1. 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

2. 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

3. 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.

4. 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

5. NHS SCOTLAND MSK ADVICE AND TRIAGE SERVICE Non- Emergency
LOW RISK
Enhanced self management resources, web, digital TV & APP
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
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 29/09/11
Ability to redirect to medical services, if safety issues

6. 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

7. 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!!

8. Monitoring Data – NHSL (Pre-pilot)

9. 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

10. 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 –

11. 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%

12. 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

13. 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

14. 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

15. 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

16. Equally Well Process

18. 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