Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
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Right person, right place, first time Transforming musculoskeletal and orthopaedic elective care services A handbook for local health and care systems
NHS England INFORMATION READER BOX Equality and health inequalities
Directorate Promoting equality and addressing health inequalities are
Medical Operations and Information Specialised Commissioning at the heart of NHS England’s values. Throughout the
Nursing Trans. & Corp. Ops. Strategy & Innovation development of the policies and processes cited in this
Finance document, we have:
• Given due regard to the need to eliminate
Publications Gateway Reference: 07424
discrimination, harassment and victimisation, to
Document Purpose Resources
advance equality of opportunity, and to foster good
Document Name Transforming musculoskeletal and orthopaedic elective care services relations between people who share a relevant
Author Elective Care Transformation NHS England protected characteristic (as cited under the Equality
Publication Date November 2017 Act 2010) and those who do not share it; and
Target Audience CCG Clinical Leaders, Care Trust CEs, Foundation Trust CEs, Medical Directors, NHS • Given regard to the need to reduce inequalities between
Trust Board Chairs, NHS England Regional Directors, NHS England Directors of patients in access to, and outcomes from, healthcare
Commissioning Operations, Allied Health Professionals, GPs, Emergency Care Leeds
services and to ensure services are provided in an integrated
Additional CCG Accountable Officers, CSU Managing Directors, Directors of PH, Directors of way where this might reduce health inequalities.
Circulation List Nursing, Communications Leeds
Description Information Governance Statement
Cross Reference N/A Organisations need to be mindful of the need to comply
(if applicable) with the Data Protection Act 1998, the Common Law
Superseded Docs N/A Duty of Confidence and Human Rights Act 1998 (Article 8
Action Required N/A – right to family life and privacy).
(if applicable)
Timing/Deadlines N/A
(if applicable)
Contact details for Elective Care Transformation programme This information can be made available in
further information Operations and Information
alternative formats, such as easy read or large print,
Quarry House
LS2 7UE and may be available in alternative languages, upon
request. Please contact 0300 311 22 33 or email
Document Status
england.contactus@nhs.net stating that this
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is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this Team Operations & Information NHS England.
document should not be saved onto local or network drives but should always be accessed from the intranet.
2 Right person, right place, first time
Elective Care
Transformation: What is it?
Contents click to return to this page
Essential Actions
for Successful Local
Transformation
Elective Care Transformation: What is it? 4
ransforming
T Essential Actions for Successful Local Transformation 5
Musculoskeletal and
Orthopaedic Elective Care: Transforming Musculoskeletal and Orthopaedic Elective Care: 6
The Challenge
The Challenge 6
The Ask
The Benefits The Ask 7
Interventions and
Case Studies The Benefits 8
Rethinking referrals Opportunities for Improvement: Interventions and Case Studies 9
1. MSK Clinical Review
and Triage Rethinking referrals
2. Standard referral
templates
1. MSK Triage and Clinical Review 9
3. First Contact 2. Standardised referral templates 13
Practitioner (FCP)
Service 3. First Contact Practitioner (FCP) Service 16
Self-management
support Self-management support
4. MSK Self-
management 4. MSK Self-management Education 22
Education
5. Patient Passport 26
5. Patient Passport
Transforming Transforming outpatients
outpatients
6. Telephone follow up 6. Telephone follow up 30
Further resources Further resources 34
3 Right person, right place, first time
Elective Care
Transformation: What is it?
Elective Care Transformation: What is it?
Essential Actions
for Successful Local
Transformation
Elective Care Transformation means the transformation of the GP referral and outpatient
process to give a better experience for patients and clinicians and to make better use of
ransforming
T
Musculoskeletal and
resources. Patients should be directed to the right person, in the right place, first time.
Orthopaedic Elective Care:
This handbook for the transformation of musculoskeletal elective care services is part of a suite of resources produced by NHS
The Challenge England’s Elective Care Transformation programme and aims to support local health and care systems to work together to:
The Ask Better manage rising demand for elective care services;
The Benefits Improve patient experience and access to care;
Interventions and
Case Studies
Provide more integrated, person-centred care.
Rethinking referrals The success of interventions designed to transform local elective care services should be measured by changes in
local activity following implementation of the intervention and performance against the Referral to Treatment (RTT)
1. MSK Clinical Review
and Triage
standard, along with patient and professional outcome and satisfaction measures. More detailed information and
suggested metrics are included as part of each intervention in this handbook.
2. Standard referral
templates
3. First Contact
Practitioner (FCP)
Service
Self-management
support
4. MSK Self-
management
Education
5. Patient Passport
Transforming Self- Community GP Outpatient Outpatient
outpatients management support clinic follow up
6. Telephone follow up
Further resources
4 Right person, right place, first time
Elective Care
Transformation: What is it?
Essential actions for successful transformation
Essential Actions
for Successful Local
Transformation
The actions below are collated from the work of the Elective Care Development Collaborative.
These actions are essential to creating the culture of change that is necessary as a basis for the
ransforming
T
Musculoskeletal and effective implementation of the interventions outlined in this handbook.
Orthopaedic Elective Care:
The Challenge Setup: Engagement:
The Ask Ensure strong support from executive level leaders Schedule regular communication and continue to
The Benefits across the system, to give permission to frontline engage with key local stakeholders across public
Interventions and
staff to innovate, help unblock problems and feed health, general practice and secondary care around
Case Studies learning and insight back into the system. the proposed approach.
Rethinking referrals Identify a cross-system team with sufficient protected Engage with appropriate GP representatives and
time to lead implementation. use local communication networks to ensure wide
1. MSK Clinical Review
and Triage Identify and engage all key local stakeholders patient and clinical engagement including GPs and
(including patients, GPs and other clinicians, GP representatives (eg Local Medical Committees).
