Case study: Pennine MSK Partnership Dr Alan Nye is a GP in Oldham, GPSI in Rheumatology, Director of Pennine MSK Partnership, Associate Medical Director of NHS Direct and Associate Medical Director of Pennine Care FT. I ve always believed we could deliver better care for musculoskeletal patients by involving a multidisciplinary team. We have such teams in general practice but many specialist services have little multidisciplinary engagement to meet patients complex social, psychological and medical needs. My aims when developing this service were to provide better care for patients, better value for money for our commissioner and a more interesting job for me. It s been really good fun - if challenging at times. What we did In 2002 I was working as a GP and clinical assistant in rheumatology in Oldham where rheumatology patients were waiting 6-9 months to be seen in secondary care. Together with Anne Browne, a nurse consultant in rheumatology, we set up a successful Tier 2 service to screen referrals to rheumatology. In 2005 we put together a business case to take over the running of the service as a Specialist PMS practice, a new type of contract that my GP partner Dr Hugh Sturgess had heard about. The PCT tendered the service through a competitive procurement process but, somewhat to our concern, decided they wanted a single unified musculoskeletal service covering orthopaedics as well as rheumatology and musculoskeletal pain. However, our bid was successful and our service was commissioned by the PCT. The service went live as a specialist PMS Service in March 2006, as Pennine MSK partnership. Start up costs were negligible as we based the service in my own GP practice. The PCT provided 5,000 to take legal and accounting advice around some of the specialist PMS contracts. Our service level agreement specified that we were to develop services to deliver as much as possible of the patient journey in rheumatology and orthopaedics. It was later expanded to include the pain service. Our Integrated Clinical Assessment and Treatment Service aims to provide the entire non-admitted musculoskeletal pathway for patients. In orthopaedics, that involves bringing them to the point of listing for surgery and in rheumatology we provide a comprehensive service in the community including the infusion of biologic drugs. Psychological medicine support is available for our chronic pain patients. Since 2006 the three owners of Pennine MSK Partnership - me, Hugh Sturgess and Anne Browne - have been running this growing service along the lines of a GP practice. Fourteen consultants
covering rheumatology, pain and orthopaedics now work in our service alongside over 20 other clinicians. The bulk of the service is based in a new LIFT build completed in November 2009; a purpose built town centre integrated care centre with day case theatres, x-ray, and plenty of clinic space from which to operate multidisciplinary teams. Psychological medicine is delivered from another LIFT build slightly out of the town centre. We also offer a choice of clinics for orthopaedic assessment in five other locations around the town. All GP referrals come through choose and book. There s a common entry point for all musculoskeletal problems and we triage the referrals to put patients in the correct pathway. All musculoskeletal referrals in the Oldham are made this way. At the moment the service is only open to patients of NHS Oldham GPs but that will change in the near future. In orthopaedics approximately 65% of the patients do not require surgical intervention and are treated and discharged. The remainder are seen by a consultant and taken to the point of listing. We work with a variety of secondary care providers, including the independent sector, so we offer choice within our service. We have a multidisciplinary team including psychology, occupational therapy, rheumatology, orthopaedics, physiotherapy and podiatry and we supply a very integrated service. The treatments offered by the service include: joint and soft tissue steroid injections, epidurals, provision of orthotics, electrotherapy, laser therapy, acupuncture, wax therapy, splints, exercises and physiotherapy. We are teaching some patients how to do their own disease modifying injections for Rheumatoid Arthritis. We avoid patient follow up appointments unless there are clear clinical grounds for them. We offer telephone follow-up and patient initiated follow-up for patients with chronic conditions so patients are only seen when there is a clinical need. Patients are listed for surgery directly within our service, but only with providers who work with our team; otherwise the patient is referred onto a further out patient appointment at the hospital of their choice. However most patients choose one of our team of providers and are directly listed. Lessons learned and obstacles overcome As one of the first specialist PMS contracts there were some legal loopholes to iron out. We were also one of the first multidisciplinary community based services so it took some time to sort out our superannuation status and indemnity insurance. The MDU hadn t come across a service like ours before. It took about a year from tendering to going live, mainly due to those two issues. Now we ve done it it would be easy for others to replicate the model. With the benefit of hindsight I wouldn t do anything differently. Our guiding principal has been to do what is right clinically and to make sure we do things which benefit patients. Everything else slots into place as long as you have that. Initially our local acute trust, Pennine Acute Hospital, looked upon us with some suspicion as competition. But as we ve grown they ve seen that we can provide certain elements of the pathway
