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Commissioning Directorate
3rd Floor, Rapid House
40 Oxford Road
High Wycombe
Buckinghamshire
HP11 2EE
Tel: 01494 552200
Fax: 01494 552274
Integrated Musculoskeletal Clinical Assessment and Treatment
Service
ITT [Part B] Specification
October 2010
SCHEDULE 2 - THE SERVICES
Schedule 2 Part 1: Service Specification
SERVICE SPECIFICATION
Service
Commissioner Lead
Integrated Musculoskeletal Clinical Assessment and Treatment Service
Emma Haffenden – Commissioning Portfolio Lead, NHS
Buckinghamshire
Tim Jones – Project Director, United Commissioning
Provider Lead
Period
Document information
This is a draft service specification drawn up to support the procurement process. Every effort has been made to
ensure that the information in this specification is accurate and it is our expectation that the final specification to
be included in the service contract will be substantially the same as this document. However, the commissioners
reserve the right to alter this specification up to the point of commercial close.
The provider should take careful note of the statements that are prefaced by the text ‘The provider will:’ and are
highlighted in bold, italic text as these will form contractual requirements and/or inform the performance
framework.
Where text or other material is not complete or is likely to change a note has been included in [bold text with
square brackets]
1. Purpose
1.1 Aims
The purpose of this specification is to set out the requirements for an integrated clinical
assessment and treatment service for people with musculo-skeletal complaints.
This will serve as an alternative to hospital based treatment for the majority of patients being
referred by general practitioners for musculoskeletal (MSK) assessments and for the management
of pain that is not neuropathic in origin. Patients w i l l be referred to hospital only when there is
a need for hospital based specialist services.
The aim is to manage musculoskeletal conditions within an evidenced-based model with an
emphasis on supported self-care, improving the quality of services and clinical outcomes,
reducing waiting times and increasing access for patients and provide value for money.
The service should be provided in accordance with a set of principles that encompass these aims.
These principles will guide the provider and commissioner in all aspects of service delivery and will
be used to inform the performance management of the service.
The provider will:

Place the patient at the centre of design and delivery of an integrated service

Be committed to close cooperation with all others on the clinical pathway, individually and as
an organisation

Fit closely with good quality management of MSK by primary care. It is not the intention that
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the service should take over from care by GPs

Work to maximise integration of the service in a way that gives a high quality patient
experience and avoids duplication (e.g. multiple assessments)

Promote interdisciplinary team care and the Single Assessment Process (SAP) to ensure that
an individual’s support needs are considered in a holistic way

Support a unified care record

Identify organisational barriers to the delivery of patient-centred care and address these
1.2 Evidence Base
Clinicians are expected to keep knowledge and skills up to date throughout their working lives and be familiar
with relevant guidelines and developments that affect their work (Good Medical Practice, General Medical
Council, 2006). This principle extends to all staff engaged in the provision of the service. A commitment to
evidence-based practice should be demonstrable through the presence of effective systems, policies and
resources.
The provider will:

Promote the use of evidence-based practice

Provide a consistent decision support system for all professionals, including trainees

Ensure effective clinical governance and support multidisciplinary clinical audit
The evidence base for effective practice is changing constantly and it is not helpful to offer a definitive list
of guidance. However, at the time of writing the following publications and standards are particularly
relevant:
The Musculoskeletal Services Framework, DH 2006
NICE Guidance, Osteoarthritis: The Care and Management of Osteoarthritis in
Adults. Feb 2008
NICE Guidance, Rheumatoid Arthritis: The Management of Rheumatoid Arthritis in
Adults. Feb 2009
NICE Guidance, Low Back Pain CG88
Lamb et al. Best back education skills training trial published in Lancet 2010
Healthcare Commission — Core Standards
The Chartered Society of Physiotherapy and professionals including Occupational Therapists,
psychologists, Nursing staff and podiatrists — Core Standards and service Standards
The British Pain Society – Guidelines for Pain Management Programmes for adults, April 2007
1.3 General Overview
In England, as in the rest of the world, musculoskeletal conditions are common, and are a major cause of illhealth, pain and disability. It is estimated that nearly one-quarter of adults and around 12,000 children are
affected by longstanding musculoskeletal problems, such as arthritis, that limit everyday activities.
Musculoskeletal conditions are the most common reason for repeat consultations with a GP, making up to 30%
of primary care consultations. The prevalence of musculoskeletal conditions generally rises with age and, since
the number and proportion of older people in the population is projected to increase in future, so the number of
people with musculoskeletal conditions will also rise. However, the functional impairment from musculoskeletal
conditions varies widely depending on a variety of physical and psychosocial factors. (Musculo Skeletal
Framework, Department of health, 2007)
At present, musculoskeletal services are provided for Buckinghamshire registered patients by:

a community based physiotherapy service (across 7 sites plus outreach to local leisure centres and
some GP surgeries) receiving referrals from GPs and other community practitioners,

