Case Study

We have worked closely with Wyre Forest CCG to re-model their MSK triage, assessment and community physiotherapy service to create an accessible service and bring care closer to home. The success of the MCAT Service Pilot, operating from three clinics, led to the model being rolled out across the whole CCG by opening eight further clinics. Our work has:

Innovation  –  MCAT Service model with ESPs placed within GP surgeries and working collaboratively was one of the first of its kind

Strong Leadership  – Formation of the new service required strong leadership structure/channels throughout with strong stakeholder engagement. Clear objectives were formed from the outset: streamline the patient pathway, bring care closer to home and reduce waiting times/referrals to secondary care/referrals for more costly interventions. Our mobilisation team, led by Mark Driver, ensured the project was implemented efficiently

Is Outcomes Based  – Performance has been measured through KPIs, PREMS, PROMS, referrer feedback questionnaires and during Stakeholder focus/engagement groups

Sustainability  – The model has made a sustainable difference to the GP population of Wyre Forest through no waiting times, a choice of treatment locations and ongoing support via Patient Portal.

Transferability  – Model can be adopted by any CCG seeking to streamline their MSK pathway.

This project stands out as it has made a real difference to the patient population of Wyre Forest CCG, their friends and carers. Of those managing long-term conditions, very few are referred back into the service with the same problem in a 12 month period.

The critical success factors have been:

• Strong Leadership throughout
• Implementation of innovative technology to bring care even closer to home via our Patient Portal
• Service design having regard to needs of local population to ensure the service is truly accessible
• Reduction in DNA rate to improve service efficiency and appointment availability
• Improved communication between GPs, clinicians and ESPs

In 2011, Wyre Forest CCG was experiencing significant inefficiencies in their MSK physiotherapy, specialist triage and assessment pathway in that:

• The average waiting time for MSK referrals was 16 weeks
• The DNA rate was 14%
• Patient accessibility to the service was poor; the service offered patients one clinic location, many miles from some patients’ homes, with limited appointment times between 8:30am-4:00pm Monday to Friday, offering no flexibility to suit different lifestyles and need
• Limited patient satisfaction data or patient experience measures were available
• Little service integration due to lack of understanding of how to work with the wider multi-disciplinary team to achieve better outcomes for the patients
• Little resource available to patients in terms of rehabilitation material and signposting information
• Lack of integration of MSK services across primary care services
• Lack of internal stakeholder upskilling / promotion of best practice
• No interoperability / clinical data sharing across primary care. Following discussions it was apparent that the root cause of the above-mentioned inefficiencies was poor accessibility to community MSK services and a lack of integration between community services in the region.

As a result we put forward a proposal to re-model their MSK physiotherapy model through a pilot, which if a success, would be rolled out across the CCG.

Following discussions with Wyre Forest, a 12-month pilot was launched which included:

• Launch of a community physiotherapy service placing a clinician within 11 out of 12 surgeries within the CCG
• Unified clinical pathways with other community services
• Launched patient specific rehabilitation services (Osteoarthritis community exercise and education services)
• Roll-out of GP Education Programme delivered at each clinic location to improve knowledge of MSK conditions, assessment techniques and treatment strategies. This vastly improved the front-line assessment of patients and ensured appropriate referrals were being made
• Set-up of a MCAT service utilising our Extended Scope Practitioners (ESPs) from one central hub in Kidderminster and two spoke clinics in more rural areas.

Utilising ESPs in this way provided a specialist community assessment and treatment service.

The aim was to reduce the amount of inappropriate referrals into secondary care, for diagnostics and for specialist procedures such as peripheral injection therapy. The statistics showed our MCAT pilot would be £200,000 per annum more cost effective if utilised across the entire CCG in comparison to the previous model. Therefore, working closely with the Commissioners and wider MDT, we rolled the model out across the whole CCG to ensure it was truly aligned to the NHS Five Year Forward Plan by delivering care closer to home. The model has vastly improved patient accessibility; we now operate from a central hub in Kidderminster with extended appointment times from 7am to 7pm Monday to Friday and from 10 spoke clinics across the geographical region, some being in very rural areas. We also facilitate Saturday clinics where patient demand requires. We have rolled-out our education programme to all clinics.

This has been a highly successful project which continues to deliver significant improvements to patient care. Over a three-year period, patients attending almost 65,000 physiotherapy sessions have done so at a convenient location/time. This has been achieved whilst also delivering a cost saving of 9% to Wyre Forest CCG. We have measured the success of the service model through:

KPIs

– Average waiting time for MSK referrals reduced from 16 weeks to 1 week;

– DNA rate fell from 14% to below 6%;

– 40% reduction in number of scans and associated costs; our clinicians always follow NICE guidelines and only refer for more costly interventions if clinically appropriate;

– 45% reduction in referrals to secondary care and associated costs. Of these, 95% went on have surgery demonstrating the appropriateness of these referrals. This validates the success of our rolling education programme – GPs know when to refer to secondary care.

The model has vastly improved patient accessibility; patients have a choice of 11 clinic locations to attend rather than one location under the previous model. This is in addition to extended clinic times, including weekend appointments. This has had a significant impact on patient accessibility to care. For example, under the previous model, patients living in Stourport and Bewdley had to commute for up to 40 minutes to their appointments at Kidderminster Hospital. Patients living in both these locations are now able to walk to their appointments within 5 minutes. Furthermore, patients can access rehabilitation and self-care resources along with relevant signposting material from the comfort of their own home via our unique Patient Portal. PREMS – In 2001, referrals were 50 per week. We currently receive approximately 150 referrals per week. We carried out almost 65,000 physiotherapy sessions in 2014.

Patient satisfaction with the service has remained extremely high despite the considerable growth – 98% of patients would recommend the service to family and friends; 97% were satisfied or very satisfied with the service. Our high satisfaction rates are attributable to: –

• Rapid access with short waiting lists
• Choice of clinics near good transport links with free parking and flexible treatment times
• Well trained/efficient/respectful staff
• Telephone service for patients with hearing impairment
• Chaperone facilities
• Liaison with carers/support workers
• Telephone/on-line support
• Provision of relevant local signposting information
• Post-treatment support via patient portal; full access available 12 months after discharge

Referrer feedback – Obtained through formal questionnaires and informally through daily clinician and Account Manager contact. Feedback from GPs has been extremely high; not only has the model brought care closer to home for the patient, but it has also vastly improved collaborative working between GPs and clinicians and facilitated shared decision making between GPs/clinicians/patients.

This initiative will be relevant to many other CCGs across the country. The hub and spoke model has been adopted by many of our clients implementing AQP contracts. It has also been adopted by another client for a sole supplier contract which we are currently implementing.

‘I am sure that this is an excellent model for the future that could be rolled out elsewhere and indeed similarly for other clinical areas.’

– Dr James Goodman

We believe the key learning points for Commissioners if considering adopting a similar service model would be:

-Ensure viability of service model is pilot tested

-Ensure clear communication, not just during mobilisation but through service delivery

-Create services fully integrated with existing services

-Incorporate the benefits of interoperability across additional services

-Gain the views of all stakeholders when creating new services

-Upskilling and promotion of best practice is vital

-Rigorous data collection can help provide tangible feedback regarding service operations