Dr Sarabjit Singh Bawa and Dr Sandeep Bawa describe how they set up a community-based clinic that reduces waiting times and saves the NHS money
The World Health Organisation found that up to 60% of people on long-term sick leave give musculoskeletal conditions as the reason and worldwide 40% of people over 70 have osteoarthritis of the knee.1
More than 30% of all GP consultations in the UK are for musculoskeletal complaintsand patients have rising expectations for prompt effective treatment that go beyond the eight week referral to treatment target set by the Department of Health.2,3
The National Audit Office in 2003 reported that there is increasing evidence that early intervention can improve outcomes for people with musculoskeletal conditionsbut many services are facing increasing challenges and 39% of patients visit their GP between three and 11 times before being offered a diagnosis.4,5.
Patients are either treated by their GP or, for most conditions, are referred to hospital for physiotherapy, podiatry, orthopaedics, othotics, or rheumatology services. Access to these specialist services is difficult in some areas, and it can take up to 12 weeks before a patient is seen in a consultant clinic, resulting in pain, ill-health and time off work.
What we did
Using the ‘musculoskeletal framework’ published by the Department of Health as a foundation, we set up a multidisciplinary clinic within a local population, served by 28 GPs, to try and improve access to specialist services and reduce waiting times for those with musculoskeletal complaints.2
In May 2001, we started a joint injection clinic in Lanarkshire, Scotland, serving a population of 52,913. The clinic is run from a local health centre, for one hour a week with 12 patients seen per session. All patients are initially assessed by the GP.
If an injection is required, potential complications of the procedure are explained and written consent is obtained from the patient. A leaflet explaining these risks is given to the patient as well as instructions on aftercare. Patients who are given an injection are offered a return appointment to assess outcome using a visual analogue scale.
The clinic is staffed by a GP, physiotherapist, podiatrist, nurse, and a receptionist. Referrals are taken from local GP’s, physiotherapists and podiatrists via a referral form.
A steering group was set up to oversee the management of the service and a pilot was run for three months with appropriate adjustments made to the running of the clinic.
What we found
During the period 1 May 2001 to 31 March 2010, 1,946 patients were referred into the clinic. The source of referrals was GPs in 84.2% of cases, physiotherapy 8.5%, podiatry 6.8%, unknown 0.47% and no source documented 442.
A total of 1535 patients were injected; 1,361 received one injection, 299 two injections and 68 three injections – which gives a grand total of 1,738 injections.
The areas injected were the shoulder (683), foot (347), elbow (295), knee (116), hand (98), hip (55), back (9), other (1) and not recorded (134). The most common reasons for injection were rotator cuff syndrome, tennis/golfers elbow and plantar fasciitis.
There were 406 patients seen who did not receive an injection because 166 referrals were found to be inappropriate, 68 patients’ symptoms had settled, 117 did not attend, 50 cancelled, four went to podiatry and one was sent for further imaging.
More than 88% of patients (1357) reported a greater than 50% improvement in pain score, 54.7% (842) returned to normal, 9.9% (153) had a 30-50% improvement, 1.9% (30) no benefit (see Graph).
Graph: Pain improvement post injection
From the information available on 1,396 patients, 1,116 were discharged, 162 seen by physiotherapy, 98 by podiatry, 10 by orthopaedics. One patient went to rheumatology, one to biomechanics and one to another specialist; with seven sent for imaging.
Value for money
To the best of our knowledge, our community-based joint injection clinic is the first of its kind in Scotland. Our results highlight the success of the joint injection clinic by providing high quality patient-centred care. It has provided successful management of patients in a community-based setting, and helps to reduce significantly the number of patients on waiting lists to see a specialist in secondary care.
The cost for a new or return appointment in Greater Glasgow and Clyde Health Board is £176. The total cost, therefore, within secondary care for the 1,946 patients seen in the joint injection clinic would have been £342,496 had these patients initially been referred to secondary care. The yearly cost for running the joint injection clinic was £6,000. Over nine years this equates to £54,000. This gives a cost saving of £288,496.
Our results show a high success rate in substantially improving patients’ symptoms (88%). The vast majority of patients were subsequently discharged from the clinic with no further onward referral required (79.9%). Our study highlights that most patients referred to the joint injection clinic with musculoskeletal problems were managed effectively without seeing a hospital consultant. This in turn shortens waiting times for others to see a hospital consultant, and allow those who need more specialist input to be reviewed and interventions performed sooner. Hospital consultants do not waste their valuable time seeing patients who do not need their specialist input.
Our multidisciplinary interface clinic provides an effective one-stop-shop for integrated care, provides shorter waiting times, early diagnosis and treatment. Patients can return to work and lead an active life sooner. Morbidity is reduced significantly and there is less of a burden on NHS finances. The clinic also offers an alternative to direct referral to an outpatient consultant clinic and provides an expert multidisciplinary opinion for onward referral to specialist services.
Dr Sarabjit Singh Bawa is a GP in Glenboig, North Lanarkshire and Dr Sandeep Bawa is consultant rheumatologist at Gartnavel General Hospital in Glasgow
1) European Bone and Joint Health Strategies Project 2005. European action towards better musculoskeletal health: A public health strategy to reduce the burden of musculoskeletal conditions
2) Department of Health 2006. Musculoskeletal Services Framework, A joint responsibility: doing it differently
3) Department of Health 2005. Commissioning an 18 week patient pathway – proposed principles and definitions: a discussion document
4) National Audit Office 2003. Hip replacements: an update: Report by the Comptroller and auditor general
5) Arthritis Care 2004. OA nation