Referrals to hospital-based rheumatology and orthopaedic services: seeking direction

C. Rao, J. P. Halsey, M. A. S. Bukhari, W. N. Dodds and W. Mitchell

Morecambe Bay Hospitals NHS Trust, UK

Correspondence to: C. Rao. E-mail: chandini.rao{at}bfwhospitals.nhs.uk

SIR, We read with interest the paper by Speed and Crisp [1] highlighting the need for integrated referral and care pathways for patients with musculoskeletal diseases. Since 1991, rheumatology out-patient workload has increased and the waiting time for an initial specialist consultation has lengthened [2, 3]. A report in 2002 found gross inequalities in the provision of rheumatological services [4].

We would like to share our experience of musculoskeletal referrals to Morecambe Bay Hospitals NHS Trust between 1 August 2001 and 30 June 2002. The Trust serves a population of 312 000 and has three district general hospitals. The musculoskeletal service comprises three whole-time equivalent (WTE) consultant rheumatologists and nine WTE consultant orthopaedic surgeons. As a pilot site for the Action on Orthopaedics project, an audit of musculoskeletal referrals was performed. The aim of this initiative was to ensure that patients with musculoskeletal conditions were ‘seen by the right specialist, in the right place, at the right time and receive the most appropriate treatment and follow-up’ [5]. Referral guidelines for common musculoskeletal diseases were developed by consensus between orthopaedics, rheumatology, physiotherapy and primary care. The guidelines were circulated to all local general practitioners in March 2001 and were also available on the Primary Care Trust website. A prospective audit was undertaken to assess adherence to these referral guidelines. Clinicians completed pro formas, which included diagnostic categorization and an opinion on whether referrals had been made to the appropriate speciality.

Eight thousand nine hundred and ninety-three cases were referred for a musculoskeletal opinion. One thousand four hundred and forty-one (16%) were referred to rheumatology and 7552 (84%) to orthopaedics. Pro formas were completed for 6067 referrals. The sex ratio of rheumatology referrals was 655 (64%) female to 368 (36%) male. The age range was 15–89 yr with a median of 55 yr. Thirty-two per cent of all rheumatology referrals were felt to have inflammatory arthritis, 26% osteoarthritis, 14% soft tissue rheumatism, 18% spinal disorders, 4% connective tissue disease and 6% other diagnoses. Conversely, the diagnostic breakdown for orthopaedic referrals was 53% osteoarthritis, 27% soft tissue rheumatism, 11% spinal disorders and 9% other conditions.

It was considered that 630 cases (10.4% of all referrals) could have been more appropriately managed by a different speciality. Of these, 380 (60%) could have been sent to physiotherapy, 117 (19%) to rheumatology, 50 (8%) to podiatry, 26 (4%) to pain management, 12 (2%) to orthopaedics and 28 (7%) to other specialities. This would have resulted in an additional 195 referrals to rheumatology per annum.

Over the study period, 87.2% of musculoskeletal referrals adhered to the guidelines. Clearly, by ensuring that patients are referred to the most appropriate department it is possible to eliminate unnecessary hospital attendances and delays in treatment. With advances in orthopaedic techniques and advances in the medical management of musculoskeletal conditions it is anticipated that there will be increasing referrals to these specialities. With an ageing population and higher patient expectations, it can be assumed that the need for specialist musculoskeletal care will increase and it is therefore vital that musculoskeletal services are developed in accordance with the needs of the local population. These will need to be supported by an education programme for primary care and all members of the musculoskeletal team. This study has confirmed that by implementing agreed referral and management guidelines it is possible to develop a more integrated, patient-centred and efficient service. Furthermore, it is possible to predict changes in workload, and therefore reallocate resources for future planning.

The authors have declared no conflicts of interest.

References

  1. Speed CA, Crisp AJ. Referrals to hospital-based rheumatology and orthopaedic services: seeking direction. Rheumatology 2005;44:469–71.[Abstract/Free Full Text]
  2. Kirwan JR (for the former South West Regional Advisory Committee for Rheumatology). Rheumatology outpatient workload increases inexorably. Br J Rheumatol 1997;36:481–6.[CrossRef][ISI][Medline]
  3. Kirwan JR, Averns H, Creamer P et al. Changes in rheumatology out-patient workload over 12 years in the South West of England. Rheumatology 2003;42:175–9.[Free Full Text]
  4. Turner G, Symmons D, Bamji A, Palfreman T. Consultant rheumatology workforce in the UK: changing patterns of provision 1997–2001. Rheumatology 2002;41:680–4.[Abstract/Free Full Text]
  5. Action on Orthopaedics. NHS Modernisation Agency, Improving orthopaedic services: a guide for clinicians, managers and service commissioners 2002; 12.
Accepted 3 June 2005





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