I’ve always believed we could deliver better care for patients with musculoskeletal problems by involving a multidisciplinary team working across primary and secondary care.
We have such teams in general practice, but many specialist services have little multidisciplinary engagement to meet patients’ complex social, psychological and medical needs.
My aims when developing this integrated service were to provide better care for patients, better value for money for our commissioner and a more interesting job for me. It’s been really good fun – if challenging at times.
What we did
In 2002, I was working as a GP and clinical assistant in rheumatology in Oldham where referred patients were waiting six to nine months to be seen in secondary care.
Together with Anne Brown, a nurse consultant, I set up a successful Tier 2 service to screen referrals to rheumatology. In 2005, we put together a business case to take over the running of the service as a specialist PMS practice, a new type of contract my GP partner Dr Hugh Sturgess had heard about.
The PCT put it out to a competitive procurement, and somewhat to our concern decided it wanted a single unified musculoskeletal service covering orthopaedics as well as rheumatology and musculoskeletal pain.
However, we bid for it and our service was commissioned by the PCT.
It went live as a specialist PMS service in March 2006. Start-up costs were almost zero as we started in my own GP practice. The PCT provided £5,000 to take legal and accounting advice around some of the specialist PMS contracts.
Our service-level agreement specified that we were to develop services to deliver as much as possible of the patient journey in rheumatology and orthopaedics. It was later expanded to include the pain service.
Our integrated clinical assessment and treatment service aims to provide the entire non-admitted musculoskeletal pathway for patients. In orthopaedics, that involves bringing them to the point of listing them for surgery and in rheumatology we provide community biologics.
Since 2006, the three owners of Pennine MSK Partnership – me, Hugh Sturgess and Anne Brown – have been running this growing service along the lines of a GP practice.
Fourteen consultants covering rheumatology, pain and orthopaedics now work in our service alongside more than 20 other clinicians. The bulk of the service is based in a new LIFT build – completed in 2010 as a purpose-built, town-centre, integrated care centre with day-case theatres, X-ray and plenty of clinic space from which to run multidisciplinary teams. Psychological medicine is delivered from another LIFT build slightly out of the town centre.
All GP referrals come through Choose and Book. There’s a common entry point for all musculoskeletal problems and we triage the referrals to put patients in the correct pathway.
All musculoskeletal referrals in Oldham are made this way. At the moment the service is only open to patients of NHS Oldham GPs, but that will change in the near future.
In orthopaedics, we take about 60% of the patients to the point of listing for surgery. We work with a variety of secondary care providers – including the independent sector – so we offer choice within our service. We have a multidisciplinary team including psychology, occupational therapy, rheumatology, orthopaedics, physiotherapy and podiatry, and we supply a very integrated service.
The treatments offered by the service include: joint and soft-tissue steroid injections, epidurals, provision of orthotics, electrotherapy, laser therapy, acupuncture, wax therapy, splints, exercises and physiotherapy.
We are teaching some patients how to do their own injections.
We avoid patient follow-up appointments unless there are clear clinical grounds for them. We offer telephone follow-up and patient-initiated follow-up
for patients with chronic conditions, so patients are only seen when there is a clinical need.
Most patients are directly listed for surgery from our service, but only with providers who work with our team. Otherwise, the patient is listed for an outpatient appointment at their chosen hospital.
As one of the first specialist PMS contracts, there were some legal loopholes to iron out.
We were also one of the first multidisciplinary community-based services, so it took some time to sort out our superannuation payments and indemnity insurance, as the Medical Defence Union hadn’t come across a service like ours before.
It probably took a year from tendering to going live, mainly due to those two issues. Now we’ve done it, it would be easy for others to replicate the model.
Our guiding principal has been to do what is right clinically and to make sure we do things that benefit patients. Everything else slots into place as long as you have that.
Initially, our acute trust, Pennine Acute Hospital, looked upon us with some suspicion as competition.
But as we’ve grown, they’ve seen that we can provide elements of the pathway more efficiently than they can and allow them to concentrate on the bits of the pathway only they can provide – the admitted patient journey. We complement one another.
We’ve got no interest in destabilising our acute trust as we want what’s best for our patients. Change is as hard for institutions as it is for the individual, but at the moment we’ve got a very good relationship.
We aim to see all referrals into the service within two weeks and monitor wait times daily so we can adjust the service to meet the needs of the patients.
