BMJ  2004;329:1325-1327 (4 December), doi:10.1136/bmj.329.7478.1325

Quality improvement report

Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme

Peter Maddison, consultant rheumatologist1, Jeremy Jones, consultant rheumatologist1, Anne Breslin, nurse specialist in rheumatology1, Craig Barton, directorate manager for surgery1, Joyce Fleur, nurse specialist in pain management1, Rhian Lewis, consultant in pain management1, Luke McSweeney, consultant orthopaedic surgeon1, Carys Norgain, therapy services manager1, Sara Smith, consultant in pain management1, Carolyn Thomas, TEAMS coordinator1, Chris Tillson, general practitioner2

1 North West Wales NHS Trust, Ysbyty Gwynedd, Bangor LL57 2PW, Wales, 2 Gwynedd Local Health Board, Eryldon, Caernarfon, Wales

Correspondence to: P Maddison peter.maddison{at}nww-tr.wales.nhs.uk

Problem The hospital based musculoskeletal service in northwest Wales was unable to cope with the demand for referrals from general practitioners. Waiting times were long, duplicate referrals to other departments were common, and general practitioners were reluctant to refer patients with common problems because of the perceived lack of service. Many referrals were made to the inappropriate specialty, especially orthopaedics. At least part of this problem was due to a lack of coordination between the four hospital departments providing musculoskeletal services and the emphasis on district general hospital based rather than community provision.

Design Review over 18 months of impact of the targeted early access to musculoskeletal services (TEAMS) programme on accessibility to musculoskeletal services.

Setting Northwest Wales.

Key measures for improvement Number of patients referred and seen with musculoskeletal problems, waiting times, number of duplicate referrals, and surgery conversion rates in orthopaedic clinics.

Strategies for change Establishing with central clinical triage a common pathway for all musculoskeletal referrals so that patients attend the appropriate department. A back pain pathway led by extended scope physiotherapists was developed, and general practitioners with special interests and extended scope physiotherapists were trained to provide services for patients with uncomplicated musculoskeletal problems in the community.

Effects of change Over 18 months the number of referrals more than doubled. Despite this, waiting times for musculoskeletal services fell; this was noticeable for rheumatology and pain management. Duplicate referrals were abolished. Surgery conversion rates did not, however, change. Questionnaires from the clinics showed a high level of patient satisfaction.

Lessons learnt Integration of hospital services that traditionally have worked in isolation can result in greatly improved access to musculoskeletal services. Community based multidisciplinary clinics run by specially trained general practitioners with special interests and extended scope physiotherapists are an effective way of managing patients with uncomplicated musculoskeletal problems and have been well received by patients and general practitioners. The huge unmet burden of need was reflected by the great increase in musculoskeletal referrals. Other approaches are needed to meet this, including better education of general practitioners and methods for identifying and modifying psychosocial risk factors for chronic pain at an early stage.


Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

General practitioners with special interests—not a cheap option
Martin Roland
BMJ 2005 331: 1448-1449. [Extract] [Full Text] [PDF]

Triage, back care, and GP clinics help musculoskeletal problems
BMJ 2004 329: 0. [Full Text]

This article has been cited by other articles:

  • Lamb, S.E., Toye, F., Barker, K.L. (2008). Chronic disease management programme in people with severe knee osteoarthritis: efficacy and moderators of response. Clin Rehabil 22: 169-178 [Abstract]  
  • Bukhari, M., Bamji, A. N., Deighton, C. (2007). Is it ever appropriate to discharge patients with rheumatoid arthritis?. Rheumatology (Oxford) 46: 1631-1633 [Full text]  
  • Lempp, H., Scott, D. L., Kingsley, G. H. (2006). Patients' views on the quality of health care for rheumatoid arthritis. Rheumatology (Oxford) 45: 1522-1528 [Abstract] [Full text]  
  • Roland, M. (2005). General practitioners with special interests--not a cheap option. BMJ 331: 1448-1449 [Full text]  
  • (2005). Robin Goodfellow (44-2). Rheumatology (Oxford) 44: 267-267 [Full text]  

Rapid Responses:

Read all Rapid Responses

Outcome measures - a missed opportunity
Martin Phillips
bmj.com, 4 Dec 2004 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