The National Musculoskeletal (MSK) NHS Lanarkshire Pilot Scottish ‘Health’ Offer – National Forum 26th January 2012 Programme has been developed through rehab framework and health works strategy. – closely aligned with quality strategy and fits with the quality ambitions and performance framework The paper tabled outlines some of the key issues around MSK problems in Scotland Presentation I will cover Why we need to improve our MSK services Describe the model that we are going to pilot Outline some of the key performance indicators that we have identified as critical to the success of this work Highlight the actions required between now and launch A critical message for the CMT – no expectation that if the pilot is a success and rollout agreed that nhs Lanarkshire will need to finance the programme - Dr. Sarah L Mitchell National Programme Manager Delivery Framework for Adult Rehabilitation

WHY ARE WE RE-DESIGNING OUR MSK SERVICES? 1 in 4 GP consultations MSK related (1 in 3 for over 75’s) More than 10 million GP consultations (MSK) each year costing £141M (UK). 30,000 patients sitting on Orthopaedic waiting list in Scotland, with conversion to surgery as low as 11%. 7.6 million working days lost due to MSK related conditions. 40,000+ MSK referrals into Lanarkshire AHP Services. Patient Experiences Variation in… Access…Management...Outcomes…Waiting Times

WHAT ARE WE PROPOSING? ……..what does that mean for each of us? A National MSK Triage and Referral Management Service for NHS Scotland utilising the technologies of NHS 24 Local referral management hubs within boards Direct referral into WHSS for those working in SME’s Development of Interdisciplinary pathways using evidence based outcome measures Development of algorithms within pathway to ensure correct service provision Early identification of employability issues, anxiety depression scores Greater utilisation of leisure facilities Increased or Decreased workload for some of us. Better use of clinical skills and resources. Better patient clinical outcomes. Right Patient, right place, right time. Some of us may have to grow our current skill set. We all need to place high value on clinical evidence and patient outcomes. We all need to be prepared to be held to account more as leaders.

Referral pathway Current referral pathway… Proposed referral pathway… Patient visits GP 1.8 times on average before being referred to AHP service GP completes written or electronic referral or patient self refers 18 days Referral received by local AHP service and put onto waiting list 20 (2) days Patient contacted and offered appointment 68 (50) days Patient attends 78 (60) days Current referral pathway… Patient calls NATS*, triaged and referral sent to local MSK Hub 5 days Within 40 days Proposed referral pathway… * National Advice & Triage Service

NHS SCOTLAND MSK ADVICE AND TRIAGE SERVICE Non- Emergency LOW RISK Enhanced self management resources, web, digital TV & APP www.nhsinform.co.uk/msk 0845 604 0001 Protocol Driven TRIAGE TOOL Ability to identify: non-emergency (non 999, A&E) callers with sprains, strains and pains of joints and muscles self referrers GP directed directed from other sources MEDIUM / HIGH RISK Referred to local MSK hub for access into local services, plus www.nhsinform.co.uk/msk Key facts – this is a separate non emergency rehab line – not using the current algorithims that nhs 24 currently use A triage tool being used – which has been shown to identify people of low . Medium and low risk – of persistant on-going symptoms – published last week in the lancet. All low risk up to 30% callers – will get good evidence based information on how to manage condition It will identify those patients who can go directly into the working health services programme WHS REFERRAL for those in paid employment & absent from work for over 4 weeks (Small-medium org) Triage Tool Developed by expert panel Safe: identifies red flags Employment: identifies WHS Includes STaRT MSK tool: stratifies into low, medium and high risk Hill et al www.thelancet.com 29/09/11 Ability to redirect to medical services, if safety issues

MSK SERVICE REDESIGN – New Process First Contact Physio assessment (EQ5D and outcome measures) HUB A&E Mental Health Leisure TRAK – automated letter sent to patient (and communication sent to CRMS) First Contact Podiatry assessment (EQ5D and outcome measures) Vocational Services Older People Services Self Management and exit from system Rheumatology Employability Services First Contact OT assessment (EQ5D and outcome measures) Community Pharmacy 2nd AHP Appointment (intervention) Process following hub – shows all possible other services which may be utilised either on discharge or concurrently Pain Services Ortho First Contact AHP telephone consultation and EQ5D Dietics TRAK / CES Info. dump

Key Performance Indicators Patient referrals into Leisure services Patient referrals into Employability services Mental Health referrals Patient experience Functional Improvement Outcomes Total MSK demand Patient DNA rates Patient referrals to Secondary care (Ortho surgery) Patient waiting times GP consultations Investigations Prescription charges - If we want to find what's best for the people of Scotland we need to measure!!

