The Department of Health (DoH) has budgeted for over £5 billion for musculoskeletal services, which has almost doubled over the last decade. This is now the fourth highest area of NHS spending1 and makes up 30% of general practice (GP) consultations.2 Sixty per cent on long-term sick leave cite musculoskeletal conditions as the cause and is also the most common reason for GP repeat visits.4 It has been suggested that up to 70% of GP musculoskeletal care could be managed by extended scope physiotherapists in the community. With the population aging, and doubling of the over 65 year olds by the year 2020, there is going to be further pressure on these resources.3
In order to avoid disjointed and duplication of services, resulting in added expenditure, the Department of Health’s (DoH) July 2006 publication has devised a framework for musculoskeletal referrals. This is in the form of a Musculoskeletal Clinical Assessment and Triage Service (MCATS) to deal with referrals between primary and secondary care.4
There is also a perception that secondary care consultations for musculoskeletal conditions are expensive, and a significant proportion of these referrals do not progress to surgery. However, progression to surgery is a blunt tool to measure the appropriateness of patient referral. Streamlining referrals both internationally and locally between primary and secondary care has reduced hospitalisation and improved services amongst carers and patients.2,5
The use of integrated care pathways and intermediate triaging services is centered on patient self-care, focused with the patient as an active agent, rather than passive receiver. This article evaluates and describes the potential pitfalls and successes in such a service.
The proposed model
Strategic Health Authorities (SHAs), in their current guise, are putting out musculoskeletal services to tender for organisations to bid for the ‘contract’. The contract will involve a collaboration of resources to diagnose, manage and treat all musculoskeletal pathologies in the community. The collaboration of resources will bid to gain control of the contract and could include the local hospital, coalition of local GPs and Physiotherapy practices, or a private medical company.
The financial package on offer involves an annual fixed sum of money, with the left-over money at the end considered ‘profit’. This is intended to encourage cost savings, preventing spiralling musculoskeletal budgetary spending. There may also be financial incentives for achieving best practice, based on patient outcomes. This is intended to encourage provision of a high quality service, centred on the patient, and counteract the real risk of focusing solely on the financial gains. As a result of best practice the musculoskeletal community now faces the challenge to develop sensible outcome measures, such as patient-out-of-work-days or the ability to perform activities of daily living, in order to evaluate the success of such a service.
The DoH framework
Tables 1 and 2, taken directly from the DoH article4, highlights the DoH musculoskeletal framework algorithm. It is important to note that these MCATS will sit between primary care (GP referrals) and secondary care (Trauma and Orthopaedic Services, Pain services and Rheumatology services). The key to this triaging service is differentiating common minor complaints from uncommon serious conditions and ultimately a timely referral to the correct service. Specific conditions such as metastatic spinal cancer, primary bone tumours, and inflammatory conditions such as Rheumatoid arthritis require early recognition and urgent investigation and treatment. Any new system of triage must have robust protocols to pick these conditions up reliably. Needless to say, detail in both the set-up and the running of such a service requires close collaboration with secondary care facilitates for on-going education, audit and advice.
Mcats design rationale
In the interest of saving ‘unnecessary’ expense, there is a prevailing thought in the DoH document that patients identified in the MCATS as requiring orthopaedic surgery could be ‘directly listed’ (Table 2). This process bypasses the elective outpatient consultation, and with its accompanying expense of £156 for the first appointment and subsequent appointments averaging £766. The ability to directly list onto a consultant’s operating list must be carefully analysed. There is obviously scope here for disagreement with the indications for, or the type of surgery proposed, with either cancellations on the day or patient dissatisfaction and complaints (and possibly the expense of lawsuits).
In the case of a well-functioning system, referrals that clearly require forwarding directly to the orthopaedic outpatients for surgery (eg. total knee replacement for significant arthritis), will be picked up at MCATS triage level. And, one would hope, not be delayed by a trial of physiotherapy or joint injection, by an extended scope physiotherapist, only to discover that onward referral to orthopaedic clinic was necessary from the outset.
Accident and Emergency (A&E) referrals to fracture clinic have also been targeted as a source of patients for MCATS services. Although on the surface this sounds a good idea, one should approach this with caution. Fracture clinics are a consultant-led service with access to specialist care, and further imaging may avoid missing important injuries and conditions that otherwise may not have been considered. Missing scaphoid fractures which were triaged as soft tissue wrist injury is just one example. On the outside it may seem resource-heavy, but fracture clinics act as a quality control-sieve and results in a degree of care to patients that could not be matched in the context of MCATS.
