Allied Health Professional Musculoskeletal Pathway Minimum Standards: A Framework for Action 2015-2016

6. Potential Onward Referral Work Up

6.1 Standard I - Clinical Supervision Framework with Case Review Policy

Goal setting is not, nor should it be, a simple prediction of what will happen; it should be the intended result of some intervention(s)^[120]. Moreover, efficiency has been deemed one of the domains in a quality health service^[121,122]. If patients are not deemed to be progressing towards the coproduced and agreed goals in the intended manner, then it is important that reasons for this are explored and appropriate intervention implemented. Integral to this process is clinical supervision and a case review policy or standard operating procedure. Clinical supervision has been defined "as a collaborative process between two or more practitioners of the same or different professions". This process should encourage the development of professional skills and enhanced quality of patient care through the implementation of an evidence-based approach to maintaining standards of practice. These standards are maintained through discussion around specific patient incidents or interventions using elements of reflection to inform the discussion^[123]. Three main functions of supervision have been identified: educative, supportive and managerial^[109,124]. Clinical supervision is not fieldwork/clinical education, mentorship, appraisal/development review, peer review, counselling or preceptorship^[123].

The 4S model of supervision - structure, skills, support and sustainability - is an example of one model which is intended to help professionals reach excellence in their practice^[125]. The embedding and sustaining of supervision schemes is a challenge in MSK services but they should be seen as integral to a culture of learning within developing services. Supervision should be career-long, regular, routine and evaluated^[126].

To ensure that any clinical supervision policy/standard operating procedure is purposeful to promoting a quality and efficient service it should include a specific case review or escalation procedure for patients not progressing within an agreed time frame. Each AHP profession will need to agree its own escalation threshold based on appropriate criteria. For example three review sessions may be an appropriate threshold for physiotherapy given that the average number of physiotherapy contacts in the UK is three^[93]. The procedure may outline the process for a telephone discussion and/or face to face discussion with an experienced colleague or other healthcare professional.

6.2 Standard J - Musculoskeletal (MSK) Service Access to Investigations as Appropriate

NHS Education Scotland (NES) (2012)^[45] outlined the role of AHP Advanced Practitioners in relation to advanced musculoskeletal practice. An example of one of the core knowledge and skills in relation to the requesting of investigations such as imaging is shown in Table 4.

Table 4: Advance Practice Framework Clinical Practice - Investigations^[45]

Evidence suggests that there is widespread variation in the extended practice of non medically qualified staff with regard to access to investigations, scope of practice, follow-up procedures, training; competencies and clinical governance arrangements^{[44,128,129,130,131]}. Advanced Practitioners are, however, making significant contributions to musculoskeletal pathways in many areas, especially in areas such as in the management of spinal conditions^[132].

Given that this contribution is currently happening in some areas and not others, then greater consistency needs to be implemented. Provided that robust and consistent clinical governance arrangements are place, then AHP musculoskeletal services should be able to access the necessary tools and investigations when undertaking roles previously done by medical staff. This practice also ensures that patients are not disadvantaged by seeing a non-medically qualified clinician.

Many services have reported positive outcomes using Advanced Practitioners in terms of reductions in orthopaedic outpatient waiting times^[35,133], professional development for the professions^[41,134], satisfactory patient management compared with orthopaedic surgeons^{[135,136,137,138]}, improved communication between AHP and orthopaedic services^[40,139], good patient satisfaction^[32,34,35], reduction in use of investigations compared to junior medical personnel^[33], freeing up of surgeons' time from outpatient clinics^[34], and for increased operating^[35,140].

The rules surrounding the legal standing of AHP advanced practice are complex^[141,142]. The General Medical Council (GMC) code of practice (2001)^[143] states, "When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedures or provide the therapy involved." The Chartered Society of Physiotherapy Scope of Practice (2008)^[127] document, for example, states, "Non-medically qualified staff who hold a registrable qualification and have undertaken to perform a medically delegated task are responsible for the consequences of performing the task which can be reasonably expected to be within their competence. Advanced practitioners are accountable for their actions done to the patient." Professionals are accountable to their regulatory body for all their professional activities, whatever the level and context of their practice, the title they can use or type of activities they can undertake^[144]. Providing that there is evidence of an individual's competence to undertake the role/activity in question and that the activity sits within the remit of their professional body the individual would be covered by their Professional Liability Insurance (PLI) as working within the scope of the profession and are working to the standard set by the Health and Care Professions Council^[145].

Regulation has been defined as "The set of systems and activities intended to ensure that healthcare practitioners have the necessary knowledge, skills, attitudes and behaviours to provide Healthcare safely"^[146]. It is, however, the responsibility of the employer to ensure that the creation of any new or extended roles comes with appropriate support and performance management mechanisms^[145]. Hence it is imperative that both clinicians and management know what the scope and expectations of the role are and the clinical governance arrangements of the service are clearly defined and documented^[129]. Frameworks and defined competencies for clinicians taking on advanced practice roles are available^[146]. Services should ensure they have robust clinical governance and service infrastructure in place to support AHP Advanced Practice roles^[146]. Clinical governance being defined as "a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish"^[147].

6.3 Standard K - Process for Onward Referral

Allied Health Professionals have clinical autonomy to best manage their patients. AHPs should be able to refer their patients to the appropriate clinical specialty. Clinical experience, however, suggests that such access is not universally available within all health boards. This variation requires some patients to return to their GP to be referred without any additional benefit to either the patient or GP. It is proposed that all boards should clearly define the process and provide a mechanism whereby AHPs can refer direct to other clinical specialties, where appropriate, for example orthopaedic surgery, neurosurgery, rheumatology and pain management services.