Download AHP activities in Scottish MSK services

AHP activities in Scottish MSK services A scoping study for NHSScotland Sue Parroy Summer 2005
WORK IN PROGRESS AHP activities in Scottish MSK services Contents NHS Argyll and Clyde 3 NHS Ayrshire and Arran 6 NHS Borders 8 NHS Dumfries and Galloway 9 NHS Fife 10 NHS Forth Valley 13 NHS Grampian 16 NHS Greater Glasgow 22 NHS Highland 26 NHS Lanarkshire 28 NHS Lothian 32 NHS Orkney 37 NHS Shetland 37 NHS Tayside 38 NHS Western Isles 42
2 WORK IN PROGRESS NHS Argyll & Clyde AHP activities in Scottish MSK services NHS Argyll & Clyde The geography of Argyll & Clyde is some of the most diverse in Scotland and presents particular challenges. There is a population of around 418750 K. Four out of five people live in the areas of Paisley and Renfrew, Greenock and Port Glasgow, Dumbarton and Helensburgh and other towns. The remaining population live in remote and rural communities, including 26 inhabited islands of which only three (Islay, Mull and Bute) have populations over 1000. Primary Care Direct Access to Physiotherapy – available at four Health Centres in Renfrewshire. [email protected] Podiatry clinics that have been set up to ease access for patients are varied including: Drop­in, direct access, emergency and nail care. A social nail care programme to be piloted in the north will have MSK input. sharon.lafferty@renver­pct.scot.nhs.uk Podiatry Biomechanical Service. Patients can self refer or may be referred by their GP, Consultant or other healthcare professional to this community based service. Alan.Best@renver­pct.scot.nhs.uk Joint working with orthotist, physio and podiatry. Biomechanic (0.5wte) based at Dumbarton [email protected] Acute care Royal Alexandra Hospital Musculoskeletal physiotherapy services [email protected] • Direct Access (self­referral), Hydrotherapy, • A Hand Clinic • Accident Emergency / Fracture Clinic, with a Senior I input who does injection therapy • Acute Low Back Pain Clinic (service has links with Diagnostic/Imaging dept, orthopaedics,Neurosurgeon and pain clinic) • Physio/Nurse led joint replacement review clinics – pilot study for 1 year • Extended Scope Physiotherapy sessions for orthopaedic knee and hand referrals • Audits have demonstrated that a trained ESP can independently manage appropriately vetted orthopaedic referrals. Podiatry Consultants and Specialist Nursing Staff may refer to the Specialist Podiatrist within acute sector for multi­disciplinary working with Orthopaedist and onward referral to community based Podiatry Biomechanical Service.
3 WORK IN PROGRESS NHS Argyll & Clyde AHP activities in Scottish MSK services Occupational therapy Staff are involved in • The Multi Agency Team for Care at Home (MATCH) team in assessments within A&E and facilitating supported discharges to prevent avoidable admission. • Pre­admission elective surgery clinics – assessments for patients awaiting elective admission for joint replacement. • Following assessment by the Occupational Therapist the Technical Instructor continues the rehabilitation process at home and therefore manage their own caseload with supervision. Vale of Leven Hospital Joint replacement surgery Patients are contacted by the Occupational Therapist as soon as their name is put on the waiting list for joint replacement. OT intervention/Home Visit offered. This allows access to the service prior to the pre­surgery assessment clinic. Inverclyde Royal Hospital, Greenock Physiotherapy. Very much part of the local community, with clear patient information leaflets. Physiotherapy outpatient services are based around the acute hospital and three peripheral health centres and one other small clinic. Weekly meetings allow staff to jointly manage referrals across the patch. Jenny.irons@ Orthopaedic sessions – There are three ESP sessions (clinics) per month: two spinal and one knee. The consultant currently triages the waiting list and allocates the referrals to ESP or consultant. Due to staffing constraints this has been found to be more time efficient than the previously tried ESP physiotherapy triage; access to diagnostics still has to be established. A domiciliary and orthopaedic team with a falls project in its infancy. Other services Multi­disciplinary Health Education Groups for Rheumatoid and Osteo­ arthritic patients delivered by Alan.Best@renver­pct.scot.nhs.uk Rheumatology services within the medical team with nurse lead clinics offering injections. The physiotherapist works closely with these clinics. An interactive exercise scheme co­ordinated by the council in Greenock: which any health professional can refer into. Patients take the referral to the leisure centre of their choice. Developments ESP Podiatrist to be part of multidisciplinary Orthopaedic Outpatient Redesign (CCI supported). This project will examine a triage system for orthopaedic referrals, with Podiatry managing the identified foot and lower limb referrals in partnership with orthopaedic consultant staff. ESP Podiatrist will undertake part of the Orthopaedic Outpatient Redesign process within a primary care setting to enable a proportion of the patient journeys to remain within the community rather than be acute based.
4 WORK IN PROGRESS NHS Argyll & Clyde AHP activities in Scottish MSK services Development of Podiatry supported self–help educational groups allowing patients a role to play in their own health management. Temporary funding obtained from Community Outpatient Services to expand Acute Low Back Pain clinics into the Health Centres. Temporary funding obtained from Centre of Change and Innovation to increase Extended Scope Practitioner sessions in Orthopaedic clinic. The intention is to see patients referred with lumbo­sacral problems. Lottery funding has been obtained to pilot an Occupational Health Physiotherapy service across Argyll & Clyde. Inverclyde Royal Hospital, Greenock Pain Clinic – physiotherapy input to a pain clinic, with access to a clinical psychologist and a pain management programme. Injection clinics – Physiotherapy led clinics in one of the health centres. Electronic referral protocols on the hospital “sky” system and in the future electronic physiotherapy referral. Self­referral to physiotherapy will be considered when the results of the national trial are published.
5 WORK IN PROGRESS NHS Ayrshire & Arran AHP activities in Scottish MSK services NHS Ayrshire & Arran NHS Ayrshire & Arran provides a range of care to around 367,000 people. It is home to 7.2% of all Scotland’s population. There is a wide mix of urban and rural areas. AHP services are managed individually across the board, although there is a move toward single system working. All the physiotherapy staff are employed by the General Hospitals division with some staff working in primary care facilities. Most of the physiotherapy staff involved in musculoskeletal services are employed by the General Hospitals Division with some staff working in primary care facilities. [email protected] There are some staff in the Community care division who also see patients with musculoskeletal conditions. [email protected] Physiotherapy Direct Access Introduction of direct access via self­referral at Brooksby Out­ Patient Clinic in Largs as part of a Glasgow Caledonian University one year study. [email protected] Orthopaedic Clinics There are 7 Orthopaedic Consultants at Crosshouse Hospital and 5 at The Ayr Hospital. • Two Physiotherapy Extended Scope Practitioners work in the orthopaedic clinics. One working at Crosshouse Hospital 5 sessions per week and the other working at Ayr Hospital 4 sessions per week. [email protected] • One Physiotherapist treats patients in the Physiotherapy Department of Crosshouse Hospital for injection therapy. [email protected] Falls Classes in Ayrshire to identify musculoskeletal neuromuscular problems and coping strategies with patients who are at risk of falls or who have already fallen. [email protected] Hydrotherapy in Crosshouse Hospital and restricted access to Hydrotherapy at Arroll Park, Ayr. Contact Susan Middleton in Physiotherapy in Crosshouse Hospital. A Physiotherapy Orthopaedic outreach service is provided to patients discharged from the orthopaedic wards of Crosshouse Hospital to facilitate prompt discharge. [email protected] Early supported discharge, for patients with fractured neck of femur, is provided by Physiotherapy from the Orthopaedic ward at Ayr Hospital. [email protected]
6 WORK IN PROGRESS NHS Ayrshire & Arran AHP activities in Scottish MSK services A service is provided for ante and post natal women with pelvic and/or low back pain. [email protected] A programme is provided for patients with chronic pain in Ayrshire Central Hospital. [email protected] Rheumatology Two senior Rheumatology physiotherapists work in out­ patients and clinics at Crosshouse and Ayr Hospitals. There is input to the rheumatology wards and Multi­Disciplinary rheumatology education sessions for patients and relatives. There is a ‘One Stop’ Multi­disciplinary Inflammatory Joint Disease Clinic for patients, held in Heathfield Clinic and Ayrshire Central Hospital. [email protected] Podiatry Podiatry service, reconfigured in 2003, is now needs, rather than demand led. Patients can self­refer to podiatry and they will be given a care programme. Healthcare professionals Ayrshire­wide can refer to Podiatry, but there is no dedicated MSK podiatry service or any podiatrists working alongside orthopaedic clinics. There are clear written protocols of care, patient information and pathways. [email protected] Other Services Domiciliary Physiotherapy board is provided Ayrshire wide. [email protected] Functional restoration classes for patients with chronic low back pain. Contact Cathy Gill in Physiotherapy at Ayr Hospital. Referrals from Occupational Health are given priority to try and facilitate staffs attendance at work. [email protected] Osteoporosis advice and exercise classes [email protected] Qualified fitness instructors lead exercise classes in the community to which physiotherapists and other health professionals can refer patients. [email protected] Developments Injection therapy by the Physiotherapy ESP in the Orthopaedic Clinics in Ayr and Crosshouse Hospitals. Contact [email protected] Pilot of a pathway for patients with osteo­arthritic hips and knees. To filter out patients attending Orthopaedic Consultants who do not require surgery. Contact [email protected]
