Our service vision is to transform musculoskeletal (MSK) services across Central Sussex – putting patients in control of their health journeys and delivering care that takes a shared decision making approach that is tailored to their needs.
What do MSK services offer?
Clinicians working within musculoskeletal services help to restore movement and function when someone is affected by injury, illness or disability. It can also help to reduce risk of injury or illness in the future.
For a number of years we have successfully delivered a community MSK service to the population of Central Sussex, seeing large numbers of people with MSK conditions who can be assessed and treated without the need to be referred to hospital. Ensuring patients see the right specialist at the right time, first time enables us to reduce inefficiencies in the system. In turn, this keeps waiting times low and supports patients to explore appropriate treatment options focussed around their needs using a shared decision making approach.
As a service, we have worked hard to keep waiting times low across all of our pathways to ensure that where appropriate, patients receive definitive treatment in a timely way within the community service and that all patients requiring onward referral to hospital are transferred within 8 weeks of receiving their referral. This helps to support our partners in secondary care in meeting their 18 week ‘Referral to Treatment’ target as set by NHS England for all NHS providers to work to.
What was the issue?
Our service is divided into a number of clinical pathways: Foot & Ankle, Hip & Knee, Spine, Shoulder & Elbow, Hand & Wrist, Rheumatology, Chronic Pain and Physiotherapy. Despite the pathway division, there is a lot of overlap and collaboration cross pathway – particularly with the physiotherapy service. Initially, waiting times across the different pathways varied significantly with the majority of them being more than 8 weeks. We know that delaying access to appropriate MSK care can impact on the clinical outcome and lead to patients requiring more input from the service. Faster access to the right care also enables patients to start self-management earlier in their recovery and reduces the risk of chronicity.
We knew from our patient satisfaction survey results that whilst patients appreciated and valued the service once they were seen, they did not appreciate the long waiting times to reach that point.
What are we doing differently?
Demand for MSK Services
Our service, like other MSK services across the country, are seeing referrals increasing and we have worked hard with both our clinical and admin team to implement various initiatives to bring our waiting times down and, importantly, to sustain low waiting times across all pathways. Whilst we have achieved a reduction in wait times across the majority of the pathways, we still have more than 8 week waits for both our hand and wrist and chronic pain pathways – both of which are engaged in redesign work to help improve the performance. All of our waiting times are available to view here on the Sussex MSK Partnership website.
Engaging with clinicians
One of the biggest challenges we have faced is working with clinicians to reduce the number of follow ups being offered to patients who could appropriately self-manage (given the right information and advice and the option to self-refer back into the service within 6 months should their problem persist). Speaking from experience as a clinician, being able to follow a patient from the start of their journey right through to the end is extremely rewarding for the clinician.
Our physiotherapy arm of the service is set up to be able to support patients through their rehabilitation over a longer period, whereas our specialist services are much more designed around assessment and signposting to the most appropriate service in discussion with the patient. So, naturally the number of follow up appointments for these services is significantly less. A notion that sticks with me from the Chartered Society of Physiotherapy frames it well: that the skill of any clinician is to reduce the dependency of the patient on therapeutic intervention. Never has this been more poignant, and whilst it may seem like an initiative driven by finance, it is absolutely the right thing for our patients to support those who can self-manage to do just that, to reduce dependency on healthcare and focus on helping those who find it more difficult to self-manage.
Understanding that whilst some patients were getting lots of input, there were still many waiting to be seen in the service and this does not represent the quality of care for all that we aspire to deliver.
Engaging with administrative staff
As part of our work to reduce waiting times and deliver a service that meets the needs of those who use it, we’ve done a lot of training with admin staff and clinicians around what ‘Referral to Treatment’ (RTT) is and why it is important. We’ve endeavoured to move the emphasis to helping people reach their definitive treatment in as short a time as possible, rather than being a target which we can align ourselves to.
In order to monitor our waiting times closely, we divided all of our admin teams into pathways so we could get a better handle on the flow of patients, and to enable staff to develop a more specialist knowledge of the pathway to support better patient stewardship.
Physiotherapy waiting times
We have seen a significant reduction in our waiting times in Horsham and Crawley physiotherapy. This was achieved through a number of initiatives, one of which was around identifying the needs of the person from the point of triage. This involved looking at which type of appointment or service would be helpful for them and whether or not they might benefit from attending a class. We also looked at our ‘new patient’ appointment durations which were variable across the physiotherapy services provided under the Sussex MSK Partnership (SMSKP). We wanted to allow enough time for a really full and thorough assessment as well as providing advice around self-management techniques and delivering care using a shared decision making approach, in the interests of engaging people with an agreed care plan. So, whilst it would have been easy to simply reduce all new patient appointment times to 30 minutes across the board, creating more capacity to see more patients, we made the decision to make first appointments 45 minutes, with the flexibility to increase or reduce this according to any additional information gleaned at triage. We know that this first appointment is critical to get right and that enabling sufficient time for both clinicians and patients can reduce the number of follow-ups required.
We have also just introduced a new self-referral option, which we have seen coincide with a slight increase in wait times. However, we are seeing additional benefits to this new system around better understanding of what really matters to people at the point they refer themselves for help. Find out more about this story here.
The role of self-management and shared decision making
Ultimately, our aim is to be able to provide patients with enough information to self-manage their condition so that they are relying less on the health system.
Really critical to all of this is asking “what matters to you?” In order to achieve a successful outcome for the patient, this has to be one of the first questions we ask our patients because it’s not always what we’re expecting.
Does the individual want surgery?
Historically, where clinically appropriate, patients were offered surgery based on a premise of ‘this is your condition and this is what we can do to fix it.’ Within SMSKP we are now placing more emphasis on giving people clear options which are relevant to them and based upon what matters to them. The option of surgery is offered alongside a discussion regarding the risks, implications and benefits to the surgery – with the patient at the centre of making that decision. We want to ensure that any patients referred for surgery does so fully informed of the evidence, is appropriate for surgery and critically wanting to have surgery. This has prompted us to provide further training to clinicians around understanding the importance of shared decision making, how this differs from informed consent. This not only allows us to more quickly establish a treatment plan centred around the patient, but it has also seen an improvement in our patient experience measures.
The six month follow-up window
Once a decision has been agreed to discharge a patient from the service, we offer patients the opportunity to self-refer back into the service should their symptoms change or deteriorate, or if they want to seek further advice without needing to be re-referred by their GP. This makes a lot of sense not only for continuity of care but also it saves valuable primary care appointments. Following a self-referral back into the service, the patient may require a telephone appointment or a face to face appointment to further discuss their management options, which may change according to their symptom presentation.
What real impact are we seeing?
Taking aside anomalous hand and wrist and chronic pain pathways and looking at all the other specialist pathways, we’ve seen a significant reduction in waiting times with almost all below our six week target (from the point of referral to the start of definitive treatment). Spine and neck has seen the most impressive reduction, with patients waiting no more than 2 weeks for an appointment.
The improvements in our access times have, not surprisingly, gone down well with our patients and this is reflected in our patient reported experience measures. We’re now finding that our ‘friends and family test’ score has improved and people are regularly commenting positively on how quickly they have been seen within the service.
Patients being able to quickly and easily access a specialist assessment and come away with a full understanding about their condition and an agreed treatment plan in place – with referral to a hospital only occurring when it is deemed clinically appropriate. This is our vision, and this is what we are delivering.
Interested in finding out more? Visit the service website: sussexmskpartnershipcentral.co.uk
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