Hospital physiotherapy service which is located at Amersham Hospital, Stoke Mandeville Hospital and
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Wycombe Hospital providing physiotherapy to BHT consultant referrals

MSK CATS (limited scope) provided by Vale Health in conjunction with community based
physiotherapy service

Chronic Pain & Fatigue Management Service based at Rayners Hedge and Amersham Hospital
provided by the community and Integrated Care division of BHT

Hospital based care (Trauma & Orthopaedics, Rheumatology and Pain Services).
1.4 Objectives
The service will have the following objectives:

Improve patient access to MSK services by establishing a community based service and
improve the patient experience through improvements in patient satisfaction.

Ensure patients are seen and treated in an environment most appropriate to their needs.

Develop agreed models of care and pathways for common musculoskeletal conditions.

Achieve a reduction of orthopaedic, rheumatology and pain management referrals to acute
hospital providers [baseline volumes and targets to be agreed at contracting]

Increase conversion rates from outpatient attendances to surgery through more appropriate referrals
to acute hospital providers.

Reduce waiting times for patients and assist in maintaining the target of a maximum 18 week
period from referral to treatment.
1.5 Expected Outcomes
The service will have the following expected outcomes:
[To be agreed in consultation with the provider at contracting stage]
2. Scope
2. Scope
2.1 Service Description
Evidence from other similar initiatives has shown that a separation of ICATS services from primary and
secondary care clinicians can have a serious impact on service quality and patient experience. The provider
will be required to demonstrate that their service is integrated and that there is real and continuous effort to
remove any barriers to effective care and providing a high quality patient experience. How this is achieved is
at the discretion of the provider. This aspect of the service will be subject to performance review.
Health need
The service will receive referrals from clinicians for all musculo-skeletal conditions – see section 4.4.
Referral and assessment
Patients will access the service via two routes:
1. Referral from general practitioners based in NHS Buckinghamshire
2. Referral from other clinician e.g. A&E departments, and non NHS specialists
The referral can be via choose and book or a paper proforma which can be faxed or posted to the service. If
the referral is via the paper proforma the service will transfer the patient details to choose and book.
The patient referral will ideally include adequate information on which to make clinical assessment as to best
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destination. Wherever possible the provider should arrange onward care based on this information.
However, some referrals will be poor quality, with inadequate information or no information in the case of self
referred patients. In these cases patients should be contacted and additional information obtained. This may
be through a questionnaire to complete followed by a telephone conversation
The provider will:

Carry out an assessment of the patient based on information available at referral. This will be
done by suitably qualified clinical staff

Obtain additional information if required

Arrange onward care
Referrals intended to go directly to secondary care - GPs and other referrers will be encouraged to send all
MSK referrals to the service that are not explicitly excluded (see 4.6).
Where the referrer is confident that secondary care is the correct treatment option. The referral pathway and
materials will allow GPs to indicate that the expectation is for immediate onward referral. If, following a paper
triage of a referral, the triaging clinician is of the opinion that the patient should be referred directly to an acute
hospital, the referral will be sent onward without delay. If the triaging clinician believes that the patient would
benefit from treatment in the service s/he should arrange treatment and notify the referrer in a timely way.
Onward referral
If assessment by an orthopaedic surgeon is required the patient will undergo a screening process (BP,
urine analysis, BMI) and be offered a choice of surgical provider. When patients are referred on it will be
stipulated in the referral the reason for referral i.e. for surgery, a surgical opinion, or because of serious
pathology.
The provider will:

Take responsibility for the patient’s experience of onward referral

Ensure that onward referral is complete and timely in order to minimise the need for duplication
of any stage of the care pathway

Ensure that imaging and other clinical information is made available to the service to which the
patient is being referred

Apply prevailing guidelines in respect of treatment thresholds and priority treatments

The patient is booked directly into surgical lists unless excepted for clinical reasons

Notify the patient’s GP of the referral including sufficient clinical information
Diagnostics
All diagnostic imaging and other tests should be available to patients in a way that is convenient and integrated
with an ambition to minimise patient visits/appointments. A list of the treatments and activities included in the
service is given at Schedule 2 Annex 3.
The provider will:

Access appropriate diagnostic imaging and other tests on behalf of the patient

Ensure that results/images/reports are received and used in an appropriate and timely way to
manage the patient

