1. NHSL 18 weeks RTT MSK Event Janie Thomson Consultant Physiotherapist NHSL

3. The direction ?

5. The Back Pain Challenge 30,000 referral to physio per annum 33% back pain 7500 referrals to orthopaedic ESP 48% back pain Work already completed on MRI and x-ray NHSL Low back pain pathway implemented July 2010

7. Problem Statement Pre Redesign Multiple access routes/assessments/opinions Variance in physiotherapy management and clinical skill set Appropriateness of MRI and x ray requests Significant number of low back pain referred for orthopaedic opinion despite no identified surgical target / low conversion to surgery Demand outweighs capacity Variable (or no) measurement of outcome/impact

8. Service Improvements Need to examine and address whole system Ortho, GP, AHP, Leisure, WHSS Introduction of self referral Drive for clinical excellence and reduction in variance Complex case clinics Learning resource file On job learning Online modules Clinical pathway development Establish exit routes

10. LOW BACK PAIN PATHWAY GP Direct Access Phone Line A & E Red Flags Self manage Surgical Opinion Urgent Ortho 1:1 physio Ax + Rx 4/52 Self Manage Ring Back 3/52WHSS Settling signpost to Active Health Not Settling Escalate to Senior Pain Association Scotland ESP Investigate if indicated Back Pain Clinic ESP / Associate Pain Clinic Self Manage Back Pain Pathway

12. Impact

14. MonthOrtho/GPPALTotalPost MRI Stonehouse Refer to Surgeon October 2010343243612 November 2010387228615 December 2010313148461 January 20113822816635118 February 20114252817064015 March 20114273908175211 April 2011307280587224 May 2011383 766457 June 2011378387765427 July 20113362796153110 August 20114153347495219 Pathway Stages

15. Pathway Stage Percentages

16. Physiotherapy MSK Pathway Summary Assessment + Intervention Patient Presents MSK issue Physiotherapy Assessment Line GP Cauda Equina Red Flags Physiotherapy 1:1 treatment ESP Complex case Diagnostics if required A&E Self Management Ortho clinic Pain Services Vocational Rehab Leisure Services Rheumatology Spinal Clinic

17. Preparation & Support Clinical training – reduce variance in practice Sign off for AHP investigation requests (monitoring systems agreement) Clinical support and mentorship (on the job) Complex cases / clinical reasoning sessions (by whom & where) Clinical escalation policies (by clinical signs or timing)

19. Injury / Knee Problem Self-Referral Telephone Triage Physiotherapy Outcome Measures Clinical Algorithms OA – Appendix B Meniscal - AppendixC AKP - AppendixD Refer to NHSL knee module guide in Education Folder Orthopaedics Referral Consultant Physio ESP Pain Clinic Surgery Pain Association Scotland Phase 4 WHSS Pain Association Scotland Discuss with ESP AppendixE Self Manage GP History, exam and working diagnosis Apply Knee Guidelines AppendixA +/- MRI x-ray +/- WHSS Discharge Primary Care Acute Services

21. Other pathways Foot & Ankle Hand Both of these pathways are in the consultation phase.

22. Benefits Primary care management enhanced by supporting AHPs to manage episodes of care autonomously Reduction in handoffs = reduced waits, reduced chronicity, reduced workplace absence Investigations pre referral, within physio episode, collapses RTT Physio refers directly to ESP (ortho) via internal referral (Trak) Increased conversion rate to surgery within acute services Outcome measures monitor quality and effectiveness of services

24. Pathway design considerations Stakeholder engagement re: onward referral / exit routes (consider workforce & capacity issues) Monitoring flow for capacity planning (eg flow to ESP changing from GP to AHP referral) Anticipate resource issues