Joint effects 2011 - An update of the involvement - 18 Weeks

Joint effects 2011 

An update of the involvement of 

Allied Health Professionals in orthopaedic 

and musculoskeletal services in Scotland 

mskscoping2011-rs.indd 1 03/11/2011 11:01


Acknowledgements 

The National MSK Redesign Programme benefits from a wide range of continuing 

support. Many thanks to all our contributors in Scotland: users of our MSK services 

and their representatives, AHPs at all levels, the Programme Board, a multidisciplinary 

expert panel, others from service delivery, policy, academia and those supporting 

employment initiatives. Also to the many clinical staff who participated in the 2011 

scoping exercise, Fraser Ferguson, Michael McMenemy and Susan Parroy for 

co-ordinating it and producing the final publications. 

Our UK partners in particular: The Arthritis and Musculoskeletal Alliance, Sue 

Greenhalgh, Consultant Physiotherapist with Bolton PCT’s Musculoskeletal Service, for 

expert input on red flags, and Dr Jonathan Hill and the STarT team at Keele University. 

© Scottish Government Health Directorates 2011 

Design and editorial platform1design.com 

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NHSScotland has a clear vision for achieving sustainable quality in 

Scotland’s healthcare. 

The National Musculoskeletal (MSK) Redesign Programme is designed to contribute 

towards achieving this aim and will bring about significant and sustainable service 

improvements for patients across Scotland in terms of better access, better advice and 

information, more targeted management and better patient outcomes, whilst at the 

same time ensuring we use our resources efficiently. 

This scoping report provides a landscape of current practice across Scotland, updating 

a similar exercise, Joint effects 2005. It clearly demonstrates that health boards have 

developed MSK services to improve patient experience and outcome. 

What is clear from these examples is that there is innovation in services across 

Scotland and much we can learn from each other. The information in this report is 

intended to support local service clinical leaders and staff in developing their MSK 

services further and to help realise the ambition we all have for these services in 

Scotland. It is intended to help to inform staff, develop networks, and share the 

learning and experience of MSK services. 

I firmly believe that we now have the opportunity to turn the vision into a reality and 

make a real difference to the many hundreds of thousands of people in Scotland who 

suffer from MSK problems. 

John Turner 

Chair National Musculoskeletal Programme Board 

Chief Executive, NHS 24 

The programme we are undertaking to transform musculoskeletal (MSK) 

services in NHSScotland is exciting and tremendously important. 

In 2007 service users said they wanted easy access and a single point of referral, 

which we agreed to test out using NHS 24, and The Delivery Framework for Adult 

Rehabilitation 2007 still underpins all our work. 

We want to ensure all musculoskeletal practitioners, heads of service and AHP 

directors are actively engaged in this innovative and crucial area. It is our shared 

responsibility to work together and make this happen. 

It is clear from Joint Effects 2011 that allied health professionals are actively engaged 

and committed to the improvement agenda. The many examples you will read 

about show this. There is still more we can do to reduce variation in our practice 

by adopting, spreading and embedding best practice before we achieve truly 

transformational change. 

We have a real opportunity to use the information in this scoping report to continue 

to transform our MSK services. We must measure and demonstrate not only the 

health impact but also the wider socio-economic impact that AHPs are having. We 

need to ensure that our practice is person centred and evidence based. I am confident 

that AHPs across Scotland will rise to both the opportunity and challenge. 

I look forward to working with you all as we deliver better services and better 

outcomes for patients in Scotland. 

Jacqui Lunday 

Chief Health Professions Officer 

Scottish Government 

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Joint effects 2011 provides an important insight into the role of allied health 

professionals in delivering care to musculoskeletal patients in Scotland. 

Since the scoping in 2005, a great deal of progress has been made in improving care 

for patients including improved patient involvement schemes, self referral processes 

and the development of outcome measures for musculoskeletal conditions. However 

as our own recent research has found, the quality of musculoskeletal services in 

Scotland continues to vary between different health boards. It will thus be important 

that the good practice identified in this work is spread widely across individual boards. 

