Reviewing the impact of a design Musculoskeletal Pathway

Musculoskeletal (MSK) services assess and treat problems that affect the bones, joints, and soft tissues. Many musculoskeletal problems are long-term conditions that require comprehensive care and pain management strategies by a variety of health professionals and across a range of services. These include both primary and secondary care services, diagnostic services, extended scope physiotherapists, occupational therapists, pain specialists, rheumatology and orthopaedics.

The Challenge 

To improve care for MSK patients, three East London NHS Clinical Commissioning Groups (CCGs) – Barking & Dagenham, Havering, and Redbridge (BHR) – designed a new patient care pathway. The new pathway was implemented in June 2016, however, BHR had concerns that there was a lack of clarity among all stakeholders about the pathway.

MSK expenditure across the CCGs specialities account for up to £31 million, which made it clear that the original pathway was not producing the desired impact.

Following the request of the CCGs, UCLPartners reviewed the data and patient flow to increase efficiencies in the delivery of the MSK pathway.

Facing the Challenge

UCLPartners held a series of workshops with key stakeholders (GPs, commissioners, secondary care clinicians, MSK service providers, physiotherapists) to clarify the MSK pathway, agree on timelines for implementation, as well as identify blocks and challenges relating to patient flow, service capacity, and commissioning specifications.

Several issues emerged including:

• Lack of clarity on pathway and processes across all stakeholders
• Need for improved communication about the pathway
• Different referral forms and processes between CCGs
• Lack of data to demonstrate patient flow through the pathway

The CCGs identified that there was a need to develop the pathway flow to truly reflect what they had put in place.

Original MSK Pathway flow and the redesigned MSK Pathway flow

Our Outcomes

Following these workshops, UCLPartners redeveloped the pathway diagram to establish a clearer presentation of patient flow as well as an action plan to identify where additional support was needed by staff working on the ground.

As a result, understanding of the pathway amongst GPs, practice managers, and other staff members has greatly improved.

Lessons learned from this work include:

1. Working with key stakeholders to agree on a clear vision for the service before implementing a new pathway.
2. Ensuring the availability of patient data to further understand patient flow data and identify issues across the pathway
3. Confirming that when commissioning new services, the specification meets expectations and that the data is available for performance evaluations
4. Testing the pathway out on a small scale to identify unintended consequences
5. Making sure that presentation of the pathway is available to all stakeholders
6. Ensuring that GPs and the practice staff who are asked to use e-referrals know how to complete the form. They should be provided with helpful resources such as ‘How to’ Guides’, Process Flow Charts, and FAQs. If the referrals are returned incomplete, make sure there is a process in place to flag this on GP IT systems for attention.
7. Checking pathways post implementation to ensure ‘workarounds’ are not put in place
8. Ensuring access to imaging and diagnostics for any new providers
9. Pre-emptively observe for delays e.g. incomplete referrals returned, accessing imaging
10. Considering the use of GP decision-making tools
11. Considering the use of self-care tools, support groups, and social prescribing