West Kent Clinical Commissioning Group (CCG)

Virtual fracture clinic to improve access and reduce referrals to secondary care

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.


The consultant and physiotherapist-led Virtual Fracture Clinic (VFC) was established in 2016/17 at Maidstone and Tunbridge Wells Hospitals in collaboration with West Kent CCG. It has improved access to specialist orthopaedic care, improved patient experience, and reduced demand for face-to-face hospital fracture clinic appointments by 38%.  Moreover, a new contract mechanism has transformed working relationships between the CCG and providers, encouraging collaborative working towards a shared goal to improve the service for patients.

Diagnose: What was the problem?

  • Musculoskeletal (MSK) services were identified as one of West Kent CCG’s three priority programmes, when RightCare started working with the CCG in 2016.
  • The primary challenge impacting on the trauma and orthopaedic emergency pathway was linked to fractures that were stabilised in A&E, with patients sent home with a referral to the fracture clinic.
  • The existing fracture clinic service experienced long waiting times; clinics frequently overran due to overbooking; and patients did not always see the most appropriate specialist.

Develop: What they changed

  • The CCG and colleagues from the service provider researched various virtual fracture clinic models operating in the UK to help inform an appropriate model for local implementation. This included discussion with Glasgow – the pioneers of the VFC approach and a multi-disciplinary visit to Brighton.
  • Based on existing good practice at other VFCs, the CCG and provider co-designed the VFC system process, developed a dynamic model, service specification and standard operating procedures to implement a new model of care from 2016.
  • Patients with a suspected fracture who have had an X-ray in A&E at Maidstone and Tunbridge Wells Hospitals are referred to the VFC via a referral form (approximately 1,000 per month).
  • On a rota basis, VFC referrals and picture archiving and communication system (PACS) images are jointly reviewed by an orthopaedic consultant and an extended scope physiotherapist on the next working day, to determine the most appropriate management plan. Administrative support is provided.
  • All patients receive a follow up telephone call on the day of the VFC review from a senior physiotherapist to discuss their management plan. This may include:
  • a face-to-face fracture clinic appointment for review by an orthopaedic specialist (sent in the post or made during the call, depending on the urgency).
  • discharge with a home management and treatment plan.
  • a plaster room appointment (made during the call).
  • Patients are emailed an information sheet relevant to their injury to help them manage their own condition as early as possible after their injury and have access to a dedicated VFC email and telephone help line for further advice.
  • The VFC is currently staffed on a weekly rotation from the core physiotherapy team of 0.6 WTE extended scope physio and two WTE band 6 physiotherapists; with administrative support provided by two WTE band 3s and a part time band 2.
  • A new aligned incentive contract, agreed with the service provider, shares the risk; increases transparency; and encourages collaborative working towards a shared goal to improve the service for patients.

Deliver: What does the local health system say changed

  • Calmer fracture clinics where the right patients are seen by the right clinicians with the potential for improved patient experience and outcomes; greater job satisfaction; and sub-specialty skill development.
  • 38% fewer face-to-face hospital fracture clinic appointments, amounting to an annual saving of £500,000 to the health system.
  • 40% of patients are discharged following the virtual triage, with a home management and treatment plan sent via email (only around five patients per month need printed material in post).
  • Waiting times have reduced from three weeks and more, to a clinically appropriate timescale, with urgent cases seen within a week.
  • High levels of patient satisfaction. Online survey results (available for completion within the email correspondence) show that 80% are extremely or very satisfied.
  • Potential for reduced patient anxiety with contact the next working day following the X-ray in A&E and subsequent email/phone support.
  • Reduced medical staffing within the fracture clinic (one orthopaedic registrar per clinic) has released time for improved training of junior doctors.
  • Increase in collaborative working within the health system as colleagues from different organisations work together towards a shared goal to improve the service for patients.

What next? Learning points from the local system

  • Electronic system to replace the existing Excel spreadsheet that has been used as a temporary workaround to manage VFC referrals.
  • Increase extended scope practitioner knowledge and capacity with a view to practitioners taking on more direct treatment (as clinically appropriate), either within the face-to-face fracture clinic or A&E.
  • Passionate and engaged clinical and managerial leadership that embraces partnership working, role diversification, professional development and service improvement is fundamental.
  • Learning through the pilot resulted in a different tariff to reflect the new clinical model.
  • Enabling collaborative working, that encourages transformation to improve patient care and staff experience, requires mechanisms which support the whole process, aligned incentives and a transparent resilient partnership approach.
  • Challenges around the IT and communication systems need careful consideration.
  • Coding of clinics to ensure visibility of activity is important and needs careful planning.
  • Keeping communication channels open to support unblocking challenges as they arise.

With thanks to:

  • Jan Jayatilake, West Kent Clinical Commissioning Group
  • Dr Nick Cheales, West Kent Clinical Commissioning Group
  • Carol Kinsella, Maidstone and Tunbridge Wells Hospital
  • Mr Justin Forder, Orthopaedic Consultant, Maidstone and Tonbridge Wells Hospital
  • Dr Bruce Pollington, Delivery Partner, RightCare

For more information please contact rightcare@nhs.net