Ensure that all images/tests are carried out and reported in a timely way to optimise patient
care

Ensure that diagnostic imaging and other tests are requested according to prevailing
guidelines and agreed care pathways
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
Work closely with providers of diagnostic services to promote integration and ensure a high
quality patient experience. This will include working with secondary care services to make
images available when patients are referred on
[Bidders may offer to provide some types of diagnostic imaging as part of the service. These must be
described and costed separately]
Treatment
The service will be able to assess a wide range of musculoskeletal conditions and make a diagnosis in order to
deliver effective, evidence and outcome based management plan. The service will also forge appropriate links
with the third sector support and advice groups to offer patients ongoing support if appropriate.
A see and treat philosophy is at the heart of this service. It is not intended to act as a referral management
centre or gatekeeper or additional tier of service between primary and secondary care. Instead the service will
accept referrals and organise care accordingly, referring onward where appropriate. A list of the treatments
and activities included in the service is given at Schedule 2 Annex 3.
Shared management with the patient’s GP
The interface between primary care and the ICATS service must be well-managed if the service is to be truly
integrated. GPs will continue to provide comprehensive and holistic care for people with musculo-skeletal
conditions and will continue to be able to access a range of diagnostic and other tests to support their
management of the patient.
The provider has an important role to play in ensuring that the ICATS service is used to its optimum.
The provider will:

Have due regard for the reasons given by a GP for a referral in the assessment and treatment of
the patient

Provide advice and guidance to referring clinicians via telephone or electronic media to support
management of patients in primary care

Provide data to GP practices on their utilisation of the service

Provide information to practices to help them improve the quality of patient referrals, in
particular:
o the completeness of referral forms/letters
o any instances where patients have been referred inappropriately

Manage discharge appropriately (see section 5)

Devise and run a programme of educational events to include the management of the primary
care/ICATS interface. The provider should maximise opportunities available of existing
programmes, meetings, resources, etc.

Notify the GP when a patient is referred onward from the ICATS
Prescribing and dispensing
There are circumstances when it will be appropriate to prescribe and supply medicines. The provider will have
the required clinical expertise to set up and deliver medicines management systems which include stocking
relevant medicines from the agreed formulary in their clinics. A list of the medicines that may be prescribed
and supplied will be agreed.. The provider can prescribe controlled drugs according to agreed treatment
protocols but will not stock them.
Prescribing decisions and recommendations will only be made by suitably qualified medical independent
prescribers.
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The provider will:

Offer patients appropriate medication at assessment where this is indicated. Medication is
likely to comprise analgesia, anti-inflammatories and intra-articular injections.

The supply of medication shall be 28 days unless otherwise agreed. The cost of medication will
be met by the provider.

Have appropriate clinical governance procedures in place including a clinical governance lead
that will ensure that all prescribing is within national and locally agreed guidelines and
treatment pathways. They will adopt policies outlining legislative and best practice relating to
the safe and secure handling of medicines.

Agree with the commissioner the formulary

Conduct regular audit to monitor prescribing

Have systems in place to ensure cost effective prescribing
Management and prevention of complex/chronic MSK pain
The service will include a s e r v i c e t o m a n a g e M S K p a i n i n s u c h a w a y t h a t e v e r y e f f o r t i s
m a d e t o p r e v e n t p a i n b e c o m i n g c h r o n i c . This should be multi-disciplinary and holistic in approach
with clear criteria for entry and agreed outcome measures.
The provider will:

Work to clear criteria and tools for determining whether patient is at risk of chronic pain with
attendant disability and social care costs

Provide a multi-disciplinary pain management/prevention programme that is:




Evidence based
Cost effective
Holistic
Multi-disciplinary
[This element of the service is to be costed separately. Bidders should assume that an agreed number
of treatments will be negotiated for provision within the contract]
Discharge
See section 6.
2.2 Accessibility/acceptability
Referral criteria are listed below in paragraph 4.4.
2.3 Whole System Relationships
The success of this service will depend on the provider developing good relationships with all those on the
pathway for musculo-skeletal care. This is a core aim and principle of the service. See other sections
especially Section 3.
2.4 Interdependencies
The success of this service will depend on the provider developing good relationships with all those on the
pathway for musculo-skeletal care. This is a core aim and principle of the service. See other sections
especially Section 3.
2.5 Relevant Clinical Networks and Screening Programmes
None at the time of writing
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2.6 Sub-contractors
The provider may subcontract elements of this service.
The provider will:

Retain liability for all aspects of service delivery and may not transfer this liability

