EAST & MIDLOTHIAN PHYSIOTHERAPY SERVICE BRIEFING PAPER FOR THE DEVELOPMENT OF PACE ASSESSMENT

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1 Introduction EAST & MIDLOTHIAN PHYSIOTHERAPY SERVICE BRIEFING PAPER FOR THE DEVELOPMENT OF PACE ASSESSMENT PACE (Physical Activity, Community Education) programmes are well established and referral pathways have been successively developed to complement these programmes and to augment options available for the management of musculoskeletal (MSK) demands on physiotherapy outpatient services. Resource management is key to the capability to meet demand and it is intended therefore to further refine PACE pathways to improve demand (referral) management in line with current capacity to deliver. Referral rates to physiotherapy remain relatively constant against a backdrop of reductions in available physiotherapy staffing numbers. PACE interventions are undertaken in a group setting with strong emphases on general rehabilitation through exercise and a variety of other physical activities. It is clear that patients continue to need physiotherapy interventions, but it is also clear that not all patients referred for out-patient physiotherapy require to be seen or have their care managed by specialist physiotherapists at the point of entry to physiotherapy care, Reference A. Physiotherapy has progressively skill and grade-mixed staffing over the last 3 years in line with the PACE philosophy of health issues being managed at the right time, by the right professional, in the right place, using the right therapeutic interventions to achieve optimal benefit for individuals as well as encouraging healthy living and a lifetime habit of physical activity. Aim The aim of this paper is to set out how physiotherapy will further develop PACE via a network of assessment clinics complemented by supported downstream therapeutic group exercise. Plan In order to maximise gains from PACE and to help with waiting lists, it is intended to optimise physiotherapy pathways to direct patients appropriately at the point of entry to their physiotherapy care via a network of fast-access assessment clinics for all but those with the most complex health issues who will be directed straight towards specialist physiotherapy. Assessment clinics will also require supported downstream therapeutic group exercise. Demand Tables and 2 demonstrate the mean referral rates to physiotherapy out-patients over the last two calendar years to date August 200 for East and Mid Lothian CHP areas respectively. These include referrals from all sources including self referral, Consultants, GPs, other health care professionals etc. Table. Mean monthly out-patient referral rates in East Lothian Mean Out-Patient Referral Rate RGH Edenhall Dunbar North Berwick Prestonpans Calendar year Calendar Year 200 to end Aug

2 Table 2. Mean monthly out-patient referral rates in Midlothian Mean Out-Patient Referral Rate Dalkeith Bonnyrigg Penicuik Newbattle Calendar year Calendar Year 200 to end Aug All referrals for physiotherapy are received in a single Referral Management Centre in the TIARA Offices in Roodlands Hospital where they are administered, triaged/prioritised, coded and registered according to agreed protocols. Currently, all referrals designated for physiotherapy outpatients are then placed on the most appropriate waiting list pending capacity being available for an appointment in physiotherapy centres across East Lothian and Midlothian. The Physiotherapy Management and Operational Groups have agreed a list of criteria that could be used during the triage/coding process to stream patients either to routine waiting lists or to assessment clinics. It is considered that up to 50% of these referrals could be fast-tracked to an assessment clinic using these exclusion criteria, with 50% being allocated to a routine waiting list. Using this rule, tables 3 and 4 show the net effect on the 200 mean referral rate data for East and Mid Lothian CHP areas respectively. Table effect on 200 mean physiotherapy monthly out-patient referral rates in East Lothian Mean Out-Patient Referral Rate RGH Edenhall Dunbar North Berwick Prestonpans Allocated to Assessment Clinic Allocated to Routine Waiting List Table effect on 200 mean physiotherapy monthly out-patient referral rates in Midlothian Mean Out-Patient Referral Rate Dalkeith Bonnyrigg Penicuik Newbattle Allocated to Assessment Clinic Allocated to Routine Waiting List Capacity The physiotherapy service development plan requires the set up of physiotherapy specialty centres where the senior, specialist physiotherapy expertise will be concentrated in order to guarantee 52-week cover for complex and most complex cases. This will require some staff to move to designated larger centres where accommodation availability will permit. Whilst subject to change as buildings themselves change, e.g. new builds in progress or planned refurbishments, the initial centres will be in Roodlands and Edenhall Hospitals in East Lothian, with no reductions in Midlothian until the new Dalkeith Medical Centre is completed and Penicuik is refurbished. In East Lothian, two of the band 5 staff on rotation will service the planned assessment and : groups. In an effort to keep providing physiotherapy local to where patients live, assessment clinics will be run in current physiotherapy departments in the community, i.e. Roodlands and Edenhall Hospitals, Dunbar Medical Centre, and North Berwick and Prestonpans Health Centres. In Midlothian, four of the band 5 physiotherapy staff on rotation will service the assessment and : groups. In the immediate short term, these will continue in all 4 sites. Venues and staffing will be subject to review and change as PACE develops further. Physiotherapy band 4 exercise professionals will staff all PACE general rehabilitation groups in sports/leisure centres in the community.

