Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems

 
Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
Right person, right place, first time

Transforming
musculoskeletal
and orthopaedic
elective care services

A handbook for local health and care systems
Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
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Document Name         Transforming musculoskeletal and orthopaedic elective care services                             relations between people who share a relevant
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2                                                                                                                                             Right person, right place, first time
Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
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
Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
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
Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
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
Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
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
Transforming musculoskeletal and orthopaedic - A handbook for local health and care systems
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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
Elective 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 time
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