7 WORK IN PROGRESS NHS Borders AHP activities in Scottish MSK services NHS Borders The Borders is a large geographical rural area, which covers 1,820 square miles. The Borders Primary Care NHS Trust provides a wide range of community, mental health and primary care services across this area to a Borders population of 106,000. It has no single main centre and over 30% of the population live in centres of 1,000 or more. The larger towns in the Borders are Hawick (16,000), Galashiels (14,000), Kelso (10,000), Peebles (7,000), Selkirk (6,000), Jedburgh (4,000) and Duns (2,540). The rurality of the area and the dispersed nature of the population are key issues for the delivery of health services, requiring many people to make long journeys for the delivery of health facilities. Podiatry There are no extended roles and limited triage of the referral into the orthopaedic service at present. Primary care Every health centre has access to on site podiatry. Acute care Biomechanical podiatry service based in the orthopaedic workshop at Borders General Hospital 4 days per week. This service sees patients on referral from GP’s, consultants and other healthcare professionals. [email protected]
8 WORK IN PROGRESS NHS Dumfries & Galloway AHP activities in Scottish MSK services NHS Dumfries & Galloway The population served is just 146,500, but within a large geographical area of about 2,400 square miles. Dumfries and Galloway stretches from Langholm in the East to Stranraer in the West, and from Kirkconnel and Carsphairn in the North down to the Solway Coast. There are a number of community hospitals throughout the region, and an intermediate unit (including maternity services and medical & surgical beds) in Stranraer. Acute care A multi­professional AHP orthopaedic triage in Dumfries and Galloway This team has been established for an number of years and covers musculoskeletal and rheumatology services. The OTs, physiotherapists and podiatrist pride themselves on integrated working. Once each week they jointly triage all general referrals coming into the orthopaedic service, and manage a large percent between them. The team also runs joint physiotherapy and podiatry outreach clinics. The physiotherapists above are qualified to administer injection therapy Other MSK services include • PT triage of GP refs to physiotherapy out patient services • Joint OT /PT MSK hand clinic • Joint PT/ Pod MSK appointments • OT and PT involved in development of Orthopaedic integrated care pathways Rheumatology services • Joint OT/PT Rheumatology clinics for people with established disease and newly diagnosed patients • Patient education groups for RA (close links with local Arthritis Care Org • There is an OT on call system for acute hand/orthotic interventions has been developed with Rheumatology clinics because of the rural area. • OT pre op assessment of all proposed hand surgery for Rheumatoid patients Other services There is good partnership working between hospital and social services OTs about home equipment and the needs of patients undergoing proposed THJR surgery. Dumfries & Galloway Council believes itself to be the only council in Scotland that has a contract with Dumfries & Galloway NHS for all orthopaedic aftercare. (equipment). [email protected]. Patients have a pre­ operative home visit and assessment by council OT staff and equipment is provided. There is a “standard hip pack” and similar for knees. The council bills on a per capita basis plus a travel allowance.
9 WORK IN PROGRESS NHS Fife AHP activities in Scottish MSK services NHS Fife Fife has a resident population of 349,429 (2001 census). 7.5% of the population are aged 75+, compared to 7.1% in the rest of Scotland. As the elderly population increases, there is also a 1% decrease in the age range 21– 31, with a declining birth rate. Changes in the delivery of health services are planned for Fife to balance the need for high quality, specialist provision, with improvements in local community services. Consultation with NHS staff and Fife residents, is ongoing through the ‘Right for Fife’. A Diagnosis and Treatment Centre (DTC) will be built at St Andrews within five years. AHP services are managed separately across the board area. Primary care Self referral to physiotherapy in West Fife. paul.lynch@fife­pct.scot.nhs.uk Physiotherapy services in GP surgeries for over 10 years and well established, self­sufficient and not reliant on hospital services. dennisbradley@fife­pct.scot.nhs.uk Physiotherapy injection therapy expanding. There are now two Clinical Specialist Physiotherapists in this area: mhairileslie@fife­pct.scot.nhs.uk; paullynch@fife­pct.scot.nhs.uk Joint physiotherapy and podiatry biomechanics clinics were established in 1995 . These aim to improve the patient journey and reduce waiting times for each discipline by providing a holistic package of care. Unfunded developments alongside these include acupuncture LauraMcBride@fife­pct.scot.nhs.uk and sports massage. Podiatry musculoskeletal clinics – These started in 1994. Initially this was held 1 session per week in a local clinic and involved only podiatry staff. These clinics now provide care approx 3 days per week in each locality, in various clinics, throughout Fife. [email protected] JulieArmstrong@fife­ pct.scot.nhs.uk Integrated Response Team. This was developed within the acute sector, the management has moved to LHCCs. This primary care based team with OTs, physiotherapists, social work and rehabilitation assistants offers 14 days of therapy based at home and is jointly funded. Team members come to hospital to assess patients and set up care packages. Rheumatology – Fife Rheumatology Disease Unit based at the Sir George Sharp Unit. This is a consultant led community rheumatology service with some access to in­patients. The non medical team providing services across Fife is community based and made up of OTs, nurses, physiotherapists and a full­time podiatrist All AHPs in rheumatology are specialists. The philosophy of the service is to teach patients long term self­management of their disease. The physios emphasise the use of local exercise facilities, the OTs run a joint protection group and also visit work environments to facilitate keeping
10 WORK IN PROGRESS NHS Fife AHP activities in Scottish MSK services patients at work and podiatrists hold 8 biomechanics sessions throughout Fife. AdeleOsborne@fife­pct.scot.nhs.uk, Joan.smith@fife­pct.scot.nhs.uk and jane.gibbson@fife­pct.scot.nhs.uk Acute care There are 8 WTE Orthopaedic Consultants, 1 Associate Specialist and 2 staff grades. AHPs are also involved with 4 Consultant Anaesthetists who work part time within pain services AHP staff work across 2 acute hospital sites; Queen Margaret Hospital in Dunfermline [QMH] and Victoria Hospital in Kirkcaldy [VHK]. A service is also provided to GP patients within Dalgety Bay surgery. A wide range of clinical experience is provided by rotation of staff across acute sites and to outreach at Dalgety Bay. Victoria Hospital in Kirkcaldy [VHK] Orthopaedic Clinics – This started in 2005. since 1998, physiotherapy extended scope practitioners have been established within the orthopaedic service in QMH. • Total of 5 staff involved in ESP role • ESPs able to authorise x­rays and MRI tests • Direct referral by ESP to theatre list with specific Consultants • PGD under development for injection therapy • Piloting use of image intensifier for specific injection therapy, working with radiologist [email protected] Joint biomechanics clinic – Podiatry and joint physiotherapy/podiatry MSK clinics since 1998. Referrals to these clinic come from Physiotherapists and Orthopaedic consultants. Consultants from other fields also use the service e.g Pain clinics and diabetes. Some patients are still referred to orthopaedics when conservative biomechanical intervention would be of benefit. Green, [email protected] A pilot for patient self referral is running within Dalgety Bay surgery at present. Results of pilot due later this year. Queen Margaret Hospital in Dunfermline [QMH] Orthopaedic clinics since 1998, physiotherapy extended scope practitioners have been established within the orthopaedic service in QMH. Joint physiotherapy and podiatry clinics – as at VHR since 2001. Joint A & E therapy service for older people – This is under development with occupational therapy and physiotherapy. [email protected] An A&E occupational therapy service for older people with MSK problems has been in place at both sites for 18 months, with an audit about to be published. A physiotherapist has just joined the service and they will become the ‘Therapy A&E team’. [email protected]
11 WORK IN PROGRESS NHS Fife AHP activities in Scottish MSK services The Technical Instructor 2 role within outpatients has been developed to be the first point of contact for selected new outpatients sent directly from Accident and Emergency and Orthopaedic clinic. Modern Hydrotherapy facility and Biodex isokinetic facilities. Good links with leisure centres particularly in the West of Fife. lynn.speed@fife­pct.scot.nhs.uk Joint biomechanical physiotherapy and podiatry service for anterior knee pain referrals come via orthopaedic consultant [email protected] or angela.green@fife­pct.nhs.uk Elective surgery. All elective hip and knee patients are seen by an Occupational Therapy Assistant T2. The role in pre­admission clinic has developed over three years. Social service OTs visit four weeks before surgery to check and deliver equipment. This has freed up professional time. [email protected] Therapy hand team of occupational therapist and physiotherapist share skills. Pain management – Locally developed multi­disciplinary pain management programme well established within QMH. Pain services under pressure to meet demand and resources limited. Developments Podiatry • Introduction of a referral management system that extends the current triage of orthopaedic referrals to include primary care practitioners. • Use of software to facilitate process mapping and decision support. • Provision of podiatry as part of triage at orthopaedic clinics to further reduce inappropriate referrals to consultant orthopaedic surgeons and aim to reduce waiting times. 7 day occupational therapy service [email protected] CCI redesign funding granted through the Orthopaedic outpatients programme [email protected] will project manage the CCI bid which includes: • Enhancement of existing ESP team to work across Acute and Primary Care, increasing the team from 5 to 12 • Investigate the need for extended Podiatry role within Orthopaedic service • Nurse­led review clinics already in place for joint replacement patients. Further development to include new patients. • Introduction of ESP led clinics in Primary Care alongside development of referral guidelines for GPs into Orthopaedic service • Redesign of present referral management system to ensure that the patient is seen by the most appropriate healthcare professional