2. Standard referral
templates managers, primary and secondary care, voluntary Further resources to support creating the correct climate for
3. First Contact
and community sector) from the beginning and successful large scale transformation can be found in Leading
Practitioner (FCP) encourage them to partake. Large Scale Change: A practical guide produced by the NHS
Service
With stakeholders, identify and understand local issues England Sustainable Improvement and Horizons Teams.
Self-management and challenges, using these to identify, analyse and agree
support possible solutions, baseline and metrics for each theme.
4. MSK Self-
management Infrastructure and workforce:
Education
5. Patient Passport Seek expert advice on infrastructure (e.g. IT and
telephone needs) as soon as possible.
Transforming
outpatients Identify staffing and skills needs as early as possible
6. Telephone follow up and secure this resource, as appropriate.
Further resources
5 Right person, right place, first time
Elective Care
Transformation: What is it?
Transforming MSK and Orthopaedic Elective Care: The Challenge
Essential Actions
for Successful Local
Transformation
There is a clear need to re-design elective care services.
ransforming
T Since 2005/6 total outpatient appointments have nearly Find out more about the 100 Day Challenge methodology:
Musculoskeletal and doubled from 60.6m to 118.6m. Some 418,000 patients www.nesta.org.uk/people-powered-results
Orthopaedic Elective Care: were waiting longer than the 18 week standard for
Frontline services were challenged to develop solutions
The Challenge hospital treatment in September 2017 – a 20% increase
under three broad themes within the 100 days. These themes
on the previous year. The steady rise in referrals has
The Ask and relevant interventions from the Wave 1 sites are
contributed to that increase.
The Benefits reflected throughout the handbook, along with further
There is also unwarranted variation in activity and outcomes information and case studies from other sources. The
Interventions and
Case Studies
across England, as shown by RightCare. themes are as follows:
Rethinking referrals Timely access to high quality elective care is a key priority,
1. MSK Clinical Review
as set out in the NHS Constitution. Therefore, the Next Steps Rethinking referrals
and Triage
on the Five Year Forward View and the NHS Operational
Improving the quality of referrals through
Planning and Contracting Guidance 2017-19 set out the
2. Standard referral advice and guidance, standardised pathways
redesign of services to better manage demand and increase
templates and referral templates
value from investment as a ‘must do’ for every local system.
3. First Contact
Practitioner (FCP) NHS England’s Elective Care Transformation Programme
Service supports health and care systems to reform and modernise Maximising shared decision making
Self-management elective care pathways. As part of this programme, the and self-management support:
support Elective Care Development Collaborative has been established
to support rapid change led by frontline teams, to develop, Improving access to self-management
4. MSK Self- support and education for people with
management test and spread innovation in delivering elective care services.
Education
long term conditions
Through this community of practice, local systems came
5. Patient Passport together using the ‘100 day challenge’ methodology
Transforming from innovation charity, Nesta. This empowers frontline Transforming outpatients
outpatients leaders, clinicians and patients to design and test
innovative ways of transforming elective care services Offering patient-initiated, rapid access and
6. Telephone follow up virtual follow ups to better meet people’s
across professional boundaries.
Further resources needs and improve access to timely care
6 Right person, right place, first time
Elective Care
Transformation: What is it?
Transforming MSK and Orthopaedic Elective Care: The Ask
Essential Actions
for Successful Local
Transformation
This handbook describes what local health and care systems can do to transform MSK and orthopaedic
elective care services at pace, why this is necessary and how the impact can be measured.
ransforming
T
Musculoskeletal and This handbook is for commissioners, providers and those leading The interventions and case studies are grouped by theme
Orthopaedic Elective Care: the local transformation of musculoskeletal and orthopaedic within this handbook. ‘How-to’ guides and case studies are
The Challenge elective care services. A powerful lesson from the 100 day testing included to illustrate the possibilities for transformation,
process was the clear benefit of bringing together a range of along with suggested metrics. The list of interventions
The Ask
clinicians, patient groups and managers from GP practices and is not exhaustive and reflects the interventions tested as
The Benefits hospitals. They demonstrated that GPs, consultants, nurses, part of the 100 Day Challenge in Wave 1 of the Elective
Interventions and allied health professionals, managers and patients working Care Development Collaborative, along with further
Case Studies together can develop new pathways that improve care, reduce relevant information drawn from other sources.
Rethinking referrals
waiting times and maximise the efficient use of NHS resources. Comprehensive guidance on redesign of gastroenterology
Included within this handbook are selected interventions services is not provided and emergency care or elective
1. MSK Clinical Review
and Triage and case studies from the Elective Care Development surgery are not covered. However, signposts to further
Collaborative Wave 1 test sites alongside further case studies. quality improvement resources are included.
2. Standard referral
The interventions are grouped into the three key themes:
templates Commissioners are asked to lead local system wide
3. First Contact
Rethinking referrals
transformation of elective care services, focussing on
Practitioner (FCP)
Service
one or more of the key themes. Interventions will
1. Advice and guidance make most difference when implemented as part of
Self-management 2. Standard referral pathways with
support
a package of transformation, rather than in isolation.
structured templates
4. MSK Self- This handbook is one of the resources produced by NHS
management
Maximising shared decision making England’s Elective Care Transformation Programme
Education and should be used alongside NHS England’s directory
and self-management support:
5. Patient Passport of elective care case studies, which describe how local
3. Self-management education for systems have successfully devised and implemented these
ransforming
T long term conditions interventions, along with further details about their
outpatients
learning throughout the transformation process.
