Lindsay Osborne and Fiona Robinson describe an initiative to manage patients with knee, shoulder and spinal problems in primary care and reduce referrals to secondary care

The Somerset Coast Primary Care Trust covers an extensive and predominantly rural area. It has a population of 140 000 patients and there are 23 general practices with a total of 94 GPs, and four community hospitals.

Following the introduction of primary care groups in 1999, musculoskeletal services in the Somerset Coast area were identified as problematic. There were long waiting times at the local acute trust Musgrove Park Hospital, Taunton for appointments and investigations; GPsÍ access to diagnostic and therapeutic services and the quality and convenience of the service for patients varied across the area. A pilot study was therefore conducted to investigate whether patients could be managed effectively in primary care.

Setting up a musculoskeletal service

A board of representatives from primary and secondary care was set up to establish a service to manage patients with knee, shoulder and spinal problems. As a result, the musculoskeletal interface clinic was developed to ensure rapid access to a range of diagnostic and treatment services (see Figure 1, below). The aims of the project were:

  • To assess and manage patients effectively in interface care
  • To monitor the effect on waiting times at the local acute trust
  • To reduce referrals to secondary care
  • To provide a convenient and ïpatient-friendlyÍ service
  • To streamline the care pathway.
Figure 1: Diagnostic and treatment services available to patients of the musculoskeletal interface clinic

Common care pathways were drawn up by the project board in collaboration with consultants and extended scope physiotherapists who were working in secondary care. The pathways, which were based on guidelines published by the Clinical Standards Advisory Group,1 provided clear cut direction on the triage and management of musculoskeletal conditions.

The 3-month pilot began in February 2000 at Bridgwater Community Hospital. It involved 10 practices with a population of 62 000 patients.

It was intended that patients should wait no longer than 8 weeks for a first appointment. Initially, two clinics per week were held, one for knee and shoulder problems and the other for spinal conditions.

Inclusion criteria

The following criteria were used to identify patients appropriate for triage:

  • Age over 16 years
  • Absence of red flags or other indications of serious pathology.


Where appropriate, patients had received primary care treatment, for example physiotherapy, before referral.

Patients with red flags or other indications of serious pathology were referred directly to the acute trust hospital as before.

Clinic staff

Each clinic was run jointly by aspecialist GP and an extended scope physiotherapist. This arrangement ensured a good working rapport and a cross transfer of information, techniques and experience. The local GPs involved in the pilot were those with an interest in orthopaedic problems and who had experience as clinical assistants in rheumatology at the acute trust hospital.


The role of the extended scope physiotherapist

An extended scope physiotherapist is a clinical physiotherapy specialist with an extended scope of practice, who sees patients referred for assessment, clinical diagnosis and management.2 Extended scope physiotherapists have postgraduate qualifications and have had additional training to enable them to fulfil their extended role which may include ordering investigations, formulating management strategies, referring to other services and even listing for surgery.

Following a GP consultation, in most areas orthopaedic patients are referred to secondary care; however, recent studies have shown that most patients can be successfully managed in primary care by extended scope physiotherapists.3

Extended scope physiotherapists have worked in the back pain service at Musgrove Park Hospital since 1996, and in 1999 as part of an initiative to reduce waiting lists their role was expanded to cover all orthopaedic clinics.

Services offered by the clinic

X-ray facilities were available on-site, and magnetic resonance imaging (MRI) scanning was purchased from a nearby MRI centre, with an agreement that scans would be received within 2 weeks. Originally short protocol MRIs with a scan report only were requested; however, for some patients a full printed MRI was found to be more useful. For patients referred to secondary care, all films were developed and forwarded with the referral letter. Blood and urine analysis was also available on site.

Patients were able to be referred rapidly to occupational therapy and podiatry services. GPs were not previously able to refer to the podiatry service patients who presented with biomechanical problems that had not responded to physiotherapy and were not suitable for surgery. Patients could also be referred for physiotherapy, and a back fitness programme for patients with chronic/recurrent low back pain has also been introduced.

Links were also formed between the musculoskeletal interface and pain clinics; and patients could also be referred to a psychologist.

All clinic contacts were recorded on the community IT system of the acute trust hospital. A copy of the patientÍs clinic record was filed in the medical notes and a letter sent to the referring GP.

How successful was the service?