12 WORK IN PROGRESS NHS Forth Valley AHP activities in Scottish MSK services NHS Forth Valley Forth Valley has a population of 279,500 served by two district general hospitals in Falkirk and Stirling. A single regional hospital in Larbert is planned for 2009. The boundaries of Forth Valley stretch as far as Loch Lomond in the West, Crianlarich in the North, and beyond Dollar in the East, which highlights the rural needs which this Division must meet. Orthopaedic redesign work in Forth Valley is led by an orthopaedic working group which has GP, orthopaedic consultants, public health consultant, radiology, physiotherapy, nursing and senior management representation. Primary care Physiotherapy Musculoskeletal service – Physiotherapy in place in 12 of the health centres in addition to main hospital departments. • All MSK physiotherapy staff work from the same clinical directorate and under the same management. • Most Senior I MSK physiotherapy staff in the Stirling locality, are not permanently sited in one health centre, and are rotated around different health centres and into the main hospital department every 2­3 years. • Two of the ESPs in orthopaedic clinics are mainly primary care practitioners and come into the hospital to carry out ESP sessions. Back Pain Management – referral pathways to secondary care are currently being reviewed. A pilot was run initially for 6 months from 1st March 2004 to August 2004 involving 3 sessions from Extended Scope Practitioners in primary care screening referrals to orthopaedics and GP direct access to MRI. This has reduced the number of direct referral letters by 75% from the three pilot sites, compared to the 6 months prior to the pilot. It has also reduced the number of patients who do go on to see the consultant by 85%. Following redesign of back pain referrals, the majority of back pain patients will be managed in Primary care, by GP and physiotherapists, the ESPs will also work with an orthopaedic consultant in his clinic weekly. [email protected] Backfit classes are provided in mixed locations, some in local leisure centres and one on a hospital site. [email protected]. There are also council run exercise referral schemes with concessionary rates for patients referred from physiotherapy. Pilot osteoporosis programme in North West Stirling, proactively identifies high risk patients and offers a programme for advice, screening and exercise. Fiona Downie (Stirling Royal Infirmary) [email protected]­hb.scot.nhs.uk Occupational health physiotherapy sessions offered for both staff in Primary Care and the Division
13 WORK IN PROGRESS NHS Forth Valley AHP activities in Scottish MSK services A Joint Podiatry and Physiotherapy Paediatric clinic currently being piloted one session per week between Oct 04 –April 05. Podiatry Acupuncture clinics recently introduced within Primary Care to treat foot conditions such as Plantar Fascitis. A Rheumatology clinic held weekly (one session) Orthotics provided to control excessive pronation in the RA foot. [email protected] Acute care Physiotherapy A computerised outpatient management system (SCI) was introduced in physiotherapy to replace the paper system in Stirling. This linked with the rest of the hospital and directly with some GPs. Booking of appointments and patient tracking has become easier. The electronic system also gives the physiotherapist up­to­date clinical information on the patient prior to the appointment. The time saved has been equivalent to the service getting a new full­time physiotherapist and amounts to an extra 400­500 patients being seen per year. Direct electronic booking for physiotherapy appointments has been introduced with referral protocols. [email protected] Orthopaedic MSK physiotherapy. 6 ESP sessions in place. 4 in Stirling and in Falkirk. The patient triage/selection process differs depending on consultant. Some consultants triage patients to be seen by the ESP, in others the ESP works autonomously with the orthopaedic team and general clinic referrals are triaged as they arrive. • ESPs have injection training and can refer for X­ray (not MRI), nerve conduction, bone scans and order bloods. [email protected] and [email protected] • A weekly ESP injection clinic at SRI physio department is held. Stirling Combined Back Clinic (fortnightly clinic). ESP Physiotherapy, psychology, consultant in pain management and specialist nurse work together managing patients with low back pain of less than six month duration. Based on back pain guideline recommendations. Aimed at addressing psychosocial factors early and prevention of chronicity. • Regular audit includes back to work indicators, follow up at 3 months, 6 months and one year. Psychology resource is minimal and often although the referral protocol states the clinic is for sub chronic pain, chronic patients benefit from this resource also. Waiting time usually no more than 8 weeks. • The Back Book is recommended. Posters advertise that it can be purchased in the local pharmacies. [email protected]
14 WORK IN PROGRESS NHS Forth Valley AHP activities in Scottish MSK services Orthopaedic medicine clinic – In conjunction with an Orthopaedic surgeon a physiotherapist provides a weekly clinic for patients with acute and post acute musculoskeletal conditions. Inpatient activity • Arhthroplasty nurses deal with follow up arthroplasty patients on both hospital sites • Orthopaedic rehabilitation beds “step down” • Therapy­led inpatient rehabilitation unit – [email protected] Other services Pain management service – two pain clinics run in Forth valley, both led by consultant anaesthetists and specialist nurses in pain management. Physiotherapy input is minimal due to lack of resources but both sites have two sessions of physiotherapy specialist and one session of psychology. Resources are too limited to have a formal pain management programme. The team work very closely with the Pain Association Scotland classes. Joint Rheumatology Clinics. • ‘One stop clinic’. Rheumatologists, physiotherapists and occupational therapist. anita.carr@ fvah.scot.nhs.uk • At Falkirk Royal a podiatry RA clinic runs in tandem with Consultant RA clinic twice a month. Pain Management Class. This is a self­run class by the patient support group associate with Pain Association of Scotland. Very close links with the pain clinic. http://www.painassociation.com/about.html NASS (national ankylosing spondylitis society) classes held (non NHS). Osteoarthritis hydrotherapy class held in Calander Mclaren High School (non NHS). Developments Centre for Change and Innovation (CCI ) bid to unify the referral pathway for back pain. CCI bid examining referral protocols for lower limb arthritis the use of ESPs, arthroplasty nurses and GPSI. Podiatry setting up Biomechanics clinics within Primary Care in 2005.
15 WORK IN PROGRESS NHS Grampian AHP activities in Scottish MSK services NHS Grampian The population of Grampian is 523,400. Half its boundary forms a border with the North Sea while inland it is mainly rural. Aberdeen is the largest urban area and the main focus of activity, and is home to 40 per cent of the region's population. The NHS in Grampian employs over 16,000 staff. It is one of the largest employers in the north east of Scotland, serving a population of 525,000 across 3,000 square miles. It has an annual budget in excess of £600 million, providing 3,400 beds in 26 hospitals. Acute services are centred at Aberdeen Royal Infirmary and Dr Grays in Elgin. Primary care and community services are provided through 20 health centres and 31 clinics, and general medical services from 87 GP practices and 360 GPs. Orthopaedic out­patient services are provided to residents of three NHS Board areas Grampian, Orkney and Shetland. Physiotherapy There are Grampian­wide physiotherapy care pathways and flow charts across the city and for referral into secondary care. Grampian Wide Low Back Pain Physiotherapy Pathway – development of a pathway for physiotherapists working in both the acute and primary care sectors. Includes standardised assessment forms and guidelines for assessment and patient management, patient information leaflets, and an electronic version of the pathway for GPs to use during consultations. The group are working with other colleagues across Scotland in the development of a Scotland­wide pathway. Gillian Grant, Clinical Specialist Physiotherapist, Aberdeen. [email protected] Primary Care Physiotherapy in primary care. There are senior physiotherapists in most GP practices, with clear physiotherapy Grampian­wide care pathways and flow charts. [email protected] There is one clinical specialist physiotherapist (?ESP) for one area of Aberdeen with no access to diagnostics. Podiatry [email protected] – more information awaited. OT [email protected] OT [email protected]
16 WORK IN PROGRESS NHS Grampian AHP activities in Scottish MSK services Aberdeen City Aberdeen City Acute Low Back Pain Physiotherapy Service. This development aims to improve access to services for patients with acute low back pain and to maximise the potential within primary care to manage this patient group. This service is provided to a number of practices in the North of the City and is hoped that this is the first stage in a city­wide roll out. [email protected] or [email protected] City Wide Physiotherapy Primary Care Triage. All primary care out­patient clinics in Aberdeen now operate a ‘triage’ system where all patients are seen for initial assessment within a 3­4 week timescale. A full assessment of their problem is carried out and the best course of action determined. From this initial assessment they may be given advice, exercises, referred for group rehabilitation, hydrotherapy, given an appointment for treatment (immediately or onto a waiting list), or referred back to their GP. The emphasis is on early intervention/advice and promotion of patient self­management. Contact Lynn Morrison: [email protected] Aberdeenshire Banff and Buchan Triage At Peterhead all back pain patients are triaged and offered one of three options, advice then placed on waiting list for physiotherapy if required, open discharge, or discharged. In Banff this service extends to all MSK patients Opt­in – Where there are higher waiting times the patient will initially be informed that a long waiting list exists and that they will be contacted when there is an available appointment. Two weeks prior to sending them their first appointment they are contacted to confirm whether or not they still require to see the physiotherapist. Exercise Recommendation Scheme This is jointly funded with the Princess Royal Trust. All MSK patients are given the opportunity to continue on with self­management by attending the local leisure centre. They are given 8 free sessions. Back Rehabilitation Groups are provided at three different sites in this area. Contact Britt Hyman for all of the Banff and Buchan services. [email protected]