Monitoring Data – NHSL (Pre-pilot)

Patient Experience (Pre-pilot) Highlights 315 data entries to date were gathered from NHS (19%) and Community Links (81%) 21% of these supplying a postcode which falls into the top 15% of deprived areas in Scotland as indicated by the SIMD 2009. 28% Post and 72% street questionnaires.). 97% of participants stated that their ethnic background was white. top three most commonly cited MSK problems are currently identified as back (39.3%), Knee (25.2%) and shoulder (21.3%). 86% of people indicating that they had an MSK related problem, attended their GP 22.8% of patients who attended GP appointment waited 3-4 weeks and 22.8% waited more than 12 weeks for MSK appointment. 90% of individuals indicated that they did not receive any help from other non NHS services 24% of people were aware of the PAL service which operated and of those that were aware of the help line and had used it, 32.5% found it very useful and 23.4% found it quite useful. 94% indicated that they had followed some or all of the advice given to them during treatment. 83% of people felt that they were given enough information on how best to manage their conditions 86% of patients unemployed at the time of their problem stated that they had no discussions with NHS staff on the benefits of employment for their health. 42% of patients in employment felt that treatment received had made a big difference in helping them stay at/or return to work more quickly. 64% of employed patients recorded that they were absent from work because of their muscle or joint problem. The most common period of sickness was cited as being between 1 and 2 weeks. Over 77% of people reported that their health had improved moderately or significantly as a result of MSK care services. 79% of individuals were likely to recommend services received to friends and family. 63% of participants that received NHS treatment for their MSK problem stated that they would either be quite or very likely to use a new interactive service linked to self management. 28% of individuals stated that they had received information from NHS staff on other support services. Again GP’s were cited as the most common source of information. Employment Status Total No % Employed Full Time 89 28 Employed Part Time 40 13 Self Employed 7 2 Student 33 10.5 Homemaker 5 Carer 8 2.5 Unemployed 30 9.5 UnemployedwithIll Health 14 4 Retired AGE Total No % 0-15 years 3 1 16-29 years 48 15 30-44 years 55 17.5 45-59 years 103 33 60-74 years 80 25 Over 75 years 26 8

NHSL PHYSIOTHERAPY New Attendances / New DNA / New DNA % Time: 01/04/2010 – 31/3/2011 Split: Locality Broken down by locality Bars show the new dna percentage for each locality Yellow showing the actual new attendances – and green the actual number of DNA’s Our performance indicator is to standardise this to 8% across each site –

NHSL PHYSIOTHERAPY Return Attendances / Return DNA / Return DNA % Time: 01/04/2010 – 31/3/2011 Split: Locality Return DNA’s again high - same and again target 8%

NHS Lanarkshire – Lower Back Pain (LBP) Analysis Collected EQ5D functional score but also used for economic analysis - on all new attendees to physio in may – this is typical profile Total of 92 patients in may had pain scores – ie mild – these patients should be targetted for straight onward referral to leisure classes – free up capacity for return appointments – help to reduce waits Straight to Leisure

LEISURE REFERRALS 12 months projection Projecting over 700 additional Leisure referrals in first 12 months Current figures indicate on average 32 referrals - figures based on EQ5D analysis indicate we can send up to 92 per month which in effect would mean an additional 700 referrals into leisure

NHS Lanarkshire – Physio Waits Current>Projected Target Pysio Weeks Wait Data Input Last Friday of Month Pysio # Patients Waiting Data Input Last Friday of Month Highlights projected waits 4 weeks – factors that contribute – 30% reduction referrals, straight ref into whss, dna reduction etc

NHS Lanarkshire - Orthopaedic Demand 2010 vs 25% Reduction Already significant improvements with back pain pathway and you can see the reduction after the intro last june – aim to reduce by another 25% which equates to 3000 reduction in referrals to ortho - Over 3000 Ortho Patient Demand Reduction

Equally Well Process

MAJOR DELIVERABLES Equitable access for MSK patients to appropriate management options Consistent, high quality information and advice Information developed and adopted across NHS Scotland Enhanced user experience True health/employability pathway Wider Cost Benefits – Full economic analysis