6. Telephone follow up Transforming outpatients
For any queries regarding this handbook or any of the
Further resources 4. Patient-initiated, rapid access and interventions or case studies, please email: england.
virtual follow ups electivecare@nhs.net
7 Right person, right place, first timeElective Care
Transformation: What is it?
Transforming MSK and Orthopaedic Elective Care: The Benefits
Essential Actions
for Successful Local
Transformation
Elective Care Transformation means transforming the GP referral and outpatient process
to give a better experience for patients and clinicians and to make better use of resources.
ransforming
T
Musculoskeletal and
Patients should be seen by the right person, in the right place, first time.
Orthopaedic Elective Care:
Suggested benefits of interventions across musculoskeletal and orthopaedic elective care pathways in each of the
The Challenge three themes are listed below:
The Ask
The Benefits
Rethinking Maximising shared Transforming
Interventions and
Case Studies referral models decision making and outpatients
Rethinking referrals
self-management
1. MSK Clinical Review
and Triage • Increase access to care • Increase the quality and amount • Improve access to care
2. Standard referral
• Reduce waiting times of information available to • Offer telephone follow up to
templates patients and practitioners
• Reduce unnecessary or patients without complications
3. First Contact • Improve communication
Practitioner (FCP) inappropriate referrals • Offer more flexible options for
Service
• Improve identification of • Improve monitoring of follow up
Self-management appropriate patients for referral health status • Improve data quality
support • Increase patient access to digital
• Reduce secondary care follow ups • Support patient management in
4. MSK Self- self-management material primary care
management • Support patient management
Education in primary care • Increase patients’ understanding • Enable effective management in
of their condition the community
5. Patient Passport • Enable effective management
in the community • Increase patients’ ability to • Improve patient experience
ransforming
T
outpatients
self-manage
• Improve patient experience • Improve patient outcomes
6. Telephone follow up
• Improve patient outcomes
Further resources
8 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
1. MSK Clinical Review and Triage
Transformation
ransforming
T What is MSK clinical review and triage? Implementation - how to achieve success:
Musculoskeletal and
Orthopaedic Elective Care: MSK triage services provide a single point of access for stablish a cross-system implementation team
E
The Challenge local MSK referrals. They provide specialist clinical review that includes all stakeholders such as orthopaedic
of incoming referrals and triage patients to the most consultants, MSK service, Rheumatology
The Ask appropriate setting for further treatment and/or diagnosis. multidisciplinary team, GPs, patients, practice
The Benefits manager, CCG leads, physiotherapists and other
Interventions and Why implement clinical review and triage? allied health and wellbeing professionals.
Case Studies Engage and communicate regularly with
Many CCGs are ensuring MSK triage services are put in
Rethinking referrals key stakeholders (in addition to the cross-
place during 2017/18, with clear referral criteria that are
system implementation team), throughout the
1. M
SK Clinical Review communicated to all GPs. The aim of MSK clinical review
and Triage implementation process. Key stakeholders include
and triage services is, to avoid inappropriate referrals,
consultants in orthopaedics, GPs, physiotherapists
2. Standard referral improve the quality of referrals and ensure that people
and other allied health professionals, nurses,
templates with musculoskeletal problems are directed to the right
chiropractors, osteopaths, diagnostic services,
3. First Contact care setting, first time. MSK conditions affect approximately
managers, patient representatives and if relevant
Practitioner (FCP) 9.6 million adults in the UK. MSK clinical review and triage
Service
rheumatology and pain specialists. Use CCG
services reduce demand on local secondary care services
communication networks such as newsletters and GP
Self-management and have the potential to reduce referrals by 20-30%
events to build awareness and uptake among GPs;
support (equivalent to 2-3% of all GP referrals).
sharing positive feedback can be powerful.
4. MSK Self-
management Agree outcome measures to evaluate the impact of
Education the clinical review and triage service (e.g. feedback
from referrers, number of referrals received and
5. Patient Passport
patient satisfaction measures). Ensure sufficient
Transforming administrative support resources for evaluation.
outpatients
6. Telephone follow up
Further resources
9 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
1. MSK Clinical Review and Triage
Transformation
ransforming
T How to achieve success (continued):
Musculoskeletal and
Orthopaedic Elective Care: Gather an evidence base with Data Protection Act Develop referral pathways for relevant services.
The Challenge
compliant dataset. Ascertain the number of patients Engage all key stakeholders that will make and receive
referred to and discharged from secondary care referrals such as GPs and secondary care specialists.
The Ask for a musculoskeletal opinion, the average wait for Agree clinical guidelines and protocols (including
The Benefits rheumatology and orthopaedic services, and the exclusions), along with the clinical audit framework
Interventions and
conversion rate for orthopaedic surgery (i.e. the and schedules.
Case Studies percentage of patients attending outpatients who
are added to the waiting list). Seek feedback throughout the process from stakeholders
Rethinking referrals (e.g. from local medical committees and patient user
Agree the service scope. Work with key stakeholders forums) and act on their comments. Consider rapid pilots
1. M
SK Clinical Review
and Triage to agree what will and will not be within the of the template in selected practices to test usability.
scope of the triage service i.e. exclusion of red flag
2. Standard referral Communicate the final pathway and template to
conditions. Options proposed by test sites include
templates
surgical referrals for T&O, MSK, Pain Management stakeholders using a range of methods such as email,
3. First Contact and Rheumatology (or a subset of these) referrals. newsletter, practice meetings and host education
Practitioner (FCP) sessions. Include a point of contact for referrers who
Service Review the standardised refferal template along with may require support using the form.
