Mid Notts Integrated Care Partnership (ICP)

Developing an MSK Together service 2017-2019

RightCare works with local health systems to identify innovative practice and share learning. Information briefs are a way of communicating early views of emerging practice. They are designed to raise interest and demonstrate good practice in the development of transformative change across the country.


Utilising the RightCare approach highlighted opportunities and potential to improve services throughout the whole referral pathway in mid Notts ICP. An approach called MSK Together was developed from this analysis and a single point of access for patients, who can either self-refer or be referred by their GP has been created. This uniform way of working has reduced spend and improved quality of patient care across the ICP.

Diagnose – what’s the problem?

The RightCare ‘where to look packs’ allowed the Clinical Commissioning Group (CCG) to rapidly review variation against peers in order to prioritise musculoskeletal (MSK) as a key area of further investigation. The focussed MSK data pack allowed local analysts to target their investigative work on specific clinical areas in order to quantify opportunities. Key findings from this were:

  • Physio referrals were sent in three different ways and there was variation in the choice offered to patients.
  • Over a third of GPs referrals bypassed triage for orthopaedics and rheumatology, surgical podiatry and pain management, with variation across the area.
  • Patients had to see their GP for a referral into physiotherapy.
  • Physiotherapists had to ask a GP to send a patient for a diagnostic test or a secondary care referral if they thought that was clinically appropriate.
  • There were two separate physiotherapy teams working in two different organisations but both caring for MSK patients.
  • Some physiotherapists kept paper records.
  • Conversion rate for some surgical outpatient clinics was approximately 52%. In one case it was as low as 25% when the business case was written.

Develop – what they changed

  • GP’s now send all referrals for any of the MSK specialities electronically into a single point of access, including pain. There are almost 1,000 a month referred in this way.
  • Patients are now able to self-refer into MSK physiotherapy, through one central point of access without seeing their GP. That’s also about 1,000 a month.
  • The MSK physiotherapists from the two organisations have been merged to work as one team, whilst still retaining their employment status with their original employer.
  • The physio’s now all work from one electronic patient record and detail their treatment notes in the GP record thus negating the need for paper physio notes and discharge letters to GPs.
  • The surgeons from the main acute trust provide two triage clinics a week in the MSK hub which both helps train the physiotherapists and ensure only patients that require a referral into secondary care are sent through to acute care.

We now work as one team, we can refer for diagnostics, refer onto other specialties and across the whole team without the GP or consultants being involved.

Deliver – What does the local health system say changed

  • There was a £2.7 million reduction in commissioner spend for acute hospital MSK activity during 17/18. Nearly half of this reduction was attributed to independent sector providers.
  • Conversion rate increased to an average of 68% for Quarter 1 of 18/19 at the main provider and for some clinics has reached 80%.
  • An average of 85% of patients reported an improvement in functionality and reduction in pain when using MSK Together services.
  • Within the health system, there is improved confidence in services moving to work as part of the ICP as well as better working together across all parts of the pathway.

What next? – learning points from the local system

  • Next steps will involve looking at how soft tissue injuries are managed when reported to the Emergency Department within the MSK service.
  • Better integration is needed with local councils to support their work in increasing exercise and keeping fit. There is also further need to embed the evidence-based pathways within secondary care.

With thanks to:

  • Ryan Cope, QIPP Efficiency Lead, NHS Mansfield & Ashfield CCG / NHS Newark & Sherwood CCG
  • Kim Ashall, Head of MSK, Mid Notts ICP
  • Simon Dale, NHSE/I RightCare Delivery Partner for the Nottingham & Nottinghamshire Integrated Care System (ICS)

For more information please contact rightcare@nhs.net