Ensure all sub-contracting arrangements are documented

Make available to the commissioner all relevant information relating to sub-contracted
arrangements. This will include, for avoidance of doubt, any information that might be
considered as commercial in confidence
3. Service Delivery
3.1 Service Model
3.1.1 Provide a high quality patient experience
The provider will place the patient at the heart of the service at all times. The provider will take responsibility to
ensure that the patient receives an integrated service.
Provision of evidence-based treatment
New evidence for effective treatment should be identified, considered and used to inform clinical practice.
The provider will:

Offer patients treatment that complies with NICE health technology assessments at all times.
Where the provider is not able to do this they must clearly highlight this to the commissioner in
writing

Have a system in place to promote use of best practice among staff. This might include
training, CPD,

Have in place a system to review clinical evidence as it emerges and to introduce this into
clinical practice without untoward delay. This should be integrated into other local groups that
make decisions for treatment for the Buckinghamshire Population e.g Formulary Management
Group
Promotion of self-care
Self-care and supported self-care are essential components of effective musculo-skeletal care. See section 6.
Engaging patients
See also section on Self-care. Engaging patients in the design of services and in improvement of the patient
experience should be integral to a high-quality, integrated service. Precisely how this is done is at the
discretion of the provider however the commissioner does have some minimum expectation and will expect all
activities to be auditable:
The provider will:
 Establish a website and portal to provide information to patients, clinicians and other
stakeholders. An example of the type of web site is provided on the link below:
http://www.eckcommunityservices.nhs.uk/main-menu-pages/your-services/specialist-clinicalservices/integrated-musculoskeletal-services.aspx

Make arrangements to carry out patient satisfaction surveys and co-operate with such surveys
that may be carried out by the commissioner. The provider shall have regard to any
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Department of Health guidance relating to patient satisfaction surveys.

Use a validated tool to demonstrate clinical benefits of the service. The commissioner expects
that this will take the form of a 'before-and-after treatment' assessment tool

Collect all data in a way that is auditable and such that the commissioner is able to request
regular or ad hoc reports

Be expected to demonstrate evidence of having used data and information collected from
patients to make improvements to service delivery

Co-operate with all reasonable requests by stakeholders (including commissioners, patient
groups, local authority/public health) for discussion on service quality and patient experience
Quality standards and clinical governance
As with all NHS services the compliance with delivery of services in accordance with Good Clinical
Practice (General medical Council, 2006) is a minimum requirement. Where a standard or document is cited
this shall include all subsequent revisions or successor standards or bodies
The provider will:

Comply at all times with core standards in ‘Standards for Better Health’ July 2004

Have plans in place, shared with the provider, to achieve the 13 ‘developmental’ standards

Comply with relevant Health Technology Assessments (guidance) issued by the National
Institute for Health and Clinical Excellence. Where the provider is not able to do this they must
clearly describe to the commissioner that this is so and the reasons in writing without undue
delay

Work to agreed local Integrated Care Pathways and agreed shared protocols and guidelines.

Comply with the clinical governance framework agreed by the commissioner and to function
under agreed operational and clinical policies.

Have in place clear policies aimed at managing risk and procedures to identify and remedy
poor professional performance.

The provider will have in place a comprehensive and auditable system of clinical governance.
This is likely to include:
o A Clinical Governance Lead to liaise with a NHS Buckinghamshire designated clinical
lead
o Prescribing lead
o Incident reporting
o Infection control
o Significant Event Analysis
o Managing Alerts
3.1.2 Manage demand effectively
One of the objectives of the service will be to ensure that patients are seen by a health professional in a setting
that is appropriate to their needs and offers best value for money.
The provider will:

Devise and run a programme of educational events to include the management of demand. The
provider should maximise opportunities available of existing programmes, meetings,
resources, etc.

Provide structured, systematic and regular feedback to referrers on the quality of their referrals.
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This might include numbers of referrals, rates per number of registered patients, disposal of
referrals

Include systems to audit compliance with agreed treatment guidelines both within the service
and along the whole MSK pathway

Record sufficient information about their activities and be able to report on the management of
all patients
3.1.3 Ensure a high quality workforce
The provider is to be given the maximum freedom to use staff in a way that meets the requirements of this
specification.
Staffing levels
Staffing levels and skill mix are at the discretion of the provider.
Please note that a TUPE obligation does apply to this procurement/contract and attached is an excel file that, to
the best of the PCT’s knowledge, shows those staff that will be subject to TUPE.
E:\BPS\Bucks\MSK\
MSK TUPE.xls
The provider will:

Have the appropriate levels of competent staff in order to:
o
Meet fluctuations in demand
o
Maintain required waiting times for patients
o
Properly assess all patients referred to the service
o
Provide all treatments set out in this specification at all times, without the necessity for
referral to other services (See appendix)
Employment status
Employment and contracting arrangements for staff are at the discretion of the provider.
The provider will:

Ensure that all staff are eligible to work in the United Kingdom

Take responsibility for all actions and practice of all staff and will not be able to transfer any
liability for service delivery to any third party

Ensure that personnel providing the service through the contract have appropriate indemnity
cover to meet in full, claims made against them as individuals. Proof of cover of the provider
must be submitted to the commissioner on request.