Self-management evidence-based guidance and recommendations.
support Work with lead clinicians from primary, secondary
and community care to tailor it to local needs. If you
4. MSK Self-
management would like a copy of a standard referral template
Education please email england.electivecare@nhs.net.
5. Patient Passport Seek IT advice and support as early as possible to
Transforming
ensure referral forms can be uploaded to GP clinical
outpatients systems and adjustments to improve usability can be
made (such as automatic pop-up and pre-population
6. Telephone follow up
of patient details).
Further resources
10 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
1. MSK Clinical Review and Triage
Transformation
ransforming
T Measuring impact
Musculoskeletal and
Orthopaedic Elective Care: The table below includes some of the metrics devised by the sites in Wave 1 of the Elective Care Development Collaborative
The Challenge as part of their logic modelling, along with additional suggestions. It is not an exhaustive list, but serves as a starting point.
The Ask
The Benefits
Suggested metrics to measure success (this list is not exhaustive)
Interventions and • Associated setup costs (£)
Case Studies • ssociated ongoing costs (£)
A
Number of:
Output
Rethinking referrals to run the service
Input
• Referrals
1. M
SK Clinical Review Number of hours to: • FFT score for cohort
and Triage • Patients triaged
• Set up service • RTT score for specialty
2. Standard referral
templates • Develop template Number of:
3. First Contact • atient satisfaction
P • Discharges in secondary care
Impact
Practitioner (FCP) measures
Service • Operations
Number of: • Professional satisfaction • atients managing their own care
P
Self-management
measures (PAM score)
Outcome
support • Participating practices
Activity
4. MSK Self- Number of: • Inappropriate referrals
• Participating consultants
management • Avoided referrals
Education • eferrals through triage
R • Face-to-face appointments
service • Face-to-face appointments
5. Patient Passport
ransforming
T
• Referrals received in total
outpatients • Referrals by practice
6. Telephone follow up
Further resources
11 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
1. MSK Clinical Review and Triage – Case study
Transformation
ransforming
T The challenge
Musculoskeletal and
Orthopaedic Elective Care: Secondary care providers of orthopaedic services in East Kent were failing to meet the
The Challenge 18-week referral to treatment target.
The Ask
The Benefits
The intervention
Interventions and The CCG introduced a locally-designed and managed GP
Case Studies triage approach for all new referrals to secondary care. Outcome
Rethinking referrals The aim was to reduce waiting times and ensure patients
get the best care. The purpose of the new service model Since implementation of the triage service in
1. M
SK Clinical Review Dec 2014, referral levels to secondary care from
and Triage
was to:
Ashford remain 40% lower than during the pre-
2. Standard referral • Understand the best orthopaedic pathways for patients triage peak period and slightly lower than the
templates • Provide specialist advice and guidance to GPs 2013/14 baseline.
3. First Contact • Improve the quality of referrals
Practitioner (FCP)
Service • Identify the true need for orthopaedic services to
inform development of an optimal service model Further information and case studies
Self-management
support You can find further details about this work,
The triage service was delivered by a local GP consortium
4. MSK Self- (Ashford Clinical Providers) whose GPs had specific as well as other case studies, in NHS England’s
management experience and expertise in musculoskeletal disorders. All MSK and Orthopaedics case studies directory.
Education For more information, please email:
primary care referrals to secondary care were initially sent
5. Patient Passport to the triage service using an internal electronic system england.electivecare@nhs.net
Transforming and the patient was contacted within 48 hours.
outpatients
6. Telephone follow up
Further resources
12 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
2. Standardised referral template
Transformation
ransforming
T What is a standardised referral template? Implementation - how to achieve success:
Musculoskeletal and
Orthopaedic Elective Care: A standardised MSK referral template is a document Establish a cross-system implementation team
The Challenge available on primary care IT systems that guides referrers that includes all stakeholders such as orthopaedic
to provide appropriate referral information. The template consultants, MSK service, GPs, practice managers and
The Ask improves the quality of referrals and underpins effective hospital-based managers, and both CCG and Acute
The Benefits triage, thereby helping patients to be directed to the trust leads.
Interventions and right care setting, first time. It complements a single point Engage and communicate regularly with key
Case Studies of access covering, for example, a T&O and MSK service. stakeholders throughout the implementation process.
Rethinking referrals Use CCG communication networks such as newsletters
Why implement a standardised and GP events to build awareness and uptake among
1. MSK Clinical Review
and Triage referral template? GPs; sharing positive feedback can be powerful.
2. S tandard referral A standardised referral template can reduce the number Agree outcome measures to evaluate the impact of
templates of inappropriate referrals and improve the quality of the template (e.g. feedback from referrers, number
3. First Contact referral information received, ensuring that referral of referrals received). Ensure sufficient administrative
Practitioner (FCP) criteria are met and sufficient details are transferred support resources for evaluation.
Service with the patient at the point of referral. This means that eview the standardised referral template and work
R
Self-management patients who need to be seen by a hospital consultant with lead clinicians from primary, secondary and
support are seen as quickly as possible, ensuring the patient is community care to tailor it to local services.
4. MSK Self- directed to the right person, in the right place, first time.
Ensure the form integrates with local Advice &
management CCGs must have clear referral criteria for MSK services,
Education Guidance services. Consider how this will work and
including conditions covered and clinical indications for
involve stakeholders from the start.
