A consultant-run lower limb orthopaedic clinic hosted by a GP practice in Nottingham is helping to break down barriers between primary and secondary care. The work was piloted within Rushcliffe, which is one of NHS England’s multispecialry community provider national vanguard sites.
As part of the pilot project at St George’s Medical Practice in Nottingham, a weekly clinic is held for lower limb (hip and knee) conditions.
Responsibility for the clinic, which was launched in April 2014, is shared between four orthopaedic consultants from Nottingham University Hospitals NHS Trust (NUH) and an extended scope physiotherapist. Twenty patients a week are seen in the GP practice setting.
From this April, the service will be taken over by a new collaboration between Rushcliffe GPs under a limited liability partnership called Partners Health, NUH and private provider, Circle, which was awarded the contract after a bidding process.
The clinic will be extended to cover upper limb condition (shoulders, elbows and hands), double in frequency and be run from two GP practice locations rather than one.
Dr Matthew Jelpke, partner at St George’s, explains the main benefit is that patients receive a rapid diagnosis and decision from a consultant on what should happen next. Feedback early on in the pilot showed that 87 per cent of patients who had used the service rated it excellent and 13 per cent rated it good.
‘It fits in nicely with the NHS Five Year Forward View that envisages more secondary care services being closer to patients’ homes and based in the community, but provided by specialists from the hospital,’ adds Dr Jelpke.
‘Latest data shows that our standardised admission ratios for hip and knee replacements reduced from 93 in late 2013 to 81 in late 2015. The national average is 100.’
By optimising orthopaedic care through early consultant assessment and diagnoses and recommendations of treatment, there have been considerable cost savings for the CCG, says Peter James, lead orthopaedic consultant at NUH.
From a commissioning point of view it shifts the focus away from payment by results, as the clinics are paid at a sessional rate. It is estimated that around £100,000 in outpatient costs have been saved since the pilot began. A further £200,000 is also estimated to have been saved as a result of reduced hospital procedures, says Dr Jelpke.
Providing more services in the community
The pilot was first started, Mr James explains, in response to the fact that Rushcliffe CCG was keen to see a greater number of musculoskeletal conditions treated in the community rather than referred to hospital.
‘At first we provided a triage service where a consultant would use referral letters to decide whether a patient required hospital or could be managed by their GP.
‘After doing that for a while it became clear we would gain much more if we actually saw the patient. We continued with the triaging service but then also set up the pilot clinic at St George’s.’
The practice agreed to host purely because it had the space. It was given funding for the project to the tune of £85,000 a year by the CCG. This paid for the consultants’ time, extended scope practitioner’s time, any subsequent physio required (up to five sessions in a hospital setting), admin time and room rental.
‘The practice itself hasn’t made any profit, it purely provided a venue,’ says Dr Jelpke.
The pilot officially comes to an end this March with the new £105,000 contract starting in April. Two other practices will take over hosting the clinics, Castle Healthcare Practice in West Bridgford and Bingham Surgery, part of Belvoir Health Group.
It will be led jointly by eight consultants (double the number involved in the pilot) to include shoulder and elbow, and hand specialists.
Again the aim is not profit, says Dr Jelpke. ‘The main thrust of it was to create a platform for greater collaborative working across the patch.’
Although the service is currently consultant-led the model may be adjusted in future to include other skilled professionals, he adds.
Its success in terms of patient feedback and cost savings has meant neighbouring CCGs are now watching with keen interest, as the NHS Right Care programme has identified opportunities both in cost and quality across musculoskeletal services in Nottingham.
Mr James says: ‘There is a feeling this model of early consultant input into the community with appropriate early decision making is beneficial. There is now a broad-based Nottinghamshire-wide committee looking at how we can get a single model of musculoskeletal healthcare for the whole region. It’s a matter for discussion, clearly.’
Ultimately, Dr Jelpke says, we want to reduce the barrier between primary and secondary care ‘to act as one team of clinicians.’ This model may also pave the way for other services such as gastroenterology, cardiology or rheumatology to follow suit.
He adds: ‘This service was initiated by Rushcliffe CCG, and as part of the involvement with the Principia (Rushcliffe) vanguard site, CCGs in Nottingham are working together to spread best practice as part of the shared transformation programme, when relevant to the population health needs.’
Picture: Sigrid Gombert/SCIENCE PHOTO LIBRARY