Rheumatology Triage and Assessment by Advanced Practitioner Physiotherapists

Purpose

In May 2016 rheumatology referrals were outstripping service capacity, leading to increasing waiting times for new patients. Following a review of new patient referrals the team identified that a significant proportion of referrals, though being appropriately referred to rheumatology, were for non-inflammatory conditions. Recognising the changing landscape of the NHS and the emphasis to look at different ways of working we put forward a proposal to pilot a rheumatology advanced practitioner physiotherapist (APP) with the following aims: -

  • Improve the triage process
  • Streamline the pathway for new patients with non-inflammatory conditions
  • Reduce waiting times
344 new patients seen by an APP
who would previously been seen by a consultant rheumatologist
100% RTT compliance
since commencement of the APP pilot

Approach

Triage pathways were agreed and appropriate groups of patients identified for the APP clinic. Primary care colleagues and consultants were sent communication about the post and learning needs of the APP physiotherapist were identified. Training was delivered through consultant shadowing, education and self-directed learning.

Triage matching exercises were completed with all consultants to ensure that there was 100% concordance before APP led triage was fully initiated. Initial clinic templates included three clinics with 4 new patient slots. A consultant new patient slot was reserved each week for any patient assessed in the APP clinic found to have a suspected inflammatory condition. Dedicated time was set aside in consultant job plans to provide clinical supervision. The APP pilot commenced in November 2016.

Outcomes

Since the start of the pilot the APP has seen 334 new patients who would have previously been seen by a consultant rheumatologist. Triage and clinic outcomes have been recorded and patient experience feedback has been collected using a hand held tablet device. Data demonstrates:-

  • Consistency in the triage process.
  • 8% of patients need to see a consultant rheumatologist
  • 34% are discharged after the initial assessment
  • 58% of patients go on for further therapy delivered in either a 1:1 or group setting.
  • Positive patient feedback reported

After falling under 95% compliance with referral to treatment time (RTT) in September and October 2016, Lancashire Care NHS trust Rheumatology Service has maintained 100% RTT compliance since the commencement of the APP pilot despite an increase in referral numbers.

Implications

A different way of providing good quality new rheumatology appointments can have added value if delivered to the right patient group. There must be support and confidence within the whole rheumatology team and amongst referring clinicians for the APP role to be effective. Communication and training within the team must be strong to allow the ESP to develop extended aspects of the physiotherapy role in order to meet the patients' needs safely and effectively.

Due to the changing landscape of the NHS and financial pressures it is important to develop roles and explore new ways of delivering rheumatology services in the NHS

Top three learning points

  1. It is important to keep objective outcome data and patient experience measures to monitor and demonstrate the impact of the service improvement project.
  2. The Rheumatology Consultants need to be integral to the design of the service improvement for it to be successful.
  3. Evolving into an ESP role you do lose your role as a treating clinician being involved in the care of rheumatology patients. I found it helpful to maintain some of my ‘treating clinician’ role by continuing injection clinics.

Fund acknowledgements

This work was unfunded

Additional notes

This work was presented at Physiotherapy UK 2018.