17 WORK IN PROGRESS NHS Grampian AHP activities in Scottish MSK services Central [email protected] Self­referral. This began in Inverurie in 2002 and has now extended to four other sites in this area. Patients can refer themselves directly into the physiotherapy department without first having to visit their GP. All patients are seen within 48 hours of self­referral. Triage – All patients in this area are seen within 10 days of referral or earlier. Following the assessment patients may be given advice and or a home exercise plan. They will then be given an appointment for treatment, put onto the routine waiting list, referred back to their GP, given an open discharge or offered back rehabilitation classes Equal Access – A group of physiotherapists meet regularly to ensure that all patients in this area are offered equal access for back rehabilitation. This may mean patients having to travel to get earlier access to a class. Deeside [email protected] or [email protected] Triage – Early assessment/triage clinics are currently running in Aboyne HC. All patients are seen within 2 weeks of their referral for full assessment. They are then either discharged with advice, given a review appointment in about 2 weeks (with exercises etc to be doing in the meantime), referred back to the GP, or referred on to a pilates/muscle balance class (running from the new year). The emphasis is on patients taking ownership of their conditions and on early intervention and treatment if necessary. If the pilot in Aboyne is successful then triage will be rolled out to the other outpatient clinics in Desside. Kincardine [email protected] Self­Referral service is provided for patients at Auchenblae and Inverbervie. Any patient requiring physiotherapy can directly refer themselves to the physiotherapy department for assessment. Back Pain Service. The back pain classes are provided in the local leisure centre, there has been good uptake of leisure services by patients following discharge from the groups. Pain Clinic ­This is a nurse led clinic with physiotherapy and occupational therapy support. Patients are referred via the GP for multidisciplinary support and rehabilitation
18 WORK IN PROGRESS NHS Grampian AHP activities in Scottish MSK services Moray [email protected] Dr Gray’s Hospital Back Pain Service – For the last 3 years all back pain patients who attend the back class are given the opportunity to continue their exercise programme at the Moray Leisure Centre. A link session is held every 6 weeks where the patients are introduced to the Moray Leisure Centre by Physiotherapy staff from Dr Gray’s hospital together with Moray Leisure Centre staff. Moray Physiotherapy MSK Team has links with two orthopaedic clinics for direct referral of shoulder and acute knee injuries. Self­referral – Patients wishing to self­refer complete a form found in the GP surgery. These are screened by the Senior physiotherapist and appointments offered as appropriate Orthopaedic Triage – Physiotherapists triage patients who have been referred to the orthopaedic surgeons and decide on future management e.g.. Surgery, podiatry, physiotherapy etc. This includes education sessions for GPs. Acute care Routes into MSK services are varied and dependant on GP referral. Aberdeen Royal Infirmary A physiotherapy­run spinal triage. This has run for 10 years and there are two physiotherapists in the back clinic for four hours per week. The service runs alongside the consultant clinic. Physiotherapists may refer for x­ ray (not MRI) and list for procedures. About 40% of patients are referred on to the physiotherapy service for further treatment. It has been estimated that this triaging allows for an extra 700 new appointments per annum, reduces waiting time and ensures that the right professional sees the patient. [email protected] GP with special interest working at the hospital alongside a physiotherapist Injection protocols. Physiotherapy injection protocols agreed (in particular for use on Shetland) but not implemented. Exercise and links to leisure: A technical instructor (TI2) who has been in post five years leads rehabilitation classes. They have had additional development including exercise coaching and City and Guilds qualifications. [email protected] . There are good links to community leisure centres across Grampian, with a notice board in the physiotherapy department listing all leisure facilities. Back Pain Rehabilitation Group. Run by one of the ESPs in back pain based on the Klabber Moffat approach. [email protected]
19 WORK IN PROGRESS NHS Grampian AHP activities in Scottish MSK services Pain clinic: Physiotherapy clinical specialist in Chronic Pain works with the pain team two mornings per week and takes forward some vocational [email protected] Occupational Health. NHS Grampian currently provides occupational health physiotherapy to around 7,000 staff employed by the acute trust across two sites. This is a self­referral system and is looking to be rolled out across Grampian in the future. [email protected] Rhuematology – Lesley Davidson [email protected] • National ankylosing spondylitis society (NASS) hold classes in the hydrotherapy pool. NHS physiotherapy staff supports this class. • Specialist ankylosing spondylitis clinic – This physiotherapy/registrar led clinic is for measurement and review of patients. The physiotherapist may give advice, refer on for physiotherapy or facilitate admission to ward. • Rheumatoid Arthritis Management Programme (RAMP) is a multi professional service for patients who have been newly diagnosed with Rheumatoid Arthritis. The team includes a physiotherapist, occupational therapist, nurse and pharmacist. • Adolescence Transition Service – for children with juvenile idiopathic arthritis Support is offered from a multi­professional team, which helps with the smooth transition from children to adult services. Physiotherpy in A&E – A senior I physiotherapist works alongside the orthopaedic consultants and A&E staff. Together with an Emergency Nurse Practitioners (ENP) they provide care immediately post soft tissue injury and fracture treatment. ENP refer soft tissue injury ankles for their review with physiotherapist 5­7 days post injury. Patients post fractures are triaged to refer on for further physiotherapy or self­management. [email protected] Geriatric Orthopaedic Rehabilitation Unit – Main physiotherapy input done by a TI 2. Occupational Health. Self referral for all hospital staff for occupational health physiotherapy.
20 WORK IN PROGRESS NHS Grampian AHP activities in Scottish MSK services Occupational therapy Is provided via community hospitals and community based rehabilitation teams, as part of a wide and varied caseload. There is not a dedicated service. Elective surgery – [email protected] Occupational Therapy cover for 4 wards – staffing consists of 1 full time Senior I, 2 x part­ time Senior 2 s, and a full time Basic Grade. Occupational Therapy input is provided for a variety of elective surgical patients including arthroplasty, spinal surgery, resection of tumour, amputation and ilizarov. Input with discharge planning in conjunction with the multi­disciplinary team and various community agencies. Pre­assessment clinics – for total hip replacement, total knee replacement and spinal surgery patients. Occupational Therapy intervention through initial assessment and liaison with the Community Occupational Therapists for provision of equipment for home. Education of post surgery precautions and functional implications carried out. Patient journey group – Occupational Therapy involvement in the development of orthopaedic integrated care pathways leading to more streamlined service. Rheumatology is primarily linked to ward services, other than hydrotherapy. Occupational Therapy out­patient service is via referral from consultant rheumatologists. Geriatric day hospital – Occupational Therapy service is provided to day patients as part of a wide and varied case load. Developments Implementation of Multi­professional Triage and Intermediate Treatment team in Orthopaedic Out­Patients. (CCI supported). The project aims to reduce out­patient waiting times and improve patient access by developing a new intermediate tier of care provided by GPs with a special interest and extended scope practitioners in an appropriate setting. Primary Care Based Triage – CCI supported – provision of a physiotherapy/GP service for patients in the primary care setting with the main aim to triage the patients and offer the most appropriate intervention e.g., physiotherapy, injection therapy, etc it is hoped that this will reduce the numbers of referrals sent on to the orthopaedic surgeons Occupational health physiotherapy telephone advice service, for all staff. To develop Occupational Therapy role within back pain rehabilitation programmes. Self­referral and triage will be extended to other primary care areas in Grampian over the next year
21 WORK IN PROGRESS NHS Greater Glasgow AHP activities in Scottish MSK services NHS Greater Glasgow NHS Greater Glasgow works to provide health care to 870,000 people living in local communities around The City of Glasgow, East Dunbartonshire (Milngavie, Bishopbriggs, Kirkintilloch), West Dunbartonshire (Clydebank), South Lanarkshire (Rutherglen & Cambuslang), East Renfrewshire (Eastwood) and North Lanarkshire (Stepps­Moodiesburn corridor). Primary care Direct access (self referral) to physiotherapy for all our health centres, either through telephone triage or drop­in clinics are in the process of being rolled out to the north of the city. Contact [email protected] who was the project manager in primary care. Podiatry­led biomechanical GPs have had open access to a service for over five years. Previously these patients would have been referred to orthopaedics. By April 2005 there will be self­referral to podiatry for patients across Glasgow April 2005). [email protected] Rolling out of physiotherapy led injection therapy service at sites within primary care. Patient group directive in process of being set up in conjunction with pharmacy. [email protected] or [email protected] for outcome of patient satisfaction questionnaire with regards to service. Greater Glasgow Back Pain Service which comprises clinical specialists and a lead clinician crossing both primary and secondary care. The service consists of mainly physiotherapists and has links with psychology, culture, leisure, imaging and orthopaedics – rolled out 2001. [email protected] Further details to follow. A service for homeless people employs both physiotherapists (1.5wte) and podiatrist (0.8WTE). Many have MSK problems. The service includes domicillary visits to hostel and temporary accommodation dwellers, clinic appointments in the purpose built health centre and self referral clinics in homeless drop in centres. In the case of orthopaedic patients, efforts are made to facilitate attendance to fracture /ortho clinic appointments and liaise with orthopaedic staff. [email protected] (Physio) [email protected] (Physio) or [email protected] (Podiatrist). Primary care has an occupational health physiotherapy and podiatry service which treats staff with MSK problems at specific sites across the city. angela.price­[email protected]