3 PACE Community Assessment Clinics PACE Community Assessment Clinics will be sessional with each session consisting of seven 30- minute new patient appointments over 3.5 hours, i.e. a half per clinic. Table 5 sets out the monthly clinic requirement in relation to the projected demand together with the time required. Table 5. Demand, Clinic Requirement and Time RGH Edenhall Dunbar North Berwick Prestonpans Dalkeith Bonnyrigg Penicuik Newbattle Demand Clinics Monthly Weekly.5.5 PACE Community : Clinics PACE Community : Clinics (: groups) will be sessional with each session consisting of two 90-minute treatment periods spread over two separate week with additional administration and travel time. Maximum permissible safe number of patients for each 90-minute session is 9 resulting in a capacity of 8 patients per week. Experience to date in the Dunbar trial of assessment type appointments suggests approximate conversion rates of 40% to PACE : clinics, 20% to PACE general rehabilitation groups, 5 % DNAs, and 25% to physiotherapy : onwards referral and management. Table 6 sets out the monthly : clinic requirement in relation to the projected demand, together with the time required. Table 6. : Clinic Requirement and Time RGH Edenhall Dunbar North Berwick Prestonpans Dalkeith Bonnyrigg Penicuik Newbattle Demand Sessions Required Monthly Weekly Given the potential range variable in demand, the recommended frequency of : sessions is one half per week in each venue. Resource Allocation Two full-time band 5 rotational physiotherapists, previously PACE East Lothian and Edenhall Out- Patients, will be reallocated to PACE in East Lothian running assessment and : clinics, with the remainder of their clinical time being with senior/specialist clinicians in Roodlands and Edenhall Hospital. In Midlothian, existing out-patient rotational band 5s and band 6 staff in Dalkeith will take over the responsibility for assessment and : clinics in their own areas. Weekly time allocations are set out in Table 7.

4 Table 7. Weekly Time Allocation Base Assessment : Clinic Comments Roodlands Roodlands -.5. Roodlands Hospital PACE Roodlands Dunbar Dunbar - 2 to be spent with specialist staff in Roodlands on (more) complex cases. To have hour of tutorial time built into diary on Roodlands. 2. Edenhall Hospital PACE Edenhall Edenhall.5 Prestonpans North Berwick Edenhall Prestonpans North Berwick to be spent with specialist staff in Edenhall on (more) complex cases. To have hour of tutorial time built into diary on Edenhall. 3. Bonnyrigg H.C. ML PACE 4. Dalkeith HC Band 6 staff 5. Newbattle M.C. Newbattle Bonnyrigg Dalkeith Newbattle Bonnyrigg Dalkeith Newbattle 3.5 to be spent with specialist staff in Bonnyrigg on (more) complex cases. To have hour of tutorial time built into diary on these. 3.5 to be spent on normal caseload. 3.5 to be spent with specialist staff in Newbattle on (more) complex cases. To have hour of tutorial time built into diary on these. 6. Penicuik H.C. Penicuik Penicuik Total time 8.5 Penicuik Total time to be spent with specialist staff in Penicuik on (more) complex cases. To have hour of tutorial time built into diary on these. Operational Implementation The TIARA Manager has set up the relevant electronic diaries and will ensure that appropriate levels of training are available to those individuals concerned, including referral coding staff. A programme of go-live dates for all sites to implement Assessment and : Group Clinics will be worked out in consultation with the Physiotherapy Management and Operational Groups. The programme will have to take account of impinging external factors such as maternity leaves and will vary in East Lothian and Midlothian. In Midlothian, assessment clinics will commence in January 20 and : clinics will be realigned in electronic diaries to accommodate these changes. In East Lothian, it is intended that go-lives will be staggered between January and April 20 when maternity leave will start to affect operations in Dunbar Medical Centre. This will be achieved incrementally.

5 Templates are set out in Tables 8 and 9 for weekly timetables for the East Lothian PACE band 5 rotational staff. These timetables need to be interpreted locally and may be adjusted in accordance with risk assessment, e.g. possible lone working situations. Evaluation Routine monthly physiotherapy data collection and analyses will include: Referral data and disposal analysis Clinical activity analysis Discharge activity analysis Additional soft data will be harvested annually and will include patient and staff quality assurance surveys via simple questionnaire. Assistance, advice and support for this will be sought from the CHP Clinical Governance Department. Conclusion A proactive approach is required to counter the growing pressures of physiotherapy demand management. It is intended to use PACE capacity to best effect to respond to these pressures. This will be delivered on a routine scheduled basis with staffing from the band 5 physiotherapy rotation, complemented by a band 6 physiotherapist in Dalkeith, and existing PACE team members. It will therefore be cost neutral. 5 November 200 Brian Brockie Physiotherapy Manager

6 Table 8. PACE Roodlands Base 8:30 9 9:30 0 0:30 :30 2 2:30 :30 2 2:30 3 3:30 4-4:30 Mon ADMIN RGH Own LUNCH RGH Own RGH : Clinic ADMIN Tues ADMIN RGH Assessment Clinic LUNCH RGH Own TRAVEL Dunbar : Clinic ADMIN Wednes ADMIN RGH Own RGH : Clinic ADMIN LUNCH RGH Assessment Clinic Thurs ADMIN Dunbar Assessment Clinic LUNCH Dunbar : Clinic TRAVEL RGH Own Fri ADMIN Roodlands Assessment Clinic LUNCH RGH Own ADMIN Table 9. PACE Edenhall Base 8:30 9 9:30 0 0:30 :30 2 2:30 :30 2 2:30 3 3:30 4-4:30 Mon ADMIN Edenhall Assessment Clinic LUNCH Edenhall Own Edenhall : Clinic ADMIN Tues ADMIN Prestonpans Assessment Clinic LUNCH Prestonpans : Clinic TRAVEL North Berwick : Clinic Wednes ADMIN Edenhall Own Edenhall : Clinic ADMIN LUNCH Edenhall Assessment Clinic Thurs ADMIN North Berwick Assessment Clinic LUNCH North Berwick : Clinic TRAVEL Prestonpans : Cllinic Fri ADMIN Edenhall Assessment Clinic LUNCH Edenhall Own ADMIN Timetables for Midlothian Health Centres will be developed with staff and e-diaries adjusted accordingly.