Relieving the Orthopaedic Outpatients Bottleneck

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Relieving the Orthopaedic Outpatients Bottleneck
Damian Armour General Manager Surgical
Services Barwon Health damiana_at_barwonhealth.org.au
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Introduction

• Victorian Travelling Fellowship Program
• Relieving the Orthopaedic Outpatients Bottleneck
• NHS Initiatives
• Overview of the Orthopaedic Assessment Service.
• Barwon Health
• Improving Access to Orthopaedics
• State-wide focus

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The Challenge Access to Ortho Outpatients
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Victorian Travelling Fellowship

• Awarded in Aug 04
• Travel to 9 NHS sites in Nov 04
• Intended Learning
• New models of Outpatient Care
• use of Primary Care to ease demand on Secondary
  Care.
• Referral Pathways for GPs.
• Consultant Physiotherapists (ESPs) GPwSI
• Change Management.
• How did they engage the Consultants?
• Funding Models.

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Victorian Travelling Fellowship

• Stockport NHS
• Aintree Hospitals
• Whiston Hospital
• Royal Liverpool Hospital
• University Hospital of North Staffordshire
• Somerset Coast PCT
• Royal Bournemouth Hospital
• Southampton Health Community
• Modernisation Agency

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Fellowship Summary

• Multiprofessional Triage Team / Orthopaedic
  Assessment Service (OAS)
• Benefits
• More timely access for patients referred with
  musculoskeletal problems.
• Orthopaedic Consultants see a higher ratio of new
  patients in their clinic who are likely to
  require surgery.
• A clear and documented framework is developed for
  patients with musculoskeletal disease.
• Physiotherapy and other allied health
  professionals are provided with a significantly
  enhanced career path.

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Fellowship Summary

• Risks
• Downstream impact on the capacity of the referral
  alternatives.
• Physiotherapy, Podiatry, Pain Clinic etc
• Elective Surgery
• GP resentment
• Seen as solution for all musculoskeletal issues.
  

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OAS Overview
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GP Referral

• Standardised GP referral template.
• Desirable for ease of triage but not a
  prerequisite for success.
• Barwon Health already has a generic Medical
  Director referral template with a high take up
  rate.
• GP Communication Plan crucial to implementation.
• Prevent backlash Expect to see a Surgeon
• Prevent all musculoskeletal issues being referred.

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Triaging

• There are varying levels of GP referral triage
  undertaken
• Referral Management
• NHS - implementing a centralised referral
  management system
• a precursor to the implementation of the Patient
  Choice system
• Paper Triage 
• Generally by an experienced Physiotherapist.
• Some sites still had Consultants triaging
• Allocated to non-consultant resources after a
  transition phase.
• Undertaken in conjunction with agreed guidelines
  (include red flags).
• Clinic Assessment 
• Undertaken if paper assessment not adequate for
  decision
• A face-to-face assessment by Primary Care
  resources.
• Communication is made with the GPs about the
  ongoing care.

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Clinic Structures

• Multidisciplinary
• Physiotherapists are the core resource
• General Practitioner with a special interest in
  Ortho.
• Other resources would include Podiatrists, OTs,
  Rheumatologists etc.
• Timeframe
• Assessments run for a period of 30 minutes
• 20 min patient consultation / 10 min
  multidisciplinary discussion.
• Patient Numbers
• Each clinician sees 6 new or 5 new/2 review.

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Clinic Structures

• Themed Clinics
• Mixture of approaches
• Themes/specialities vs generic in nature.
• Types
• Lower Limb, Upper Limb, Spinal, Injection clinics
• Some sites also ran a mixture of specialised and
  generic clinics.
• Location
• Primary care or secondary care settings.
• Dependant upon responsibility for the service.
• Logistical matters (e.g clinic space, access to
  diagnostic services).

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Clinic Structures

• Clinic Outcomes
• Not just Assessment
• One Stop Shop
• Assessment / Advice / Discharge

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Downstream Impact

• OAS clinics will result in an improvement in
  waiting times for initial assessment. 
• However implications are
• Waits for treatment clinics (e.g Physiotherapy,
  Podiatry and Pain Clinic) will increase.
• Increased listing rates result in an increase to
  the elective surgery waiting list.
• Patients receiving immediate assessment, advice
  and discharge within the OAS clinic will benefit
  without impacting on downstream resources.

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Downstream Impact

• A study within one of the sites indicated
  approximately
• 33 of GP referrals would receive immediate
  treatment and discharge.
• 33 requiring a Consultant opinion.
• remainder requiring other non-invasive therapy.
• Other sites found that only 20 required a
  consultant opinion.