Ensure that its workforce is able to meet the needs of the service including taking account of:
o
Professional registration
o
Criminal Records Bureau checks
o
Appropriate skills and qualifications
o
Mandatory training
o
Training and development plans
o
Making sure the clinical workforce is able to meet the needs of the patient
Page 10 of 24
Staff development
The scope and nature of staff development programmes is at the discretion of the provider.
The provider will:

Ensure that they will have an approach to staff development that is consistent, transparent and
amenable to audit

Ensure that all staff are adequately trained to perform their duties

Ensure that staff development is carried out in a way that contributes to the delivery of a high
quality service in accordance with this specification

Ensure that staff development programmes are auditable at review

Ensure that there is adequate clinical supervision at all times
3.1.4 Ensure infrastructure that is fit for purpose
An integral service will need to rest on a sound infrastructure that supports the aims of the service.
Comprehensive clinical record system
An essential component of any service is a clinical record system that captures all relevant clinical data and
makes this available in way that supports high-quality, integrated care. An essential secondary function of
such a system is the provision of information to allow proper monitoring of service quality, service development
and demonstration of value for money.
The provider will:

Maintain a comprehensive electronic record of care for every patient

Hold records on a single database to support service quality and improvement

Utilise the information to improve the quality of care

Utilise the information to maintain clinical governance

Utilise information in planning service improvements

Record all relevant clinical and other information according to a data set to be agreed with the
commissioner

Provide regular and ad hoc reports on service performance as agreed with the commissioner
Information Governance
High standard of information governance are essential wherever patient identifiable information is collected,
processed and stored.
The provider will:

Will make sure that information relating to patients is managed and safeguarded according to
the law and to NHS good practice

Ensure that every patient is given the opportunity to consent to their data being accessed for
secondary use (e.g. service improvement, contract monitoring, etc)
Information Technology
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Organisations providing services to the NHS are required to work within a framework that promotes
increasing integration and standardisation of NHS information and communications systems.
The provider will:

Work in ways that support national and local programmes and utilises IT in ways that maximise
patient care. The Provider will have regard to:
•
Connecting for Health
•
Choose and Book
•
Communication and use of e mail systems

Be N3 compliant, be registered with an Information Governance Statement of Compliance

(IGSOC) and through registration Authority enable the use of smart cards.

Will publish their Directory of Services (DOS) on the Choose and Book system.

Participate in PCT audits and data collection and adherence to record keeping.
Review of the service
The specification will be jointly reviewed by the provider and commissioner with regard to its effectiveness and
suitability for patients from time to time. In no way should this service specification preclude the provider
from innovating and/or developing new ways of working.
4. Referral, Access and Acceptance Criteria
4.1 Geographic coverage/boundaries
The service should be available to the patients of all practices in NHS Buckinghamshire.
4.2 Location(s) of Service Delivery
Patient telephone booking, patient telephone assessment and assessment/triage of clinical
correspondence - location not specified
Patient face-to-face assessment including x-ray must be delivered from one or more sites within the NHS
Buckinghamshire area. Precise locations are not specified but service must be provided with due regard
to:


Travel time via private car maximum 40 minutes
Access via public transport - no more than 5 minutes walking time from bus stop
All diagnostic services should be available from providers within the NHS Buckinghamshire area.
Patient treatments (following assessment) including physical therapy should be delivered from a range of
convenient locations within NHS Buckinghamshire area. Precise locations are not specified but service
must be provided with due regard to:


Travel time via private car maximum 30 minutes
Access via public transport - no more than 5 minutes walking time from bus stop
Currently this element of the service is provided from a number of locations. Any change in the number
or location of service delivery points may be determined as a major service change. The provider should
therefore consider the following as preferred delivery points:
Page 12 of 24








High Wycombe
Marlow
Aylesbury
Buckingham
Chalfont/Chesham
Amersham
Burnham
Thame
The provider will:

consider the suitability of service delivery points with regard to:
o
o

Therapeutic environment
Access for patients with a disability
Obtain the views of patients on the location and suitability of service delivery points and
makes changes as required
4.3 Days/Hours of operation
Hours of operation are at the discretion of the provider. T he provider will ensure that some services are
provided outside core (9am to 5pm) working hours every week that the service operates. Services will
operate every week of the year unless agreed in advance by the commissioner. The service could be
available on weekends or Public Holidays.
The provider will:

