National MSK Redesign NHS Scotland and Partners*
Improvement and Value Update Summary- April 2014
In 2012, a team of local and national NHS leaders set out to redesign MSK services in Scotland. The aim was to
improve access, efficiency, quality and patient experience. The programme is a joint effort, with spread and
sustainability work now involving all the territorial health boards of Scotland, through active dissemination of
best practice knowledge and implementation of each intervention in all locations.
* This document relates to work done principally by the early adopter boards NHS Lanarkshire, NHS Lothian
and NHS Ayrshire and Arran, their GPs and patient groups; NHS 24; Working Health Services Scotland and local
Leisure services; the Scottish Government Health and Social Care Directorate; the University of Glasgow; and
GE Healthcare Finnamore.
The Problem
AHP MSK services deal with high volume demand, currently presenting in Scotland at 400,000+ referrals per
annum. 20-30% of all GP consultations are for MSK complaints, with 10 million work days lost annually from
MSK problems. MSK secondary care activity is high, with duplication across GP, orthopaedic and AHP services.
There is variation in patient experience in information, access, waiting times and investigations.
The Approach
The following new approaches were prioritised for testing with patients and staff of NHS Lanarkshire, NHS
Lothian and NHS Ayrshire and Arran:
1. Musculoskeletal Advice and Triage Service by NHS 24
 National self-management platform, through NHS Inform
 National self-referral model through a single point of access
 Telephone call handler protocol triage model
2. IT and Referral Management
 Electronic Referral Management
 Efficient administration processes
 Reminder Systems
 National MSK dataset reporting
3. Clinical Pathways
 Evidenced based, person-centred pathways
 AHP impact on MRI Demand
 Minimum Standards Framework
4. Exit Route Solutions
 Leisure partnerships
 Employability pathway
 MSK pathways into Specialist Pain services
 Mental Health pathways
MSK Scotland- National Re-Design
Impact - Introduction of Musculoskeletal Advice and Triage Service (MATS)
Prior to commencing MATS, NHS Lanarkshire had self-referral and a physiotherapy telephone assessment line.
NHS Lothian had paper self-referral, while NHS Ayrshire and Arran no self-referral system.
Between January 2012 and July 2013, 41,764 prospective patients contacted MATS and completed a protocol
based triage tool over the telephone. Excluding 4720 calls which did not seek MSK telephone triage, the
breakdown of MATS outcome was as follows:
Refer to Board
29536 (79.7%)
Refer to WHSS
2085 (5.6%)
Emergency Care
2
GP
394 (0.9%)
Self- Management
5027 (13.5%)
Telephone triage by non-clinical staff has been shown to be safe and equitable, but further tests of change are
required to achieve self-management rates comparable with those achieved by clinical telephone consultation.
Further optimisation using web self -assessment and physiotherapy telephone consultation models is under
development.
Impact - IT and Referral Management
Electronic patient tracking and electronic outcomes measures –has enhanced capacity and capability to
establish, manage and analyse data for improvement. This has included the introduction of a MSK dataset
reported nationally through National Services Scotland, Information Services Division (ISD).
Electronic referral - referrals now are sent to Boards instantaneously, reducing this part of the patient journey
by approximately 10 days on average and providing verifiable data for performance reporting.
Administration Hub- improved slot fill in Lanarkshire from 82% to 93%, contributing to reduced waits and
freeing up clinical time.
Clinical E-Vetting- now completed electronically. Clinicians can access all referrals from any computer in their
organisation.
Reminder System - In Lanarkshire, an electronic reminder of appointment solution was pursued with Netcall’s
Remind and Remind+. DNAs have been reported as low as 3% and sustained at 6%. [see chart] Ayrshire has
implemented similar systems and demonstrated almost identical impact.
Lanarkshire Physiotherapy DNA
25.00%
NP DNA
Rate
20.00%
15.00%
10.00%
5.00%
MSK Scotland- National Re-Design
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
0.00%
Impact - Clinical Pathways
Clinical Pathways have increased clinical accountability and embedded evidenced based practice, ensuring
quality of care and patient support by the appropriate person at the appropriate time. Close working across
General practitioner, Orthopaedics and Allied Health Professional Services reduced duplication and variation.
Focus on pathways, process and supported clinicians was crucial, with clear escalation policy and tailored
education key to success.
Lanarkshire and Ayrshire introduced enhanced clinical pathways by body region, which facilitated patient flow
shift from Orthopaedic Consultancy to Extended Scope AHP services. They also facilitated shift from
ESP/Advanced Practitioner into MSK physiotherapy (Lanarkshire) and into podiatry, orthotics and occupational
therapy services (Ayrshire). This is now seen as standard practice.
