smithdown Road, Liverpool. L15 2HE
Rheumatology Consultant Clinics
Broadgreen Hospital, Thomas Dr, Liverpool. L14 3LB Aintree University Hospital, Longmoor Lane, Liverpool, L9
7ALRheumatology Clinical Assessment (RCAS)
Aintree: Aintree University Hospital, Longmoor Lane, Liverpool, L9
7ALThe Royal:
South Liverpool Treatment Centre, 32 Church Road, Garston, Liverpool. L19 2LW
Kensington Neighbourhood Centre, 155–157 Edge Lane, Liverpool L7 2PF
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MCAS and Neck & Back Pain clinics include physiotherapy services. Some of these clinics currently support very few patients.
During the pilot patients were asked to look at a list of possible sites where they could have their MCAS appointment and say whether it would be more convenient, less convenient or would make no difference to them. The list included current sites and other NHS sites across the city where services could be offered. Some patients selected more than one site.
The most popular sites, where services are already located were the Royal, Broadgreen, Aintree and South Liverpool Treatment Centre. Childwall was the 5 th
most convenient for 16% of the patients surveyed, making it more convenient than the current service locations in Yew Tree, Ropewalks, Mere Lane and Litherland. There is currently no service in Childwall. Further analysis of the responses showed that 97% of patients attending Aintree, 84% at RLBUHT and 81% attending Ropewalks were happy with the clinic location.
Currently the Neck and Back Pain clinics are provided in the most community venues. If the option to join services up is taken, we may need to increase the locations where patients can get MCAS support to ensure we are not reducing access for people. We would like to know people’s views on whether additional locations would be needed and what would be the best additional locations if so.
Given the findings of the orthopaedic trial and the positive views of patients and GPs, NHS Liverpool CCG wants to hear from patients, individuals and communities about their views on making these in the new contracts and also extending the benefits to both orthopaedic and rheumatology services.
We would like people’s views on these 3 options available for service delivery.
Option 1Continue with the current scenario with three separate services that GPs can refer to according to whichever specialty they think is best. Musculoskeletal Clinical Assessment Service (MCAS) Rheumatology Clinical Assess and Treatment Service (RCAS) Neck & Back Pain
Same locations, patients have a choice of where/when to be assessed and treated.
Option 2Combine some of the services so GPs refer to MCAS or RCAS and the patient is then assessed Combine MCAS and Neck and Back Pain Keep RCAS separate Review location of services to ensure good access. Patients have a choice of where to be assessed and treated and a wider choice of
appointment times.
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Option 3To have one service that combines MCAS, Neck and Back Pain and RCAS. GPs refer patients to this one community service for assessment, treatment or referral. We review location of services . Patients have a choice of where to be assessed and treated and a wider choice of appointment times.
Alongside this engagement we are asking for people’s views about pain services. For details of this process please visit the website www.liverpoolccg.nhs.uk/getinvolved
Info linkshttp://www.nhs.uk/conditions/physiotherapy/pages/introduction.aspxhttp://www.nhs.uk/conditions/chiropractic/Pages/Introduction.aspxhttp://www.nhs.uk/conditions/osteopathy/pages/how-is-it-performed.aspxhttp://www.arthritisresearchuk.org/arthritis-information.aspxhttp://www.nhs.uk/conditions/Rheumatoid-arthritis/Pages/Introduction.aspx
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Orthopaedic and Rheumatology Services Asking for Views
Location (if applies)…………… VCSE organisation (if applies)…………
Questions
1. Which proposed option do you think will offer patients a better service? Option 1- maintaining separate services Option 2 – joining up some services Option 3 – joining up all services Don’t know
Please tell us why you have chosen this answer (optional free text)____________________________________________________________________________________________________________
2. Have you used any of the services being reviewed? Yes No
If no please go to Question 8
3. Please say if you? Are currently using NHS MCAS/Physiotherapy Services (Orthopaedic) Have previously used NHS MCAS/Physiotherapy Services Have not used this service (please go to question 4)
3a. How would you describe your experience of using this service?
Excellent Good Average Disappointing Poor
Please tell us why_____________________________________________________________________________________________________
3b. Do/did you feel involved in the development of your care plan/s? Yes No Not applicable
4. Please say if you? Are currently using NHS RCAS/Physiotherapy Services (Rheumatology) Have previously used NHS RCAS/Physiotherapy Services Have not used this service (please go to question 5)
4a. How would you describe your experience of using this service?