Consider the service opening hours with regard to:
o
o

Patient demand as evidenced by call volume and requests for appointments
Achievement of waiting time targets
Obtain the views of patients on opening hours and makes changes as required
4.4 Referral criteria & sources
The service will accept all referrals from clinicians for musculo-skeletal conditions unless excluded (see 4.6).
An indicative list of conditions is given in Annex 4. A list of services to be provided is given in Annex 3.
For more information on management of referrals see 2.1.
4.5 Referral route
The service will be available to all patients registered with a GP in NHS Buckinghamshire.
Other clinicians and service providers will be able to refer patients to the service.
The provider will:

Ensure that the service is specified on the Service Directory
4.6 Exclusion Criteria
Patients should not be referred to the service where they:
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




Are not registered with a NHS Buckinghamshire GP
Have not reached their 16th birthday [see section ‘Age of patient’ below]
Require emergency treatment
Have suspected cancer
Have post operative or post traumatic complications
The service should not be used for patients who have:










‘Red flag’ symptoms - these patients should be referred directly to an acute hospital, including
severe pain or constant pain, day and night
Pain associated with significant trauma
Joint instability where there would be no benefit to the patient in undergoing therapy
Patient has a past history of related cancer- red flag
Systemic steroids as declared in the GP letter of referral, or discovered at first consultation in the
service
Systemic illness (fever, malaise, rigors)
Significant weight loss suggestive of serious infection or malignancy as declared in the GP letter
of referral, or discovered at first consultation in the service
Persisting severe restriction of lumbar flexion
Widespread neurology with or without upper motor neurone signs
Structural deformity
Exceptions to the exclusion criteria are set out below:
 A patient who does not quite fall into the above but nevertheless in the opinion of the referrer
there is a clinical case to exclude serious life threatening disease such as cancer (The referrer
should indicate on the proforma that in their opinion the referral is not suitable for ICATS.)
 A patient with a very high BMI, with significant co-morbidities or with high ASA scores should be
referred into the service only if the referring GP (and subsequent clinical assessment) considers
it appropriate; if this is not clear, the provider should refer back to the GP
The provider will:

Have in place clear policies for managing patients that are excluded or otherwise not suitable
for treatment by the service

Ensure that all staff are aware of policies and audit practice
[Age of patient – currently in NHS Buckinghamshire patients with minor MSK problems between
their 6 th and 16th birthdays are seen and treated in the adult outpatient physiotherapy service.
Consideration is being given to whether these patients should be seen in the ICATS. Bidders are
invited to state in their response whether they will accept referral of patients within this age group.
Financial and service consequences should be detailed separately within their offer]
4.7 Response time and prioritisation
All referrals will be dealt with on a first-come, first-served basis. The service will assess patients and may
allocate appointments based on clinical need.
Referrals to the service will be assessed as soon as possible by the provider, with all new appointments
following a GP referral taking place no more than 4 weeks from the date the GP referral was received by
the provider, unless the patient chooses to attend at a later date (after being offered at least two different
appointment dates and two different appointment times within the four weeks).
Performance of the provider on response and waiting times will form part of the performance review of
the service.
The provider will:
 Work to ensure that waiting times are kept as short as possible
 Ensure that response and waiting time standards and that any breaches of standards are
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reported to the commissioner in a timely way. Standards are set out in Schedule 2 Annex 2
5. Discharge Criteria & Planning
Timely and well-supported discharge, with effective onward communication is central to an integrated service
and high-quality patient experience.
The provider will:
 Make available to the patient’s GP a summary of care including such information as is necessary
for management of the patient. This will be in the form of a printed electronic or paper
document or of an electronic document only where requested by a referring practice
 Provide a summary of care to the GP within an agreed time period, suggested to be 3 working
days
 Ensure that discharge summaries are dispatched to the patient’s GP within the agreed response
time – see Schedule 2 Annex 2 for response standards
6. Self-Care and Patient and Carer Information
Promotion of supported self care
Supported self-management needs to be a guiding principle for this service, informing all aspects of service
delivery, most importantly patient interaction.
The provider will comply with good practice on supported self-care. How this is incorporated into operating
procedures and day-to-day practice is at the discretion of the provider. However, we would expect the
following activities to be part of service delivery in a way that is auditable at performance review:
The provider will:

