Improving Access to Musculoskeletal Services:

A New Model of Care

Ian HoldingSenior Lecturer Musculoskeletal Medicine, Otago

BSc, MBBCh, FRNZCGP, Dip MSK Med., MPainMed, FAFMM

The Problem

• System relies heavily on referral to hospital.

• Many patients with musculoskeletal problems do not need to be treated in hospital.

• They can receive faster and more appropriate care in the community.

System of waiting, rejection and failed promises

• If patients, whose needs could be better met elsewhere, are referred to hospital:– They endure a wait for access to services (no active

management) or– They are rejected - 2000 people in the past or 30 per

week.

• These patients also increase the waiting times for those who do require specialist hospital care, particularly orthopaedic surgery, thus creating delays before crucial interventions can be offered.

• Cont.

• Orthopaedic surgeons, rheumatologists, neurologist, neurosurgeons, spend valuable time seeing patients who do not need their input.

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The Solution

• The approach is based on shared care, structured around the patient journey (often defined in integrated care pathways)

• International evidence shows that better integration of, and collaboration between, primary, secondary and social care can reduce hospitalisation and provide better care and a better service.

The UK experience

The Musculoskeletal Services Framework – A joint responsibility: doing it differently

Author: Department of Health, NHS

Publication date: 12 July 2006

Musculoskeletal Medicine

• Rheumatology, Orthopaedics, and Rehabilitation Medicine(Neurology and Sports Medicine)

• These are related to Musculoskeletal Medicine, but each one focuses on particular conditions or special ways oftreating them.

The Community MSK clinic

• Service model

• Philosophy

• Rooms

• Staffing

MSK Clinic background

• 30% of all GP consultations are about Musculoskeletal (MSK) conditions.

• In Canterbury 50% of referrals to Orthopaedics do not meet the threshold for Surgeon assessment.

• Many of these patients could be assessed and treated in the community by Musculoskeletal Medicine Specialists.

Referral pathway

The single point of entry for referrals will be the Orthopaedic Referral Gateway (ORG) : 

• Referral to rapid access diagnostics – MRI and Ultrasound, or 

• Referral to Secondary Care Orthopaedic Outpatient Services, or

• Referral back to GP with advice re treatment in General Practice and supported by the HealthPathways website

Referral criteria – MSK clinic

1. Patients deemed by the ORG to have conditions where treatment with joint and soft tissue injections is likely to be of benefit:

• Shoulder pain e.g. Rotator cuff syndrome • Wrist pain e.g. Carpal tunnel syndrome• Ganglion, Trigger finger• Heel pain e.g. Plantar fasciitis• Foot pain e.g. Mortons neuroma • Neck, Thoracic & Lower back pain over 6 week’s duration

Referral criteria – MSK clinic

2. Patients with ill-defined MSK conditions requiring MSK expertise to develop a care plan, or for whom GPs require a second opinion, e.g. spinal conditions, lateral hip pain, ill defined limb pain.

MSK Clinic exclusions:

• Have an injury accepted by the Accident Compensation Corporation

• Under the age of 15 years

• Not enrolled in a Canterbury PHO

• Require on-referral e.g. diagnostics, physiotherapy, as this will be managed by the Patient’s GP.

Experience to Date

Summary