22 WORK IN PROGRESS NHS Greater Glasgow AHP activities in Scottish MSK services Acute care Northern Division (north/east sector) Stobhill Musculoskeletal Unit. Patients are triaged by senior nursing staff and assessed and managed by 4 physiotherapists (20 sessions) and a podiatrist with orthopaedic training. Approximately 80% of referrals are managed in this way. In 8 months at Glasgow Royal Infirmary (GRI) 1,228 new patients were managed; 27% were discharged, 22% were placed on surgical waiting lists, 13% were referred for investigation and 30% referred for physiotherapy. Patient satisfaction was high with 76% happy to be seen by a physiotherapist instead of a consultant and 94% were satisfied or very satisfied with the service. This service is being further developed. The aim to have eight ESPs working up to 40 sessions over the next six months following training. The team includes a consultant surgeon and clinical nurse manager. Through team working, communication and accurate information much has been achieved. Including decreased waiting time, increased surgical capacity and sub­specialisation for the consultants and other team members. [email protected] and [email protected] Podiatry one stop triage clinics – In Stobhill, podiatrists have been triaging orthopaedic referrals for foot, ankle and gait problems since 1998. One­stop clinics are in place whereby patients receive an assessment, diagnosis and specially manufactured insoles, if required at the initial visit. Therefore, treatment begins immediately, with only a review appointment required. Only 6% of the referrals required to be referred onwards to the orthopaedic surgeons for surgery (750 patients assessed per annum. However, since the establishment of the designated orthopaedic podiatrist post at GRI (July 2003), referrals for surgery can be triaged by the orthopaedic podiatrist depending on the condition. A PGD for the administration of steroid injections has been in place since November 03, and training is being rolled out to all the podiatrists in the Acute Sector. The podiatrist sees foot and ankle patients. (Primary forefoot, toes, hallux valgus and heel pain. People are triaged and options include minor Surgical sessions and steroid injections. Continuity is ensured and patients have pre­ operative, surgical and post­operative follow up. [email protected] Joint podiatrist / orthotist clinics are in place to assess footwear requirements / splints – previously seen by orthopaedic consultants. Podiatrists are part of the Rheumatology Team within Stobhill Hospital and Glasgow Royal Infirmary. [email protected] West Glasgow Orthopaedic Clinics – Extended Scope Practitioner Physiotherapist in Orthopaedics. In the West a physiotherapist with an extended scope of practice effectively triages and manages care of referrals to the Orthopaedic
23 WORK IN PROGRESS NHS Greater Glasgow AHP activities in Scottish MSK services Department. The physiotherapist has the capacity to arrange any further haematological or radiological investigation required and can refer directly onto other specialists, including Rheumatology and Pain Clinic and can list directly for Surgery. This service was developed initially to work with two Orthopaedic Surgeons and effectively decreased waiting time to Out Patient Appointment while maintaining high levels of patient satisfaction. This has developed over the past five years and is now supplemented by the appointment of three extended scope physiotherapists to assist in the management of all Orthopaedic referrals. [email protected] Rheumatology – An Extended Scope Practitioner Physiotherapist in Rheumatology at Gartnavel General Hospital, triages and manages care of patients referred to Out­Patient Clinic carries out joint injection and sees also in­patients. [email protected] Direct Access pilot in the acute setting run April – June 2004 at the Western Infirmary, incorporating joint working with Primary Care. West Glasgow due to go full Direct Access (self­referral) for all GP practices accessing both Primary Care and Hospital sites. Western Infirmary, Gartnavel General Hospital. [email protected] Southern Division Southern General and Victoria Infirmary There is orthopaedic surgery and trauma on both sites, with the same Integrated Care Pathways (ICPs) for all upper and lower limb arthroplasty patients. • Lower limb arthroplasty. OT in pre­assessment for all lower limb arthroplasty patients. Routine patients are seen by TI3 on both sites. DARTeam is available to orthopaedic patients. Effectively hospital to home. [email protected] • Geriatric Orthopaedic Rehabilitation Unit GORU unit officially open late from October 2004. • Victoria Infirmary. National Brachial Plexus service. Other services ESP in Rheumatology, who is also involved in GP injection training. [email protected]. Acute and Chronic Pain Management Clinics – Glasgow Royal Infirmary and Southern General (Pain Management in UK, Dr Foster). OT input is about to be provided to all these clinics. [email protected] Glasgow­wide osteoporosis service, written up as part of the CSP project. http://www.csp.org.uk/effectivepractice/sepp/databasebyproject.cfm?id=32 Occupational Health and Injury prevention for all undertakers in Scotland – Margaret Revie (Independent Practice) –
24 WORK IN PROGRESS NHS Greater Glasgow AHP activities in Scottish MSK services New training post part­funded by the health board to look at the training and CPD requirements of leisure centre staff/instructors delivering physical activity programmes with a health component. [email protected] Developments Greater Glasgow Foot and Ankle Triage Service aims to provide the 3000 patients traditionally referred to an orthopaedic surgeon. The service will be lead by specialist podiatry practitioners and start with a primary care based MSK service for assessment and treatment as required. [email protected] (CCI supported). Saturday orthopaedic OT service (in the Southern division).
25 WORK IN PROGRESS NHS Highland AHP activities in Scottish MSK services NHS Highland NHS Highland serves a population of some 208,000 residents and sees a proportion of its patients from the influx of tourists to the Highlands, which at certain times of the year can double or even triple the local population. NHS Highland’s catchment area comprises the largest and most sparsely populated part of the UK with all the attendant issues of a difficult terrain and a limited internal transport and communications infrastructure. The area covers almost 25,784 km² (10,000 square miles), which represents approximately one third of the Scottish land surface. The geographical nature of the region presents particular challenges for the efficient and effective delivery of health care services. Primary care Patient Self­referral to Physiotherapy. Raigmore Hospital provides physiotherapy services within Inverness GP Practices. A patient self­referral clinic is currently being piloted within two GP Practices. This pilot is part of the National Survey. A Physiotherapy Musculoskeletal Triage is based in GP practices within Inverness. Patients are assessed by a senior physiotherapist and given appropriate advice and exercise. 3 sessions of treatment is offered within the practice. Some patients only require advice and discharge, others may be inappropriate for physiotherapy. An injection therapy service is provided by trained physiotherapists within GP practices in Inverness. Referrals are accepted from physiotherapists, GPs and consultants. This has reduced patients waiting times for this treatment by xxx weeks. In the absence of this service X nos. of patients would be managed by the Orthopaedic Department at Raigmore Hospital. It is anticipated that this service will be expanded in the near future. East Highland Primary Care [email protected] The MSK physiotherapy service – The out­patient service consists of an established MSK service in nine GP practices and health centres plus provision to two Community Hospitals out­patient departments. Direct access (self­ referral) has been introduced to six practices. This will be rolled out to all the other practices once impact is established. Informal physiotherapy screening service prior to referral to secondary care. Physiotherapy­led injection therapy service based in the community and community hospital. Referrals are accepted from all GP’s, physiotherapists and consultants. Although we do not have accurate figures, this has had an impact on the number of referrals to secondary care. Patient group directives being reviewed to cover all physiotherapists in NHS Highland.
26 WORK IN PROGRESS NHS Highland AHP activities in Scottish MSK services An open access community wide podiatry service (Biomechanics is un­ resourced) – many practitioners have acupuncture skills and one assistant practitioner undergoing training. A central functioning old electronic diary and appointments system keeps good data which demonstrates consistent growth over the past 10 years. Personal footcare is discontinued and patients are assessed and graded High Risk, Medium Risk and Low Risk. [email protected] Acute care AHP lead clinics have been piloted but these have been hampered by lack of space. Other services Highland Rheumatology Unit. This is an ARMA standards of care good practice entry. Lynn Forbes [email protected]. There is also a physiotherapy led injection clinic, multi­professional case management, a weekly National Ankylosising Spondylitis Class and a telephone help line. Other developments are self medication audit, dedicated computer software and education programmes. Musculoskeletal clinical specialist post based in Town and County Hospital – Nairn. Developments AHP Orthopaedic Referral Facilitator. CCI supported. This post aims to improve appropriateness of referral and reduce orthopaedic waiting times the impact of this role will be audited and evaluated. The postholder will work closely with orthopaedic consultants, GPs and community staff to ensure orthopaedic referrals are sent to the most appropriate team member. Other activities would include devising protocols, educating GPs and community staff (physios), identifying staff with an interest in developing their orthopaedic skills and possibly developing orthopaedic specialist roles within the community. Patient Self­referral to Physiotherapy (Badenoch and Strathspey) is currently being piloted in Grantown on Spey GP practice. This pilot is part of the National Survey. Back Pain Project. Plans to develop a back pain project, in practices and to extend to leisure centre based class/group work for chronic back pain.
