Organisation redesigns it service by developing a series of interventional strategies, reducing more than 680 elective procedures, saving £1m

The MSK Clinical Programme Group at Gloucestershire CCG has a range of stakeholder covering all partners across the health and social care community. It has sought to set the strategic vision for our MSK services and has unified all service level transformation work behind this strategy. Coordinating a number of existing initiatives alongside numerous new ones, and setting a clear vision for an Integrated MSK model has enabled significant change to take place which provides significant value to Gloucestershire population.

This extremely large programme has been a collaborative approach to MSK redesign, across a number of providers led by the Commissioning group. It has sought to understand the complexity of the set of specialities (Physio, Podiatry, Advanced Practitioner, Orthopaedics, Rheumatology, Pain Services, Falls Services) that comprise the main components of our MSK services.

Challenges

1) Lack of connectivity between providers

2) Lack of standardisation in terms of internal processes for each service

3) No clear MSK model or pathways

4) Increasing demand in all services

5) Benchmarked high for procedures against comparable CCG’s

Actions

1) Built a series of cross-organisational MDT’s for complex case management and Clinical Network Groups for cross-organisational operational problem solving.

2) Set of standards produced for all services to adhere to within their spec e.g. triage, redirection, referral to other services, etc

3) Developed 42 clinical pathways

4) Built plan to redesign patient-flow in accordance with pathways and ensure appropriate gate-keeping mechanisms and redirection in place. This will ensure that conversion rate improves, but procedure numbers come down in line with benchmarked comparables, whilst maintaining a focus on delivering this through quality improvements at the front end of the pathway and shared-decision making with patients

5) Set in motion a series of service level redesign projects coordinated behind the strategic vision. Therapies, advanced practitioners services and dedicated integrated falls strategies have supported the new model.

Results

1) Cross-organisational forums ensured a timely discussion, and ‘right place’ for patient cases. They have provided an opportunity for Service leaders to feel empowered to resolve cross-system problems, have complex case management discussions and share learning between services. They have been extremely well attended and there has been a drive towards ensuring that the needs of a patient can be discussed and assessed prior to an appointment. This has reduced duplication and ensured patients get to the right place, first time.

2) We have embedded shared decision making with patients so that patients who choose not to have surgery are supported in that decision with alternative options.

3) We have continued to monitor patients experience and friends and family test results and have seen the services achieve consistently high feedback and now have forums to address cross-system issue which may have been leading to poor patient experience.

4) We are in the process of implementing a virtual fracture clinic which ensures that patient who do not require attendance at a fracture clinic, can be supported over a telephone consultation.

5) We have standardised services, to ensure that where we have more than one provider that best-practice is shared between providers to ensure that we improve overall experience and reduce variation.

Value

1) To date we have seen a reduction of more 680 elective procedures, leading to a saving of £1m - with no investment.

2) We continue to evaluate patient experience and satisfaction and results remain high

3) Early pathway intervention through education and exercise, combined with shared-decision making has ensured that procedure reduction has been achieved by improving quality rather than restricting access to or rationing services. Evaluation of our intervention has shown increasing numbers of patients feeling they have benefited in terms of pain reduction and function improvements from initiatives such as ESCAPE pain programmes.
4) We have early access to physiotherapy and core physio, with stratification in place to ensure that the patient’s needs are met appropriately and redirected to the right level of clinician first time.

5) We have supported patients that may have ordinarily gone for surgery with early education and exercise interventions, with a view to moving towards self-management where appropriate. We have ensured patients are stepped-down through the pathway and put in place elements which improve communication between services and encourage a seamless transition from one service to the next when required.

In detail

Ambition:

To deliver a truly integrated, multi-organisational, MSK Model that ensures simplified timely access, high-quality interventions and outcomes.

To ensure that the connectivity between these services, and levers in place to direct the flow of patients truly ensure Right Person, Right Care, Right Place, Right time.

The Programme has sought to standardise practices within each service, build connectivity across organisational boundaries and developed a range of pathways that support patient flow. The first phase of the programme is now almost complete and phase 2 will completely transform the system.