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Excellent Good Average Disappointing Poor
Please tell us why (free text)4b. Do/did you feel involved in the development of your care plan/s?
Yes No Not applicable
5. Please say if you? Are currently using NHS Neck and Back Pain Services Have previously used NHS Neck and Back Pain Services Have not used this service (please go to question 6)
5a. How would you describe your experience of using this service?
Excellent Good Average Disappointing Poor
Please tell us why (free text)5b. Do/did you feel involved in the development of your care plan/s?
Yes No Not applicable
6. Have you ever been treated by an osteopath? Yes No Please go to question 7.
6a. If yes, how would you describe your experience of using this service? Excellent Good Average Disappointing Poor
6b. Would it be beneficial to include osteopaths as part of the new service? Yes No Not sure
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7. Have you ever been treated by a chiropractor? Yes No Please go to Question 87a. If yes, how would you describe your experience of using this service?
Excellent Good Average Disappointing Poor
7b. Would it be beneficial to include chiropractors as part of the new service Yes No Not sure
8. How would/do you travel to medical appointments? (you can choose more than one) Walk On the bus By car By train By taxi By bike Other (please specify)
9. How would you like to receive information about how you can manage your condition/injury or one that might arise? (you can choose more than one) From a professional From a leaflet Training / education session Through peer support – i.e. somebody who has gone through what you’re going
through Personalised tools Websites Email Social media Smartphone apps Other – please specify I am not interested in taking action myself
10. When would you like to receive information about looking after your condition/injury/? (You choose more than one option)
At your first GP appointment At your first appointment with the specialist service
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During treatment On discharge Not at all Don’t know
11. For any services discussed here, would you like to be able to contact the service after a period of treatment if the same condition recurred within a specified time period?
Yes No
12. Please tell us anything else you would like say about any of the issues raised here________________________________________________________________________________________________________________________________________________________________________________________________
It helps us to understand whether we have heard from a diverse range of people if you could also answer the following questions…or as many as you wish to answer.
13. Do you identify yourself as...
Male Female Prefer not to say
Is your current gender identity the same as the one you were assigned at birth? Yes No Not sure what the question means
14. Age...
Under 18 18-25 26-44 45-64 65-75 76+ Prefer not to say
15. Do you consider yourself to have a disability? Yes No Prefer not to say
Please tick if you have any of the following
Physical disability Visual Impairment Learning Disability Hearing Impairment / Deaf Mental illness/ distress Long term illness that affects your daily activity
Dementia
Other (please write in) ______________________________________________
16. Sexual Orientation...
Bisexual Heterosexual Gay/Lesbian Other Prefer not to say
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17. Which of these options best describes your ethnic background?
Please select one box for each (the options are listed alphabetically)
Ethnicity – do you identify as...Asian or Asian British: Bangladeshi Indian Pakistani Other Asian background (please write in if you wish)____________________________
Black or Black British: African Caribbean Other Black background (please write in if you wish)____________________________
Chinese or Chinese British: Chinese Other Chinese background (please write in if you wish)__________________________
Mixed Ethnic Background: Asian & White Black African & White Black Caribbean & White
Other Mixed background (please write in if you wish)____________________________
Other Ethnic Group: Arabic Other (please write in if you wish)____________________________
White: British English Irish Scottish Welsh Polish Latvian Gypsy / Traveller
Other White background (please write in if you wish) ____________________________
Prefer not to say
18. Do you have a religion or belief? Yes No Prefer not to say
If yes, please tick one of the below... Buddhist Christian Hindu
Jewish Muslim Sikh No religion Prefer not to say Other (please specify if you wish)________________________________________
Thank you so much for sharing your views with us we really appreciate it!
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Keep in Touch? - If you would like to know how your ideas have helped, what happens next or to be involved in other health issues in Liverpool, please drop us an email at [email protected] or call 0151 296 7537.
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Appendix 3: Who was engaged, where and how:Who you engaged with When Where Engagement method
usedPRAXISPatients attending relevant clinics
9th to 27th March 2015
AQP (36)Aintree Hospital (26)Mere Lane (4)Kensington (49)Garston (27)Broadgreen(68)AUH Yew Tree (16)Spire (20)Rocky Lane, Chiropractor (11)Unclassified (20)
Face to face interview with structured questionnaire
AGE CONCERNVulnerable Older People
9th to 20th March2015.