27 WORK IN PROGRESS NHS Lanarkshire AHP activities in Scottish MSK services NHS Lanarkshire Lanarkshire has a declining and ageing population in common with Scotland as a whole. The population of Lanarkshire in 2003 was 555,440. In 2003, 8.6% of the population was aged 65­74 and 6.1% aged 75 and over. These proportions have risen over the past 15 years from 7.5% and 4.7% respectively. Over the next 15 years they will continue to rise to 10.6% and 8.6% respectively. AHP services managed separately at each site. An existing ESP service is currently in place on each acute hospital site with a total annual capacity of 2500 patients. The aim is to establish a single Lanarkshire wide resource. Historically, cross­site working and multi­professional working has not been strong. Primary care A podiatry­led biomechanical service. The public and General Practitioners have had access to this for over seven years. Previously these patients would have been referred to an orthopaedic department at one of the three acute sites within NHS Lanarkshire. A service for homeless people which has recently started includes podiatry input for those with musculoskeletal foot deformity. Back Pain Classes in the community On 2 sites physiotherapy staff take back pain classes in the community. Hunter Hails, East Kilbride this started in 2001. [email protected] and Coatbridge Health Centre where classes using the Klabber Moffat approach are taken in the ‘Time Capsule’ sports centre. Patients are then encouraged to join the ‘Get Active’ scheme and continue classes at a reduced rate. Direct Access Pilot Site Motherwell. [email protected] Electronic data collection. 2 pilot sites using PIMS. Early Supported Discharge Team based in Primary Care. This is not specifically an MSK service but does cover a high proportion of these cases. It offers a home based time limited (6 weeks) rehabilitation service following discharge. With a team of 3 Physiotherapists, 3 Occupational Therapists, 3 Rehab Support , 1 social work assistant, 1 clerical worker, 1 speech therapist, 1 team leader. Based at Cleland Hospital. Covering Motherwell/Wishaw/Clydesdale areas. Acute hospital covered is Wishaw General. Clydesdale LHCC – Occupational Therapy does not have a specific MSK service but in covering the 3 GP hospitals in the area deals with a high proportion of these cases.
28 WORK IN PROGRESS NHS Lanarkshire AHP activities in Scottish MSK services Acute Care Monklands Hospital Orthopaedic Specialist Physiotherapist (Sept 2003). [email protected] Low Back Pain Screening Service commenced June 2004. Four sessions per week. Early to judge impact on out­patient consultant waiting times. However, no consultants in Lanarkshire undertake spinal surgery so this service will not affect waiting times for surgery. Occupational Therapy Hand Injury Clinics for both trauma and elective hand surgery. Treatments include scar and oedema management, thermoplastic and lycra splinting and a wide variety of therapeutic treatment media to improve functional work and leisure skills Supported Discharge teams; Rapid response (prevention of admission, 1 PT, 1 OT 1 TI III ) and an early supported discharge team (1.9 PT, 2 OT,3 Ti111, 1 speech and language, 1, 1 social work assistant. ,3 discharge co­ ordinators) Hairmyres Hospital Orthopaedic Outpatients – Extended scope physiotherapy practitioner (700 orthopaedic out­patients per year) [email protected]. Five sessions working along side each of five consultants funded through the orthopaedic budget. One new patient clinic (Dear Dr letters). “Consultants triage waiting lists and put any patients who may not require surgery on this list.” Service includes: joint injections, ability to order blood tests, X­rays for arthoplasty review only and MRI via the consultant. Triage clinic in Physiotherapy Outpatients. Non­urgent patients receive a 20 minute assessment by a senior Physiotherapist to establish their treatment path. The appropriate course of treatment is then arranged. This decreased the average waiting time in our department from 6 weeks to less than 2 weeks. [email protected] Assistant led back pain classes with good links to leisure centres and ESP clinics. Physiotherapy hand service, Margaret Merrill Supported Discharge teams; Rapid response (prevention of admission, 1 PT, 1 OT) and an early supported discharge team (3 PT, 2 OT,2 Ti111, 1 speech and language, 1 CPN, 1 social worker,4 discharge coordinators)
29 WORK IN PROGRESS NHS Lanarkshire AHP activities in Scottish MSK services Wishaw Hospital Orthopaedic Outpatients – Extended Scope Physiotherapy Practitioner – Tracey Coulton. ([email protected]). Service established in May 2000. Patients are triaged by Orthopaedic Consultants. Three sessions per week in Orthopaedic clinic assessing spinal patients. Access to all onward investigations but MRI, X­Ray & blood tests are via consultant. No spinal surgery is performed at Wishaw but ESP can refer directly to Neurosurgery at Southern General. Podiatrist Led Surgical Footwear Clinic has reduced waiting times for patients requiring orthopaedic or surgical footwear. This has also released appointments) within the consultants new patients clinics resulting in a much more efficient service. A protocol, which was developed in conjunction with the consultant orthopaedic surgeons, establishes whether adaptation to the patient's existing footwear is required, if stock footwear can be supplied or if there is a need for bespoke footwear. A one stop foot clinic has been established where patients are seen jointly by a podiatrist and an orthopaedic surgeon. [email protected] Patients with common foot conditions are triaged (annual capacity 516). This has reduced numbers of patient appointments and orthopaedic waiting times). Following CCI funding this service is about to be piloted at Hairmyres Hospital. Ultimately it is planned that this service will be available in all three acute hospital sites. Supported Discharge teams; Rapid response (prevention of admission, 1 PT, 1 OT OTA 0.50 ) for ECU and A/E and an early supported discharge team (2 PT, 3 OT, 3 Ti111, 1 speech and language, 1 social worker, 1 discharge co­ ordinators) NB The management and funding is split between Acute and Primary Care in a variety of different ways – not consistent across Lanarkshire. Also MSK patients may be seen as part of the general occupational therapy caseloads in both Primary and Acute settings Occupational Therapy Rheumatology Service patients are offered group joint protection education, activities of daily living assessment thermoplastic splinting, relaxation therapies for pain management Other services A limited rheumatology podiatry service also operates with podiatrists working directly with rheumatologists. The Health Return Project. – Last year Kate Rouband was seconded to this [email protected]. The clinical director for this is [email protected] and covers the West of Scotland. This is one pilot site of a project with 8 sites across the UK funded by the department of work and pensions.
30 WORK IN PROGRESS NHS Lanarkshire AHP activities in Scottish MSK services Lanarkshire Workplace Assessment Service aims to assist small and medium sized enterprises to: Prevent an increase in workplace related accidents, protect the health and safety of employees, in the industrial community and provide a comprehensive assessment of health and safety. A team of two specialists in Health & Safety and Health Promotion will visit workplaces and conduct a comprehensive assessment of its’ safety and health status then write a confidential report prioritising any suggested action. [email protected] The HOPE Project Healthcare Occupational and Primary for Employees – The project has been in operation since May 2000. The aim of the project is to provide occupational health advice to employees who present to their General Practitioners, Accident & Emergency Departments, or Physiotherapy Departments in Lanarkshire with work­related ill health. Developments of this project are based on the findings and include sessions on Stress Management, Back Care, Upper Limb Disorders and Skin care. [email protected] Developments Lanarkshire­wide scoping for a unified Back Pain Pathway. An additional 1500 patients seen by redesigning physiotherapy and podiatry services, including extending the scope of podiatry to include requests and investigations (x­ray scans, blood tests), using the results and investigations to assist clinical diagnosis, cortisone and steroid injections, listing patients for minor foot surgery. Consider ESP clinics running in primary care. Build on existing electronic referral systems. To roll out the one stop foot clinics at all sites across Lanarkshire (part CCI funded). [email protected]
31 WORK IN PROGRESS NHS Lothian AHP activities in Scottish MSK services NHS Lothian The Lothian population of 778,500 is projected to grow to 793,244 (+1.8%) in the next five years, as against the rest of Scotland where the population is, in general, declining. Lothian also has an ageing population, but with different demographic trends in different areas. Edinburgh is predicted to have a slight decrease in the over 70s which are predicted to grow in East, Mid and West Lothian. It has been accepted by the health board redesign committee that there will be an external review of all aspects of MSK services (including trauma, orthopaedics, surgery, theatres and rheumatology) Lothian wide. [email protected] is on the core group and steering group. Primary & Community Division East & Midlothian The Out­Patient Physiotherapy Service consists of two Community Hospital Departments and seven Health Centre based ones: four in East Lothian and three in Midlothian. All areas take Consultant & GP referrals & cater for all musculoskeletal conditions across a large spectrum of age groups. One centre is participating with the Direct Access (self­referral RCT). Midlothian Back Pain Project – large scale project to look at LBP pathways, implement screening protocols and set in place the most appropriate treatment at the most appropriate time by the most appropriate individual. Included leisure centre based class/group work for 'yellow flag' patients. This has led onto the Chronic Pain Service, which identifies individuals with chronic pain and seeks to manage this within established systems developed from the Astley Ainslie model. East Lothian Musculoskeletal Service at Roodlands Hospital – Initially a GP led project, a physiotherapy ESP is doing five sessions as an integral member of the team that now includes an Orthopaedic Medicine Consultant, Rheumatologist and Orthopaedic Surgeon. This involves triage of referrals, clinical management of cases, injection, onward referrals to surgery, treatment of highly complex patients in conjunction with local physiotherapy departments, chronic pain management, ENT patients and quick access to orthopaedist and podiatrist. There is also dedicated administration and nursing staff. The post includes a teaching and audit/research commitment.
