Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) prog
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《英国医生杂志》
1 North West Wales NHS Trust, Ysbyty Gwynedd, Bangor LL57 2PW, Wales, 2 Gwynedd Local Health Board, Eryldon, Caernarfon, Wales
Correspondence to: P Maddison peter.maddison@nww-tr.wales.nhs.uk
Abstract
Musculoskeletal conditions are a major cause of chronic disability in the United Kingdom and one of the commonest reasons for referral to secondary care. In the 1995 health survey for England, 18% of adults reported some form of moderate or severe disability.1 Musculoskeletal disorders accounted for 34% of these and serious disabilities for 40%. In the 1998 Welsh health survey, 25% of respondents stated that they were being treated for "arthritis."2 This rose to over 60% in those aged over 85 years. Musculoskeletal conditions accounted for nearly 20% of all general practitioner consultations in 1991-2,3 of which around 5% were referred for a specialist opinion. Because different specialties are involved in managing these patients and waiting times are often long, it can be difficult for general practitioners to know to whom to refer a patient. Consequently, patients are often referred to an inappropriate health professional and referred twice or more for the same problem. Lack of access to appropriate services means that factors that predict chronicity in common disorders such as back pain4 cannot be addressed sufficiently early, thus compounding their social and economic impact.
Outline of context
The key objectives for change were to provide a coordinated service for all patients referred with musculoskeletal problems so that specialists saw those with appropriate problems, to minimise duplicate referrals, to reduce waiting times, and to offer more services locally.
Key outcome measures
Information was gathered from the hospital based information management system (Isoft). Orthopaedic data did not include accident and trauma patients. Patient satisfaction questionnaires were developed but had not been used routinely before change to the service. These considered access to the service and outcome.
Analysis and interpretation
The four departments were integrated by establishing the targeted early access to musculoskeletal services (TEAMS) programme, which incorporated a common pathway for all referrals for musculoskeletal problems combined with a central clinical triage of patients to the appropriate clinical service based on information in a generic referral letter (fig 1). A senior manager was allocated to the services, and a full time coordinator was appointed to oversee the referral process and to set up the service on the patient information management system to code and track patients through the system. New services included a back pain pathway led by extended scope physiotherapists, and three community based musculoskeletal clinics run by general practitioners with special interests5 and extended scope physiotherapists for patients with uncomplicated musculoskeletal problems. Workshops were held for general practitioners throughout the assessment period, providing an opportunity for their input into the process and development of referral guidelines. These and the referral letter proforma were made available on the trust's website.
Fig 1 Flow diagram showing clinical triage of patients referred to targeted early access to musculoskeletal services
Effects of change
Since the introduction of the targeted early access to musculoskeletal services, a large proportion of the increased burden of referrals has fallen on physiotherapy services. It is apparent, however, that many referrals to physiotherapy are inappropriate. We are therefore establishing a programme run by general practitioners with special interests and extended scope physiotherapists to educate general practitioners about the role of physiotherapy in the management of musculoskeletal problems. We are also introducing methods for identifying those patients with non-specific musculoskeletal pain that is unlikely to respond to biological interventions and developing self management interventions based on modifying health beliefs and behaviours. We are also establishing clinical pathways for common hand conditions, such as carpal tunnel syndrome, to help remove the backlog of patients waiting to be seen in the orthopaedic clinics.
Contributors: PJM was the lead writer of this paper; he is guarantor. The other authors are members of the Targeted Early Access to Musculoskeletal Services Project Group and contributed to the design of the programme, its implementation and monitoring, and the preparation of this report.
Funding: Innovations in care programme for orthopaedics, Welsh Assembly government, and North Wales NHS Trust.
Competing interests: None declared.
References
Joint Health Surveys Unit. Health survey for England 1995. Vol 1: findings. London: Stationery Office, 1997.
Welsh Office. Better health better Wales: a consultation paper. Cardiff: Welsh Office, 1998.
McCormick A, Fleming D, Charlton J. Morbidity statistics from general practice. Fourth national study 1991-1992. London: HMSO, 1995.
Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subacute low back trouble. Spine 1995;20: 722-8.
