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Good practice guide

Review of orthopaedic services

Self-assessment checklist for NHS boards

Case Study 1 – New ways of working to reduce waiting times for orthopaedic patients

Reducing the number of referrals to orthopaedic consultants, NHS Lanarkshire

During 2004, NHS Lanarkshire received two-year funding from the Scottish Executive’s Centre of Change and Innovation. The NHS board used this funding to set up an Extended Scope Practitioner (ESP) service at Hairmyres hospital which was extended to the whole of NHS Lanarkshire in 2007.

The ESP service aims to use the skills of specialist non-consultant staff to reduce orthopaedic waiting times and improve data quality and patient satisfaction.

The lead ESP screens all referrals to the orthopaedic department (approximately 1,000–1,200 per month) from GPs, consultants and other health professionals. Patients are then referred to a physiotherapy ESP, spinal ESP, podiatry ESP or to an orthopaedic consultant in accordance with an agreed protocol.

Around a third of referrals are referred to the ESP service rather than to a consultant. Approximately ten per cent of the patients seen by an ESP are subsequently referred to an orthopaedic consultant.

The ESP service has helped to meet the national waiting times targets for orthopaedic outpatients by providing an additional 680 outpatient appointments per month.

ESPs deal with approximately 98 per cent of back pain referrals, which allows consultants to focus on patients who are more likely to require surgery.

Waiting times have reduced from around 87 weeks in May 2005 to around six to eight weeks to see an ESP, and 12 weeks to see a consultant in December 2009. The salary cost of this service is approximately £290,000 a year.

Treating patients in the community, NHS Greater Glasgow and Clyde

The Greater Glasgow Back Pain Service (GGBPS) started in September 2002 and is a community physiotherapy-led service available to all patients with lower back pain.

The service consists of 13 clinical physiotherapy specialists who lead the management of lower back pain in the Greater Glasgow area of NHS Greater Glasgow and Clyde.

The team also has direct access to dedicated clinical psychologists for patients with acute lower back pain at risk of developing chronic pain. The salary cost of this service is around £450,000 a year.

Patients are referred to the service by a GP, or they can self-refer, and around 700 new patients are seen each month. Some require the help of experts in pain management while others benefit from continuing exercise.

The service has reduced the number of back pain referrals to the orthopaedic service – only one per cent of back pain patients are referred for imaging or surgical opinion.

The GGBPS has reduced the average waiting time for orthopaedic referral in one area from 42 to ten weeks, and 93 per cent of patients with acute back pain are seen by the service within two weeks.

Dedicated upper limb service, NHS Fife

Dedicated upper limb service, NHS Fife to reduce the 84-week wait for the orthopaedic service in 2001, NHS Fife set up a dedicated upper limb team. This team is made up of the following healthcare professionals:

  • one consultant orthopaedic surgeon.
  • one staff grade doctor/surgeon.
  • two upper limb specialist nurses.
  • ESPs in physiotherapy.

All upper limb work is directed through this specialist team. In 2007/08, the team dealt with around 5,700 outpatient appointments, 880 day cases and 200 inpatients.

Waiting times for access to the dedicated upper limb team is currently 12 weeks and are expected to reduce to nine weeks from March 2010. The cost of this service is approximately £400,000 a year.

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