5. Patient Passport referral, which are communicated to all GPs. A
standardised referral template can ensure that these Seek IT advice and support as early as possible to ensure
ransforming
T
outpatients criteria are explicit and understood. the form can be uploaded to GP clinical systems and
adjustments to improve usability can be made (such as
6. Telephone follow up automatic pop-up and pre-population of patient details).
Further resources
13 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
2. Standardised referral template
Transformation
ransforming
T How to achieve success (continued):
Musculoskeletal and
Orthopaedic Elective Care: Seek feedback throughout the process from stakeholders Communicate the final pathway and template to
The Challenge
e.g. from local GP councils and patient user forums stakeholders using a range of methods such as email,
and act on their comments. Consider rapid pilots of newsletter, practice meetings and host education
The Ask the template in selected practices to test usability. sessions. Include a point of contact for referrers who
The Benefits Ensure necessary amendments are made to the may require support using the form.
Interventions and
template based on this feedback.
Case Studies
Rethinking referrals
Measuring impact:
1. MSK Clinical Review The table below includes some of the metrics devised by the sites in Wave 1 of the Elective Care Development Collaborative
and Triage as part of their logic modelling, along with additional suggestions. It is not an exhaustive list, but serves as a starting point.
2. S tandard referral
templates
Suggested metrics to measure success (this list is not exhaustive)
3. First Contact
Practitioner (FCP) Number of: • DNA rate
Service • Number of hours to Output
Input
develop template • GP written referrals made • Wait time until first outpatient
Self-management appointment
support • Associated costs • Patients triaged using the
standardised referral template • Wait time for follow up
Impact
4. MSK Self-
management
outpatient appointment
Education
• Proportion of GPs Number of: Number of:
Outcome
using a standardised
Activity
5. Patient Passport referral template • Patients discharged from • GP referrals rejected
secondary care
ransforming
T • Size of specialty-specific • Face-to-face appointments
outpatients
patient cohort • Unnecessary GP referrals
• Follow up appointments
6. Telephone follow up
Further resources
14 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
2. Standardised referral template – Case study
Transformation
ransforming
T The challenge
Musculoskeletal and
Orthopaedic Elective Care: Patients in Fylde Coast were often referred to multiple specialties, including MSK and Pain
The Challenge Management, sometimes with insufficient referral information. This prevented effective
The Ask triage and resulted in a number of inappropriate referrals. As a result, it could take several
The Benefits
appointments at various specialties for a patient to find the right person to see.
Interventions and
Case Studies The intervention
Rethinking referrals A cross-system team was established in Fylde Coast to
1. MSK Clinical Review devise and implement a standardised referral template to Outcome
and Triage be used by primary care as a single point of access for
2. S tandard referral referrals to the MSK triage service, covering MSK, T&O • More than 90% of the 155 referrals to the MSK
templates and Pain Management Services. triage service used the template (48% of the
templates were complete)
3. First Contact The template was developed collaboratively by primary and
Practitioner (FCP) secondary care and piloted with 5 GP practices across Fylde • The template supported the decision to redirect
Service
Coast and Blackpool CCGs. Prior to piloting, the template 23% of referrals into a more appropriate specialty
Self-management was introduced to local Practice Managers’ Bodies where it
support was discussed with all GPs (not just the pilot practices.) IT
4. MSK Self- advice was sought from the beginning and the template
management was made available on the practice computer system (EMIS). Further information and case studies
Education
GPs completed the rest of the template and attached it to a Somerset also piloted a standardised referral template.
5. Patient Passport
referral on ERS. The template reflected GP comments, You can find further details about Somerset and
ransforming
T ensuring it was an easy-to-use tool that included automatic Stockport’s work, as well as other case studies, in
outpatients pop-up and pre-populated fields. Evaluation was carried NHS England’s MSK and Orthopaedics case studies
6. Telephone follow up out throughout the process. directory. For more information, please email:
Further resources england.electivecare@nhs.net
15 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
3. First Contact Practitioner (FCP) service
Transformation
ransforming
T What is a First Contact Practitioner service? Implementation - how to achieve success:
Musculoskeletal and
Orthopaedic Elective Care: A First Contact Practitioner is usually an Advanced Practice Establish a cross-system implementation team
The Challenge Physiotherapist who has the advanced skills necessary to that includes all stakeholders such as orthopaedic
assess, diagnose and manage musculoskeletal problems. consultants, MSK service, GPs, practice managers and
The Ask A First Contact Practitioner service enables patients who CCG leads.
The Benefits would usually present to the GP in primary care with an Engage and communicate regularly with key
Interventions and MSK issue to either refer themselves directly into existing stakeholders throughout the implementation
Case Studies physiotherapy services or see a First Contact Practitioner process. Use CCG communication networks such as
who is based in general practice. newsletters and GP events to build awareness and
Rethinking referrals
uptake among practices; sharing positive feedback
1. MSK Clinical Review
and Triage
Why implement a First Contact can be powerful.
Practitioner service? Review current local MSK pathway, models of care,
2. S tandard referral
templates Patients presenting with MSK make up to 30% of levels of referrals to orthopaedics/rheumatology
3. F irst Contact primary care consultations and 10% of all GP referrals. and investigations. Compare your gap analysis with
Practitioner (FCP) Enabling people to self-refer to first contact MSK national guidelines and good practice examples.
Service practitioner services can speed up access to treatment, Work with stakeholders to agree changes to
Self-management reduce GP workload and associated costs, reduce commissioning models and ways of working that
support prescription costs, increase self-management and reduce support change and address transitional issues as
4. MSK Self- inappropriate referrals to secondary care. Self-referral services are redesigned.
management into physiotherapy can cut costs by £33 per patient.
