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Tackling delay in Orthopaedics

Why was the initiative launched?
What was done?
Plans for the clinics in primary care
Good timing
Did it work?
Patient reaction
Tips for success
For more information contact
Providing a physiotherapy outreach service in primary care in Doncaster.

Why was the initiative launched?

Since 1996 two orthopaedic physiotherapy practitioners have worked with consultant orthopaedic surgeons to provide an initial assessment of newly-referred patients. Only those patients needing a surgical opinion were seen by the consultant. This helped reduce the pressure on consultant time and significantly reduced waiting time.

After initial success it proved difficult to continue to meet targets and increase activity. There was a limit to the number of secondary care clinics because consultants only held one or two outpatient clinics a week. Managers wanted to explore whether orthopaedic physiotherapy practitioners could work with GPs to reduce the number of orthopaedic referrals, and thereby further reduce waiting times.

What was done?

A group of experienced practitioners working with the consultant orthopaedic surgeons tackled the preparatory work for the new initiative. They revised the protocol used in hospital for relevance in primary care. It defined the range of tasks to be undertaken, the nature of medical cover required, and arrangements to fast track patients needing to be seen by a consultant. The practitioners shadowed consultants to help equip themselves for their new role. An important aim was to maintain the links between practitioners and consultants. A detailed activity analysis was undertaken to demonstrate the success of the new approach.

In summer 1999 a training seminar on management of acute low back pain was arranged for local GPs as part of the PGEA programme. It was an opportunity to promote the role of orthopaedic physiotherapy practitioners. GPs were impressed by the presentations and the potential offered by the new service, and agreed to identify practices to pilot the new approach. Questions needed to be resolved about the funding of the administrative costs involved, but eventually two practices in each PCG area agreed to take part in the six-month trial (six practices in all).

Plans for the clinics in primary care

Each pilot practice started with one clinic a month from September 1999. Practices were asked to keep to one side possible referrals to secondary care and the orthopaedic physiotherapy practitioner reviewed them to recommend whether patients be seen at the clinic in primary care or referred to a consultant. Practices were encouraged to send urgent referrals to the hospital and not wait for a physiotherapy practitioner visit or clinic. The patient letter explained how the system worked and made clear that a referral to the consultant could proceed if patients wished.

Good timing

The health authority was under increasing pressure to address long orthopaedic waits and agreed to provide funding for three years for an additional orthopaedic physiotherapy practitioner. This allowed the initiative to be extended to another 13 practices with high referral rates.

A new the orthopaedic physiotherapy practitioner was appointed in October 1999. The three orthopaedic physiotherapy practitioners decided that each of them spend time in primary care, secondary care and in the physiotherapy department. This rotation ensured that they retained a balanced set of skills.

Did it work?

The primary care initiative had a marked impact on referrals. Over the first seven months (September 1999 to March 2000) fewer than 10% of patients seen by the orthopaedic physiotherapy practitioner were referred to a consultant (Table 1). The waiting time is now down to about 3 or 4 weeks. Table 2 compares the rates of referrals in practices with orthopaedic physiotherapy practitioners clinics with other practices in Doncaster. The situation is complicated by other local initiatives to tackle waiting lists. GPs regularly contact practitioners for advice. The service is being extended to all practices in the Doncaster area.

Table 1: Care paths for patients seen by orthopaedic physiotherapy practitioners at primary care clinics in Doncaster:

  Sept 1999 to Mar 2000
  Patients Percent
Referred to Orthopaedic Clinic 40 7.4
Referred to Pain Clinic 3 0.6
Discharged 128 23.7
Referred to physiotherapy 306 56.6
Injected 34 6.3
Follow up by OPP 30 5.5
Total 541 100

Table 2: Impact of orthopaedic physiotherapy practitioners (OPP) on referrals

  Numbers of referrals Change
  98/99 99/00 Number Percent
PCG 1        
With OPP 563 421 -142 -25
Without OPP 479 544 +65 +14
PCG 2        
With OPP 739 598 -141 -19
Without OPP 533 538 +5 0
PCG 3        
With OPP 837 554 -280 -33
Without OPP 1160 1064 -96 -8

Patient reaction

Patients like the new approach. Not one seen in primary care has insisted on being referred to the consultant. This echoes the experience in secondary care, with only a handful over the four years demanding to see the consultant.

The responsiveness of the system is illustrated by the experience of one patient seen at the monthly clinic. It was clear to the orthopaedic physiotherapy practitioner that this patient had a serious back problem and needed to be seen urgently by the consultant. The fast track arrangement meant that the patient was seen the following week at the consultant's clinic. Under the old arrangements the wait would have been several weeks. The level of care each patient receives is appropriate to the severity of their problem: doing the right thing right, and at the right time.

Tips for success

√ Make sure plans allow sufficient time to develop relationships with new organisations in primary care: you are competing with a very busy agenda.
√ A pilot phase can test new ideas. Constantly re-evaluate the service and feed back the impact and successes.
√ Make sure that patients understand the consequences of your initiatives: respect their wishes if they want to go through traditional routes.
√ Be incremental: in Doncaster a sound base in secondary care ensured that rapid progress could be made when the initiative moved into primary care.
√ Teams are effective when members trust one another. Promote understanding of new roles and work hard on links between practitioners and GPs.
√ Involve everyone affected when sorting out operational issues: don't forget clerical staff.
√ Make sure that necessary clerical support is available.
√ Make sure that resources exist before looking at ways to increase referrals.

For more information contact

Val Jones, Orthopaedic Physiotherapy Practitioner
Rehabilitation Department
The Doncaster Royal and Montagu Hospital
Doncaster Royal Infirmary, Armthorpe Road,
Doncaster DN2 5LT

Telephone: 01302 366666 Fax: 01302 320098

The following materials are available:
Referral protocols for use in primary and secondary care.
Job description for orthopaedic physiotherapy practitioners.

ImpAct bottom line

Build a history of success to help move posts from project to recurrent funding: be patient because it can take several years to get to this stage!


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