32 WORK IN PROGRESS NHS Lothian AHP activities in Scottish MSK services Edinburgh Community Physiotherapy Service. Physiotherapy out­patient services at 13 sites across the city. Pilot studies include Direct Access (2 sites), Telephone Triage and Triage screening clinics piloting at two sites. Three (2wte) clinical specialists/ESP have direct access to x­ray and ultrasound scanning. Injection therapy is provided by the Lead physiotherapist at Tollcross Health Centre. [email protected] Community Back Pain Classes. This pilot is due to run until 2005 with Edinburgh City Council and was funded by Primary Care Development Fund. The classes are “sports coach led”. [email protected] A Chronic Pain Management satellite service is held in City Centre clinics, accessible to all patients within our service. [email protected] Staff injuries Physiotherapy service – based within Occupational Health Service for all Primary and Community division. Astley Ainslie Hospital Out patient physiotherapy treatment principally for patients with musculo­ skeletal problems. [email protected] Acute care All trauma patients are seen in the Royal Infirmary Edinburgh (RIE). West Lothian patients are returned to St Johns on average at 72 hours post surgery. • The service has been reconfigured so that Medical Consultants and other clinicians work in specialist teams, e.g. Soft tissue, knee, arthroplasty, foot and ankle. • Combined Rheumatology and Orthopaedic clinics . • City wide Low Back Pain physiotherapy pathway group working. • It envisaged that a “pan Lothian” approach to services should follow the health board review. University Hospitals Division Royal Infirmary of Edinburgh The orthopaedic service is divided into sub­speciality teams. Extended scope orthopaedic physiotherapists have worked in the service since 1995. Their clinics run concurrently with the orthopaedic consultants. There are three orthopaedic physiotherapy practitioners (knee 1 wte, spine 1 wte, upper limb .98wte) doing a total of 10 sessions per week. They are able to inject, order any investigations (including MRI) and, in certain circumstances, add patients to the surgical waiting lists. These sessions are funded by the orthopaedic department. [email protected]
33 WORK IN PROGRESS NHS Lothian AHP activities in Scottish MSK services Foot and ankle service. This consultant led service includes a specialist podiatrist, orthotist and nurse led follow up. The consultant allocates all referrals to the relevant practitioner. Appointments are given within 6 weeks. The new service has helped reduced waiting times for the foot and ankle orthopaedic consultant from 45 weeks (May 2003) to 9 weeks. [email protected] / [email protected] Arthroplasty practitioners (two physiotherapists and a nurse) see all the post­arthroplasty lists. Consultant involvement with these patients finishes after discharge from the ward unless there are problems. There is a patient helpline and patients can ask to be reviewed. Practitioners take blood, order X­rays and in certain circumstances can list for surgery. [email protected] and [email protected] Pre­admission. All patients listed for THR are seen by OTs at preadmission clinics. Patients are sent a pro forma and asked to measure certain things to enable equipment provision. [email protected] Assistant caseload. All occupational therapy and physiotherapy assistants are Tec 3’s. Physiotherapy assistants have own case load, work weekends and see all primary THRs within set protocols and OT assistants see the primary total knees protocols [email protected] Pre­discharge class for all patients who have had elective hip surgery run by OT’s allows consistency of information and good use of time, 8 patients: 1 hour. Multi­Disciplinary Supported Discharge Team. [email protected] This team is for Orthopaedic patients aged 70 and over admitted with orthopaedic trauma to RIE. It is assumed that all patients will need the team until proven otherwise, therefore discharge planning starts at admission. The hospital based team is led by a Consultant Geriatrician. 2 domiciliary physios and 1 TI3 are based at McLeod St. Clinic. Discharge is supported by home OT assessment, timely equipment provision, domiciliary physiotherapy, telephone follow­up, liaison nurses and provision of private homecare up to three times per day, over 7 days for the first 3 weeks following discharge. Western General Hospital Minor injury clinic with extended scope physiotherapist [email protected] working alongside nurse practitioners. Combined Occupational Therapy, Physiotherapy and Rheumatology Clinic (WGH). These started in August 2003 and offer patients a choice of appointment time, a common assessment and patients and staff spend less time. To date the number of non­attenders has reduced, 56 hours of therapy time has been saved and the waiting list is reduced. [email protected] and [email protected]
34 WORK IN PROGRESS NHS Lothian AHP activities in Scottish MSK services West Lothian Healthcare Division St Johns Hospital, Livingston MSK Physiotherapy Clinic Session – One extended scope physiotherapist [email protected] is doing 3 clinic sessions one knee, one general musculoskeletal and one general musculoskeletal primary care clinic. Developments Primary & Community Division East Lothian Back Pain Project – similar to that in Midlothian, the physiotherapist in Dunbar is preparing a self referral service for people with back pain, It will have departmental & leisure centre components. If successful, this will be rolled out across the whole county with the intention of having a fully open access system for all conditions. E­booking of appointments. Our services use TIARA for clinical information. A pilot is set to begin to prove the concept of e­booking of physiotherapy appointments by GP/GP staff for patients at the time of consultation, followed by e­referrals. Primary & Community Division West Lothian Ultrasound scanning (pilot) and direct access to orthopaedic waiting lists in secondary care for named AHP clinical specialists. (Possibly in Edin Community Physio – not St Johns) Establish central booking office for Lothian for all MSK referrals. Develop protocol based referral systems. Enhanced services underdevelopment. GPwSI, ESPs to see new and follow up patients. Expand the numbers of specialist practitioners to support equity of service across Lothian. Lothian Primary and Community Division Foot and Ankle Service. By 2005 it is hoped that this service will be expanded and run in health centres across the Lothians. [email protected] / [email protected] An "E­access" Internet­based physiotherapy knee clinic based at the University Health Centre. Funded from Lothian Change and Innovation Fund 2004/05. [email protected] Injection therapy – Patient group directives. (PGD). Working closely with pharmacy, two PGDs (Kenalog and Lignocaine) for injection therapy are almost signed off. [email protected] Website – Edinburgh Community Physiotherapy Service is developing a Website to be available on SHOW and NHS Lothian Intranet for both patient and GP access detailing Service, wait times, new developments and literature downloads. Aim to “go live” April 2005. [email protected]
35 WORK IN PROGRESS NHS Lothian AHP activities in Scottish MSK services Rapid Response. Funding from Sutherland implementation monies is allowing us to expand the Rapid Response service across the whole of Edinburgh. Each locality will have a Rapid Response service (consisting primarily of Physiotherapists and Occupational Therapists) working to common criteria and service standards to provide an urgent multi­disciplinary assessment to begin an immediate programme of rehabilitation, thus avoiding unnecessary hospital admission. University Hospitals Division Awaiting results of the service review. Rapid recovery arthroplasty service aimed at reducing length of stay is under discussion. [email protected]
36 WORK IN PROGRESS NHS Orkney AHP activities in Scottish MSK services NHS Orkney NHS Orkeney is the smallest health board in Scotland. The total population of Orkney is just under 20,000 with most people live on Mainland, the main island. Kirkwall, the capital, with a population of 7,500, is the administrative centre of Orkney with a good mix of shops, supermarkets and small local businesses. NHS Shetland Shetland NHS Board is responsible for purchasing health care for a population of 23,000. Local Hospital and Community Services are provided from the Gilbert Bain and Montfield Hospitals. In addition, visiting consultants from Grampian University Hospitals NHS Trust and Grampian Primary Care NHS Trust provide out­patient clinics as well as in­patient and day­case surgery to supplement the service provided by our locally­based Consultants in General Medicine, General Surgery, Paediatrics and Psychiatry.
