Orthopaedic Referrals Via  Multi-Professional Triage Teams and ‘Polyclinics’ Mr Benedict Rogers MA MSc MRCGP FRCS(orth) Th...
“ The days of the district general hospital seeking to provide all services to a high enough standard are over.”   Sir Ara...
Polyclinics - the next big thing? Nick Triggle ,BBC News, 7th Oct 2007 <ul><li>Department of Health. 2000;   The NHS Plan:...
<ul><li>Policy rhetoric  </li></ul>MPTT and Polyclinics <ul><li>No substantive evidence base </li></ul><ul><li>No publishe...
Aim Evaluate consecutive referrals to a DGH  lower limb orthopaedic clinic Direct from GP Via MPTT/Polyclinic
Methods
<ul><li>9 month prospective study </li></ul><ul><li>Survey 277 consecutive patients reviewed in DGH lower limb orthopaedic...
Comparative statistical analysis of the temporal differences between the two groups was performed using an ANOVA (SPSS 11....
Results
277 Patients  Referred for lower limb orthopaedic opinion 132 patients Via MPTT clinic 145 patients Direct from GP 76 pati...
MPTT patients wait 62.4 days longer (p<0.05) than patients referred directly from their GP P<0.05  P<0.05 Referral Time to...
Patient perception of role of healthcare professional at MPTT / ‘Polyclinic’ 84% incorrectly identified the healthcare pro...
Assessment of diagnoses made for the cohort of patients initially assessed at the MPTT/‘Polyclinic’ clinic   Over 50 % had...
Discussion
Discussion <ul><li>Long time delays </li></ul><ul><li>Patients unclear of healthcare professional </li></ul><ul><li>Delay ...
Discussion <ul><li>This study is not blinded </li></ul><ul><li>No access to patients not referred on from Polyclinic to ho...
Discussion <ul><li>Diagnosis of initial GP often same as MPTT/polyclinic </li></ul><ul><li>? superfluous tier of consultat...
Discussion <ul><li>But, only primary care literature available </li></ul><ul><ul><li>Poor methodology </li></ul></ul><ul><...
Discussion <ul><li>Geographical variation </li></ul><ul><ul><li>Concurrent consultant clinics  </li></ul></ul><ul><li>Subs...
Discussion <ul><li>Significant changes in service provision </li></ul><ul><li>Initial will lack evidential support </li></...
Conclusion <ul><li>This study….. </li></ul><ul><li>… ..highlights concerns regarding patients referred from Polyclinics </...
Polyclinics to replace traditional doctors’ surgeries  Simon Alford, The Sunday Times, 16 Feb 2008 Ignore GPs. Polyclinics...
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Polyclinic Evaluation

