National MSK Redesign NHS Scotland and Partners*

National MSK Redesign NHS Scotland and Partners*

Improvement and Value Update Summary- April 2014

In 2012, a team of local and national NHS leaders set out to redesign MSK services in Scotland. The aim was to improve access, efficiency, quality and patient experience.The programme is a joint effort, with spread and sustainability work now involving all the territorial health boards of Scotland, through active dissemination of best practice knowledge and implementation of each intervention in all locations.

* This documentrelates to work done principally by the early adopter boards NHS Lanarkshire, NHS Lothian and NHS Ayrshire and Arran, their GPs and patient groups; NHS 24; Working Health Services Scotland and local Leisure services; the Scottish Government Health and Social Care Directorate; the University of Glasgow; and GE Healthcare Finnamore.

The Problem

AHP MSK services deal with high volume demand, currently presenting in Scotland at 400,000+ referrals per annum. 20-30% of all GP consultations are for MSK complaints, with 10 million work days lost annually from MSK problems. MSK secondary care activity is high,with duplication across GP, orthopaedic and AHP services.There is variation in patient experience in information, access, waiting times and investigations.

The Approach

The following new approaches were prioritised for testing with patients and staff of NHS Lanarkshire, NHS Lothian and NHS Ayrshire and Arran:

1. Musculoskeletal Advice and Triage Serviceby NHS24
2. National self-management platform, through NHS Inform
3. National self-referral model through a single point of access
4. Telephone call handler protocol triage model

1. IT and Referral Management
2. Electronic Referral Management
3. Efficient administration processes
4. Reminder Systems
5. National MSK dataset reporting

1. Clinical Pathways
2. Evidenced based, person-centred pathways
3. AHP impact on MRI Demand
4. Minimum Standards Framework

1. Exit Route Solutions

• Leisure partnerships
• Employability pathway
• MSK pathways into Specialist Pain services
• Mental Health pathways

Impact - Introduction of Musculoskeletal Advice and Triage Service (MATS)

Prior to commencingMATS, NHS Lanarkshire had self-referral and a physiotherapy telephone assessment line. NHS Lothian had paper self-referral, while NHS Ayrshire and Arran no self-referral system.

Between January 2012 and July 2013, 41,764 prospective patients contacted MATS and completed aprotocol based triage tool over the telephone. Excluding4720 calls which did not seek MSK telephone triage, the breakdown of MATS outcome was as follows:

Refer to Board / Refer to WHSS / Emergency Care / GP / Self- Management
29536 (79.7%) / 2085 (5.6%) / 2 / 394 (0.9%) / 5027 (13.5%)

Telephone triage by non-clinical staff has been shown to be safe and equitable, but further tests of change are required to achieve self-management rates comparable with those achieved by clinical telephone consultation.Further optimisation using web self -assessment and physiotherapy telephone consultation models is under development.

Impact -IT and Referral Management

Electronic patient tracking and electronic outcomes measures –has enhanced capacity and capability to establish, manage and analyse data for improvement. This has included the introduction of a MSK dataset reported nationally through National Services Scotland, Information Services Division (ISD).

Electronic referral - referrals now are sent to Boards instantaneously, reducing this part of the patient journey by approximately 10 days on average and providing verifiable data for performance reporting.

Administration Hub- improved slot fill in Lanarkshire from 82% to 93%, contributing to reduced waits and freeing up clinical time.

Clinical E-Vetting-now completed electronically. Clinicianscan access all referrals from any computerin their organisation.

Reminder System- In Lanarkshire,an electronic reminder of appointment solution was pursued with Netcall’s Remind and Remind+. DNAs have been reportedas low as 3% and sustained at 6%. [see chart] Ayrshirehas implemented similar systems and demonstrated almost identical impact.

Impact - Clinical Pathways

Clinical Pathways have increased clinical accountability and embedded evidenced based practice, ensuring quality of care and patient support by the appropriate person at the appropriate time. Close working across General practitioner, Orthopaedics and Allied Health Professional Services reduced duplication and variation.

Focus on pathways, process and supported clinicians was crucial, with clear escalation policy and tailored education key to success.

Lanarkshire and Ayrshireintroduced enhanced clinical pathways by body region, which facilitated patient flow shift from Orthopaedic Consultancy to Extended Scope AHP services.They also facilitated shift from ESP/Advanced Practitioner into MSK physiotherapy(Lanarkshire) and into podiatry, orthotics and occupational therapy services (Ayrshire).This is now seen as standard practice.

