Allied Health Professional (AHP) Musculoskeletal Pathway Framework (National Minimum Standard)

1. Introduction

It is estimated that between 20 to 30% of all General Practitioner (GP) consultations are about musculoskeletal complaints ^[1],[2], with spinal and soft tissue disorders within the top ten of conditions ranked by annual contact rates per 1000 practice population^[3]. Musculoskeletal conditions are associated with the worst quality of life scores compared with a myriad of conditions, including mental health, cardiovascular and respiratory diseases, visual and hearing impairment renal disease and cancer^[4]. Some 10 million working days are lost on average per annum through musculoskeletal problems^[5] and musculoskeletal patients are the second largest group of patients (22%) in receipt of incapacity benefits after patients suffering from mental ill-health^[6]. Orthopaedic activity is high and continues to increase with activity growing in some countries in the region of 12 per cent in ten years for both inpatients and outpatients^[7]. Elective joint replacement surgery is predicted to rise by 4.2% per year^[1]. The number of people in Scotland having hip and knee joint replacements has grown from 7,000 to 15,000 in the last 10 years. The cost in Scotland for orthopaedics has risen from £180 million 1999/2000 to £360 million in 2007/8^[8]. Possible causes for the rise in activity includes the ageing population and increased longevity^[9], expansion of new procedures and technology in orthopaedics^[10], obesity and increased use of alcohol^[11], perceived increased patient demand due to a greater awareness of diagnostic and therapeutic advances^[12]. In 2007 it was estimated that the total cost to society of musculoskeletal conditions was in the region of £7 billion^[13]. With this increased activity it is estimated that the demand for Trauma and Orthopaedic surgeons will overtake supply in the next five to ten years^[11].

Policy initiatives to improve the patient experience, for example the 18 week Referral to Treatment Standard^[14], Shift in the Balance of Care agendas^[15],[16], and also to respond to socioeconomic pressures, for example the European Working Time Directive^[17], the limitation of junior doctors hours^[18], changes to the General Practitioner (GP) and Consultant contracts^[19,20], and the financial pressure on public services^[21] ; have put further pressure on services to redesign or reconfigure traditional musculoskeletal services.

These demands on future services have been further compounded by the rise in complexity and sub specialisation of trauma and orthopaedic surgery^[11], the reduction in orthopaedic spinal surgeons (owing to changes in medical training, perceived low success of spinal surgery and reduced opportunity for private income)^[22], the increased feminisation of medicine^[23] and the increased litigation culture^[24]. Rising GP referral rates to acute services^[25] have also been suggested as a possible contributing factor to altered referral thresholds possibly owing to guideline implementation^[25], disgruntlement at the lack of access to other services, for example physiotherapy^[26], or increasing clinical diagnostic uncertainty^[27].

Policy makers and clinicians have searched for innovative ways to try and cope with increasing demand for musculoskeletal services^[1],[28]. While the intent of many of these innovations are often admirable they are commonly introduced unilaterally and locally, leading to widespread unnecessary national variation^[8] between health boards and even within the same health board. This variation results in a 'post code lottery' of care for those with musculoskeletal conditions in the National Health Service (NHS) Scotland^[29].

It has been estimated that between 10% to 40% of new orthopaedic referrals do not require a surgical opinion and of patients on a waiting list, between 5% and 15% do not want or need surgery^[30]. It has therefore been considered important that General Practitioners (GPs), orthopaedic services and AHP services work in unison to ensure that referrals are appropriately reviewed to ascertain which patients require acute hospital referral and those patients who could benefit from rapid access to more locally based community services^[28],[31].

Many healthcare services have acknowledged the expertise of AHPs with extended roles and reconfigured their services to incorporate AHPs into patient management models working in collaboration with the medical team^{[32],[33],[34]}.

The idea of AHPs supporting orthopaedic services is not new. The concept was thought to be first reported in the United Kingdom (UK) by Byles and Ling^[35]. These authors noted the increasing rise in surgical workload of orthopaedic surgeons and suggested that a physiotherapist could effectively see many patients who required conservative orthopaedic management. This was backed up by numerous studies highlighting that many patients who were referred to orthopaedic outpatient departments either failed to attend (often because their condition had improved), were referred for physiotherapy or a simple appliance, or received treatment that they could have received from a general medical practitioner^{[36],[37],[38]}. Historically it was estimated up to 60% of all referrals to an orthopaedic outpatient clinic could be managed safely by a physiotherapist and to the satisfaction of most patients^[35]. The subsequent introduction of physiotherapists undertaking musculoskeletal extended scope roles termed Extended Scope Physiotherapists (ESPs) or Advanced Practitioners has been widely regarded as a positive development^{[32],[35],[39],[40],[41]} and anecdotally successful^[42],[43]. Other AHPs have followed suit in developing advanced practice roles.

In Scotland the term Advanced Practitioner has now been used to encompass the work of ESPs and also the extended/enhanced work of other AHPs. Advanced AHP Practitioners have been defined as "experienced professionals who have developed their skills and theoretical knowledge to a very high level which is supported by evidence. They perform a highly complex role and continually develop practice within Musculoskeletal Services"^[44].

All Health Boards in Scotland have developed their services to incorporate these advanced practice roles to varying degrees, acknowledging the expertise and efficiency that they bring to delivering services fit for the future. These roles are proving critical to the development and delivery of evidence based pathways of care. This document marks the start of a journey towards reducing unnecessary variation in musculoskeletal care by outlining a minimum standard framework for the management of MSK conditions across NHS Scotland.