Ros Meek 

Director 

Arthritis and Musculoskeletal Alliance 

We at Keele University are delighted to be working together with the MSK 

redesign team in Scotland to pilot the suitability of the STarT MSK tool which 

is a modification of the hugely successful STarT Back tool. 

This work takes forward recent primary care research demonstrating the benefit of 

stratified models of care for low back pain problems, recently published in The Lancet. 

This project seeks to build on this proven decision aid and will expand this approach to 

individuals with a range of musculoskeletal conditions. In collaboration with the MSK 

redesign team in Scotland we will ensure that the new risk stratification approach 

can safely assist the selection of the large group of low-risk patients who are unlikely 

to benefit from additional interventions beyond minimal packages of reassurance 

and information. We also anticipate that our stratified approach will help to facilitate 

patient access to treatment resources for those who really need them in a timely and 

cost-effective manner. 

I would like to congratulate this team for trail blazing an exciting path that is likely to 

have substantial benefits for MSK patients in Scotland. Well done! 

Dr Jonathan Hill 

Arthritis Research UK Lecturer in Physiotherapy 

Keele University 

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Contents 

The policy context 6 

The musculoskeletal umbrella 6 

Person-centred, safe and effective 7 

The National Musculoskeletal Redesign Programme 8 

Multi-professional MSK care pathways 8 

The National Advice and Triage Service 8 

Working Health Services Scotland 11 

The 2011 Scottish AHP MSK scoping 12 

Wider aims 12 

Method 12 

Findings 12 

Conclusion 13 

Summary of MSK services 15 

Overview 16 

Service descriptions 20 

Glossary 47 

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The policy context 

In 2007 the need for musculoskeletal (MSK) service redesign was signalled by the 

Scottish Government Health Directorates (SGHD) Co-ordinated, integrated and fit 

for purpose – The delivery framework for adult rehabilitation. The aim is to create a 

modern, effective, multi-disciplinary, multi-agency approach to rehabilitation services 

that are flexible and responsive, using the best that technology can offer. 

Its most recent publication, Achieving sustainable quality: A 20:20 Vision (2011) 

recognises the challenges healthcare will have in the future and the need for services 

to be radically different. 

Some problems affect specific parts of the body, others cause widespread muscular 

pain and fatigue. Autoimmune response conditions such as rheumatoid arthritis and 

ankylosing spondylitis are often progressive and are not related to age. 

The key role of the allied health professionals (AHPs) in delivering a sophisticated 

and integrated approach to health, life and work in relation to MSK conditions is 

recognised by the Scottish Government. Since the publication of Joint effects 2005 

there have been significant developments in both policy and front-line service delivery 

to support this. 

All Scottish Health Boards are now involved in the National Musculoskeletal Redesign 

Programme. The SGHD is supporting a major redesign of patient musculoskeletal 

pathways to improve services for patients, introduce more responsive and appropriate 

pathways, and support greater cost effectiveness across the system. 

The musculoskeletal umbrella 

Musculoskeletal conditions is a broad term encompassing around 200 different 

problems affecting the muscles, joints and skeleton. These conditions result in 9.5 

million lost working days, and currently cost the UK economy £7.4 billion a year. In 

Scotland back and neck pain are in the top 10 most frequent conditions seen by GPs. 

Forty-eight percent of work-related illness in Scotland is of MSK origin. One in four 

patients, over a million people in Scotland consulted their GP for a MSK condition 

last year. 

Disorders such as osteoarthritis and osteoporosis are becoming increasingly common 

as a result of an ageing population. The number of people in Scotland having hip 

and knee joint replacements has grown from 7,000 to 15,000 in the last 10 years. 

The cost in Scotland for orthopaedics has risen from £180 million 1999/2000 to £360 

million in 2007/8. 

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Person-centred, safe and effective 

The three national quality ambitions for NHSScotland clearly state that all services will 

be person-centred, safe and effective. Alongside this, a wide ranging and evidencebased 

work programme underpins the National Musculoskeletal Redesign Programme. 