more efficiently than they can allowing them to concentrate on the parts of the pathway only they can provide the admitted patient journey. We complement one another. We have no interest in destabilising our acute trust as we want what is best for our patients. Change is as hard for institutions as it is for the individual but at the moment we have got a very good relationship. Outcomes We aim to see all referrals into the service within two weeks and monitor wait times daily so we can adjust the service to meet the needs of the patients. Our 18 week compliance is 99% and most patients are listed for surgery by week 7. We provide services from seven different locations across Oldham with a choice of appointment times throughout the day including evenings, ensuring ease of access and the provision of care closer to home. We run on average 120 clinics per week. Wherever clinically possible we treat new patients as See and Treat and operate a one stop service for our patients. Approximately 40% of new patient referrals are treated in this way. We were awarded the Customer Service Excellence Award in March 2009 and have been reaccredited in 2010 and 2011. The latest quarterly patient satisfaction surveys results show that 89% of patients are satisfied with our service. The transfer of all hospital based rheumatology patients into our community service was completed earlier this year. In 2009 we transferred 34 patients who were on injectable methotrexate for rheumatoid arthritis, from weekly attendance at hospital to self injection at home. This resulted in about 1 million recurrent saving for NHS Oldham and improvements for the patients who no longer need to attend hospital on a regular basis. The redesign of the pathways for joint injections from admitted day cases to outpatient procedures undertaken within the locally agreed treatment tariffs, has also recurrently saved approximately 1million. We are totally funded by Payment by Results and have agreed a series of local tariffs which are below national tariff for our treatments. We continue to work with our Commissioners to reduce costs whilst maintaining a high quality service. The average conversion rate from GP referrals to orthopaedic surgery run at around 35% - i.e. out of every hundred referrals from primary care seen in orthopaedic consultant clinics, 35 are listed for surgery. In our case the conversion rate is 90% from our consultant clinics. This is because the initial assessment by the clinical professional team filters out those patients who can be safely and adequately treated without the need for a consultant appointment. The future
Our CCG is very keen on the programme budgeting model and sees this method of contracting as the way to provide best value. By aligning clinical responsibility and financial accountability in the same organisation you work to stay in balance while delivering good healthcare. In May of this year we took advisory control of the programme budget for musculoskeletal conditions, working in partnership with the CCG. Our commissioner has quantified the cost of musculoskeletal services (for rheumatology and orthopaedics but not including pain) totalled 23 million in 2010/11. The budget and statutory accountable status still sits with our commissioner but we have been charged with designing and commissioning integrated care pathways across all musculoskeletal conditions. We will, in partnership with the CCG, commission contracts on behalf of the commissioner. We are currently working on the redesign of Carpal tunnel, nail surgery and pain services pathways. The CCG will control the payments, oversee all the contracts and be the accountable organization. We have an open book arrangement with the CCG and commissioner in proposing redesign options. All costing and pricing proposals will be jointly agreed prior to procurement. We put patients right at the heart of our pathway with a service designed to provide a better clinical outcome and a better patient experience. Patients have the opportunity to see many different professionals depending on what their clinical needs are and they have more time in the appointment. We do this while saving money for our commissioner - it s a win/win situation. [Box] 60 second summary Initiative: GP-led Integrated Clinical Assessment and Treatment Service for MSK patients Start up costs: 5,000 from PCT for legal and accounting advice Staffing: 36 Administrative staff, 16 Clinical Staff directly employed, 47 further clinical staff under different contracts (see staffing box) Savings: Agreed a series of local tariffs which are below national tariff for our treatments. Outcomes: Aims to see all referrals into the service within 2 weeks. Aims to treat new patients as One Stop See and Treat - 40% of new patient referrals are treated in this way. 89% patients are satisfied with the service 99% 18 week compliance Contact info : alan.nye@nhs.net
[box] Staffing On the administrative side we directly employ a Finance and Business Director, a Business Operations Manager, Customer Care Manager and Data and Information Manager plus 32 administrative staff. The clinical staff we directly employ consists of a Consultant in Rheumatology,a Consultant Nurse in Rheumatology and Clinical Governance lead, a Consultant spinal physiotherapist, specialist hand physiotherapist, specialist occupational therapist, 3 rheumatology nurse specialists, 1 clinical assessment nurse, 1 infusion nurse and 5 health care assistants. We also jointly fund a Consultant Rheumatologist post with Pennine Acute Hospital. All other clinicians are either seconded or employed on an SLA either privately or with their employing authority. These staff consist of 18 Clinical Specialist Physiotherapists, 5 Clinical Specialist Podiatrists, 3 Senior Podiatrists, 11 Consultant Orthopaedic Surgeons, 5 additional Consultants in Rheumatology and 1 GP with a Special Interest in Rheumatology. We also provide a Chronic pain service and work with 2 Consultants in Psychological medicine, 1 Clinical Psychologist and 1 Cognitive Behaviour Therapist. We have a strong ethos of staff development. All employed staff attend mandatory training (e.g. basic life support, manual handling, fire safety, hand washing technique, ANTT training) and have regular appraisals whilst working towards a Continuous Development Plan. We support our staff financially though the provision of course fees and study leave. Many staff are undertaking NVQ s in Business Administration, Customer Care and Health and Social Care. Our nursing staff are working towards further professional qualifications and our senior nurses are undertaking prescribing qualifications to increase the potential for nurse led care. Our clinical staff both attend and contribute to local national study days/conferences. [box] Oldham Clinical Commissioning Group When established: 2010 Number of practices: 49 Population: 220,000 (covers Oldham) Pathfinder status: 2 nd wave pathfinder