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Workforce Issues - Orthopaedic Consultants

• In NHS - full time with about 7 clinical sessions
  per week for their Trust.
• High degree of subspecialisation.
• Role in the OAS
• need to be willing reallocate traditional
  consultant tasks to other clinical resources.
• flexible in relation to the management of their
  allocated time (swap clinics for theatre
  sessions).

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Workforce Issues GPs

• Play a key part in the OAS
• as a referrer
• as a participant in the clinics themselves
• Utilisation of GPwSIs was mixed.
• Integration of a GP within the clinics assists in
  the relationship building with GP community.
• The availability of a medically trained resource
  within the clinic provides a required level of
  clinical expertise.

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Workforce Issues Physiotherapists

• Success depends on the ability of the
  organisation to successfully enhance the role.
• Extended Scope Physiotherapist (ESP)
• Injection Therapy
• Ordering of X-Rays and Blood Tests
• Ordering of MRIs
• Listing for surgery
• Competency development
• Documented guidelines outlining the core
  competencies of ESP.
• Orthopaedic Consultant Signoff
• Society of Orthopaedic Medicine training course

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Workforce Issues Other

• Other Allied Health Professionals
• Podiatrist
• Rheumatologist
• Administrative Staff
• Crucial in managing patient expectations
• HMOs
• Reduced the need to work in clinic
• Safe working hours.

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Change Management

• Ensure all stakeholders (esp. Surgeons and GPs)
  embrace the concept of the OAS.
• Start the OAS small (e.g. with a particular body
  part) and expanding gradually.
• Many sites started with new referrals as opposed
  to going back through the waiting list.
• Documented procedures and protocols in addition
  to the continuing education of staff is critical.

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Government Influences

• Advances would not have been achieved without a
  comprehensive focus on the matter by NHS.
• Outpatient Targets. No one waiting greater
  than...
• 21 weeks by April 2003,
• 17 weeks by 2004,
• 13 weeks by 2005.
• Underpinned by a national outpatient service
  improvement collaborative and modernisation
  program.
• Many of the sites visited recognised the evolving
  problem well before the targets were set.

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Measurement

• Patients by service type (e.g. back/spine, lower
  limb, upper limb)
• Conversion rates for Surgery
• Waiting Number and Waiting Times
• Service Outcomes
• Referral to Physiotherapy (Primary or Secondary)
• Referral to Orthopaedic Consultant
• Assessment, Advice Discharge
• Investigation (including type) and further review
• Other Referral (Pain Clinic, Podiatry, Rheum)
• DNAs

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Outcomes

• Patients
• Improved Access17 weeks for all referrals.
• Patients satisfied with care.
• Lower DNA / FTA Rates (6)
• Surgeons
• Higher listing rates, better time utilisation.
• 20 to 30 of referrals require a consultant
  opinion
• Many now rely on OAS.
• Physios/Allied Health
• Enhanced Career Path

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Barwon Healths Strategy
Improving Access to Orthopaedics Steering
Group Orthopaedic Spokesperson GM Surgical
Services Project Leaders (3) Orthopaedic
Surgeon DND Surgical Services Chief
Physiotherapist BM Surgical Services Project
Manager ESAC
Project Manager (PT)
Outpatient Access Project Lead - Physio Exec
Sponsor - GMSS Surgeon Deb Schulz (Chief
Physio) Lisa Adair (NUM OPD) Jeff Urquart (GP)

• Theatre
• Project Lead - R Cockayne
• Exec Sponsor - DNDSS
• Surgeon Mr Willams
• Anos Representative
• Lee Rendle (ANUM Ortho)
• Haydn Lowe (ESAC)
• Audrey Williams (CSSD)

• Inpatient Access
• Project Lead - L Coleman
• Exec Sponsor - BMSS
• Surgeon
• Haydn Lowe (ESAC)
• Mick ODonnell (NUM Ward)
• Rehab Rep

Focus Areas OP Waiting Numbers OP Waiting
Times Physio led services Better use of
consultant time.

• Focus Areas
• Turn around times
• Start times
• Equipment Issues
• Consumables

• Focus Areas
• Length of Stay
• Rehab Predictor
• Patient Education
• Bed Management in Ward

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State-wide Focus

• Awareness of the Outpatient issue
• Cant manage what you dont measure
• Identify existing initiatives.
• National International
• Coordinated/Consolidated focus
• NHS Modernisation Agency
• DHS Collaborative

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References

• Chartered Society of Physiotherapists (UK)
• www.csp.org.uk/download/sep/pdf/csp_sep_ocos.pdf
• NHS Modernisation Agency
• www.modern.nhs.uk/serviceimprovement/1339/1990/770
  0/Orthopaedics GuidevFinal.pdf

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Questions
?