Executive Summary:
We offer a comprehensive MSK Extended Scope Physiotherapy triage service to primary care practices who are looking for a flexible, cost effective solution supporting General Practitioners in the assessment, management and pathway referrals for patients who have MSK conditions.
Our service is affordable, practical and audited through clinical, financial and reattendance outcomes.
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MSK (Musculoskeletal) disease is one of the most prevalent long-term conditions with over 200 MSK conditions affecting approximately 10 million people of all ages in the UK. The cost to the national health economy has been estimated at 7.4 billion pounds per year with Long term conditions accounting for £3 of every £4 spent on healthcare.
Exaggerating the Chronic disease landscape is the acknowledgment that the population is ageing and socially the burden of care now sits the patients’ relatives who have not been trained to reproduce ergonomic correct handling postures. Those clients who can work often extend their retirement age without considering the Musculoskeletal issues that can arise by doing so.
Within one local county the overall spend for MSK conditions amounts to £61 million.
As the population continues to rise and with Long term conditions focusing on the older population, the challenge to Primary Care Physicians will be significant in cost in time, pressure to assess and long term Pharmacological support, cost in staffing portfolios to manage additional workload and with the decrease in GP trainees additional stress as vacancies occur due to GP retirement and other issues causing leave.
In 2015 Oxfordshire County Commissioning Group (OCCG) reviewed the MSK pathway and concluded with study with the following statements:
- Patient dissatisfaction was high due to a lack of timely access, lack of transparency and coordination of delivery.
- 18-week RTT was not being achieved due to the increasing demand on the service
- Delay and Duplication within primary care services through and reflective in secondary care
- The pathway lacked coordination and integration.
Consistently patients asked for:
| Patient | General Practitioners |
|---|---|
| A single point of access referring to all services | Rapid access to primary care advice/intervention |
| Responsive service with timely access | Reduction in unnecessary barriers |
| Patient to be placed at the right time/right place for their condition | Patient able to seek choice in therapy support with advice to which provider suits the condition e.g. Chiropractor, Osteopath, Physio |
| Flexible and local service | Engagement with Physicians improving education and communication |
| Ease of access through Primary care estates | Improved communication with secondary care provider |
| Access back to the referrer | Value for money |
| Access to Public Health agenda and self help | Advice on best choice clinician where able to do so |
| Engagement and understanding of the patient, their social circumstances and health and social care | Engagement at all levels with ability to sign post to local services |
The BMA recently published a paper clearly highlighting the need for Extended Scope Practitioner Physiotherapist to work in Primary care sustaining the workforce level as GP practitioners reduce in numbers. (30% of a GP caseload has been cited as having an MSK bias.)
With a national agenda to levy support for Primary Care Physicians, new ways of working could be considered that could free up the burdens of GP caseload, reduce costs of Pharmaceuticals, reduce the referral paperwork for primary care /secondary care referrals, and create a source of income through Injection therapy and Ultrasound clinics if there is a possibility to do so.
Extended Scope Practitioner Physiotherapists through continued professional development and Masters level education, with staged experience within a clinical realm of medical specialism (such as MSK conditions) have achieved additional scope to act as an Autonomous practitioner. This engages Physiotherapy specialist skills to support a more in-depth and advanced reasoning capability. Skills such as Blood test analysis, Non-Medical prescribing, IrMER qualifications, Injection therapy and advanced exercise prescription.
The highly specialized Physiotherapists can act with autonomy, with additional the training to assess, diagnose and provide management pathways for MSK conditions with the added benefit of understanding other Allied Health and Physician led clinical care pathways that may have an impression upon the skeletal state. They are integral in understanding the Health and Social care agenda, plus have a greater understanding of the additional complimentary and other non- medical traditional therapies such as Chiropractic bias that a patient may wish to discuss with the clinician leading the assessment process.
Whilst wishing to be supported with the primary care medical governance, ESP Physiotherapists are trained to recognize the symptoms of serious pathology and biopsychosocial factors that can be presented in MSK diseases.
Future designs into a practice model may enable those Physiotherapy practitioners who have gained competence in Injection therapy and ultrasound diagnostic s to be able to assess, diagnose, therapeutically treat, provide exercise and outcome in a one stop shop case scenario.
In summary:
- Autonomous Clinicians
- Able to assess, diagnose, manage MSK referrals to primary and secondary care, review Bloods and radiology reports to support the diagnosis, offer advice and exercise platforms to improve the condition
- Trained to identify serious pathology and bio psychosocial factors.
- Can access advanced practice skills
- Key role in well- being, exercise prescription
- Future non -medical prescribers
- Income generation through injection therapy clinics and diagnostic ultrasonography.
