The Government’s recent White Paper, Equality and Excellence: Liberating the NHS (DH, 2010), set out proposals to hand over health-care commissioning and control of £70bn of the NHS budget to GPs by 2013. This followed significant pressure from the Government over recent years to move services out of hospitals and into community settings, closer to people’s homes. In 2006, a White Paper was published outlining a new direction for community services and a vision for the future of health and social care (DH, 2006d); orthopaedics was one of six specialties mentioned in the paper. The Musculoskeletal Services Framework, published later the same year (DH, 2006a), focused even more attention on MSK services (DH, 2006a). These reports, and others (Parker, 2006; Singh, 2006; NHS Institute, 2009) referred to developing the role of specialist practitioners as a way of meeting the demand for enhanced primary-care services. Framing the Contribution of Allied Health Professionals (DH, 2008a) responded to the plans laid out in the Transforming Community Services Quality Framework (DH, 2009) by giving specific examples of ESPs’ roles in community-based MSK services.
Each year in the UK, GP referrals to hospitals account for more than £15bn of the NHS spend (DH, 2009b), and a recent review of GP referrals by The Kings Fund considered a number of different referral management systems (Imison & Naylor, 2010). One such approach to managing GP referrals is to filter them through a primary-care-based MSK interface clinic. These ‘Tier 2’ services or ‘CATS’ (Clinical Assessment and Treatment Services) deliver a triage, assessment, and treatment service in the community. In a review of MSK services across England,
77 ARMA found that by 2009, 79% of PCTs had established a ‘CATS’ service (ARMA, 2010). These interface clinics are usually led by GPs with a special interest in MSK medicine (GPswSI) or by ESPs, and their primary function is to reduce the number of referrals to hospitals by managing as many patients as possible within primary care. Hay & Adebajo (2005, p.1210) warned that ‘simply transferring the workload from secondary to primary care will not work, as this will just turn our problem into their problem’. They also cited weaknesses in the other five systems studied: referral management centres, peer review and feedback, guidelines, and financial incentives. They mentioned a Cochrane review of methods designed to improve the process of referring patients to specialist care (Akbari et al., 2008), which found 17 studies concerning the need to educate professionals about referrals and the use of both financial incentives and organizational change to influence referral processes. They found little evidence for organizational change, but there was some evidence supporting a second opinion prior to referral to hospital services, and using physiotherapy to improve the referral process for orthopaedic patients (O'Cathain, Froggett, & Taylor, 1995).
The NHS Institute for Innovation and Improvement produced a report recommending key characteristics of best-practice MSK interface services, by observing a number of exemplary services in the UK (NHS Institute, 2009). The report acknowledged the importance of ESPs in these services and stressed the importance of clinical governance arrangements, including training, mentorship, and competencies. However, surprisingly little evidence exists for the effectiveness of these interface service models. Imison & Naylor (2010) confirmed that there was a lack of strong evidence to support them. In their conclusions they expressed concern that interface services could misdirect referrals (if GP referral letters contain inadequate information) and delay access to a hospital specialist. They also posited that they could be duplicating secondary-care work instead of substituting for it, with a resultant increase in overall costs.
A retrospective observational study by Patel et al. (2011) looked at the accuracy of a range of primary-care clinicians’ diagnoses of shoulder disorders by comparing the diagnosis made in primary care with the diagnosis made in a single upper limb
78 orthopaedic clinic in secondary care. MSK interfaces accounted for 63% of these referrals; the remainder were from GPs (35%) and independent physiotherapists (2%). Thirty-seven per cent of patients were referred without any diagnosis and where one was given, it matched the initial diagnosis made in the surgeon’s clinic in only 50% of cases. This figure dropped to 32% if a comparison was made with the final diagnosis based on further information derived from imaging or surgery; diagnosis given by the surgeon was consistent with the final diagnosis in 70.5% of cases. Slightly higher kappa values in the GP group suggested that they were more accurate at diagnosing shoulder pathology than the MSK interface clinic, although GPs might have been referring complex shoulder presentations to the interface clinic for further assessment, and managing the more straightforward cases themselves. However, this observation led the authors to conclude that MSK interface clinics do not appear to be any better than general practice.
A report from the National Public Health Service for Wales (Webb, 2010) published a ‘rapid review’ of the evidence for the effectiveness of MSK interface services. The intended audience for this report was the North Wales Strategic Board and its aim was to find out if these services led to a delay in referral for a surgical opinion. Their search ran from January 2000 through to May 2009 and included systematic reviews and meta-analyses, randomized controlled trials, guidelines, and observational studies. The author, the sole reviewer, found no high-quality (level I or level II) evidence relating to effectiveness but they mentioned a level III evidence study by Maddison et al. (2004), which will be discussed later in this chapter.