● ● 2005 AHPs do count. The AHP Census Day demonstrated that neuro-MSK and 

orthopaedic patients represent 65% of the caseload of occupational therapists, 

physiotherapists and podiatrists. 

●● 

●● 

●● 

2006 to 2009 National work and publications on patient self referral 

(www.selfreferralphysioinfo.com). 

2007 Co-ordinated, integrated and fit for purpose – the delivery framework for 

adult rehabilitation (SGHD). 

2009 NHS Quality Improvement Scotland (NHS QIS) published a systematic review 

on service delivery organisation for acute low back pain recommending that the 

physiotherapy management of low back pain (LBP) should take account of existing 

evidence-based guidelines. 

● ● 2009 Health works, The SGHD’s Fit for Work Service will allow workers to access 

rapid diagnosis and referral to services for common physical and mental health 

conditions in a bid to reduce their time out of work. 

●● 

●● 

2009 National physiotherapy low back pain audit – Improving back care in 

Scotland (NHS QIS) identified that over 55,000 people each year are referred 

to physiotherapy with back pain. Audit cycles demonstrated improvement in 

recording of red and yellow flags, improving patient safety and treatment in line 

with best guidance. 

2010 Scottish backs (www.scottishbacks.co.uk) a web-based relaunch of the 

award-winning Working Backs Scotland. 

●● 

●● 

●● 

●● 

●● 

●● 

2010 A national dataset of clinical outcome measures for MSK conditions. Nine 

measures were agreed, based on a review of the literature and professional 

consensus. These measures will be used across Scotland. 

2010 The healthcare quality strategy provided reinforcement that services need to 

have a direct and positive impact in supporting everyone in Scotland to live longer 

healthier lives and to participate more productively both economically and socially. 

Increased effectiveness, efficiency and productivity of the health sector in Scotland 

will make a significant and direct contribution to economic growth. It focuses on 

three quality ambitions: safety, effectiveness and person centredness. 

2010 Realising potential, an action plan for AHPs in mental health reflected the 

key role of rehabilitation within mental health services. This rehabilitation-focused 

initiative builds on the understanding that both physical health and mental 

wellbeing are integral to all AHP services and future healthcare provision. 

2010 The Evaluation report of Lothian and NHS 24’s telephone physiotherapy self 

referral pilot identified benefits for patients in being able to access physiotherapy 

via the telephone. However, in terms of sustainability and cost effectiveness, the 

evidence for that particular operating model was less convincing. 

2011 From strength to strength: Celebrating 10 years of the AHPs in Scotland 

(SGHD) identified significant developments in the MSK AHP workforce in terms of 

their extended roles in diagnostics, prescribing and advanced treatments. 

2011 Achieving sustainable quality: A 20:20 vision, most recently published by the 

Scottish Government, clearly articulates the need for services to play their part in 

achieving sustainable quality. It also recognises the challenges healthcare will have 

into the future and the need for them to be radically different. It calls on health 

services to be bold enough to be able to meet these future demands in a way that 

is sustainable by making changes to turn vision into reality. 

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The National Musculoskeletal Redesign Programme 

2010 – 2013: Allied Health Professional involvement 

The need for redesign was signalled within the Delivery framework for adult 

rehabilitation published in 2007. The framework identified that considerable 

improvements could be made for patients in both their outcome and experience of 

Scotland’s MSK services. In particular by: 

●● 

improving access to services 

●● 

providing consistent and high quality information about their condition 

as early as possible 

●● 

providing information and advice to support self-management 

●● 

shortening waiting times 

●● 

adopting evidence-based treatment plans 

●● 

enabling people to stay in or return to work 

●● 

ensuring an equal, high quality of care across Scotland 

●● 

achieving sustainability and efficiencies to reinvest in better MSK services. 