Education Look for opportunities to innovate. Focus on
relocation of existing Advanced Practitioners and
5. Patient Passport shift of triage and post-op care to primary care.
Transforming
outpatients
6. Telephone follow up
Further resources
16 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
3. First Contact Practitioner (FCP) service
Transformation
ransforming
T How to achieve success (continued):
Musculoskeletal and
Orthopaedic Elective Care: Establish the workforce model for implementation. Negotiate local agreements with radiology
The Challenge
Identify knowledge and skills gap to introduction departments for First Contact Practitioners to order
of First Contact Practitioner services. Work with investigations required.
The Ask local workforce action boards, training providers, Ensure a range of patient access options. For
The Benefits employers, apprenticeship programmes and example, through General Practice, community and
Interventions and
Community Education Providers Networks (CEPN) independent providers.
Case Studies to upskill the workforce and increase numbers of
advanced practitioners. Address training needs. Work with your local
Rethinking referrals CEPN and existing physiotherapy/MDT providers to
Ensure appropriate banding for the First Contact support existing staff in First Contact Practitioner
1. MSK Clinical Review
and Triage Practitioner role. Most are currently 8a. Take account posts and facilitate networking to share continuing
of advanced practice skills integral to the role: professional development and peer learning. Ensure
2. S tandard referral
independent prescribing, injection therapy, analysis First Contact Practitioners can provide specific
templates
of diagnostics and investigations, leadership of training and development of GP reception staff and
3. F irst Contact service integration and innovation.
Practitioner (FCP) care navigators.
Service Develop robust clinical governance systems with Design marketing materials. Work with local
Self-management strong leadership and clear accountability. Establish communications teams to design compelling
support close collaboration between clinicians in primary and marketing materials for patients, promote the First
secondary care to agree shared solutions and clinical Contact Practitioner services directly to people in
4. MSK Self-
management governance arrangements. the community, e.g. in GP practices, pharmacies and
Education
Integrate the First Contact Practitioner services patient groups and keep GPs and specialist teams
5. Patient Passport into local referral pathways. Ensure First Contact informed about First Contact Practitioner services.
Transforming
Practitioners are present in primary care both as part Establish a feedback mechanism. Proactively
outpatients of a GP team and a larger physio or multi-disciplinary gather feedback from patients on the First Contact
team in secondary care/the community. Agree Practitioner service and how it might be improved.
6. Telephone follow up
onwards referral routes (e.g. secondary care, frailty, Establish processes to make any necessary changes.
Further resources social care).
17 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
3. First Contact Practitioner (FCP) service
Transformation
ransforming
T Measuring Impact
Musculoskeletal and
Orthopaedic Elective Care: The table below includes suggested metrics. It is not an exhaustive list, but serves as a starting point.
The Challenge
The Ask Suggested metrics to measure success (this list is not exhaustive)
The Benefits • Number of patients accepting • £ prescribing related
Interventions and offer to see FCP to MSK
•
Amount of time invested
Case Studies
• Number of patients seen by • Patient satisfaction measures
•
Specification of stakeholders
Output
Rethinking referrals FCP who would otherwise
Input
involved
1. MSK Clinical Review have been seen by a GP • GP satisfaction measures
and Triage •
Costs of training (£)
• Costs of interventions (£) Number of:
2. S tandard referral
•
Patient cohort size
Outcome
templates • Number of repeat • Patients requiring
3. F irst Contact appointments with GP GP appointment
Practitioner (FCP)
• Waiting times across pathway • Referrals for further
Service
• Patients who return to & stay treatment (needs to be
Self-management
support in work identified)
Activity
• Number of patients seen by
Impact
4. MSK Self- FCP who would have seen • Conversion rates for • Referrals for orthopaedic/
management the GP orthopaedic surgery rheumatology opinion
Education
• Reduced MSK demand in • Patients discharged to self-
5. Patient Passport
secondary care manage
Transforming
outpatients
6. Telephone follow up
Further resources
18 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
3. First Contact Practitioner (FCP) service – Case studies
Transformation
ransforming
T The challenge
Musculoskeletal and
Orthopaedic Elective Care: Traditional GP referrals to MSK services require patients to attend a GP appointment before
The Challenge being put on a waiting list to see a specialist. This can lead to delays in access to treatment,
The Ask increased GP workload and inappropriate referrals to secondary care.
The Benefits
The interventions
Interventions and
Case Studies In West Cheshire, a GP physiotherapy service was piloted
Rethinking referrals across 36 practices and was then expanded to evening Outcome
1. MSK Clinical Review
appointments. The capacity of the service stands at
and Triage 11,000 patients per year, which is 25% of total GPs’ MSK • 60% of self-referred patients were discharged
caseload. Quick access to advice provides rapid return after the first appointment. 3% of self-referred
2. S tandard referral
templates to function and no need for further treatment. There patients needed to see the GP for reasons such as
is scope to increase the capacity of the service further. medication reviews or non-MSK conditions.
3. F irst Contact The service was developed with a successful clinical
Practitioner (FCP) • 99% of patients rated the service as good or
Service triage assessment and treatment service already in place.
Outcomes were positive, with high satisfaction with the excellent and were happy to use it again. 91%
Self-management
service from both GPs and patients. rated the service 8+ for benefit to their practice.
support 45% rated the service 10/10.
4. MSK Self-
management • There were 20% fewer referrals to MSK physio
Education therapy services (after 5 years of an annual 12%
5. Patient Passport
increase) resulting in a reduction in waiting times.
Transforming • Annual savings: 84% patients would have seen
outpatients the GP saving £540k, 4% less MSK imaging saving
6. Telephone follow up £11,495, 5.9% fewer X-rays saving £28k, 2%
fewer orthopaedic referrals saving £70k.
