What Musculoskeletal (MSK) Conditions are Referred from Routine General Practice (GP) and what Impact does this have on Developing Innovative Care Models for Patients with MSK Conditions in Primary Care

Introduction: The current ethos within the United Kingdom (UK) health system is to encourage community management of health problems, increasing primary care workload. Yet General Practice (GP) is currently in ‘crisis’ with significant workload pressures. GP Federations have been developed to allow more collaborative working between GP practices and help develop new innovative models of care to better manage the GP workload pressures. Musculoskeletal(MSK) conditions constitute approximately 20% of General Practice(GP) consultations and therefore the Belfast GP Federation aimed to assess the demand for MSK conditions to allow development of new primary care-based treatment pathways for these conditions. The aim of this paper is therefore to assess the demand for orthopaedic, rheumatology and chronic MSK painful conditions by assessing the referrals from 2 GP practices and the referrals to one orthopaedic Integrated Clinical Assessment and Treatment services (ICATs) clinic for these conditions and then propose innovative models of care to manage this demand within the community. Methods: Secondary care referral rates for two urban GP surgeries in the Belfast area were assessed in April, 2016 to orthopaedics, rheumatology and chronic pain clinics. The referrals to an orthopaedic ICATs clinics, staffed by one GPwSI in MSK, in May 2016 were also reviewed. The orthopaedic ICATs team receive referrals from GPs regarding musculoskeletal conditions and this particular service is based in the Southern Trust area of Northern Ireland. Results: Overall from the 2 GP surgeries there was 59 orthopaedic referrals, 11 to rheumatology and 3 to the chronic pain clinic. The commonest joint referred to the orthopaedic clinic was knee (15 referrals, 25.4%) and the commonest reason to refer to rheumatology was to exclude an inflammatory arthritis (6 referrals, 54.5%). There was then 25 referrals to ICATs, with the commonest reason for referral being neck (6 referrals, 24%) and back (4 referrals, 16%). The commonest treatment options employed within the ICAT service included joint injections (8 patients, 32%) with referral to in-house physiotherapy (8 patients, 32%). Conclusions: UK GP is currently under significant workload pressures and musculoskeletal conditions, including orthopaedic, rheumatology and chronic painful conditions, make up a significant proportion of this workload. The main musculoskeletal areas which GPs are referring to secondary care include knee and spinal conditions. To help better manage this workload within primary care we propose developing a new community-based monthly musculoskeletal clinic based within local GP surgeries, supported by a MSK educational programme open to all GPs in the area. Outcomes which will be monitored from this quality improvement work will include secondary care referrals and maintaining high patient satisfaction as well as improving GP confidence in managing MSK conditions.


Introduction
Musculoskeletal (MSK) conditions make up a significant workload within general practice (GP), with one in seven GP consultations reported to be for MSK conditions [1]. The current ethos within the UK healthcare system is for a 'shift left' in patient management and within Northern Ireland there is the Transforming Your Care policy [2], with more and more medical conditions being managed within the community. Yet GP within the UK and in Northern Ireland is in 'crisis' [3,4], with significant workload pressures on those who work within the community and in the primary care team. The onus is therefore on those working within GP and the community to develop innovative models of care, breaking down the traditional barriers between primary and secondary care, allowing more effective management of the workload within primary care by developing integrative models of care. One way to do this is to invest in GP Federations [4,5], a GP Federation being a collection of practices and primary care teams who work together, "developing and delivering high quality, patient-focused services for their local communities" [4] delivering care to approximately 20 GP practices and 100,000 patients [5]. Such primary care investment and collective working is in keeping with the recent call from the Northern Ireland General Practitioners Committee of the British Medical Association (BMA) to better support NI GP and avert this 'crisis' [3].
With this in mind, the Belfast GP Federation has appointed 2 MSK clinical leads to develop innovative models of care for patients with orthopaedic, rheumatology and chronic MSK painful conditions. The first part of this role is therefore to assess the demand for these conditions within the community to allow the Federation to better plan the innovative models of care for musculoskeletal patients. The aim of this paper is therefore to assess the demand for orthopaedic, rheumatology and chronic MSK painful conditions by assessing the referrals from 2 GP practices and the referrals to one orthopaedic Integrated Clinical Assessment and Treatment services (ICATs) clinic for these conditions and then propose innovative models of care to manage this demand within the community.