37 WORK IN PROGRESS NHS Tayside AHP activities in Scottish MSK services NHS Tayside NHS Tayside provides primary care and secondary care services across Tayside with full supporting services to a population of approximately 400,000. A number of NHS Tayside services are provided in partnership with other statutory and voluntary organisations, and has close links and provides teaching facilities for the two Universities in Dundee. NHS Tayside has a workforce of approximately 14,000 and a budget of £562million. The Tayside/NE Fife Orthopaedic Service provides specialist care for 480,000 population and delivers both out­patient and in­patient services in all three acute hospital settings: Ninewells hospital, [email protected] Perth Royal Infirmary [email protected] and Strathcathro Ambulatory Diagnostic and Treatment Centre [email protected] In addition, outpatient services are currently delivered in peripheral clinics close to the patients own communities, across Angus (4 sites) and Perth and Kinross (5 sites) and Kings Cross Hospital, Dundee. There are links established with the leisure centres in Dundee for ‘fitness for life’ referrals and Biodex isokinetic facilities are available at Perth Royal Infirmary and Ninewells Hospital. Standardised Assessment forms throughout Tayside Musculoskeletal assessment forms have been standardised throughout Tayside to enable ease of audit. Patient information leaflets are standardised and available on the intranet. Primary care Self­referral to physiotherapy has been ongoing in Carnoustie for many years. The Arbroath site is involved in the Scotland wide direct access pilot. It is planned to introduce self­referral to all outpatient Physiotherapy departments in Angus. Self referral at KXH has reduced the waiting list by 8 weeks [email protected] Injection Therapy is currently available within Carnoustie HC and there are plans for training and implementation in all areas in Angus – seeking funding for this. Injection therapy also available at KXH with 7 physiotherapists completing in­house training – PGDs agreed [email protected] Musculo­skeletal outpatient clinics are run from 6 sites in Angus based locally in the towns – Arbroath, Brechin, Carnoustie, Forfar (2) and Montrose. Early Supported Discharge/Prevention of Admission. There is a limited community service available across Angus both for direct GP/consultant/other health profession referral for this service. Orthopaedic Screening – Stracathro Hospital: 1 WTE clinical specialist physiotherapist screens back referrals coming into the orthopaedic department, provides assessment, diagnosis and treatment of patients referred to the clinic by Angus GPs. There are 6 clinics per month across the
WORK IN PROGRESS 38 NHS Tayside AHP activities in Scottish MSK services two sites. ESP’s can request x­rays, but not other investigations. [email protected]. Redesign of podiatry in Perth and Kinross Local Healthcare Co­ operative. This was previously a demand led service, where many patients expected a certain level of service based on their age alone. In 2003 there were waiting times, averaging 30 months for low risk patients. Baseline criteria were introduced, self­help was encouraged and greater use was made of the podiatry assistant. By January 2004, the wait had reduced to 6­9 months; 15% of the old case load was discharged. The proportion of patients suitable for treatment by a podiatry assistant increased from 7% to 17%. [email protected]. (This relates to the podiatry service as a whole not just MSK services). Rheumatology patients are treated by a dedicated clinical specialist physiotherapist in Kings Cross Hospital Dundee who links into the rheumatology clinic at Ninewells. [email protected] The Community Pain Management Clinic was originally started as a bio­ psychosocial multidisciplinary Primary Care Initiative in 2002 to address the need for a community based service that could reduce the pressure on the Acute Pain Service while satisfying the needs of patients who suffer from less complex pain syndromes. It includes Physiotherapy, Pharmacology and Cognitive Behavioural Therapy input, and is designed to improve the management of patients who suffer non­malignant musculoskeletal pain by addressing the effects that pain has on their lives and empowering them to develop self management skills. Initially available to 10 GP Practices it is now available to all GP Practices in Dundee and will be provided 4 sessions a week, with increased input from Pharmacists and Cognitive Behavioural Therapists, to accommodate 200 referrals a year. This service is a community adjunct to the Consultant led Pain Service in Ninewells and as the only Physiotherapy­led pain management service in Scotland. An audit of the impact of this Clinic demonstrated an annual saving in drugs costs of £136.59 per patient. The wider health economic impact of this Clinic remain to be evaluated in terms of reduced GP visits and reduced hospital costs. To date it has not been possible to secure recurring funding for this initiative which continues to survive on non­recurring funding. Occupational Therapy Rheumatology services are provided by three locality hospitals, Pitlochry, Crieff and Blairgowrie. Patients are provided with core Occupational Therapy input including education, support, pre and post operative assessment, ADL assessment, joint protection and splinting. Waiting times are approximately 6 weeks. A limited, needs led community rehabilitation service is also available. [email protected] or [email protected] or [email protected]
WORK IN PROGRESS 39 NHS Tayside AHP activities in Scottish MSK services Acute Care The Tayside Back Pain Pathway. This was developed and includes the long established spinal service with ESPs now present in Dundee, Angus and Perth. Patients are either triaged to a physiotherapist with extended skills who will assess, diagnose, treat and discharge independently, or to a Consultant with sub­specialist expertise as appropriate. • Approx 70% of patients referred to secondary care are discharged directly by the physiotherapy service without requiring a consultant opinion. • It is estimated that this physiotherapy screening service takes the equivalent of 17 months of patients off the orthopaedic waiting lists. • Orthopaedic clinics • The Ninewells site for Physiotherapy has two main clinical specialist physiotherapy clinics for spinal and knee orthopaedic patients. The Spinal Service (possibly the first in Scotland) was started in 1992 and [email protected] has been in post for four years. Referrals are taken off the consultant list and X­rays (not MRI’s) can be requested. • In Strathcathro Hospital a clinical specialist physiotherapist screens the back referrals coming into the orthopaedic department and provides assessment, diagnosis and treatment of patients referred to the clinic by Angus GPs. There are 6 clinics per month across the two sites. ESP’s can request x­rays, but not other investigations. [email protected]. • The shoulder screening service has demonstrated that up to 57% of patients can be successfully assessed, treated and discharged without the need for a consultant appointment. [email protected] Trauma and elective hand clinics; Ninewells are covered weekly by OT and PT. Patients are immediately assessed and treated appropriately. Both PT and OT are able to discharge patients without Consultant follow up, so reducing the Consultant waiting lists and ultimately improving patient care. [email protected] (0T) [email protected] (PT) Early supported discharge scheme Early orthopaedic discharge scheme provides OT + Homecare services/Rehab with access to Physio via referral to community rehab team. [email protected]. Ninewells Hospital; OT Technical Instructor 2 covers all total hip and knee arthroplasties ,intervention as well as pre­admission clinics for total hip arthroplasties [email protected]. Specialised services at KXH include Back pain, rheumatology, upper limbs, pain management, community rehabilitation and biomechanical assessment. Biomechanical clinic involves assessment by both podiatrist and physiotherapist.
WORK IN PROGRESS 40 NHS Tayside AHP activities in Scottish MSK services Occupational Therapy Rheumatology services are based in Perth Royal Infirmary. Patients are provided with core Occupational therapy services such as education, splinting, ADL assessment and joint protection as well as pre and post operative assessment, treatment and support. Waiting times for this service are approximately 9­12 months. A limited, needs led community rehabilitation service is also available. [email protected] and [email protected] Developments CCI bid includes mention the development of – A patient referral tool based on the patient’s self­assessment with objective markers for prioritisation which will enhance triage decision making. All screened referrals will be directed hereafter to the most appropriate practitioner [email protected] CCI bids have enabled development of hip and knee screening clinics in Perth, Dundee and Angus and hand screening clinics in Dundee. Hand ESP can request EMG studies Ninewells hospital Joint Health and Social Care approach to patient management, in particular elective hip replacements: [email protected]. This aims to reduce length of stay in hospital. To include: • Planned access and care to community aids when a patient is placed on consultant’s waiting list. • Pre­admission pilot with hospital OT visiting patient at home 3­4 weeks prior to admission re preparation, education, exercise and to ensure necessary equipment is in situ.
WORK IN PROGRESS 41 NHS Western Isles AHP activities in Scottish MSK services NHS Western Isles NHS Western Isles Board integrated health organisation providing Primary, Secondary and Community Health Services. It serves a population of 29,000 residents, which increases in the summer months due to an influx of tourists from all over the world. The board works closely with other organisations such as representatives of the public, voluntary bodies and local authority in a multi­agency approach to the improvement of health on the Western Isles and the promotion of healthy lifestyles. The main hospital in the islands is based in the north in Stornoway, Isle of Lewis, with a small hospital in the South on the Isle of Barra, and a new hospital on the Isle of Benbecula (opened in March 2001) in the centre of the Western Isles. On the Primary Care side we have 15 practices across the islands. Orthopaedic and rheumatology services are currently under review. The consultant rheumatologist is retiring and the current orthopaedic consultant is a locum. Physiotherapy The Physiotherapy Department is based at two main sites, however we provide physiotherapy to a number of outlying surgeries, clinics, patients homes, schools, Residential Homes and Hostel, Hydrotherapy pool etc. The Physiotherapists travel significant distances in order to provide their services, including a twice weekly visit by a Physiotherapist to the Isle of Barra, involving a long drive and then a ferry journey of one hour each way! There are currently no clinical specialists or ESPs. [email protected] Junior physiotherapy rotation – Four month joint physiotherapy junior rotation with North Glasgow NHS Trust. This has proved very successful and resulted in two permanent recruitments. “This gives a new impetus to staff” and challenges their thinking with the latest research. Junior staff who have all done four year degrees give regular presentations – one about their student project. Podiatry [email protected] Radiology [email protected] Two radiographers undertake and report on MSK ultrasound scans. Close working relations with physiotherapy have developed. It is thought that with the use of ultrasound arthogram and arthoscope numbers have been reduced. Malcolm is also reporting on CT brain scans. Developments Teleradiological reporting is under discussion
WORK IN PROGRESS 42