There are three key work areas: 

1 Multi-professional MSK care pathways 

2 A pilot using NHS 24 telephony to provide a National Advice and Triage Service to 

signpost to information and local MSK services. 

3 Embedding Working Health Services Scotland in all MSK pathways 

Multi-professional MSK care pathways 

AHPs within health boards across Scotland are working as part of multidisciplinary 

teams, developing and introducing a range of MSK care pathways. 

This MSK scoping exercise demonstrates a lot of ‘pathway activity’. More is planned. 

Business redesign approaches are being used to modernise services and ensure 

patients have access to high quality, consistent information about their condition as 

soon as possible. 

Pathfinder Boards have focused on pathways that are based around the highest 

patient activity, i.e. low back pain, hip and knee problems. They have adopted a 

multidisciplinary approach and take a ‘patient-eye view’ of the existing service on 

offer, asking the question “why” at each step of the patient journey. 

The aim is to reduce duplication and take steps out, so people can access the most 

appropriate healthcare option quickly, easily and safely. 

There are many more AHPs practicing in new ways, e.g. referring patients for, and 

acting on, diagnostic tests, prescribing medication and undertaking injections avoiding 

the need for another GP referral. The MSK pathway programme is being supported 

by dedicated project management support with training for new roles and advanced 

practice provided through NHS Education for Scotland (NES). 

The National Advice and Triage Service 

NHS 24 is leading on the development of the national point of access to MSK services 

using their established telephony platform. The NHS 24 pilot will go live in two early 

adopter sites between December and January. The project will be evaluated and is due 

to report in early Summer 2012. 

The service will operate Monday to Friday, 9.00 am to 8.00 pm. Patients and those 

wanting access to advice and information will be encouraged to call a national 

number. The first person a caller will talk to will be a call operator. They will be taken 

through a series of questions about their MSK problem, covering demographic details, 

key safety and problem-specific questions, risk indicators and employment. Call 

operators follow protocols developed by MSK experts, have extensive training and 

clinical supervision on hand at all times. 

The protocol has been developed and endorsed by a national expert panel including 

service users and is based on the NHS 24 operating model where patient safety 

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comes first. It also includes the STarT MSK screening tool under development at 

Current referral pathway 

Keele University. This assists in identifying people at low, medium or high risk of 

experiencing persistent problems. 

It is anticipated that by using this approach, NHS 24 will be able to manage a 

proportion of callers on behalf of local AHP services, free up much needed frontline 

18 (0) days 

20 (2) days 

68 (50) days 

capacity and avoid many GP appointments. 

Low-risk callers 

Advice and information resources available on 

the web, via digital TV and even through a smart 

phone application. Encouraged to call the NHS 24 

service back after two weeks if their symptoms 

don’t improve. 

Medium or high-risk callers Will be referred directly to local MSK services 

as well as being provided with advice and 

information resources. 

Callers with work-related issues Working Health Services and local employability 

services, where appropriate. 

Patient visits 

GP 1.8 times GP completes 

on average written or 

Referral 

before being electronic 

received 

referred to referral 

by local 

AHP service or patient 

AHP service, 

self-refers 

put onto 

waiting list 

Proposed referral pathway 

5 days 

Patient 

contacted and 

offered an 

appointment 

78 (60) days 

Patient attends 

GPs will be encouraged to direct their patients to the new MSK line but will still 

Less than 40 days 

be able to refer directly into local services if they feel the new phone service is not 

appropriate for some patients. 

Callers will have quick and easy access to high quality advice and information about 

how to manage their condition from Day 1 and direct referral if needed into local 

MSK services. This contrasts sharply with current practice. Currently, patients may 

need to visit a GP on more than one occasion before being referred to a local MSK 

service and then face a long wait (can be around nine weeks in many services) before 

receiving advice or the required treatment. 