Further resources
19 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
3. First Contact Practitioner (FCP) service – Case studies
Transformation
ransforming
T The interventions (continued)
Musculoskeletal and
Orthopaedic Elective Care: In Nottingham there was a 12% referral rate to In Darlington, a First Contact Practitioner service was
The Challenge orthopaedics by GPs. Therefore, a 12 month pilot of a implemented in December 2015 and results were
First Contact Practitioner service was undertaken, with recorded until the end of September 2016, with practice-
The Ask 2 GP practices involved. 555 patients were seen by 2 GP based GP physios seeing 1147 patients. Four GP surgeries
The Benefits physios, providing 2 half days each week. were involved.
Interventions and
Case Studies
Rethinking referrals The outcome The outcome
1. MSK Clinical Review 54% of patients were discharged after the first Only 2% of patients needed to see the GP. 74% of
and Triage appointment (71% in total after the first or second patients discharged to self-manage. Consultant to
2. S tandard referral appointment). 27% were referred to physiotherapy in consultant referrals reduced by 18%: saving £26k
templates secondary care, with 2% to the GP, 3% for diagnostics in 7 months. High patient satisfaction was recorded:
3. F irst Contact and 1% to orthopaedics. This reduction in referral to • 100% would recommend and use again.
Practitioner (FCP) orthopaedics resulted in savings of £3,085 per patient.
Service • 96% rated advice 8 or more out of 10.
70% of patients reported continuous improvement
Self-management at 6 months. 80% of 350 patients across the 2 sites • 93% rated outcome of visit 8 or more out of 10.
support were satisfied with: the service, the information
4. MSK Self- provided and their confidence in practitioners.
management
Further information and case studies
Education
5. Patient Passport You can find further details about Nottingham
and West Cheshire’s work, as well as other case
Transforming
outpatients
studies, in NHS England’s MSK and Orthopaedics
case studies directory. For more information, please
6. Telephone follow up email: england.electivecare@nhs.net
Further resources
20 Right person, right place, first timeElective Care Opportunities for improvement: Rethinking referrals
Transformation: What is it?
Essential Actions
for Successful Local
3. First Contact Practitioner (FCP) service – Case studies
Transformation
ransforming
T Measuring Impact
Musculoskeletal and
Orthopaedic Elective Care: The table below includes suggested metrics. It is not an exhaustive list, but serves as a starting point.
The Challenge
The Ask Key priority data collection areas
The Benefits • MSK demand in secondary care • Patients’ capacity to self-care
Interventions and • Referrals for orthopaedic/rheumatology opinion • Patients discharged to self-manage
Case Studies
Rethinking referrals • Conversion rates for orthopaedic surgery • Patients referred/signposted to physical
activity or prevention services
1. MSK Clinical Review • Referrals for injections, radiology, physio treatment in
and Triage secondary/community, pain management services • Patient experience
2. S tandard referral
templates • Costs: MSK medicine prescribing costs, cost of • Patient feedback
investigations
3. F irst Contact • Waiting times across pathway
Practitioner (FCP) • GP capacity:
Service • MSK patients who return to work and stay
Self-management
• Repeat MSK appointments at GP surgery in work
support
• Patients seen by FCP who would have seen the GP • Shared Decision Making
4. MSK Self-
management • GP feedback • Patient related outcomes
Education
• Process measures
5. Patient Passport
ransforming
T
• Healthcare practitioner feedback
outpatients
6. Telephone follow up
Further resources
21 Right person, right place, first timeElective Care Opportunities for improvement: Shared decision making and self-management support
Transformation: What is it?
Essential Actions
for Successful Local
4. MSK self-management education
Transformation
ransforming
T What is MSK self-management education? Implementation - how to achieve success:
Musculoskeletal and
Orthopaedic Elective Care: Self-management education supports patients to Establish a cross-system team to design the education
understand and manage their own condition effectively. workshops. Include GPs, extended scope practitioners
The Challenge
It enables patients to understand the variety of options (ESP), pharmacists, surgeons, pre-op nurses, patient
The Ask available to them and facilitates informed, shared reps and allied health and wellbeing professionals.
The Benefits decision making. Self-management education encourages ngage and communicate regularly with key
E
Interventions and and empowers patients to take responsibility for their stakeholders throughout the implementation
Case Studies own health and wellbeing through behavioural change process. Use CCG communication networks such as
and improve their quality of life. It follows NICE guidance newsletters and GP events to build awareness and
Rethinking referrals
on self-management interventions (CG177, 1.3.2) and can uptake among practices; sharing positive feedback
1. MSK Clinical Review be provided in various ways for example: through local can be powerful.
and Triage
workshops or as an online resource.
2. S tandard referral
Identify target group and engage with patients
templates and clinicians to understand their needs (test sites
Why implement MSK self-management targeted people with hip and knee osteoarthritis).
3. F irst Contact education? Ensure the education is tailored to their needs.
Practitioner (FCP)
Service Effective self-management education has the potential Review national guidelines and good practice
Self-management to increase levels of Patient Activation. Highly activated examples. Use your gap analysis to understand
support patients are more likely to adopt healthy behaviour, whether you need to set up new education options
4. MSK Self- to have better clinical outcomes and lower rates of or signpost to existing offers.
management hospitalisation, and to report higher levels of satisfaction Decide on the format for the offer. Options include
Education with services. It should also increase the quality and face-to-face and online education. Agree the desired
5. Patient Passport amount of information available to patients and length of session (typically 90 minutes).
practitioners, along with their understanding of their
Transforming
outpatients condition and their ability to self-manage. This can reduce
the workload for health professionals and delay the need
6. Telephone follow up
for surgical intervention.
