Amanda Hensman-Crook, MSK Practitioner, Windermere Health Centre
Musculoskeletal practitioners are an emerging model of care designed to deliver a streamlined patient-centred service while addressing the growing demands on general practice and secondary care.
The service creates capacity in general practitioners’ clinics, improves relevant referral and conversion rate to surgery for secondary care, and provides an efficient care pathway for patients with direct access to a specialist service for musculoskeletal problems.
It provides value for money across the heath service, and is shown to be effective and efficient, allowing the best care in the right place at the right time.
A new way of working
Feeling the constraints and ever changing demands on primary care, a GP practice in the South Lakeland Locality took the initiative to look at a different way to manage their patient load1.
Musculoskeletal related problems make up almost a quarter of a GP’s caseload, 2 3 taking up significant consultation time, but they were pinpointed as something that could be more effectively streamlined to ensure the best care for this patient group, while creating capacity for GP consultation for other medical conditions.
The practice is now into it’s third year of providing the service. The aims were;
- To develop, refine and enhance the model of service delivery for musculoskeletal consultations based on patient and other stakeholder perspectives.
- To provide direct access to a specialised musculoskeletal service for patients.
- To free-up GPs to focus on other medical conditions, and to provide greater accessibly to see the GP within a shorter waiting time.
- To ensure relevant musculoskeletal referral into secondary care.
- To evaluate the impact of the musculoskeletal practitioner post regarding: accessibility, patient satisfaction, safety, efficiency of the care pathway, cost effectiveness and the impact on the wider health system.
- To enhance musculoskeletal knowledge within the multi-disciplinary team (MDT).
To deliver on these aims, the role would require:
- A clinical musculoskeletal physiotherapist with extended scope skills such as injection therapy, ordering and interpretation of x-rays/ultrasound scans/MRI scans and bloods, and non-medical prescribing.
- The provision of highly specialised assessment and diagnostic triage to determine the basis for referral, investigations and further management into secondary care.
Musculoskeletal education and advice for the MDT.
- Audit/research on the outcomes from the service.
The hours were worked out on the basis that the average number of musculoskeletal patients in the practice was around 20%. The length of consultation is 20 minutes with a 20 minute admin break in a session (4 hours).
All patients presenting to the surgery with a musculoskeletal problem or rheumatological condition are eligible for the service and gain access by booking directly with the musculoskeletal practitioner at reception, via a GP, nurse practitioner or the onsite physiotherapist.
Outcomes from the service
Capacity: the total referrals in one year are an average of 710.
Of these, 79% of the overall number would normally have seen a GP as a first contact, so saving 560 GP appointments over 12 months.
Source of referral:
The main source of referral is from direct referral at reception, with the GPs utilising the service as the second main source.
Outcome from referral:
The most common outcome of referral is exercises and advice regarding the condition, followed by injection, referral to physiotherapy, referral to secondary care and further investigations.
Impact on secondary care:
The referral rate into secondary care between May 2013 - February 2014 prior to the new post was 188 patients. Between May 2014 - February 2015 since the new post there were 147 patients referred. This resulted in 41 fewer patents needing a first initial contact with secondary care. May 2015 - February 2016 showed a further reduction of 31 patients with an overall reduction of 39% - a saving of £9,376 for the practice.
Conversion rate to surgery from those referred was 80%.
The number of steroid injections within the practice May 2013 - February 2014 were 98, but between May 2014 - February 2015, 190 injections (124 from the practice physiotherapist) were delivered - a 93% increase.
The implications of this are potentially:
- Patients are no longer being sent to secondary care for injections (other than spinal/hip under image intensifier).
- Patients are being kept away for longer/or preventing cold operative procedures as they able to be managed for their symptoms locally.
- More income from injecting for the practice.
Looking at statistics from secondary care, there is a direct correlation between the number of injections performed in primary care and the reduction of peripheral joint injections in clinic.
The patient satisfaction survey shows that the musculoskeletal practitioner role has proven to be a very popular addition to the primary care service. A survey was handed out to all patients for a month and 50% were returned. Overall patient satisfaction of the service showed 90% ‘excellent’, 9% ‘very good’ and 1% ‘good’.
Each category tested (time given for consultation, thoroughness of examination, explanation given for the complaint, advice for the condition, outcome from consultation and approach the consultation) showed results of between 88% and 96% for excellent, 4% and 12% for very good and 4% for good.
A model for the future
Establishing the new role into primary care has had positive implications for the patient, primary care, secondary care, and NHS finances.
The patients are now able to directly access a highly specialized service without a long wait to get to the right person at the right time, streamlining their care pathway.
It has had a significant impact on capacity for the general practitioners to focus on medical conditions, improving throughput and creating an opportunity to broaden their experience in musculoskeletal care.
Secondary care now has more relevant referral with an excellent conversion rate with a positive impact on throughput.
It is a cost-efficient role that saves money by streamlining a service and eliminating unnecessary appointments with other healthcare professionals.
For primary care it is slightly cheaper to employ at a band 8a, and attracts income into the practice from performing steroid injections previously done in secondary care.
Since the role has been established:
Several pilots have been taken up nationally and a number of practices have now employed physiotherapists as part of their primary care team.
- Joint publication between the BMA, RCGPs and CSP regarding implementation of physiotherapy roles into primary care has been published.
- Physiotherapy cost calculator showing impact and cost of establishing the role in primary care has been developed.
- Physiotherapy has been included in Work Health and Disability green paper for signing fit notes.
1 McElduff.P, Lyratzopoulos.G et al, (2004) Will changes in primary care improve health
outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK. Quality and Safety in health care, vol 13(3): pp 191-197
2 Pekka.M, Esko.K et al, (2000) Pain as a reason to visit the Doctor: a study in Finnish primary care. Quality Health Care, vol 9: pp 201-215 10.
3 Rekola.K, Keinanen-Kiukaanniemi.S et al, (1993) use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultation with a physician. J Epidemiol Community Health vol 47: pp 153-157