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Creating a successful community musculoskeletal management model

A clear vision backed by a solid evaluation has meant success for a local musculoskeletal scheme, says Dr Jon Tose and PBC lead manager Sue Gill

A clear vision backed by a solid evaluation has meant success for a local musculoskeletal scheme, says Dr Jon Tose and PBC lead manager Sue Gill

The South Tyneside Intermediate Musculoskeletal Assessment and Treatment Service (STIMATs) is a community-based service, offering triage, assessment and treatment for patients with musculoskeletal problems who would otherwise be sent directly to secondary care.

• It provides rapid access to a choice of community clinics in South Tyneside.
• Over 80% of patients referred to STIMATs are seen within the community, with less than 20% being signposted elsewhere.
• Patients benefit from an initial 45-minute appointment with a generalist who can offer a holistic approach.
• Patients can self-refer back to the service within three months of discharge.
• The service is provided by five GPs and one physiotherapist.

So why was the service created?

Identifying local need

GP Dr Jon Tose believed 20% of his consultations related to musculoskeletal problems, many of which required referral to secondary care.

• In 2005, there were 4,200 orthopaedic referrals to the local acute trust in South Tyneside.
• Patients faced a journey of up to five miles to the hospital.
• Waiting times were three months to the outpatient clinic, and a further six months to surgery.
• Conversion rate to surgery was 25%.

Taking on board the fact that patients were unhappy with their experience of the secondary care service, Dr Tose undertook a review of 100 orthopaedic referrals, which showed that at least 40% of cases could have been managed in primary care.

Developing a clear proposal

We looked at new models of care being developed in different parts of the UK, and adapted what was needed to develop a scheme that would meet the needs of the local population. Talking to patients and colleagues – not only in primary and secondary care, but also in the PCT and acute trust – helped to establish a clear list of objectives. These were to:

• reduce waiting time to see a specialist
• provide services closer to patients' homes
• develop a multidisciplinary and holistic approach
• improve the patient's experience
• ensure the patient sees the right specialist for their condition
• increase GP confidence in dealing with musculoskeletal problems
• reduce the burden on secondary care
• develop agreed patient pathways for common conditions
• provide a cost-effective service.

The initial business plan was developed by Sue Gill. Innovative ideas need a robust business plan to support their application, and we worked closely together to ensure that there was a strongly argued case – one that communicated not only the clinical need for the scheme, but also its viability. Retrospective analysis of orthopaedic referrals to secondary care were used in capacity planning. We calculated the number of sessions that could be funded and this decided the size of the pilot.

Service delivery

Once approved by the PCT, the pilot scheme was rolled out to five practices in South Tyneside – these practices were invited to refer their orthopaedic patients to STIMATs instead of secondary care.

Patients could be referred for triage or assessment or treatment.

Local consultants were supportive of the scheme, and were happy to engage in meetings and offer training. They had initial concerns that significant conditions, such as rheumatoid arthritis, might be missed, but this was addressed by drawing up clear guidelines and patient criteria for GP referral.

Because of the clear referral guidelines established at the beginning, very few inappropriate referrals have been received and patients can still be referred directly to secondary care by GPs.

Project evaluation

Evaluation of the success of the pilot scheme was based on several criteria. STIMATs continues to be measured against these.

Orthopaedic referrals

The number of orthopaedic referrals directly to secondary care has reduced by 1,100.

• Some 1,400 patients were referred to STIMATs last year.
• Fewer than 200 of these were referred on to secondary care from STIMATs.
• Consequently, 1,200 patients were successfully managed in the community – many of whom would otherwise have been seen in outpatients after a long wait.

Waiting times

41213112Waiting times for patients to be seen at STIMATs are consistently less than two weeks – the next available appointment is calculated prior to each monthly team meeting.

Patient satisfaction

Patient satisfaction was rated through three patient satisfaction surveys, as well as patient interviews.

• Patients continue to be delighted with their experience.
• They feel that their condition has been explained to them and that they are involved in deciding their management plan.
• Many of the musculoskeletal problems are long-term conditions and, most importantly, patients feel they are more able to cope with their problems after their consultation at STIMATs.

GP satisfaction

GP satisfaction was assessed with two anonymous questionnaires, and again, feedback has been encouraging. Local consultants also expressed positive views.

Economic evaluation

The economic evaluation of the project took into account the cost of the service and the costs incurred through GP referral activity, and was crucial in getting the professional executive committee to endorse the scheme.

Referral activity is calculated on the number of referrals prevented from entering secondary care because of STIMATs being in place, which is used to provide forecasted data for the whole of the population. The cost of this activity is then worked out in terms of new patient appointments and review appointments using the national Payment by Results (PbR) tariff.

The difference between the two costs (prevented referral activity and the service costs) are the savings made in terms of secondary care outpatient appointments. This provides the economics for the cost of full rollout of STIMATs – however, actual costs are calculated in a similar way.

An economic evaluation of the service demonstrated that the calculated cost of new appointments and review appointments in STIMATs were considerably less than PbR costs:

• Orthopaedics – new £152; review £75
• Rheumatology – new £258; review £105

Overall, evaluation of the project showed that if patients referred to STIMATs had otherwise been referred to orthopaedics, then an additional cost of £198 per patient would have been incurred. Projected savings are in the region of £600,000 a year.

Achieving success

The evaluation of the initial pilot, including the patient satisfaction surveys and economic evaluation, was submitted to the professional executive committee, who endorsed rolling out the scheme to other practices in South Tyneside. PBC groups have also approved the project and a phased expansion of the service has now been planned.

The projected savings versus PbR that have been extracted from the pilot data are planned for reinvestment in other services and in increasing musculoskeletal capacity.

The success of STIMATs has depended on working closely with partners in primary care, local hospitals and the PCT.

Essential skills have included:

• communication and co-operation between partners and team members
• working together as a team, meeting regularly to share experiences and understand individual strengths
• adopting rigorous assessment criteria
• IT support to set up databases to audit referrals, case mix, procedures, investigations, prescribing and so on
• increasing awareness and monitoring satisfaction through information leaflets and patient and GP surveys.

In the future the service will be run as a not-for-profit community interest company, although the exact financial structure has yet to be finalised.

Dr Jon Tose is a GP partner at the Central Surgery in South Shields and a GPSI in musculoskeletal medicine at the Glen Primary Care Centre in Hebburn, South Tyneside. He has a specific interest in sports and exercise medicine

Sue Gill is PBC lead manager for the NHS South of Tyne and Wear, which serves Gateshead, South Tyneside and Sunderland PCTs

Dr John Tose (front), Dr Glen Ray and secretaries Catherine Smith (left) and Jenny Green Dr John Tose (front), Dr Glen Ray and secretaries Catherine Smith (left) and Jenny Green Lessons learned 60-second summary

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