Aims and objectives:
Over a number of years there has been an increasingly high demand for orthopaedic services across the Nottingham acute trusts. Gedling PCT needed to make its own contribution to faster access for patients, greater choice, and the opportunity for patients to access services closer to their home, avoiding the need to go into hospital for outpatient assessment or further treatment. In September 2003, Gedling PCT designed a local service to manage this increasing demand whilst at the same time providing opportunities for local clinicians to develop special interest skills. The key objectives were to:
- Set up a community based, multi-disciplinary orthopaedic triage system and clinic in a variety of orthopaedic areas from referral to discharge
- Manage a reduction in demand for hospital appointments by 10% in the first twelve months.
Support for the change:
The service has been supported by adopting change management techniques including process mapping and matching capacity with demand. This has also included ensuring variation in demand can be dealt with by both the primary care and secondary care clinicians.
There has been an extremely high level of regular communication and reinforcement at GP practice level. This has been targeted at influencing GP referral behaviour through the Gedling Referral Management system.
There was early identification of GP with Special Interest to champion the service among local GPs, PCT staff, hospital orthopaedic services and other district wide fora. This GP, coupled with specialist physio continue to provide a high level service one year on.
The success of the service has been built on the dedicated clinical and management resource and commitment to support the service on a day-to-day basis.
Patient and public influence:
All patients have been involved in preliminary evaluation of the original service design the quality of the service, and their individual patient outcomes. Two patient satisfaction questionnaires have been used to measure:
1) Access to services and
2) Outcomes of treatment and overall quality of the service.
In Questionnaire 1, over 98% of patients were highly satisfied with the level of access to the community service (based at a local GP practice and not necessarily their own) as well as the professionalism of staff involved and the quality of the service.
In Questionnaire 2, 86% of patients reported a successful treatment outcomes as measured by the degree of shared treatment plan goals achieved after six weeks of being discharge.
This individual patient feedback has helped shape the service and influence PEC and Board decisions to offer the Soft Tissue Clinic as a mainstream locally enhanced service from July 2004.
Impact on the workforce:
Measuring the results:
Results were measured in terms of access, patient outcome and patient satisfaction as described above. To date, over 30% of orthopaedic referrals have been seen in the Gedling Soft Tissue Clinic, far exceeding our original estimations. Performance is high compared to other local PCTs. Other local demand management and community based clinics have offered community-based services but have not indicated that they are able to keep the equivalent numbers of patients out of the hospital system. We are to other local PCTs to adopt the model produced in Gedling. Local GPs and PCT staff have shared in this service through locally organised events.
Improved performance:
Between September 2003 and September 2004, 32% of over 500 general orthopaedic referrals have been triaged away from a hospital setting, with over 150 appropriate patients been offered and appointment in the community based Soft Tissue Clinic.
In terms of improved access in comparison with waiting list times, 59% of patients have been seen in Soft Tissue Clinic in less than 8 weeks (no patient obtains a first appointment in more than 12 weeks). To date, the clinic has had only one DNA (Did Not Attend).
In over 12 months, no patient has been referred back to secondary care with the same orthopaedic problem.
Reflecting diversity:
This service development over the last 12 months has not been limited to populations that are generally easier to manage. There is clear access to the service based on clinical need as identified by GPs and the GPwSI during the patient triage system.
Sharing the learning:
The Soft Tissue Clinic has been presented at local GP evening meetings, with regular communication via practice letters, regular updates at PEC and local GP Board meetings. The service and its results have also been showcased at the district wide Musculoskeletal Forum with other community practitioners. Furthermore, the service is due to be presented to the primary and secondary care musculoskeletal steering group during December 2004.
Outstanding features:
The best feature of this service is the strength of the GP/Manager partnership which has designed and implemented this service, provided regular evaluation to all parties and continues to drive it forward. This is coupled with the valuable commitment of the specialist physio and administrative staff at the front end of the clinic. This all makes for a secure team effort which is sustainable, and producing a high quality service for local patients.