The current Government’s plans to relinquish power to GPs through GP commissioning consortia will only serve to increase the focus on GP referral management systems. Community-based MSK interface clinics (DH, 2006a; NHS Institute, 2009) provide commissioners with the foundation from which to develop their primary-care services. Ideally, these services incorporate the input of hospital-based MSK specialists (orthopaedic surgeons, rheumatologists, neurosurgeons, neurologists, and pain management consultants) and utilize the skills of ESPs and other clinicians working in extended roles, such as podiatrists.
79 In practice, a variety of interface service models exists and many of them are staffed by ESPs with little or no support from medical colleagues (Bernstein, 2009); if clinical governance arrangements are inadequate, this presents an unacceptable level of risk and employers should be concerned about this. Indeed, in a prospective audit of referrals made to a hospital orthopaedic clinic by a multi- professional MSK interface clinic, Rogers, Kabir & Bradley (2008) concluded that interface clinics delivered sub-optimal care, and that this could have far-reaching medico-legal implications.
Roberts et al. (2003) described a survey of the characteristics of community-based MSK services, either current or planned, by contacting Primary Care Trusts in the UK (n=461). Recruitment targeted five professional groups: business managers, chairpersons, chief executives, clinical governance leads, and commissioning leads. The overall response rate was 328/461 (71%), and 233 of these organizations identified at least one MSK service. In total, respondents described 350 services and alluded to a further 87 services. The majority of them were located in primary care but not all of them were necessarily interface clinics according to the ‘Tier 2’ or ‘CATS’ model. In fact, they identified five main service models: physiotherapy, ‘scanning services’, rehabilitation services, injection clinics, and ‘others’. Respondents identified clinical leads for the majority of clinics (n=237), and it transpired that physiotherapists or GPswSI led three-quarters of all services. It is not known how many of these physiotherapists were working in ESP roles. Education and training for community-based MSK practitioners were described as ‘patchy’ despite some examples of good practice and only six services referred to a specific level of competency for their MSK community staff. Rymaszewski et al. (2005) supported the MSK interface model in primary care but emphasized the importance of closer integration with hospital-based specialists and argued that ESPs need to experience working alongside orthopaedic surgeons and rheumatologists in order to acquire the level of expertise and experience needed for their extended role.
80 Maddison et al. (2004) described the introduction of ‘TEAMS’ (Target Early Access to Musculoskeletal Services), a community-based project in North West Wales led by ESPs and GPswSI. Its aim was to tackle the long waiting times in secondary- care orthopaedic, rheumatology, spinal, and pain management clinics. Despite an increase in overall MSK referrals of 116% following the introduction of the service, there was still a gradual reduction in hospital waiting times over 18 months – perhaps because ‘TEAMS’ referred less than 10% of patients overall to hospital services. The conversion rates for orthopaedic surgery in secondary care remained unchanged and there could have been any number of reasons for this, but the authors do not posit an explanation. Their outcome measures included not only waiting times for secondary-care services but also conversion rates for surgery, which were an indication of the appropriateness of referrals to orthopaedic clinics.
Sephton et al. (2010) described an evaluation of a primary-care-based MSK CATS using a prospective observational-cohort study design. The service, led by a team of advanced musculoskeletal physiotherapy practitioners (ESPs), managed GP referrals to orthopaedics, rheumatology, and pain management services based in secondary care. Patients (n=217) were sent self-administered postal questionnaires measuring general health status (Short Form-36 and the EuroQol EQ-5D), a pain visual analogue score, and two validated patient satisfaction questionnaires at three and 12 months following recruitment. Their results demonstrated a statistically significant improvement in pain at three months (p=0.001) and again at 12 months (p=0.002). They also found a statistically significant improvement in the EuroQol EQ-5D at three months (p=0.043) and 12 months (p=0.035), and an overall patient satisfaction rate of 72% (out of 167 completed questionnaires). Data were missing at three months from 45 patients, and two patients returned incomplete data sets. At 12 months, data were missing from 68 patients and a further two patients returned incomplete questionnaires. Changes in pain scores were the most significant but one could argue that this was simply due to the passage of time. A before and after study design might have resulted in a more robust measure of the effectiveness of the service but because it had been in operation for four years, this was not possible.
81 MSK services face competitive times ahead with the imminent arrival of GP commissioning consortia. Furthermore, the recent ‘Any Qualified Provider’ policy (NHS Choices, 2012) means that in the near future the ESP role is likely to be scrutinized by commissioners and patients alike. It is almost the norm for NHS services to be set up without any evidence that they will be successful, and without consideration for their subsequent evaluation. The pace of change within the NHS means that there is little time to evaluate services before the next health- care reform must be implemented. Indeed, Ferguson & Cook (2011) questioned whether the primary-care orthopaedic interface model was sustainable in a constantly changing NHS, which is at the mercy of the political and economic environment.