1. The MSK Referral System Dr Louise Pollard Consultant Rheumatologist Lewisham and Greenwich NHS Trust

2. MSK Clinical Assessment Triage and Treatment Service (MCATTS) commissioned to include MCATS and triage element Central access point for ALL MSK referrals (orthopaedic and rheumatology) using standardised referral template Does not include pain clinic Referrer indicates referral route which is subject to triage by consultant rheumatologist Where secondary care management is appropriate, choice of provider will be offered by the service (GSTT/Kings/QEH/PRUH) Service committed to delivering ‘one stop shop’ approach with lower follow up rates across the pathway (although investigations can be undertaken if needed) Summary of pathway:

3. REFERRAL FORM

5. Aim of Referral Form All Musculoskeletal Referrals – Upper limb – Lower limb – Foot – Back – Orthotics – Rheumatology – Orthopaedics Separate Physiotherapy Referral Form

6. MCATTS Upper, Lower Limb and Foot Clinics Upper limb clinics – Rheumatologists – Upper limb orthopaedic surgeons – (Extended scope physiotherapist) Lower limb clinics – Orthopaedic surgeons Foot clinics – Extended scope podiatrists

7. What is The MCATTS Upper and Lower Limb Clinic Best For? Simple, non complex joint and soft tissue conditions – Rotator cuff pathology/Frozen shoulder – Epicondylitis – CTS – Tendinopathies – Consideration of joint replacement

8. What is Upper and Lower Limb MCATTS Clinic not Good For? Complex conditions Chronic pain syndromes (only chronic spinal pain suitable for MCATTS) Patients who have had multiple treatments and been seen in other departments already or under follow up Not a suitable clinic ‘for another opinion’ Patients with previous joint replacement or complex surgery of affected joint Abdominal and chest pain

9. MCATTS Foot Service Aim is a short episode of care which may include: –Diagnostics –Injection therapy –Provision of orthotics –Referral to other services – physiotherapy, secondary care –Referral to foot health services for intensive course of treatment or for on going treatment

10. MCATTS Foot Service Extended Scope Podiatrist led service: Managed separately from Foot Health Services Appropriate patients are those with MSK foot problems and those who may benefit from foot orthotics or footwear Designed for patients not already known to Foot Health Services For other types of foot problem or urgent access it is more appropriate to refer directly to Foot Health Services Referral process to Foot Health Services remains unchanged

11. Foot Health Referral Guidelines for Primary Care PathwayType of ConditionsReferral Route General Podiatry Skin lesions (corns/callous), Nail pathologies, foot deformities, vascular assessment. People with diabetes identified as ‘at or high’ risk of foot ulceration. Non painful - Musculoskeletal related foot pathologies e.g flat feet., Pes cavus etc Community Foot Health Service MSK FootPainful - Musculoskeletal related foot pathologiesMSK Service Foot SurgeryAll cases requiring a surgical opinionMSK Service Ingrowing ToenailsAcute ingrowing toenails Walk in ‘emergency nail clinic’ at the Ladywell Building (South UHL) - e very Mon & Thurs 1.30-3.00pm Minor Foot ulcer / wound  Localised cellulitis  Superficial ulceration/wound  Minimal purulence  Not probing to bone  No systemic signs/symptoms of infection Urgent referral (within 1 working day) to Community Foot Health Service Significant Foot Ulcer wound/infection  Spreading cellulitis (>5cm)  Deep/penetrating ulcers  Probing to bone Immediate referral to the ‘acute foot/diabetic unit’ in the hospital they attend for their diabetes or vascular care. Limb/life threatening wound/infection  Limb/life threatening infection  New/spreading gangrene/extensive necrosis  Extensive cellulitis/ lymphangitis requiring IV antibiotics  Patient systemically unwell, requiring IV antibiotics Immediate referral to nearest A&E

12. MCATTS Back (Spinal) Service When to refer directly to physiotherapy When to refer to MCATTS

13. What to Refer to MCATTS? Complex Spinal Problems ie: with history of previous surgery, with associated psychosocial issues / high levels of anxiety Patients who have had several courses of conservative treatment ie: physiotherapy / other interventions with no improvement Patients with persistent / worsening neurological signs where further investigations are indicated For advice on further management Patients with high levels of distress and anxiety

14. What to refer directly to GP Direct Access Physiotherapy Simple mechanical low back pain Back pain with sciatica with minimal / no neurology Simple mechanical neck pain Neck pain with referred symptoms with minimal / no neurology

15. MCATTS Back Care to avoid giving patient expectation of scan Include all relevant psychosocial / past medical history on referral Helpful to include any clinical / management questions you have Avoid duplicate referral Not quicker to refer to MSK Backs for physiotherapy if direct access physiotherapy is what is required

16. What to Put on the Referral Form The more information we have the easier and better triage will be. MCATTS back (Lower Back and Neck) – Must have ESR available at time of triage – Patients with high ESR cannot be seen in MCATTS – If ESR high consider cause, investigate appropriately – If high ESR felt rheumatological, refer rheumatology – ESR one of most useful discriminators in distinguishing simple back pain from cancer etc.

17. What to Put on the Referral Form If you are unsure of where the problem is (neck/shoulder) – Give as much information as possible – Patients will get the most out of their appointment if we can triage to the correct clinic If the patient has had surgery on the joint before please give details – Previous replacements and complex reconstructions will be seen in orthopaedics not MCATTS Ensure history of trauma is described

18. What to Put on the Referral Form If the patient has chronic pain please give that information – Chronic pain syndromes (other than chronic back pain) are not suitable for MCATTS – These patients take a lot of time to be seen – Cause delay the MCATTS clinic – Better seen in secondary care

19. Key Messages All MSK referrals should be made on the MCATTS referral form and sent through the central MCATTS pathway Please provide as much information as possible Please don’t refer chronic pain (except chronic back pain) to MCATTS Clearly describe history of trauma ESR required for spinal referrals Patients should be told to cancel appointments if no longer needed Please refer one condition at a time (i.e. unconnected problems should be referred separately as will need to be managed separately) Please don’t send duplicate referrals to different services

20. Any Questions