Nationally recognized to:
- Reduce onward referrals to secondary care
- Improve conversion rates
- Reduce unrequired investigations
- Offer choice of rehabilitation methodology and access to other services which could reduce the need and reliance on pharmacology
- Increase numbers to self- manage
- Encourage and attract patients to seek community based exercise and weight loss where necessary
What do we offer at the Banbury Private Physiotherapy Practice:
Our solution to support Primary Care General Practitioners was designed in 2016; It has been tried and audited with a proven outcome that the service adds value to both the Primary Care team and their Adult patients.
Our MSK practitioners are accredited Senior and Extended Scope specialist practitioners who offer a wealth of clinical practice and diagnostic capabilities endorsed with over 10 years of Clinical experience within the NHS, plus the proven advantage of holding a Masters and Post-Graduate Diplomas in Extended Scope Practice, Ultrasonography and Injection therapy.
Each practitioner has worked within the primary care setting, acting as the diagnostician for the MSK conditions, acting as a sole practitioner assessing, offering the patient a clinical diagnosis, ratified pathway plan, public health advice and referral to either secondary or other primary care teams to offer best management solutions.
The clinicians can document the assessment on the EMIS practice systems enabling the General practitioner the clarity of the diagnosis through a comprehensive and rationalized assessment tool.
All documents are completed prior to the clinician leaving the estate, and each patient will be rehearsed in simple instructions supporting self-management and the understanding of any medications that have been prescribed
Each clinician audits the work through a tool created by our practice thereby maintaining the quality standards expected in our performance review with the practice managers.
The tariff for our services is the cost per patient assessment and includes the documentation time, 2 free phone call review consultations and the indemnity of our practitioners through our insurers and professional liability.
We do not charge for travel and offer a comprehensive service for 48 weeks of the year. We can offer weekend and late evening appointments and can be flexible in the working days booked with 1 week advance notice.
The practice could also offer a children’s MSK triage service for those aged 5 years to 16 years.
Operational Management of the service:
The service will run to a specified weekday agreement.
The Banbury Private Physiotherapy Practice manager will oversee the service providing a quarterly analysis of sessions attended, patients reviewed, areas of clinical trends identified by the Practitioners, positive practice and risk areas that may require improvement or development opportunities.
Questions will be regularly asked of the service which will reflect the 5 CQC Domains:
- Is the Service Safe. How will this be proved?
- Is the service Effective. Can audit measure outcomes?
- Is the service Caring. Can this be identified through customer satisfaction?
- Is the service responsive. Did the practitioners identify vacant slots?
Information and Confidentiality:
- Information relating to patients within any NHS/Private practice setting is held securely and strictly in accordance with Caldicott Guidance, the Data Protection Act and the NHS Code of Practice.
- The Banbury Private Physiotherapy Practice LTD is registered with the Information Commissioners Office (ICO). All staff within the practice must undertake an annual mandatory information governance training and certification is available for viewing as evidence of completion of the course.
- Information on patients receiving clinical advice is recorded in compliance with NHS Information standards
Quality:
- We endorse our quality by:
| Type | What | Why | Who | Review |
|---|---|---|---|---|
| Clinical Audit of practice | Review of sample cases over a specific time/ mix of clinical cases | Ensure that the clinician is offering the breadth and depth of clinical analysis, plus critique of clients and supporting with best clinical practice ad choice | Samples will be reviewed by the practice director. All staff will be appraised | Quarterly |
| Skill /specialist mix analysis | Development of specialism within practice. Each practitioner will engage with a specialist interest and proactively educate peers and colleagues to best practice | Development of education and specialism through evidence ensures quality and reflective practice. | The practice director and operational manager will support and endorse specialism developing interest through timetables training events and linking to the appraisal process | Quarterly |
| Clinical Skill and Education | the practice portfolio of clinicians rather than accepting new grade therapists to minimize costs. | Maximizing on clinical experience lends to best practice intervention. In doing so, clinical performance dictates shorter therapy intervention plus communication enables better self-management programs for the individual | Extended scope Practitioners and Advanced therapy practitioners | Daily |
| Health and Safety | Ensuring that everyone whether employee, Associate or Client/family have the upmost quality care and environment to support and mitigate risk where possible | Reduction of risk and improving the client experience assists with the ethos of best health | All members of the Banbury Private Physiotherapy Practice with the Director and ownership of the practice director | Daily |
| Peer review and case study discussions | Single case study discussions with broader discussions surrounding new evidence and Nice guidance/lavender statement pathways | Maintaining up to date practice and fitness to practice. | Clinicians within the practice | monthly |
| Patient satisfaction feedback | Review of patient satisfaction feedback | Ensure that consistency in approach, communication and patient views maintains standards of care | Practice manager/Practice Director | monthly |
Medical Supervision:
The ESP Practitioner will have access to medical supervision from an Orthopaedic specialist working at Bedford Hospital
Audit/ Measurable:
- Waiting time from booking to face to face contact.