To ensure spread of this quality of care, value and sustainability and a healthy population approach, a National MSK Standards Framework is now out to consultation through The Scottish Government.

MRI- NHS Lanarkshire introduced a MRI protocol and direct access to low back pain MRI by Extended Scope Physiotherapists significantly reduced the number of MRI requests per annum by more than 50%, contributing to both cost reduction and patient safety.

Impact - Mental Health

NHS Lanarkshire introduced a model to support patients identified as having mental health problems.

19.4% of MSK patients indicated moderate to extreme anxiety or depression at the beginning of their MSK treatment and required a supported self-management intervention. At discharge only 9% of patients indicated a moderate to extreme level of anxiety or depression. 69% of those offered a self- management resource pack had reported a decrease in their scores.

Impact - Working Health Services Scotland (WHSS)

Working Health Services Scotland (WHSS) provides back-to-work support for people who are either absent, or at risk of becoming absent, from work due to health problems.

Between December 2011 and September 2013, 1325 individuals received Case Management services from WHSS. The table below highlights the health improvement achieved.

Mobility / 38%
Self –Care / 41%
Usual Activity / 45%
Pain / 41%
Anxiety / 20%

Impact– Capacity versus Demand

Ayrshire and Arran introduced a single entry point to MSK pathways through an AHP led MSK hub. This resulted in:

• 25% reduction in demand into orthopaedic consultancy services over an 18 month period
• Shiftof consultant time from clinic into theatre
• Reduction of patient waiting times for consultant toapproximately 6 weeks and reduced the number of those waiting to see a consultant by 50%- see chart below.

Implementation of the low back pain pathway resulted in significant improvement in Orthopaedic Outpatient capacity in all early implementer sites, with NHS Lanarkshire reporting a shift of 1800 patients per annum and NHS A&A a shift of 945 orthopaedic appointments in the first 6 months of the redesigned service and Orthopaedic Consultants have now formally reported conversion rate to surgery change from 35% to 70% following implementation.

Low back pain previously accounted for 40% of AHP ESP/ advanced practitioner capacity and now accounts for less than 10%, following a shift from ESP to general MSK physiotherapy services, creating advanced practitioner capacity to see additional orthopaedic consultancy knee and shoulder referrals. Improvements in Orthopaedic surgical conversion rates have also been observed.

Modelling the Financial Impact

If all boards were to adopt all measures found to be advantageous by the Early Adopters, then we estimate the healthcare-only net financial benefit to be as shown below.

Improvement Stream / Net benefit minimum / Net benefit maximum
1 / Self –management / 146,605 / 1,629,138
2 / DNA / 442,000 / 646,000
3 / Orthopaedics / 1,660,000 / 2,490,000
4 / MRI / 506,000 / 1,012,000
Total / £2,754,605 / £5,777,138

Next Steps

Further tests of change are expected to provide additional cost benefit and outcomes:

1)Web based self- assessment and signposting to community partners

2)Improvement self- management resources

3)Telephone and video clinical triage to improve self- management after AHP consultation

4)GP Decision Support Tool and closer partnership provision with GP practice including AHP prescribing

5)New and Return slot times related to clinical complexity

Recommendations

Health Boards are now being supported nationally to develop their own MSK delivery plans. Clinical leaders at all levels are also being supported to develop quality improvement capacity to enhance improvement culture.

We recommend that:

Health Board leaders actively support their AHP leaders’ efforts to implement service change, in order to ensure delivery of value and quality benefits in the Board’s own geography.

Boards carry out a baseline assessment and gap analysis of their current position in relation to final outcomes in early implementer sites and deliver on a Board MSK Action Plan to include all the elements described.

Board leaders support their AHP teams in driving small tests of change to contribute to national evidence of best practice. This will enable all boards to drive service quality and productivity beyond the improvements already achieved in the early implementer sites.

We use service data, patient experience data and the national dataset and 4 week data to drive excellence, performance and accountability.

Other specialities and sectors across health and social care familiarise themselves with the learning for the MSK programme impact and identify what processes and outcomes may be utilised in their setting. In particular, AHP advanced practice and general services have a significant role to play in shift from consultant speciality services.Leaders should investigate whether the model components are transferrable to other service pathways to support population health, cost control and experience of care?

MSK Scotland- National Re-Design