Department of Health and Royal College of General Practitioners. Implementing a scheme for general practitioners with special interests. London: DoH, 2002.(Peter Maddison, consultan)
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Abstract
Musculoskeletal conditions are a major cause of chronic disability in the United Kingdom and one of the commonest reasons for referral to secondary care. In the 1995 health survey for England, 18% of adults reported some form of moderate or severe disability.1 Musculoskeletal disorders accounted for 34% of these and serious disabilities for 40%. In the 1998 Welsh health survey, 25% of respondents stated that they were being treated for "arthritis."2 This rose to over 60% in those aged over 85 years. Musculoskeletal conditions accounted for nearly 20% of all general practitioner consultations in 1991-2,3 of which around 5% were referred for a specialist opinion. Because different specialties are involved in managing these patients and waiting times are often long, it can be difficult for general practitioners to know to whom to refer a patient. Consequently, patients are often referred to an inappropriate health professional and referred twice or more for the same problem. Lack of access to appropriate services means that factors that predict chronicity in common disorders such as back pain4 cannot be addressed sufficiently early, thus compounding their social and economic impact.
Outline of context
The key objectives for change were to provide a coordinated service for all patients referred with musculoskeletal problems so that specialists saw those with appropriate problems, to minimise duplicate referrals, to reduce waiting times, and to offer more services locally.
Key outcome measures
Information was gathered from the hospital based information management system (Isoft). Orthopaedic data did not include accident and trauma patients. Patient satisfaction questionnaires were developed but had not been used routinely before change to the service. These considered access to the service and outcome.
Analysis and interpretation
The four departments were integrated by establishing the targeted early access to musculoskeletal services (TEAMS) programme, which incorporated a common pathway for all referrals for musculoskeletal problems combined with a central clinical triage of patients to the appropriate clinical service based on information in a generic referral letter (fig 1). A senior manager was allocated to the services, and a full time coordinator was appointed to oversee the referral process and to set up the service on the patient information management system to code and track patients through the system. New services included a back pain pathway led by extended scope physiotherapists, and three community based musculoskeletal clinics run by general practitioners with special interests5 and extended scope physiotherapists for patients with uncomplicated musculoskeletal problems. Workshops were held for general practitioners throughout the assessment period, providing an opportunity for their input into the process and development of referral guidelines. These and the referral letter proforma were made available on the trust's website.
Fig 1 Flow diagram showing clinical triage of patients referred to targeted early access to musculoskeletal services
Effects of change
Since the introduction of the targeted early access to musculoskeletal services, a large proportion of the increased burden of referrals has fallen on physiotherapy services. It is apparent, however, that many referrals to physiotherapy are inappropriate. We are therefore establishing a programme run by general practitioners with special interests and extended scope physiotherapists to educate general practitioners about the role of physiotherapy in the management of musculoskeletal problems. We are also introducing methods for identifying those patients with non-specific musculoskeletal pain that is unlikely to respond to biological interventions and developing self management interventions based on modifying health beliefs and behaviours. We are also establishing clinical pathways for common hand conditions, such as carpal tunnel syndrome, to help remove the backlog of patients waiting to be seen in the orthopaedic clinics.
Contributors: PJM was the lead writer of this paper; he is guarantor. The other authors are members of the Targeted Early Access to Musculoskeletal Services Project Group and contributed to the design of the programme, its implementation and monitoring, and the preparation of this report.
Funding: Innovations in care programme for orthopaedics, Welsh Assembly government, and North Wales NHS Trust.
Competing interests: None declared.
References
Joint Health Surveys Unit. Health survey for England 1995. Vol 1: findings. London: Stationery Office, 1997.
Welsh Office. Better health better Wales: a consultation paper. Cardiff: Welsh Office, 1998.
McCormick A, Fleming D, Charlton J. Morbidity statistics from general practice. Fourth national study 1991-1992. London: HMSO, 1995.
Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subacute low back trouble. Spine 1995;20: 722-8.
Department of Health and Royal College of General Practitioners. Implementing a scheme for general practitioners with special interests. London: DoH, 2002.(Peter Maddison, consultan)
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