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Polyclinic Evaluation

  1. 1. Orthopaedic Referrals Via Multi-Professional Triage Teams and ‘Polyclinics’ Mr Benedict Rogers MA MSc MRCGP FRCS(orth) The Fred Heatley Meeting 27 Feb 2008, Brighton
  2. 2. “ The days of the district general hospital seeking to provide all services to a high enough standard are over.” Sir Ara Darzi, Health Minister, The Guardian, 11 July 2007
  3. 3. Polyclinics - the next big thing? Nick Triggle ,BBC News, 7th Oct 2007 <ul><li>Department of Health. 2000; The NHS Plan: a plan for investment, a plan for reform </li></ul><ul><li>Department of Health. 2002; Improvement, expansion and reform - the next 3 years: priorities and planning framework 2003-2006 </li></ul><ul><li>The NHS Plan 1 , formalised concept of extended roles </li></ul><ul><li>Primary care setting </li></ul><ul><ul><ul><ul><ul><li>- Reduce OPA load by 1 million by 2006 2 </li></ul></ul></ul></ul></ul><ul><ul><li>- Improve quality of referrals </li></ul></ul><ul><li>Musculoskeletal : GPwSI & physiotherapists </li></ul><ul><li>Multi-Professional Triage Teams or ‘Polyclinics’ </li></ul>
  4. 4. <ul><li>Policy rhetoric </li></ul>MPTT and Polyclinics <ul><li>No substantive evidence base </li></ul><ul><li>No published studies regarding </li></ul><ul><ul><ul><ul><ul><li>- Temporal delays </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- Patient perception </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- Diagnosis </li></ul></ul></ul></ul></ul>
  5. 5. Aim Evaluate consecutive referrals to a DGH lower limb orthopaedic clinic Direct from GP Via MPTT/Polyclinic
  6. 6. Methods
  7. 7. <ul><li>9 month prospective study </li></ul><ul><li>Survey 277 consecutive patients reviewed in DGH lower limb orthopaedic clinic </li></ul><ul><ul><li>Demographics </li></ul></ul><ul><ul><li>Time delays </li></ul></ul><ul><ul><li>Patient’s perception of MPTT professional </li></ul></ul><ul><ul><li>Diagnosis made, assessed by senior author </li></ul></ul>
  8. 8. Comparative statistical analysis of the temporal differences between the two groups was performed using an ANOVA (SPSS 11.5) Patient Demographics Date GP Referred to MPTT clinic Date @ MPTT clinic Date @ Hospital Orthopaedic Clinic Reviewed @ MPTT by whom? GP/physio Patients perception of MPTT professional consultant/junior doctor/ GP/physio/nurse MPTT Clinic Diagnosis None made/Correct/Incorrect?
  9. 9. Results
  10. 10. 277 Patients Referred for lower limb orthopaedic opinion 132 patients Via MPTT clinic 145 patients Direct from GP 76 patients Seen by GPwSI 56 patients Seen by physiotherapist 277 new patient referrals Hospital orthopaedic clinic
  11. 11. MPTT patients wait 62.4 days longer (p<0.05) than patients referred directly from their GP P<0.05 P<0.05 Referral Time to Hospital Orthopaedic Clinic
  12. 12. Patient perception of role of healthcare professional at MPTT / ‘Polyclinic’ 84% incorrectly identified the healthcare professional conducting their consultation at the MPTT clinic.
  13. 13. Assessment of diagnoses made for the cohort of patients initially assessed at the MPTT/‘Polyclinic’ clinic Over 50 % had no diagnosis or the incorrect diagnosis
  14. 14. Discussion
  15. 15. Discussion <ul><li>Long time delays </li></ul><ul><li>Patients unclear of healthcare professional </li></ul><ul><li>Delay in making diagnosis </li></ul>
  16. 16. Discussion <ul><li>This study is not blinded </li></ul><ul><li>No access to patients not referred on from Polyclinic to hospital consultant </li></ul><ul><li>Diagnostic analysis – subjective, potentially open to bias </li></ul>
  17. 17. Discussion <ul><li>Diagnosis of initial GP often same as MPTT/polyclinic </li></ul><ul><li>? superfluous tier of consultation ? </li></ul><ul><li>Are benefits of reduction in waiting list for surgery being lost? </li></ul><ul><li>Mixed messages/difficult rapport/manage expectations </li></ul><ul><li>Risks sub-optimal care </li></ul><ul><li>Possible medicolegal implications </li></ul><ul><li>Financial cost </li></ul>
  18. 18. Discussion <ul><li>But, only primary care literature available </li></ul><ul><ul><li>Poor methodology </li></ul></ul><ul><ul><li>No analysis of temporal delays </li></ul></ul><ul><ul><li>Non specific outcome analysis (only using SF36) </li></ul></ul><ul><ul><li>Open to criticism of bias </li></ul></ul><ul><li>“ A key question is how the evidence base can be developed to support policy decisions” </li></ul><ul><li>Kernick Br J Gen Pract 2005 </li></ul><ul><li>Is this evidence-based medicine ? </li></ul>
  19. 19. Discussion <ul><li>Geographical variation </li></ul><ul><ul><li>Concurrent consultant clinics </li></ul></ul><ul><li>Subspecialty variation </li></ul><ul><ul><li>Upper vs lower limb clinics </li></ul></ul><ul><li>Protocols </li></ul>
  20. 20. Discussion <ul><li>Significant changes in service provision </li></ul><ul><li>Initial will lack evidential support </li></ul><ul><li>Continual evaluation & audit needed </li></ul><ul><ul><li>Accurate cost – benefit analysis </li></ul></ul><ul><ul><li>Longer term patient outcomes </li></ul></ul><ul><li>Such a study yet to be conducted </li></ul>
  21. 21. Conclusion <ul><li>This study….. </li></ul><ul><li>… ..highlights concerns regarding patients referred from Polyclinics </li></ul><ul><li>What of patients seen in Polyclinics and not referred? </li></ul>
  22. 22. Polyclinics to replace traditional doctors’ surgeries Simon Alford, The Sunday Times, 16 Feb 2008 Ignore GPs. Polyclinics are the future Cradle-to-grave healthcare is as realistic as Dr Finlay's Casebook. We need specialists David Aaronovitch, The Times, 19 Feb 2008 ‘ Waste’ warning on polyclinics ITN news 16 Feb 2008 GPs’ leader hits out at plans for Soviet-style ‘polyclinics’ Anushka Asthana, The Guardian, 17 Feb 2008 ‘ Super surgery’ plans condemned ‘ Polyclinics’ may threaten the patient base of hospitals BBC News 16 Feb 2008 B.Rogers MA MSc MRCGP MRCS FRCS(orth) N.Bradley FRCS (Orth)

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