Methods
Secondary care MSK referral rates for two GP surgeries in the Belfast area were assessed in April, 2016 to orthopaedics, rheumatology and chronic pain clinics. Practice 1 serves a patient population of approximately 9,000 and has 5 GP partners and 1 salaried GP. Practice 2 serves a patient population of approximately 6,900 and has 3 GP partners and 1 salaried GP. Both practices use Egton Medical Information Systems (EMIS) computer systems, are urban GP surgeries and have one partner with a specialist interest in the area of primary care musculoskeletal conditions. The referrals to 5 orthopaedic ICATs clinics, staffed by one GPwSI in MSK, in May 2016 were also reviewed. The orthopaedic ICATs team receive referrals from GPs about patients with musculoskeletal conditions, being community-based clinics (straddling the divide between primary and secondary care) and this particular service serves the Southern Trust area of Northern Ireland. Within the ICATs service, the doctor can manage the patients themselves (e.g. with joint injections, exercise advice) or refer to colleagues within the service including extendedscope physiotherapists and podiatry. If the condition cannot be managed within the ICATs service then a secondary care referral will occur. For physiotherapy services, the patient can be referred to ICATs physiotherapy, which offers specialist musculoskeletal physiotherapy, or to 'core' physiotherapy which provides general physiotherapy services. No ethical approval was required for this study as it an audit of musculoskeletal conditions referred to secondary care.

Practice 1 referrals
On reviewing referrals to orthopaedics, rheumatology and the pain clinics from this surgery in April 2016, there were 37, 4 and 0 referrals, respectively. The orthopaedic referrals (Table 1) included 9 for knee osteoarthritis, 6 with back pain, 5 paediatric cases (2 abnormal gaits with 1 each of clicking hip, suspected brachial plexus injury at 8 week check, and fixed flexion deformity of finger at 8 week assessment), 4 with neck pain, 3 hip osteoarthritis, 3 shoulder issues (confirmed bilateral rotator cuff tear, suspected bicipital tendonitis, and glenohumeral osteoarthritis), 2 acute knee injuries, and one each of trigger finger, trochanteric bursa, carpal tunnel syndrome, osteoporosis assessment and plantar fasciitis. The 4 rheumatology referrals (Table 2) included 2 to exclude an inflammatory arthritis and one each for carpal tunnel syndrome and steroid/local anaesthetic injections for widespread hand osteoarthritis.   Alternative management options, which could have been considered in practice prior to the secondary care orthopaedic referral included 10 for local anesthetic/steroid injection with or without exercise advice, 10 for physiotherapy and 1 referral each for an MRI and osteoporosis management. Alternative management options for the rheumatology secondary care referrals were to consider steroid/local anaesthetic injections in the GP surgery for 2 of the referrals.

Practice 2 referrals
On reviewing referrals to orthopaedics, rheumatology and the pain clinics from this surgery in April 2016, there were 22, 7 and 3 referrals, respectively. The orthopaedic referrals (Table 3) included 6 for knee symptoms and 3 each for shoulder symptoms, foot pathology and paediatric cases (one each for flat feet, poor balance and unilateral tiptoe walking). There were then 2 referrals for carpal tunnel syndrome with one each for a wrist ganglion, back pain, neck pain, osteoporosis assessment, and lateral epicondylitis/tennis elbow. Whereas the rheumatology referrals (Table 4) included 4 to exclude an inflammatory arthritis and then 1 each for neck pain with radiculopathy, suspected fibromyalgia and complete supraspinatus tendon rupture in the shoulder. Finally, the 3 pain clinic referrals (    Alternative management options which could have been considered in practice prior to the secondary care orthopaedic referrals included 7 for local anaesthetic/steroid injection with or without exercise advice, 5 for physiotherapy, 3 for podiatry and 1 osteoporosis assessment. Whereas the alternative to rheumatology secondary care referrals included 2 to physiotherapy and 1 to the orthopaedic shoulder consultant to consider operative repair of the complete rotator cuff tear. Finally, the chronic pain referrals could have been alternatively managed with in-house analgesic titration with a pain management course/techniques.

Orthopaedic ICAT clinic referrals
There were 25 referrals (Table 6) to orthopaedic ICATs received in May 2016 to one GPwSI, managed over 5 clinics. The presenting issue included 6 with neck pain and 4 each of back pain, hip pain and carpal tunnel syndrome. There were then 2 referrals each for trigger finger and shoulder symptoms with one each for neck pain, Dupytren's contracture and wrist pain. Treatment within the ICATs service included 8 receiving steroid/local anaesthetic injections to the affected area with or without exercise prescription, 8 referred to the ICATs physio, with 3 referred to core physiotherapy. Two patients were also referred for an MRI of the affected area with one patient each receiving an ultrasound guided steroid/local anaesthetic injection, hand splints and exercise prescription with advice about their condition. Only 4 patients were referred onwards from the ICATs service, with 3 referred to core physiotherapy and 1 for an ultrasound guided steroid/local anesthetic injection.