To ensure spread of this quality of care, value and sustainability and a healthy population approach, a National
MSK Standards Framework is now out to consultation through The Scottish Government.
MRI- NHS Lanarkshire introduced a MRI protocol and direct access to low back pain MRI by Extended Scope
Physiotherapists significantly reduced the number of MRI requests per annum by more than 50%, contributing
to both cost reduction and patient safety.
Impact - Mental Health
NHS Lanarkshire introduced a model to support patients identified as having mental health problems.
19.4% of MSK patients indicated moderate to extreme anxiety or depression at the beginning of their MSK
treatment and required a supported self-management intervention. At discharge only 9% of patients indicated
a moderate to extreme level of anxiety or depression. 69% of those offered a self- management resource pack
had reported a decrease in their scores.
Impact - Working Health Services Scotland (WHSS)
Working Health Services Scotland (WHSS) provides back-to-work support for people who are either absent, or
at risk of becoming absent, from work due to health problems.
Between December 2011 and September 2013, 1325 individuals received Case Management services from
WHSS. The table below highlights the health improvement achieved.
Mobility
Self –Care
Usual Activity
Pain
Anxiety
MSK Scotland- National Re-Design
38%
41%
45%
41%
20%
Impact – Capacity versus Demand
Ayrshire and Arran introduced a single entry point to MSK pathways through an AHP led MSK hub. This resulted
in:
 25% reduction in demand into orthopaedic consultancy services over an 18 month period
 Shift of consultant time from clinic into theatre
 Reduction of patient waiting times for consultant to approximately 6 weeks and reduced the number of
those waiting to see a consultant by 50%- see chart below.
Orthopaedic Outpatient Waiting List
2500
2000
1500
Total Waiting
1000
500
Implementation of the low back pain pathway resulted in significant improvement in Orthopaedic Outpatient
capacity in all early implementer sites, with NHS Lanarkshire reporting a shift of 1800 patients per annum and
NHS A&A a shift of 945 orthopaedic appointments in the first 6 months of the redesigned service and
Orthopaedic Consultants have now formally reported conversion rate to surgery change from 35% to 70%
following implementation.
Low back pain previously accounted for 40% of AHP ESP/ advanced practitioner capacity and now accounts for
less than 10%, following a shift from ESP to general MSK physiotherapy services, creating advanced practitioner
capacity to see additional orthopaedic consultancy knee and shoulder referrals. Improvements in Orthopaedic
surgical conversion rates have also been observed.
Modelling the Financial Impact
If all boards were to adopt all measures found to be advantageous by the Early Adopters, then we estimate the
healthcare-only net financial benefit to be as shown below.
1
2
3
4
Improvement Stream
Self –management
DNA
Orthopaedics
MRI
Total
Net benefit minimum
MSK Scotland- National Re-Design
146,605
442,000
1,660,000
506,000
£2,754,605
Net benefit maximum
1,629,138
646,000
2,490,000
1,012,000
£5,777,138
Next Steps
Further tests of change are expected to provide additional cost benefit and outcomes:
1)
2)
3)
4)
5)
Web based self- assessment and signposting to community partners
Improvement self- management resources
Telephone and video clinical triage to improve self- management after AHP consultation
GP Decision Support Tool and closer partnership provision with GP practice including AHP prescribing
New and Return slot times related to clinical complexity
Recommendations
Health Boards are now being supported nationally to develop their own MSK delivery plans. Clinical leaders at
all levels are also being supported to develop quality improvement capacity to enhance improvement culture.
We recommend that:
Health Board leaders actively support their AHP leaders’ efforts to implement service change, in order to
ensure delivery of value and quality benefits in the Board’s own geography.
Boards carry out a baseline assessment and gap analysis of their current position in relation to final outcomes
in early implementer sites and deliver on a Board MSK Action Plan to include all the elements described.
Board leaders support their AHP teams in driving small tests of change to contribute to national evidence of
best practice. This will enable all boards to drive service quality and productivity beyond the improvements
already achieved in the early implementer sites.
We use service data, patient experience data and the national dataset and 4 week data to drive excellence,
performance and accountability.
Other specialities and sectors across health and social care familiarise themselves with the learning for the MSK
programme impact and identify what processes and outcomes may be utilised in their setting. In particular,
AHP advanced practice and general services have a significant role to play in shift from consultant speciality
services. Leaders should investigate whether the model components are transferrable to other service
pathways to support population health, cost control and experience of care?
MSK Scotland- National Re-Design