Patient calls 

NATs, is triaged 

and referral 

sent on to 

local MSK 

service 

Patient 

contacted and 

offered an 

appointment 

Patient attends 

9 



Promotional material for use by the pilot health boards Lothian and Lanarkshire 

10 



Planned evaluation 

1 Safety for patients 

2 Acceptability to user and clinicians 

3 Reliability of clinical pathways and system 

4 Impact on GP and AHP services, costs and patient experience and outcome 

5 Value as a national model for other AHP professions and morbidities 

Working Health Services Scotland 

Working Health Services Scotland (WHSS) is a Government-funded pilot scheme to 

treat people who are off, or struggling to stay in, work and are employed by small and 

medium companies of less than 250 people. It aims to help employees remain in, or 

return to, work quickly after a period of absence. People can self-refer, calling 0800 

019 2211, and referrals are welcome from GPs, other health professionals and partner 

organisations. 

This service will be embedded in the new MSK pathways in every health board and its 

impact evaluated. Opportunities to raise the profile of work-related health issues and 

signpost people who may benefit will be part of the MSK pathway process. 

The programme is based on telephone-case-managed support for employees. It 

includes fast access to a range of therapies and counselling services based on the 

individuals’ needs. 

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The 2011 Scottish AHP MSK scoping 

In 2005, a scoping study of the involvement of allied health professions in 

musculoskeletal services was undertaken at the request of the Chief Professions 

Officer of the SGHD to identify productive and creative models and used to share and 

learn from these experiences. There were two publications: AHP activities in Scottish 

MSK services 2005 and Joint effects 2005. An update of this work was commissioned 

to support the National Musculoskeletal Redesign Programme. As in 2005, this work 

has focused primarily on the activities of three professional groups and their support 

teams: occupational therapists, physiotherapists and podiatrists although some 

examples from other AHPs have been provided and are included. 

Wider aims 

●● 

To promote and share practice between services and professions. 

●● 

To enable the exchange of useful resources available to the public, patients 

and clinicians. 

●● 

To demonstrate to a wider audience the important input and impact AHPs have on 

MSK services in Scotland. 

●● 

To update AHP activities in Scottish MSK services 2005 to represent a snapshot of 

AHP MSK activity in Scotland in 2011. 

Method 

The update was undertaken between January 2011 and September 2011. A database 

of AHP contacts was developed and all AHP directors in every board were notified 

by email and at their monthly meetings. A template was developed and circulated 

widely by email. Summaries for publication were agreed and recirculated. There were 

a few, but not many, follow-up phone interviews for clarification. AHP directors were 

circulated twice with the full database reports in confidence. 

Findings 

As to be expected, there have been considerable developments in both services 

and practice. Boards have clearly been using the three quality ambitions to drive 

improvements. Developments have been found in a range of areas, notably: 

Patient involvement in service development and quality assessment is much more 

common. Patient focus groups, video diaries and feedback and even the use of a 

patient postbox have made it easier to listen to patients’ views on AHP services. 

Self referral is widely available and in some health boards there is nearly 100% 

coverage for community AHP services. In other boards it is patchier. However it 

is still disappointing that only a few services really market this to patients. With 

some exceptions, finding information on Scotland’s AHP MSK services requires an 

understanding of the structure of healthcare and quite complex use of web search 

engines. Self referral forms can be found but it is not always easy. 

Drop-in clinics and a wide range of appointment times with evening clinics are 

offered by a number of services. Some more specialised services have moved out into 

the community. 

Patient pre-assessment forms, self completion questionnaires and screening 

tools are clearly being used more. Follow-up is also common, either by use of a 

phone call post discharge, or a postal questionnaire including a range of outcome 

measures. 

National agreement for MSK clinical outcome measures achieved in 2010 should 

lead to increased use of validated measures. However, converting individual patient 

clinical outcome measures (PROMs and PREMs) more widely to demonstrate wholeservice 

impacts and improvements is still quite unusual. 

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There is much greater standardisation of assessment and referral forms across 

many health boards and more patient information provided although the extent and 

content varies. 

There has been a lot of pathway and redesign development, which continues as 

part of the current National MSK Redesign Programme. 