- Reduction in referrals to secondary care trend
- Referrals made to primary care Physiotherapy/Podiatry
- DNA rate
- Patient satisfaction
- % of patients with treatment/pathway plans
- Number of Cortico- steroid injections requested per quarter
- Reduction in repeat referrals in the practice.
- Long Term condition re-referral rate
- Quality Analysis
- Financial analysis
Public Health Agenda:
All clinicians within the practice are well rehearsed on the latest evidence and guidance on Complimentary medicines, Nice.Org, and National NHS pathways /agendas.
Future development: one stop shop approach:
Extended Scope Practitioner therapists hold a wealth of additional skills which could be used to offer an ‘Acute diagnostic and management ‘service
- Ultrasonography: Real time and dynamic imaging offers an on the stop result which could be used for optimal management of soft tissue injuries, gold standard CS injections and outcome measures of intervention.
- Corticosteroid injections: MSK injections for soft tissue and certain joint conditions as a means of pain management prior to Physiotherapy. Future review of the patient post injection to ensure best practice and standards of excellence in non- medical prescribing care
- MSK Telephone triage and Acute service access through self- referral.
Step 1: The Referral Process:
Referrals are made into the MSK Assessment service through two possible routes:
1: Straight through reception /Telephone triage.
2: Through the GP following a telephone or face to face consultation
Whilst point 2 creates a small-time delay, it does enable the exclusion of red /yellow flags, minimizing risk to the practice and the Physiotherapy practitioner.
Step 2: An appointment is made with the MSK Physiotherapy Practitioner on a day and time which is acceptable to all. The appointment will last 20 minutes
Step 3: MSK Assessment (20 minutes)
The patient will undertake an assessment comprising of
1: A review of the case history and pertinent past medical history which may have an impression upon this episode of the condition
2: A subjective and objective examination with outcome measure markers for future reference and audit purposes.
3: The patient will be offered a diagnosis, some public health self-management advice, pertinent management advice including exercise where appropriate to do so, a review of the medication (following a discussion with a Physician), a review of Radiology or a request for Radiology/blood tests etc.
Should further investigations be appropriate the patient will be asked to re book to review and discuss with the Physiotherapist.
4: At the point of the diagnosis, a discussion will be held offering a choice of treatment pathway. This may entail a referral to the primary care direct access services or a referral to secondary care. There is an opportunity to open dialogue for self- management and ‘do nothing’ at this stage.
Occasionally there may be a referral or sign post to Health and Social Care services, Charitable organizations, National research bodies (ARC/Osteoporosis society), falls prevention etc.
The patient will then be discharged from future review.
It must be emphasized that should the patient seek guidance from a private practitioner, the service will not offer an appointment within the service provider practice, but will offer a comprehensive list of providers to allow the patient to choose from a participant in the community.
The emphasis of the service focuses on Customer Care and self -management intervention.
The Physiotherapy team are well versed and focused on the first point of Customer care, trained and specialize in Triage, health guidance and critical appraisal of disease management for MSK conditions, excellent in understanding pain management,
health deterioration, and can ease the concerns of patient anxiety and need.
The therapy team are capable and conditioned to using IT systems such as TM2 and EMIS practice management systems. The records will be written as the patient discusses the case, and the therapist will record objective markers such as Ranges of motion in degrees, Oxford scale muscle testing, Joint
Referrals that require urgent referral following Physician discussion:
- Oncology, metastatic bone disease, deteriorating blood related disorders
- Fragility fractures, vertebral collapse, trauma.
- Women’s health patient’s referral to women’s health team
- Pregnancy related MSK after 20 weeks referred to Women’s Health PGP class
- Equipment needs- Community therapy service
- Patients who appear malnourished or have excessive weight loss, night pain and fever- require urgent investigations
- Vitamin D deficiency with ethnicity.
- Hot joints/locked joints
Appendix 2: Case Study Southern UK region savings costs.
| Total GP contacts | 920 |
| Cost of total GP contacts | 34,960.00 |
| Proportion of patients with MSK issues | 276 |
| Cost of GP seeing the patient | 10,488.00 |
| Cost of Physiotherapy | 4135.51 |
| Inefficiency costs | 235.08 |
| Cost saving | 6114.15 |
| Annual Saving: | £259,252.36 |
|---|
Appendix 3:
Physiotherapists/Allied Health Care Practiti0ners- Our Guarantee
Physiotherapists, over the last decade have striven to meet fluctuating demands on the Health and social care services, creating innovation through extending the scope of practice enabling individuals to seek advanced and expert practice through post graduate education and clinical reflective practice.