Offer a comprehensive range of patient information on musculoskeletal conditions, including
advice on self-management, and will direct patients to other resources as appropriate

Will ensure that clinicians having contact with patients should be trained in shared decisionmaking with regular updates

Give relevant information to patients as to what services to access should a treatment
complication arise outside these normal hours

Make available all relevant information resources to GPs. The provider may recover the costs
of producing this material
Information to support choice of treatment
Patients will be given an explanation of their condition and advice about all management options which will be
discussed with the patient including non surgical and surgical (if appropriate).
The provider will:

Discuss with the patient relevant treatment options and will make the patient aware of
prevailing policies on procedures of limited clinical value

The provider will make available to patients the agreed procedure for booking appointments
and the policy on DNAs and cancellations.
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Information for carers
The provider will ensure that information is provided for carers that supports the philosophy of supported self
care. The requirements set out in the section above will apply also to carers
7. Quality and Performance Indicators
Service aspect
Quality and
Performance
Indicator(s)
Threshold
Method of
Measurement
Consequence of
Breach
HCAI Control
Service User
Experience
Improving Productivity
[All quality and performance indicators will be devised in collaboration with
the service provider at contracting stage. However the provider should take
careful note of the statements relating to quality and performance elsewhere
in this specification. These will be used to inform the final indicator set]
Access
Personalised Care
Planning
Outcomes
Additional Measures for
Block Contracts:[All quality and performance indicators will be devised in collaboration with
the service provider at contracting stage. However the provider should take
careful note of the statements relating to quality and performance elsewhere
in this specification. These will be used to inform the final indicator set]
8. Activity
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Activity Performance
Indicators
Threshold
Method of
Consequence of
measurement
breach
[Activity targets and expectations will be agreed in
collaboration with the service provider at contracting
stage]
Activity Plan
See Schedule 2 Annex 1
9. Continual Service Improvement Plan
There is no separate requirement for a plan of this type. Ongoing service improvement will form part of the
performance and review process.
10. Prices & Costs
10.1 Price
[Activity prices and costs will be agreed in collaboration with the service provider at contracting stage]
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Schedule 2 Annex 1: Summary of Activity Plans
See separate Excel workbook Schedule 2 Annex 1 final.xls in this ITT folder
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Schedule 2 Annex 2: Summary Quality and Performance Indicators
Response and waiting times
[All response and waiting times to be agreed with the provider at contracting stage]
Definition
Response time
Telephone answer
Contact patients who have been referred to offer an appointment
Offer of (first) assessment appointment
Offer of treatment (first after assessment) appointment
Dispatch of discharge information
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%
achievement
Schedule 2 Annex 3: List of treatments and activities
This list states which treatments and activities are to be provided in this service and which are to be
accessed via referral or other means. [This list is subject to final agreement]
Activity
Initial assessment of referrals (paper) MSK
Initial assessment of referrals (paper) Rheumatology
Initial assessment of referrals (paper) Orthopaedics
Initial assessment of referrals (paper) Pain (MSK)
Initial assessment of referrals (paper)Physiotherapy
Initial assessment of patient (face-toface) - MSK
Initial assessment of patient (face-toface) - Rheumatology
Initial assessment of patient (face-toface) - Orthopaedics
Initial assessment of patient (face-toface) - Pain (MSK)
Initial assessment of patient (face-toface)- Physiotherapy
Type
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
Assessment and
diagnosis
MRI scan
Imaging
Dexascan
Imaging
Plain film x-ray
Imaging
Ultrasound
Imaging
CT scan
Imaging
Other specialised imaging
Imaging
Status
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Order test and manage
according to result
Order test and manage
according to result
Provide or order test and
manage according to result
Injection soft tissue - joint (except spine)
Injection intra-articular
Injection - image guided
Injection - spine
Procedure
Procedure
Procedure
Procedure
Neurophysiology - nerve conduction test
Procedure
Physical therapy - physiotherapy
Physical therapy - physiotherapy (to
include exercise)
Physical therapy - women's health