There is the possibility however, for managing acute on chronic conditions in MCATS, such as back pain turning up to A&E instead of their GP with no red flags. This may actually be excellent use of the A&E and MCATS interface. There will be other such examples that can be decided at a local level.
Opportunities for the clinician to influence the MCATS design
These MCATS are being rolled out irrespective of secondary care opinion and therefore will directly affect this patient cohort. For this to benefit both patients and practitioners it is important to be involved at grass roots level. Early development in the design and implementation of these systems will ensure patients are not simply being subjected to a delay in their necessary treatment. This means sitting in on the meetings during the set-up phase of these MCATS. Clinicians ultimately need to ensure that there are no additional delays in patients requiring secondary care, and there is an improvement in the conversion rate of patients benefiting from surgical intervention in clinic. Points in the treatment algorithm (Tables 1 and 2) where we may reasonably influence the patient journey are:
Forging good links with the MCATS assessment as well as treatment staff to clarify what constitutes appropriate cases for immediate onward referral to secondary care.
Ensuring ease of communication of the triage system and the T&O department in cases of triage difficulty (e.g. by email or a direct line of contact to a nominated trauma secondary care consultant).
Also some real time involvement in the MCATS clinics themselves both for patient assessment and educational purposes for the MCATS staff. E.g. Once or twice monthly. Here patients providing diagnostic doubt or treatment difficulty can be brought and specialist opinion sought.
There needs to be good leadership between the primary and secondary care services, and the use of clinicians who work in both locations can optimise the link use of resources available between the two. With improved staff recruitment and retention, there is enhanced staff education and risk management. By providing hospital staff that are engaged in the process, and hospital consultants, who will ultimately have the responsibility for medical and surgical intervention, early in the process will safely empower the care of patients in this ‘half way house’ environment. Table 3 suggests the areas to be considered in setting up a musculoskeletal MCATS.
A number of health services have already established a clinical assessment and triaging service (CATS) structure e.g. elderly falls and adolescent and mental health services. This assessment system has the ability to offer a multidisciplinary environment and opinion instead of a direct referral to an outpatient clinic. The collaboration of local services can conduct clinical assessments, organise investigations and provide advice and treatment that otherwise would have occurred at a secondary level. This should all be supported with evidence-based guidelines and monitored by clinical audit. Ultimately the patients that need surgical intervention need early onward surgical referral. Table 4 shows unpublished successes of MCAT services already in use.
What does the future hold?
With a well-run and organised MCATS a greater proportion of patients seen in secondary care will be listed for surgery, with appropriate conservative measures exhausted in the community. The delay in referral, to exhaust conservative measures, needs to be balanced against an inappropriate delay in those who clearly need early surgery. For this type of service to work effectively it relies on a close relationship and work with hospital consultants and with this a possible change to the pattern of work to include peripheral and community based clinics. Involvement of hospital consultants will enable elimination of services that will disadvantage the patient, such as direct patient listing.
At the heart of the development of a successful MCATS is the need for close collaboration between clinicians in both primary and secondary care and a robust clinical governance system with strong leadership and clear accountability.
- An intermediate musculoskeletal triaging service needs to have a multidisciplinary approach and close liaison with secondary care to maximise patient care and outcomes.
- Involvement in local MCATS design and set-up will allow successful auditing of data to implement on-going review.
- A well-functioning system allows appropriate management in the community to improve outpatient conversion rate to surgery, potentially saving money and decreasing outpatient waiting lists.
- The key to this triaging service is differentiating common minor complaints from uncommon serious conditions and ultimately a timely refer to the correct service.
1. Department of Heath. Budgeting estimated England level gross expenditure for all programmes and subcategories for all years collected. http://www.dh.gov.uk/health/2012/08/programme-budgeting-data/, 2012.
2. European Bone and Joint Heath Stratergies Project. European action towards better musculoskeletal health: A public health strategy to reduce the burden of musculoskeletal conditions. The Bone and Joint Decade, Lund, Sweden. 2005.
3. NICE, The Management of Hip Fracture in Adults. National Clinical Guideline Centre (NICE) London: National Clinical Guideline Centre, 2011. CG124.
4. The musculoskeletal services framework: a joint responsibility: doing it differently. Department of health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4138413, 2006.
5. Maddison, P., et al., Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. BMJ, 2004. 329(7478): p. 1325-7.
6. Dr Foster Health guide weblink http://www.drfosterhealth.co.uk/features/outpatient-appointment-no-shows.aspx.