MSK Pathway Redesign
Generic pathway redesign






Phased reduction of consultant to consultant referrals in
orthopaedics apart from suspected cancer, review of
referrals by COG/community provider (phased introduction
from November 2010 and complete by March 2011)
Consultant to consultant referrals to be directed to
community provider and treated as GP referrals
Recommend contract variation to prevent consultant to
consultant referrals in trauma attracting new tariff. If a
patient is transferred within trauma due to consultant
speciality then only a FU tariff can be charged (By
December 2010 and needs to be costed out)
90% orthopaedic patients directly listed with community
provider working with local trusts (Phased over November
to July 2011)
Diagnostic review – by March 2011 – review primary care
use of MRI and EMG. Working with COG review clinical
benefit of continuing contract.
Review GM CATS activity in MSK (50 cases a month) these
should not be paid and referred direct to PMSKP
(December 2010)
Better Care Better Value Procedures
Basket 1
 Spinal procedures
o Audit of Direct spinal neurology referrals that have
bypassed PMSKP for appropriateness and working
with COG on training/performance management of
high referring practices
o Audit of spinal procedures and bench marking
against national and SHA figures. Agree NICE
compliant pathway for spinal pain procedure with
PAHT pain clinic (Both by March 2011)
Basket 2
 Arthroscopic washout of knee (£61k)
o Contract variation for prior approval for this
procedure
 Spinal cord stimulation (£29k)
o Audit of activity as a part of Back pain review under
spinal procedures above
MSK Pathway Redesign

Trigger finger (£19k)
o Contract variation for prior approval and patients
must have been referred on by PMSKP and all other
treatments tried and failed (Above 3 procedures by
March 2011)
Basket 4
 Knee Replacement Surgery (£1.837k)
o Ensure Enhanced recovery pathway in place by
March 2011 and all patients offered IDM in
community hub – total activity £1.8m plan for 10%
reduction when IDM fully implemented by April 2011
 Hip Replacement Surgery (£1.584k)
o Ensure Enhanced recover pathway in place by March
2011. All patients offered IDM when this is available
– (5% reduction by end of 2011)
Basket 5
 Carpal Tunnel (£139k)
o Ensure all patients assessed in PMSKP
o Ensure all directly listed within PMSKP
o Stop open access nerve conduction in primary care –
should only be used for pre-op assessment where
needed and no as a primary care diagnostic step
(need to quantify saving) (Above 3 by March 2011)
o Use IDM for all patients when this is available (end
2011)
Primary Care Pathway Elements


Minor Surgery LES
o Increase activity delivered in primary care for single
and double joint injections (£41 and £82) reducing
activity in PMSKP stop Minor surgery LES payment
for more than 2 injections – clinical governance and
cost saving for activity in PMSKP
 Development network of AWP for this activity
 Clinical governance framework for primary care
injections (From April 2011 and need to put an
estimated cost)
Referral Management
o Audit pattern of referrals in rheumatology and
orthopaedics by practice across Oldham
o Working with COG offered training and support to
high referring practices
o Agree with COG new referral management LES
covering referral thresholds and minimum data set of
MSK Pathway Redesign


referral letter information (implement during
2011/12) (There is some figures on variation in
referral patterns across Oldham and we could
estimate the saving from bringing the top 25% down
to average by end of 2011/12)
Drugs Management
o Audit variation in spend in MSK BNF drugs chapters
o Working with PCT medicines management and COG
offer support to high prescribing practices
o Develop new medicines LES (by end of 2010/11 for
above three)
o Ensure all high cost drugs (Biologics) used in line
with NICE guidance (December 2010)
o Develop guidelines for specific areas:
 Vitamin D deficiency
 Primary care management of neuropathic pain
 DMARD monitoring and near patient testing –
reducing any adverse events and drugs used in
line with NICE guidance
Develop choice of provider through AWP in:
o Physiotherapy
o Podiatry
o Diagnostics
 NCS
 MRI
 NOUS