The Current definition of Physiotherapy (2007):
‘Any activity undertaken by an individual Physiotherapist that may be situated within the four pillars of Physiotherapy practice where the individual is educated, trained and competent to perform that activity. Such activities should be linked to existing or emerging occupational and practice frameworks acknowledged by the profession and be supported by a body of evidence.
Physiotherapy practice is made up of four elements that become integrated in practice.
Physiotherapy values: A set of values that are shared by all CSP members – regardless of their occupational role, practice setting, or level of practice. These values inform the behavior of CSP.
Extended Scope Practitioner Physiotherapists thus:
- Demonstrate a technical mastery of complex skills within unpredictable and specialised contexts
- Have a critical awareness of the political, social, economic & institutional factors shaping the health & wellbeing economy & how they inform the current & future design, delivery & professional development of physiotherapy at a local & regional level
- Evaluate their own and others performance in unpredictable and specialised contexts (CSP Framework 2011)
- Physiotherapy knowledge: The theoretical knowledge required for physiotherapy practice. Physiotherapy knowledge shapes, and is shaped by the profession’s constantly evolving scope of practice. Although an individual’s knowledge base will be shaped by the demands & context of their practice, physiotherapists must demonstrate how their knowledge & understanding relates to physiotherapy & their individual scope of practice
- Physiotherapy practice skills: The practical (psycho-motor) skills used by the physiotherapy workforce. An individual’s skill-base will evolve per their experiences & context of practice, but practitioners must demonstrate how their skills relate to physiotherapy & their personal scope of practice
The term Extended Scope Practitioner (ESP) reflects the breadth and depth of clinical practice and postgraduate undertaking to enable them to work within one given area of medical practice and practice with competency outside of the traditional role of a Physiotherapist.
Summary of support to expert continuum
| Framework level | Complexity | Predictability | Sphere of influence | Personal Autonomy |
|---|---|---|---|---|
| Advanced | Specialized caseload of clients with complex needs | Practice within complex and unpredictable contexts which demand innovation | Clients: Staff within primary and secondary care, professional networks at local and national level | Professionally and legally accountable for own actions |
| Expert | Highly specialized caseload of clients with complex needs | Practice within complex, unpredictable and normally specialized contexts demanding innovative work | Clients: staff within primary and secondary care, national policy makers, professional and public leaders in health and health/social care agenda, | Accountable for own actions. Practice characterized by an element of risk taking – guided by own knowledge & relevant professional codes/standards /guidelines. |
Contextual reference:
Benefit of a Primary Care ESP Triage Service:
For GP’s:
- Release of GP time allowing the practitioner additional time to assess more Acute systemic needs, mental health or Long -Term conditions
- Support patients to guiding a more proactive self- management approach
- Reduction in prescription costs
- Reduction in unnecessary Radiology costs
- Improve practice targets
- Improve the practice profile in having a multi -disciplinary team approach
- Gain additional expertise and training through therapy led education forums
- Expand the whole person approach as therapists work in union to offer a Health and Social Care approach.
- Gain a better understanding of the Physiotherapy profession and the advantages that therapists can provide.
- Value for money – £15.00 per patient as assessed by our Physiotherapist
- In house, dynamic imaging for soft tissue injuries and non -medical prescribing.
- Income generation through Injection therapy clinics.
For Physiotherapists:
- Opportunities to work within a true Primary care service, blending into the assessment/triage role and supporting patients in their preferred choice of disease management
- Supporting General Practitioners to an advanced skill of MSK practice and assessment and linking with them to support those with Long Term conditions or the Older person in Health and Social Care agenda
- Promoting the Public Health agenda of nutrition and exercise in self -management programs for the patients.
- Develop clinical scope of practice, developing a better understanding of blood tests, pharma and rationale underpinning individual patient management.
- Opportunities to develop MSK audit within primary care and developing researched evidence practice alongside audit to improve patient services alongside the GP team
- Work alongside Paramedic teams in the acute phase of disease management
- Improve communication skills at the forefront of medical management of the patient.
For the Patient:
- Rapid access to consultation both for simple self -help advice on the telephone, or face to face assessments
- Opportunity of rapid access to chosen intervention as secondary care referrals are appropriately instigated
- Rapid access pathway as less appointments to attend, better for the patient’s own social circumstances i.e. less time away from the work place
- Better triangulated care
- Longer appointment times giving the perception of being ‘listened too’ and support even though we are aware that GP’s offer a sterling service
- Logistics reduce DNA rate
For Public Health:
- Physiotherapists, like all Allied Health Care Professionals are adaptive to policy, creating methods to encourage patients to maintaining and seeking a healthier lifestyle.