Using Advice and Guidance to reduce the burden on patients and secondary care specialisms

Most patients with MSK pain, through a personalised approach, are supported to self-manage or undergo active rehabilitation. Others may require additional investigations to confirm a diagnosis and facilitate a discussion on management options.

Where there is need for a secondary care opinion, clinicians have the skills and competencies to make referrals into secondary care. However, there may be circumstances where clinicians are unsure if a specialist opinion is needed.

The aim is to ensure that people with MSK pain referred into secondary care needed the specialist expertise.

Midlands Partnership University Foundation NHS Trust needed to ensure governance processes were consistent across a large geography, where the service refers into multiple providers, including University Hospital of North Midlands, University Hospital of Burton, and Derby and Royal Wolverhampton NHS Trust. To achieve this the trust undertook the required business change, which included:

• developing and agreeing the process of managing A&G requests between clinicians and administrative staff to our secondary care providers
• mapping the steps to ensure results from secondary care providers are promptly managed by the trust’s administrative team and onto requesting clinicians for appropriate action. 

The data presented is from 25 August 2022 to 6 June 2024.

In summary:

• 51% of A&G requests were converted to an appointment/referral by the receiving hospital
• 49% were not converted and once returned to the referrer, patient care continued to be managed in Community and Pain Services or primary care

This saved secondary care clinic appointments, unnecessary travel and waiting time for patients.

The project initially started with two pilot areas (North and East Staffordshire) so that the governance processes could be checked and refined. From initial data of over 300 patients, 45% of secondary care appointments were found to not be needed. This allowed the trust to expand the project to the rest of the service.

Some secondary care specialties converted the A&G request into a referral if it was appropriate for their service. Others did not, even where the MSK Services indicated the request could be converted.  

Consistency was important to establish. When A&G requests were deemed appropriate by secondary care they should be converted into a referral or appointment using e-RS, rather than asking the Community team to convert to a referral. This avoided delays for patients and unnecessary administrative work. 

It was recommended that time required for A&G activity is suitably supported in job planning for secondary care colleagues. Themes were also collected around the questions being asked of the secondary care specialties to support additional training for the Community MSK and Pain Service.

From a clinician’s perspective, the introduction of A&G to the trust’s MSK service has brought great value to day-to-day clinical practice. It has helped hugely with decision making when uncertainty exists, particularly in complex cases.

The trust shared the process and data at regional NHS England meetings and within Staffordshire and Stoke on Trent Integrated Care System (ICS). This has contributed to the development of agreed standards across the Staffordshire and Stoke on Trent ICS, which have been drafted and will associate to this case study when published.

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