The regular use of systems and technology to support patient care still remains 

highly variable. Some services have, and make good use of, legacy systems. Others 

have built their own databases to support quality improvements but there are still 

many services that are dependent on paper for the retrieval of patient outcomes. 

Many but not all have access to e-GP referrals and some specialised services are using 

e-vetting very successfully. 

The lack of systems and diary management can only hamper flexible and adaptable 

service development, however some services have effectively used off-the-shelf 

products as an interim measure. 

Advanced AHP practice in partnership with other clinicians forms the basis for many 

services. Most services are delivered within community settings, health centres and 

community hospitals. Ensuring advanced practice is integrated into normal services 

and not seen a ‘stand-alone’ is clearly a current development in some boards. The 

use of injection therapy is now widespread throughout physiotherapy and podiatry in 

Scotland and in some places available within every service. 

Increasing links to exercise and better integration of work, health and leisure are 

evident; some boards lead the way in this. Staff skill mix has been adjusted to include 

exercise and fitness professionals within the traditional healthcare team. There are also 

examples of exercise classes being targeted at particular populations and links with 

the voluntary sector to deliver patient-led group activity. 

In the hospital sector the use of education classes in preparation for planned joint 

replacement surgery is becoming widespread. 

Conclusion 

Scotland has led the world in permitting and promoting self referral to AHP services, 

this approach now underpins Scottish Government Policy, but many AHP services are 

still quite difficult to find on the internet. How patients and the public learn about self 

referral is also difficult to judge. The NHS 24 pilot may assist with this. 

AHPs are in a unique position to support and promote Scottish policies on working 

health, and assist as many people to stay at work, or return to work as soon as 

possible. More needs to be done to establish links with leisure services and to be 

effective advocates for physical activity and public health. 

Services will have to demonstrate they are not only effective and efficient but that 

they add value. The national approach to consistent outcome measurement will 

support this. 

There continues to be variation in the delivery and management of musculoskeletal 

services between and within individual health boards in Scotland. This is also 

confirmed by The Arthritis and Musculoskeletal Alliance (ARMA)’s Musculoskeletal 

Map of Scotland due for publication later this year. 

It will be important that the good practice identified in this report and the 

opportunities offered by the National MSK Redesign Programme are used 

to reduce variation and continue to drive improvements in the quality of 

musculoskeletal services for the people of Scotland. 

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14 



13 

Summary of MSK services 

All entries have been submitted and agreed by contributors. They are backed up 

by more detailed information which will be released as a PDF file to AHP managers 

and contributors. Many services have offered to share their existing resources. The 

overview table is to help you find your way around the entries and to prompt the 

sharing of ideas and existing resources. 