Further resources
22 Right person, right place, first timeElective Care Opportunities for improvement: Shared decision making and self-management support
Transformation: What is it?
Essential Actions
for Successful Local
4. MSK self-management education
Transformation
ransforming
T How to achieve success (continued):
Musculoskeletal and
Orthopaedic Elective Care: nsure the education sessions are accessible. Offer the
E esign marketing materials. Work with local
D
The Challenge
education at a range of times (day time and evenings) communication teams to keep GPs and specialist
and make resources available online (e.g. recordings teams informed about the education sessions.
The Ask of advice provided in face-to-face sessions). Integrate the education into local referral pathways
The Benefits Identify admin support. Establish processes to and promote the education directly to people in the
Interventions and manage referrals and self-referrals, including sending community. For example in GP practices, pharmacies,
Case Studies invites, booking patients, on-the-day registration etc. patient and community groups.
Rethinking referrals Find and book a venue for the education session. Establish a feedback mechanism. Proactively gather
1. MSK Clinical Review If this is an online session, organise a webinar and feedback from patients on the education offer and
and Triage
circulate details and instructions. how it might be improved and establish processes to
2. S tandard referral make any necessary changes.
templates If this is a face-to-face session, book a convenient
community venue and inform participants about
3. F irst Contact
Practitioner (FCP)
parking, accessibility, etc.
Service Co-design the agenda and content. Include talks and
Self-management Q&As on self-management techniques, treatment
support options available and risks and benefits. Link to other
4. MSK Self- self-management support such as patient passports
management if available. Invite local health and wellbeing support
Education services to host stands/give a talk at the event.
5. Patient Passport Agree who will deliver the education sessions. Consider
Transforming who is best-placed to deliver the education locally (e.g.
outpatients GP or ESP) and build dedicated time into their schedules
6. Telephone follow up to do this. Ensure at least one talk is delivered by a
relevant surgeon to support the self-management message
Further resources by secondary care. Consider including two expert
patients with opposite experiences of surgical treatment.
23 Right person, right place, first timeElective Care Opportunities for improvement: Shared decision making and self-management support
Transformation: What is it?
Essential Actions
for Successful Local
4. MSK self-management education
Transformation
ransforming
T Measuring Impact
Musculoskeletal and
Orthopaedic Elective Care: The table below includes some of the metrics devised by the sites in Wave 1 of the Elective Care Development Collaborative
The Challenge as part of their logic modelling, along with additional suggestions. It is not an exhaustive list, but serves as a starting point.
The Ask
The Benefits
Suggested metrics to measure success (this list is not exhaustive)
Interventions and • Number of sessions held Number of:
Case Studies
• Amount of time to prepare
the self-management • Percentage of patients reporting • Patients having self-cared
Output
Input
Rethinking referrals education intervention increase in knowledge scores before presenting to GP
1. MSK Clinical Review • £ associated costs (time/ • Percentage of patients reporting • Patients taking proactive
and Triage increase measures to manage
resources)
2. S tandard referral in confidence condition referrals
Outcome
templates
• Face-to-face
3. F irst Contact Number of: appointments
Practitioner (FCP)
Service • Short courses developed • Number of patients • DNAs
discharged from secondary
Activity
Impact
Self-management • Invites sent care • Patients participating in
support peer support
• Attendees at workshops • PROMS and PREMS scores
4. MSK Self- Percentage increase in:
management • Questionnaires returned • FFT score for cohort
Education • Confidence scores
• Patients in cohort
5. Patient Passport • Knowledge scores
Transforming
outpatients
6. Telephone follow up
Further resources
24 Right person, right place, first timeElective Care Opportunities for improvement: Shared decision making and self-management support
Transformation: What is it?
Essential Actions
for Successful Local
4. MSK self-management education – Case study
Transformation
ransforming
T The challenge
Musculoskeletal and
Orthopaedic Elective Care: Stockport’s orthopaedics service reported that they were seeing a high number of patients
The Challenge with knee osteoarthritis who could benefit from self-management support.
The Ask
The Benefits
The intervention
Interventions and Following NICE guidance (CG177, 1.3), the 100 day challenge
Case Studies team introduced local knee workshops to help educate The outcome
Rethinking referrals and empower patients to self-manage their condition,
promote early intervention and support shared decision 50% of attendees were self-referred. Of the 83
1. MSK Clinical Review
making about treatment options. The team ran three 90 feedback questionnaires, the event increased the
and Triage number of patients who felt very confident
minute workshops aimed at patients over the age of 50,
2. S tandard referral who have been diagnosed with osteoarthritis (OA) and managing their OA, by more than 650% (increase
templates from 8 to 61 patients.) Around 90% of attendees
who have not yet been referred to secondary care.
3. F irst Contact Between thirty and forty people attended each workshop. responded that they were likely or extremely likely
Practitioner (FCP) to recommend the event.
Service The workshops were delivered by a multi-disciplinary
Self-management team including a GP, pharmacist, pre-op nurse, physios
support and allied health and social care organisations. Individuals
were referred by local orthopaedic services and GP Further information and case studies
4. MSK Self-
management practices. The workshops were also advertised in the You can find further details about Stockport’s
Education community to attract self-referral, including in libraries, work, as well as other case studies, in NHS England’s
pharmacies, golf and leisure clubs and GP practices. The MSK and Orthopaedics case studies directory.
5. Patient Passport
workshops included information on: What OA is, For more information, please email:
Transforming conservative management (physio and exercise), pain
outpatients england.electivecare@nhs.net
management, and surgical options (risks and benefits).
6. Telephone follow up They also featured stands run by local community
Further resources organisations, highlighting support available locally.
25 Right person, right place, first timeYou can also read
