Musculoskeletal/Sport and Exercise Medicine clinic in GP surgery

Dr Neil Heron

The problem

Musculoskeletal (MSK) symptoms are common within primary care but some GPs are not comfortable managing these; waiting times for hospital appointments are a major cause of patients’ complaints.

Current UK healthcare policies emphasise a need for more community-based management. We aimed to pilot an innovative general practice-based clinic to improve the management of MSK and Sport and Exercise Medicine (SEM) symptoms within general practice.

dr-heronThe approach

This project was conducted in an inner-city practice of approximately 9,000 patients and five GP partners.

The practice commissioned a novel monthly four-hourly clinic, staffed by one GP with a specialist interest in MSK and SEM conditions.

Each patient was allocated a 20 minute appointment.

All primary care staff within the practice could refer any patient for whom they considered hospital referral appropriate, with no specific exclusion criteria. Management plans included injection therapy, exercise prescription and onward referral.

After two three month periods (August-October 2014 and January-March 2015) numbers of consultations, sources of referral, reasons for referral and management outcomes were described; patient satisfaction was assessed by questionnaire, offered to 10 randomly selected patients by reception staff and self-completed by patients. Costs of the clinic were compared to current options.

Findings

All 83 patients (36 males and 47 females; aged 35-77 years) were seen within four weeks of referral (one third of orthopaedic referrals in 2013 waited over 9 weeks for appointment). Most were referred from other GPs; some came from physiotherapy and podiatry. Shoulder problems were the most frequent reason for referral. The commonest management option was steroid injection, with most patients being given advice regarding exercise and analgesia; there were five onward referrals (two to physiotherapy; one to rheumatology; one to occupational therapy; and one to orthopaedics).

Comparing August-October data in 2014 and 2013, total, orthopaedic and rheumatology referrals were reduced by 147, 2 and 3, respectively; within the practice MSK presentations and physiotherapy and x-ray referrals were 60, 47 and 90 fewer, respectively.

Comparing the referral rates between January to March 2014 and the same period in 2015, overall referrals from the practice were reduced by 152 and orthopaedic and rheumatology referrals were reduced by 9 and 4 respectively. Meanwhile physiotherapy and x-ray referrals were reduced by 41 and 3.

The cost per attendance at the clinic was £61; initial orthopaedic-ICAT assessments cost £82 and a consultant appointment £213.  This clinic option therefore appears to offer a conservative cost saving of between £1,743 and £12,616 per eighty three patients reviewed, depending on which alternative referral option you are comparing the clinic to.

Satisfaction questionnaires were returned by all 10 selected participants and provided positive feedback, expressing preference for community-based, rather than hospital, management.

Consequence

Our pilot study indicates that this novel service model has potential for efficient and effective management of MSK and SEM complaints in primary care, reducing the need for hospital referral and the clinical burden on general practices.  The innovation deserves further evaluation in a full-scale trial to determine its generalisability to other practice settings and populations.

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