Our 18-week compliance is 99% and most patients are listed for surgery by week seven. We provide services from seven different locations across Oldham with a choice of appointment times throughout the day, including evenings, ensuring ease of access and the provision of care closer to home. We run on average 120 clinics per week.
Wherever clinically possible, we treat new patients as ‘see and treat’ and operate a one-stop service for our patients. Approximately 40% of new patient referrals are treated in this way.
We were awarded the Customer Service Excellence Award in March 2009 and have been reaccredited in 2010 and 2011. The latest quarterly patient satisfaction surveys results show 89% of patients are satisfied with our service. We are totally funded through payment by results, and have agreed a series of local tariffs that are below national tariff for our treatments.
The typical conversion ratio for GP referrals in orthopaedic surgery runs at around 35% – so that means out of 100 referrals from primary care into orthopaedics, 35 ended up being listed for surgery. In our case, the conversion rate is 90% from our consultant clinics as those not needing surgery are diverted onto more appropriate treatment pathways.
Our CCG (see box, page 28) is very keen on the programme budgeting model and sees this method of contracting as the way to provide best value.
By aligning clinical responsibility and financial accountability in the same organisation, you work to stay in balance while delivering good healthcare.
In May of this year, we took advisory control of the programme budget in musculoskeletal conditions. Our commissioner has separated out the musculoskeletal spend (rheumatology and orthopaedics not including pain) and that comes to £23m.
The money and accountable status still sits with our commissioner, but we have been charged with designing and commissioning integrated care pathways across musculoskeletal conditions.
We will commission contracts on the commissioner’s behalf – we are currently working on carpal tunnel, nail surgery and pain services – but the CCG will control the payments, oversee all the contracts and be the accountable organisation.
We have an open-book arrangement – meaning the PCT understands the financial flows from managing the programme budget so there is complete clarity in how the money is spent and used.
We put patients right at the heart of our pathway with a service designed to provide a better clinical outcome and a better patient experience.
Patients have the opportunity to see many different professionals depending on what their clinical needs are, and they have more time in the appointment.
We do this while saving money for our commissioner – it’s a win-win situation.
Dr Alan Nye is a GP in Oldham, GPSI in rheumatology, director of Pennine MSK Partnership and associate medical director of Pennine Care FT
Initiative GP-led integrated clinical assessment and treatment service for MSK patients
Start up costs £5,000 from PCT for legal and accounting advice
Staffing 36 administrative staff, 16 clinical staff directly employed, 47 further clinical staff under different contracts (see staffing box p30)
Savings A series of local tariffs below national tariff
Outcomes Aims to see all referrals into the service within two weeks. Aims to treat new patients as a one-stop ‘see and treat’ – 40% of new patient referrals are treated in this way.
Compliance 99% for 18-week target
On the administrative side, we directly employ a finance and business director, a business operations manager, customer care manager and data and information manager, plus 32 administrative staff.
The clinical staff we directly employ are a consultant in rheumatology, a consultant nurse in rheumatology, a clinical governance lead, a consultant spinal physiotherapist, a specialist hand physiotherapist, a specialist occupational therapist, three rheumatology nurse specialists, a clinical assessment nurse, an infusion nurse and five healthcare assistants. We also jointly fund a consultant rheumatologist post with Pennine Acute Hospital.
All other clinicians are either seconded or employed on a service-level agreement privately or with their employing authority. These staff consist of 18 clinical specialist physiotherapists, five clinical specialist podiatrists, three senior podiatrists, 11 consultant orthopaedic surgeons and one rheumatology GPSI. We also provide a chronic pain service and work with two consultants in psychological medicine, one clinical psychologist and one cognitive behaviour therapist.
We have a strong ethos of staff development. All staff attend mandatory training – for example, basic life support, hand-washing technique and infection control training, and have regular appraisals while working towards a continuous development plan. We support our staff financially though the provision of course fees and study leave.
Many staff are undertaking NVQs in business administration, customer care and health and social care. Our nursing staff are working towards further professional qualifications and our senior nurses are undertaking prescribing qualifications to increase the potential for nurse-led care. Our clinical staff both attend and contribute to national study days and conferences.
Oldham Clinical Commissioning Group
Number of practices 49
Pathfinder status 2nd wave pathfinder