Approach:

From the outset, the programme has been inclusive, collaborative and entirely co-designed and with the patient at the centre of every decision. The new integrated MSK service model has involved undertaking the following work:-

•Service Walkthroughs

•Public Health Needs Assessment

•Evidence Base Report for each service area

•Lessons learned analysis from other areas

•Patient and Clinical Feedback Report

•Data and Finance ‘As is’ Report

•‘As is’ Process Maps

•Workshops and Recommendations Reports

•Service Specifications for all services

Following this work, a series of recommendation reports were produced and some thematic analysis was carried out to understand the root cause of the problems and allow resources to focused on areas which would have the biggest impact on outcomes. This work was triangulated with other information sources such as the RightCare Commissioning for Value Packs. The Programme has tackled all services across the entire but from an acute perspective outcomes being measured were ‘quality of life’ and ‘function improvements’ alongside a reduction in the number of patients requiring surgery. However, it is important to recognise that the focus was truly on value and not on ‘rationing’ of surgery. It aimed to reduce procedures by improvements in shared-decision making and early conservative intervention with exercise and education as per the evidence base.

Phase one has also been carried out with a focus simply on streamlining and improving current systems, without any major change since we sought to minimise risk to patients. In order to fully transform the model, it was accepted that there was a need to improve quality and efficiency across the pathway and reduce variation as much as possible where it exists, without creating further disruption for clinicians expected to deliver the change.

Outcome:

Improved integrated, multi-disciplinary and multi-organisational working with a reduction of over 600 procedures constituting over £1m saving. This has been achieved by improving quality rather than restricting access to, or rationing, services. It has ensured patients have a diagnosis as early as possible, are supported with best -practice conservative management where appropriate and encouraged to be involved in decision-making. We have also implemented a number of initiatives that either streamline processes or improve patient-centred care, including:

1) Self referral for Physio & Podiatry

2) Stratification tool - STaRT back with targeted treatment plans introduced for back pain both providers with specific CBT training of staff to ensure competencies to underpin

3) Strong focus on health promotion – assessments include health screening and brief interventions to include – weight management, smoking, alcohol consumption, history of falls, level of physical activity GCS LiA work on MECC

4) Evidence based ESCAPE pain programme now in place to facilitate self-help of OA/Long term conditions

5) Moved groups (Back to fitness, ACL, Lower limb, ESCAPE) out of hospital into community locations to facilitate people continuing with physical activity once their treatment has finished

6) Integrated hand therapy service (Hand therapists either a Physio or an OT) – reducing duplication

7) Integration of falls assessment and management into core physiotherapy. Increased provision across the county and a connectivity with community balance classes.

8) Programme of psychological skills training to include MECC

9) Physiotherapists work in both core MSK and the Advanced practitioner service to support a seamless patient pathway

10) Physiotherapists work in both core MSK physiotherapy and the multidisciplinary Pain Self Management Service. This includes a more integrated approach to complex case discussion and core physio education programmes.

Spread:

Focus remains on best-practice and across the wider system. It has acknowledged the complexity of the patient journey when that patient is in pain and the variation in biopsychosocial impact that can have. This model, once phase 2 is implemented, will deliver a true Right Person, Right Care, Right Place, Right time that can be replicated across any service. The most exciting part of the project is that we have had over 80 engaged patients, clinicians and manager sharing the problem and solution and that significant improvements continue to be made, even before investment and before the major transformation piece has been implemented.

Value:

To date we have seen a reduction of more 680 elective procedures, leading to a saving of over £1m - with no investment. We continue to evaluate patient experience and satisfaction and results remain high. All work ensures a focus on supporting patients with shared-decision making, making every contact count (MECC) (our physio department have been approached over being an exemplar) and delivering high quality education and exercise intervention to support patients with self-management. Involvement: This has been a truly collaborative approach, delivered by the will of all partners to go above and beyond their normal duties to help deliver a hugely ambitious piece of transformational change.

No additional resources have been provided to support the project thus far. One of our biggest successes has been unifying everybody behind the strategic vision we have for MSK services and engaging such a wide group of stakeholders. The plan to set the strategic vision was attended by over 80 representatives across a range of patient groups, voluntary care organisations, clinical and commissioning partners, at which there was a 100% sign-off. Difficult decisions have been taken at times, but providers, managers, and clinicians have put aside organisational differences or interests to ensure we deliver a model that is right for the patient.