Discussion
Musculoskeletal conditions, including orthopaedic, rheumatology and chronic painful conditions, make up a significant workload for routine GP. Through the analysis which has been performed, it can be seen that knee and hip conditions, particularly osteoarthritis affecting these areas, as well as back and neck pain, shoulder, foot and paediatric orthopaedic pathology are common reasons for onward referral from GP to secondary care. Other common reasons for referral include carpal tunnel syndrome, trigger fingers and the need to exclude an inflammatory arthritis. Common treatment options for these musculoskeletal conditions include steroid/local anesthetic injections to the affected area, exercise prescription with or without physiotherapy input, pain management and information sharing about their condition to enable patient empowerment.

Prevalence of MSK conditions in primary care
The main joint being referred from primary care in this project was knee, with the commonest pathology detected here being osteoarthritis. This finding is in keeping with previous authors [1] who found the knee and back to be the commonest body regions presenting in GP patients with MSK symptoms. Although other authors reported the back and neck regions as the commonest presenting areas for MSK conditions in primary care [6]. This difference may be explained by the fact that our study is looking at the MSK referrals from practice and not simply reporting the MSK conditions presenting to routine GP. The GPs may therefore be filtering out these other musculoskeletal presentations within their own clinics.

Future plans-quality improvement project to manage MSK conditions in primary care
From this analysis, to help reduce secondary care referrals for musculoskeletal conditions as well as better manage the workload in primary care from musculoskeletal conditions, 2 options have been proposed. The options have included a monthly specialist musculoskeletal clinic based within the local GP surgeries to run alongside an ongoing educational programme to generally up-skill GPs on musculoskeletal conditions. The next step for developing the monthly specialist musculoskeletal clinic within the GP surgery is to pilot this within 10 local surgeries. The clinic would accept referrals for chronic conditions, including shoulder pathology (adhesive capsulitis, shoulder impingement, acromioclavicular (AC) joint symptoms), knee (with symptoms of locking or instability to be referred directly to orthopaedics), hand (carpal tunnel syndrome, trigger finger, 1st carpometacarpal osteoarthritis, de Quervain's tenosynovitis), elbow (lateral and medial epicondylitis) and a chronic pain management programme. Prior to referral, treatment pathways for common musculoskeletal conditions will be available for the GPs to refer to and the referrer should consider an X-ray of the affected joint with or without an appropriate inflammatory blood screen if clinically indicated. This clinic will be staffed by a local GP with a specialist interest in musculoskeletal conditions with access to physiotherapy, pharmacy, podiatry, psychology and musculoskeletal ultrasound imaging. This approach has been previously trialed with significant success in reducing onward secondary care referrals for musculoskeletal conditions and radiology referrals as well as providing high patient satisfaction, although this approach was only piloted in one surgery [7,8]. This innovative community based musculoskeletal clinic would then be supported by a monthly education programme on common musculoskeletal conditions seen within primary care and open to any GP within the Belfast GP Federation to attend. Outcomes which will then be monitored from this quality improvement project will include onward secondary care referrals from the practice and patient satisfaction with the new service as well as improving GP confidence in managing musculoskeletal conditions.

Potential limitations
This is a review of 2 practices' referrals to orthopaedics, rheumatology and chronic pain clinics over one month along with a review of orthopaedic ICAT referrals to one doctor over one month period. The review therefore may be influenced by the practices and the GPwSI which were reviewed as well as the month of the year which the review was performed. In particular, both practices already had a GP with a specialist interest in MSK conditions working in the practice and the referrals for these conditions may therefore be low compared to GP surgeries without access to such a resource. The review of referrals from the practices is dependent on appropriate coding and the data is therefore limited by the statistics provided to us, which may lead to under-or over-estimating of referral rates.

Conclusion
Primary care and GP within the UK is currently under significant workload pressures and musculoskeletal conditions, including orthopaedic, rheumatology and chronic painful conditions, make up a significant proportion of this workload. The main musculoskeletal areas which GPs are referring to secondary care include hip and knee conditions, soinal conditions, shoulder and hand pathology, including carpal tunnel syndrome and trigger finger. To help better manage this workload within primary care we propose developing a new community-based monthly musculoskeletal clinic based within local GP surgeries, led by local GPs, supported by a MSK educational programme open to all GPs in the area. Outcomes which we will be monitored from this quality improvement work will include secondary care referrals and maintaining high patient satisfaction as well as improving GP confidence in managing MSK conditions.