In August 2000 the project was expanded to cover the entire PCT area, with a second clinic based at Minehead Community Hospital. In August 2001 a second acute trust hospital, at Weston-super-Mare, began accepting referrals from the interface clinics.

Between 14 February 2000 and 31 March 2001, 94 clinics were held; there were 736 new patients and 369 follow-up appointments. Some 59% of the patients had knee and shoulder problems, while the remainder had spinal problems. The ratio of new patients to those attending for follow up was substantially lower than that encountered in secondary care (Table 1, below).

Table 1: Clinical attendances 14 February 2000 - 31 March 2001

Clinics held

Patient attendances

Number of new patients

Number of follow-up attendances

Number of DNAs (new and follow-up)

Average number of patients per clinic

Ratio of new to follow-up patients

Average waiting time to first appointment (days)



736 (67%)

369 (33%)

101 (8.3%)




The expanded service now holds 13 clinics each month.

The project was awarded Beacon status in November 2000.

Referrals to secondary care

Only 80 patients (11%) were referred from the clinic to secondary care, with a diagnosis confirmed by MRI scan or with clear examination findings (Table 2, below). Of these patients, 29 (36%) were added directly to the in-patient waiting list; this demonstrates the streamlined nature of the care pathway. Forty-eight patients (60%) were added to the outpatient waiting list, of whom 31 patients were listed for surgery following a secondary care consultation. This means that 75% of patients referred from the interface clinic to secondary care undergo surgery.

Table 2: Outcome of referrals to a consultant orthopaedic surgeon
Number of referrals 80
Added directly to in-patient waiting list 29 (36%)
Added to outpatient waiting list 48 (60%)

Of whom:


Undergone surgery or on waiting list


Being followed up in the outpatient department


Discharged without surgery


Already on in-patient waiting list, only seen in outpatients


Outcome not known

DNA in secondary care 3

We wanted to know whether the clinics had reduced the number of patients referred to the orthopaedic department at the acute trust hospital. This was difficult to establish because patients who did not meet our inclusion criteria could not be eliminated from the data; also, the Somerset Coast PCT is only one of four bodies that refer patients to the local acute trust hospital. However, we compared all referrals, including patients with serious pathology and those under 16 years of age, over a 2-year period.

We found a small decrease in referrals, of 0.06%, at a time when the referral rates of the other local PCG, Taunton and Area PCG, had increased by 7.67% (Table 3 below).

Table 3: Change (%) of orthopaedic referrals 1999/2000-2000/2001

Somerset Coast PCG

Taunton and Area PCG

- 0.06

+ 7.67


We felt it was important to obtain feedback from patients and GPs; 119 patients were given a standard validated health questionnaire (SF12) on their first attendance and another at discharge. The 57 responses (48%) were analysed using the Wilcoxon test. This showed that patients who responded felt that their pain had improved significantly (p = <0.05).

A patient satisfaction questionnaire was sent to 250 patients of whom 132 (53%) responded. This showed:

  • 75% of respondents felt the treatment they had received had helped them in dealing more effectively with their problem
  • 70% felt that it was the kind of service they wanted
  • 39% felt the service they received was excellent.

A survey of GPs, with a response rate of 41% (38 responses from 93 questionnaires sent out), found that 84% of respondents supported the continuation of the project.


The musculoskeletal interface clinic has shown that a selected group of patients can be managed effectively in primary care.

The service has encouraged teamwork, resulting in better communication and a more holistic approach to the management of patients. Regular meetings are held to discuss innovations in the service. To promote best practice, staff involved in the service have met and talked to other organisations including the National Primary Care Collaborative and the National Orthopaedic Collaborative.

The Somerset Coast PCT is committed to team development and has recently funded two extended scope physiotherapists to take the Diploma in Injection Therapy course.


  1. Clinical Standards Advisory Group Report. Report on Back Pain. London: HMSO, 1999 pp. 1-89.


  2. CSP Information paper. PA 29. Chartered Physiotherapists working as ESPs. London: The Chartered Society of Physiotherapy, 2000.
  3. Hattam P, Smeatham A. Evaluation of an orthopaedic screening project in primary care. Br J Clin Governance 1999; 4(2): 45-9.

We thank Jill Allen, Project Manager (Commissioning) Somerset Coast PCT, for providing data.

Guidelines in Practice, September 2002, Volume 5(9)
© 2002 MGP Ltd
further information | subscribe