Introduction
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 phys