Physical therapy - women's health
Assessment
Order test and manage
according to result
Order test and manage
according to result
Order test and manage
according to result
Provide
Provide
Refer
Refer
Order test and manage
according to result
Provide
Treatment
Provide
Assessment
Treatment
Provide
Provide
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Physical therapy - osteopathy
Physical therapy - osteopathy
Physical therapy - chiropracty
Physical therapy - chiropracty
Accupuncture
Accupuncture
Bio-mechanical aids - splints, collars, etc
Bio-mechanical aids - splints, collars, etc
Mobility aids - mechanical only
Mobility aids - mechanical only
Orthotics
Orthotics
Multi disciplinary management of MSK
pain
Multi disciplinary management of MSK
pain
Pain management
Pain management
Rheumatology
Rheumatology
Orthopaedics
Orthopaedics
Surgical procedures requiring general
anaesthetic
Prescription of non-opioid analgesics
Prescription of infused medicines - nonexcluded drugs
Administration of infused medicines non-excluded drugs
Prescription of infused medicines excluded drugs
Administration of infused medicines excluded drugs
Prescription of injected medicines - nonexcluded drugs
Administration of injected medicines non-excluded drugs
Occupational therapy
Occupational therapy (including home
adaptations)
Occupational therapy (minor or
rehabilitation)
Assessment
Treatment
Assessment
Treatment
Assessment
Treatment
Assessment
Fitting
Assessment
Fitting
Assessment
Fitting
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Provide
Refer
Refer
Assessment
Provide
Treatment
Provide
Specialist
assessment
Specialist
treatment
Specialist
assessment
Specialist
treatment
Specialist
assessment
Specialist
treatment
Specialist
treatment
Assessment
Provide
Assessment
Refer
Procedure
Refer
Assessment
Refer
Procedure
Refer
Procedure
Provide
Procedure
Provide
Assessment
Refer
Treatment
Refer
Assessment
Provide
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Refer
Refer
Refer
Refer
Refer
Refer
Refer
Occupational therapy (minor or
rehabilitation)
Podiatry (MSK only)
Podiatry (MSK only)
Phlebotomy
Treatment
Provide
Assessment
Treatment
Procedure
Pathology - blood test
Procedure
Pathology - other test
Procedure
Provide
Provide
Provide
Order test and manage
according to result
Order test and manage
according to result
Exercise - as part of physical therapy for
MSK
Exercise on prescription
Patient materials to support treatment
Choice and booking of provider for
specialist care
Application of clinical thresholds
Application of surgical priorities policies
Booking and choice for patients
Dietetics and Weight Management
Dietetics and Weight Management
Treatment
Provide
Treatment
Other
Refer back to GP
Provide
Other
Provide
Other
Other
Other
Assessment
Treatment
Provide
Provide
Provide
Refer
Refer
All activities are for patients aged 16 years and
over
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Annex 4 : Indicative list of conditions for referral
Note that this is not an exhaustive list and should not be considered as a definitive for contractual
purposes
Treatment conditions
Upper Limb
Repetitive strain injury/occupational over-use
Shoulder instability
Shoulder bursitis
Rotator cuff tendonitis
Rotator cuff tear
Biceps tendonitis
Frozen shoulder
Calcific tendonitis/Supraspinatis calcification
Acromio-clavicular arthritis
Gleno-humeral arthritis
Hand
Skeletal and soft tissue injury to the hand and wrist
Work related musculoskeletal disorders
Peripheral nerve injury/compression (e.g. carpal tunnel)
Tendon injury
Hand/wrist problems related to rheumatic conditions
Dupuytren’s disease
Osteoarthritis
Hip and knee
Hip bursitis
Inflammatory hip or knee pain
Non-specific hip or knee pain
Labral tear
Greater trochanteric pain
Iliopsoas strain
Pubic bone/abdominal wall related pain
Anterior knee/patellar pain & spain
Meniscal condition knee
Cruciate ligamentous condition knee
Osteoarthritis
Foot and ankle
Heel spur and Plantar Fascitis
Ankle sprain/instability
Achilles tendonitis
Tarsal tunnel syndrome
Tibialis posterior/peroneal tendonitis/strain
Medial gastrocnemius strain
Anterior/posterior ankle impingement
Osteo-chondral defect ankle/foot
Metatarsalgia
Hallux Valgus/rigidus
Hammer toe
Sesamoiditis
Tailor bunion
Osteoarthritis
Back
Chronic lower back pain
Non-specific back pain
Mechanical back pain
Discogenic back pain
Facet syndrome
Spinal stenosis
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Spondylolysis/listhesis
Rheumatology
Inflammatory arthritis
Osteoarthritis
Osteoporosis
Reactive arthritis
Connective tissue disease and psoriasis
Gout
Fibromyalgia
Chronic Pain
Medically unexplained symptoms of pain
General musculoskeletal pain
Headache (including migraine)
Myofascial pain syndromes
Post-thoractomy pain
Chronic regional pain syndromes
Stump and phantom limb pain
Neuropathic pain
Trigeminal neuralgia
Temporomandibular joint disorder
Post-mastectomy pain
Women’s Health
Pelvic floor weakness and pain
Other pain
Health
Promotion/
Prevention
Facilitate return to work
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