Relieving the Orthopaedic Outpatients Bottleneck by xfz11675

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									Relieving the Orthopaedic
Outpatients Bottleneck




Damian Armour
General Manager Surgical Services
Barwon Health
damiana@barwonhealth.org.au


Department of Human Services
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
The Challenge –
Access to Ortho Outpatients
                               Routine Orthopaedic Outpatient Waiting list patients
 <1    1-2    2-3    3-4    4-5    5-6    6-7    7-8    8-9    9-10  10-11 11-12    > 12
Month Months Months Months Months Months Months Months Months Months Months Months Months                          Total
   54     85     45     64     60     57     52     45     42     81     34     58    342                           1,019


                                        Orthopaedic Outpatients Waiting List
                                            Patients Awaiting their 1st Appointment
                                   1 - Urgent            2 - Semi Urgent              3 - Routine

       1200


       1000


           800
Patients




           600


           400


           200


            0
                 2003   2004    2004    2004    2004    2004    2004       2004   2004     2004     2004   2004   2004
                  12     01      02      03      04      05      06         07     08       09       10     11     12
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 GP’s.
  – Consultant Physiotherapists (ESP’s) & GPwSI
  – Change Management.
     • How did they engage the Consultants?
  – Funding Models.
Victorian Travelling Fellowship
                                1   Stockport NHS
                                2   Aintree Hospitals
                                3   Whiston Hospital
                                4   Royal Liverpool
                                    Hospital

     2                          5   University Hospital of
                                    North Staffordshire
                        1
     3                          6   Somerset Coast PCT
     4                          7   Royal Bournemouth
                                    Hospital
     5
                                8   Southampton Health
                                    Community
                                9   Modernisation Agency

                            9




            6   7   8
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.
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.
 OAS Overview
                                               Stage 1 – GP Referral
GP sees patient with an Orthopaedic/musculo-skeletal condition and ‘refers’ them into the OAS.

Specialist physiotherapists review all referral letters to identify the appropriate care pathway

Appropriate treatment not clear from referral             Appropriate treatment clear/unambiguous from referral

                                                                     Patient referred directly to Orthopaedic consultant

                                                                     Patient referred directly to pain management

                                                                     Patient referred directly to physio for treatment

                                                                     Patient referred directly to Orthotics

                                                                     Patient referred directly to podiatry, rheumatology

                                                                     Patient referred directly back to GP

                 Stage 2 – Face to face physiotherapy triage assessment
Patient has an assessment in a locality based clinic by a specialist physiotherapist to identify appropriate care pathway.

                                                                     Patient referred directly to Orthopaedic consultant

                                                                     Patient referred directly to pain management

                                                                     Patient referred directly to physio for treatment

                                                                     Patient referred directly to Orthotics

                                                                     Patient referred directly to podiatry, rheumatology

                                                                     Patient referred directly back to GP
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.
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.
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.
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).
Clinic Structures

• Clinic Outcomes
  – Not just Assessment
  – One Stop Shop
    • Assessment / Advice / Discharge
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.
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.
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).
Workforce Issues –
GP‟s

• Play a key part in the OAS
  – as a referrer
  – as a participant in the clinics themselves
• Utilisation of GPwSI‟s 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.
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
Workforce Issues –
Other

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

• Patients
  – Improved Access:17 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.
• Physio‟s/Allied Health
  – Enhanced Career Path
Barwon Health‟s 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            Theatre                             Inpatient Access
Project Lead - Physio        Project Lead - R Cockayne           Project Lead - L Coleman
Exec Sponsor - GMSS          Exec Sponsor - DNDSS                Exec Sponsor - BMSS
Surgeon                      Surgeon – Mr Willams                Surgeon
Deb Schulz (Chief Physio)    Anos Representative                 Haydn Lowe (ESAC)
Lisa Adair (NUM OPD)         Lee Rendle (ANUM Ortho)             Mick O‟Donnell (NUM Ward)
Jeff Urquart (GP)            Haydn Lowe (ESAC)                   Rehab Rep
                             Audrey Williams (CSSD)

Focus Areas                  Focus Areas                         Focus Areas
OP Waiting Numbers           Turn around times                   Length of Stay
OP Waiting Times             Start times                         Rehab Predictor
Physio led services          Equipment Issues                    Patient Education
Better use of consultant     Consumables                         Bed Management in Ward
time.
State-wide Focus

1. Awareness of the Outpatient issue
  – “Can‟t manage what you don‟t measure”
2. Identify existing initiatives.
  – National & International
3. Coordinated/Consolidated focus
  – NHS Modernisation Agency
  – DHS Collaborative
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/1339/1990/7700/Orthopaedics
    GuidevFinal.pdf
Questions




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