Age Concern Liverpool and Sefton Poppy Centre
Group explanation and then one to one discussions
NEURO MUSCULAR CENTREIndividuals with muscular dystrophy – a progressive neuromuscular condition
9th to 20th March2015
At the Neuromuscular Centre
Face to face questionnaire with individual and physiotherapist or using the same questionnaire in a phone interview.
WHISCDiverse communities and service users
Tuesday 10th March 2015
WHISC 120 Bold Street, Liverpool.
International Women’s Day Event concentrating on holistic pain relief and including a focus group, relaxation and therapy sessions and a questionnaire.
ONLINE SURVEYRespondent profile included ‘communities of interest’, ‘members of the public’ and ‘existing service users’
9th to 27th March 2015.
On-line Structured self-completion questionnaire.
VOICE OF NATIONSRespondent profile included 24 people from the BME Community (African Origin)
9th to 27th March2015
LA Health and Wellbeing Clinic and Pentecost Baptist Church
Drop-in information management, group discussion and structured questionnaire.
Table 6: Groups that were engaged with
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Appendix 4: A note on the statistics used in the Orthopaedic and Rheumatology services consolidation report
Six independent engagement exercises were used to obtain opinions about the preferred options for the future of Orthopaedic and Rheumatology Services in Liverpool. Merging these six sets of findings into one consolidated report presented a number of methodological challenges. This note is designed to provide the reader with the nature of these challenges and potential implications for the accuracy of the statistics contained therein. These challenges were as follows:
Representativeness of the Sample to the Population of Orthopaedic and Rheumatology Service UsersOne fundamental question is how representative is the sample of respondents of the total population of service users. Without a detailed statistical profile of service users it is impossible to say. However, by sampling from a wide range of different groups, and arriving at a broad consensus, then it is reasonable to assume the results provide an accurate estimate of user opinion. For some groups that have been narrowly defined, such as vulnerable older people or patients with muscular dystrophy, we can be much more certain that we know how these groups feel. However we have no way of knowing what proportion they make up of the total sampling population and therefore we have no way of weighting their involvement to their ‘correct proportionality’.This is in contrast to the online survey, WHISC and Voice on Nations research which covered a much broader category of respondent with the possibility respondents could have been included in one or more groups. Again we have no way of knowing how relevant these groups are to the total population of service usersThere is also the issue of service users and non-service users to consider and these were not identified as one of the classification variables. Both service users and non-users were merged in some of the analysis.
Actual Statistics AvailableGiven the challenges faced by the different groups in administering the questionnaire there was considerable variation in the standard of statistics produced. Praxis used a statistical survey analysis package to generate statistics about one group of respondents i.e. service users. No other engagement exercise (with the exception of the online survey) appeared to use any form of automated analysis – they did manual analysis. As a consequence the standard of analysis was, understandably, not as comprehensive or as detailed as those using an electronic process. Very often the base statistics on which percentages were calculated was missing and therefore there was no way of knowing who or how many people answered the question. Subsets of qualifying questions were similarly affected. The main consequence of this is that we had to make a ‘judgement’ or an ‘estimate’ based on incomplete information in order to capture something meaningful from the data. We were cautious in not merging such statistics across different groups because of the danger of producing a statistic that appeared to have more credibility than it deserved – a kind of ‘false exactitude’. For example, where we have produced a statistic such as 80%+ it is because we don’t have the actual numbers to be more precise. All we can conclude from the accumulated evidence is that the statistic is almost certainly over 80%.
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Merging Qualitative and Interpretative Data into the Consolidation ReportThroughout the consolidation report we have retained the wording used by the original author. We adopted this approach because to do otherwise would risk misinterpreting both content and sentiment. For example where an author used the word “unheard” it was obviously used to convey a particular meaning and it would have been dangerous for us to assume what point they were actually intending to communicate. Similarly, where an author has made a generalised suggestion such as “the terminology needs to be appropriate” we cannot provide the evidence that prompted the comment.
Suggestion for Future Engagement ExercisesWhere the intention is to merge statistics from different engagement exercises then there should be one consistent methodology for analysing responses to structured questionnaires. Ideally the information output specification should be agreed in advance and one option might be for one organisation to manage data analysis for all organisations involved. Primary statistical data could be returned to the relevant organisations for them to interpret and add their own unique insights.
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