Children and young people commonly experience musculoskeletal (MSK) problems. Some are serious and need to access care quickly at a specialist centre, but many others are a result of normal variance in childhood development and therefore can be managed closer to home.
An initiative developed by the Pennine MSK Partnership, alongside Newcastle University and Oldham Clinical Commissioning Group, has been paving the way for a better use of resources by starting a community-based service for children and young people. Last year the team won a BSR Best Practice Award for their innovative solution to this challenge.
Dr Jill Firth, Consultant Nurse in Rheumatology for Pennine MSK Partnership, explains: “We’re a community-led MSK service with experience in effective triage in adults and we were aware of the growing pressures on the specialist services related to children and young people. There were many children who had issues like knocked knees and flat feet who were waiting a long time to be seen in a central specialist centre. This had a knock-on effect on the waiting times for others who had more serious conditions, such as inflammatory arthritis, neurodisability or cancer.”
The team recognised that they could adapt their current adult model of community-based triage and test it on children and young people to see whether they could safely provide care closer to home and cut down on unnecessary referrals.
Called ‘Rightpath’, the initiative aimed to support allied health professionals with paediatric expertise to promptly identify GP referrals and triage them to the appropriate specialist paediatric service or to Rightpath community-based physiotherapy or podiatry.
“We spent a lot of time developing and testing the guidance with the specialist paediatric content provided by the team from Newcastle University led by Professor Helen Foster,” says Dr Firth. “There was no triage guidance in existence for children and young people, so we had to brainstorm what was needed and develop it ourselves.”
It was a collaborative process which included a number of workshops with representation from primary and secondary care, specialist services, commissioners and the BSPAR parents’ group. Once the guidance had been developed and the relevant staff were trained, it was tested rigorously in a pilot phase.
“Staff were asked to keep a weekly log of how they found using it and if they had any areas of uncertainty,” says Dr Firth. “Allied health professionals had access to a Consultant Rheumatologist and GP with Special Interet for advice at the point of triage and we also had regular feedback sessions so we could share learning. One of the main things we looked at was whether the triage was safe and appropriate, and we found that no children had been triaged inappropriately to Rightpath clinics.”
The pilot, which took place between September 2016 and April 2017, saw referrals for 365 children and young people triaged using the guidance. The results showed that a third of referrals could be safely seen closer to home. “For many patients they would have had to wait 3-4 months to be seen but could now be seen within three weeks,” says Dr Firth.
“It’s a win-win situation for children and young people to be seen efficiently by appropriately trained allied health professionals as well as relieving pressure on specialist services,” says Dr Firth.
Data collected in the pilot were evaluated and analysed by the team at Newcastle University and shared with Oldham Clinical Commissioning Group (CCG). “The commissioner felt that it was so successful that it was very important to embed the service and maintain it for the future,” explains Dr Firth.
The feedback from patients and their parents was overwhelmingly positive, with parents highlighting how quick and efficient the community-led experience was. The high satisfaction scores reflected the effort made by staff to listen to concerns and help them understand their child’s health.
The service, which has now been embedded for two years, continues to flourish and referrals for over 1,700 children and young people have now been triaged with a third seen in community based clinics. It has already been replicated in South Tyneside with similar success. “We’ve had a lot of interest from others in the model and it can be adapted and replicated in other areas of the country,” says Dr Firth. “The most labour-intensive part was the development of the robust triage guidance and it’s been well-tested and refined, so we want to be able to share this learning with others.” The service is currently commissioned on a year by year basis whilst the CCG are trying to resolve the issue of releasing the savings from the specialist commissioning budget.
The team are currently working on a Rightpath website to provide a central resource for the wider MSK community to access the triage guidance, recommendations for training and development and signposting to other useful resources.
“Winning the Best Practice award from BSR was very important to us,” says Dr Firth. “It came at a time when we were looking to secure funding, so the external validation that it was an innovative solution to pressures faced by all was invaluable. It was also nice for the team who’d worked so hard and for the recognition of a service that’s really improving patient care.”
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