1 NHS Ayrshire and Arran 20 

12 

2 NHS Borders 22 

3 NHS Dumfries and Galloway 23 

4 NHS Fife 25 

15 

5 NHS Forth Valley 27 

8 

6 

6 NHS Grampian 29 

7 NHS Greater Glasgow and Clyde 31 

8 NHS Highland 35 

9 NHS Lanarkshire 36 

5 

14 

4 

10 NHS Lothian 38 

11 NHS National Waiting Times Centre 39 

11 

1 

7 

3 

9 

10 

2 

12 NHS Orkney 40 

13 NHS Shetland 42 

14 NHS Tayside 42 

15 NHS Western Isles 45 

15 



Overview 

NHS Ayrshire and Arran 

Patient involvement 

Access: evening, one stop 

Self referral 

Pathways and redesign 

Systems and technology 

Advanced practice 

Injection 

Outcomes 

Demonstrate value 

Exercise, work and health 

Pre-assesment, screening and follow up 

AHP Board Lead on MSK Redesign ● ● ● ● ● ● judith.reid@aapct.scot.nhs.uk 

AHP Electronic Diary Management ● billy.mcclean@nhs.net 

AHP Low Back Pain Pathway ● ● ● ● ● ● ● ● judith.reid@aapct.scot.nhs.uk 

AHP Orthopaedic Services ● ● carol.kirk@aaaht.scot.nhs.uk 

AHP Pain Services ● ● arlene.sloan@aapct.scot.nhs.uk 

Counterweight Programme ● ● ● carolyn.paton@aapct.scot.nhs.uk 

Occupational Therapy Hand Service ● gillian.cowan@aaaht.scot.nhs.uk 

Physiotherapy Service ● ● billy.mcclean@nhs.net 

Podiatry Service ● ● ● ● ● ● helen.jackson@aapct.scot.nhs.uk 

Service Redesign in Orthotics ● ● ● colin.keith@aapct.scot.nhs.uk 

NHS Borders 

Musculoskeletal Physiotherapy in 13 locations ● ● ● ● maggie.stobie@borders.scot.nhs.uk 

Podiatry Service ● ● pamela.gordon@borders.scot.nhs.net 

NHS Dumfries and Galloway 

Back Pain Service ● ● ● ● ● ann.grant@nhs.net 

Dumfries and Galloway Royal Infirmary Physiotherapy Department ● sherylreason@nhs.net 

Dumfries and Galloway-East Physiotherapy ● ● ● amanda.hall@nhs.net 

Electronic Triage of orthopaedic GP referrals by lead podiatrist helps waiting times ● ● neil.malcolm@nhs.net 

NHS Fife 

Fife Physiotherapy Service ● ● ● ● ● ● ● ● grant.syme1@nhs.net 

Fife Podiatric Learning Disability Service ● ● ● karen.hutt@nhs.net 

Hand Therapy Team ● sheilamclellan@nhs.net 

Integrated Pain Management Service ● ● melanie.hutchison@nhs.net 

16 




Self referral 





Injection 

Outcomes 



Orthopaedic Foot and Ankle Service ● ● carolyntodd@nhs.net 

Podiatry Musculoskeletal (Biomechanics) Service ● ● ● ● ● ● ● ● carolyntodd@nhs.net 

Rheumatology Podiatry ● ● ● adele.osborne@nhs.net 

Rheumatology ● ● janet.harkess@nhs.net 

NHS Forth Valley 

Extended Scope Practitioner Clinics in Orthopaedics ● ● ● ● ● lesleydawson@nhs.net 

Forth Valley Back Pain Service and Exercise Classes ● ● ● ● ● ● nturvill@nhs.net 

Forth Valley Physiotherapy ● ● ● ● ● catriona.phin@nhs.net 

Occupational Therapy for In-patients ● rosina.mcguire@nhs.net 

Orthotic Services (Open Referral) ● ● ● lynne.rowley@nhs.net 

Podiatry Service ● ● ● gordon.mclay@nhs.net 

Rheumatology ESP Clinics ● ● anitacarr@nhs.net 

Rheumatology Occupational Therapy ● rosina.mcguire@nhs.net 

NHS Grampian 

Elective Orthopaedics Occupational Therapy ● ● ● eve.cruickshank@nhs.net 

Grampian Physiotherapy Services ● ● ● ● ● ● lynn.morrison @nhs.net 

Moray Occupational Therapy ● ● ● judith.fairburn@nhs.net 


Orthopaedic Rehabilitation Unit 

eve.cruickshank@nhs.net 

Orthotics Services ● ● steven.lindsay@nhs.net 

Rheumatology ● f.mccurdy@nhs.net 

Supported Discharge Service Stroke and Trauma Orthopaedics ● ● ● beththomson@nhs.net 

NHS Greater Glasgow and Clyde 

Call Centre Access and evening clinics popular with patients ● ● ● paul.higgins@ggc.scot.nhs.uk 

Community Physiotherapy Services. Out-patient musculoskeletal services – Renfrewshire CHP ● ● ● ● elizabeth.lightbody@ggc.scot.nhs.uk 

ESP Orthopaedic Foot and Ankle Triage Service ● ● ● paul.higgins@ggc.scot.nhs.uk 

MSK Physiotherapy Service Review ● ● ● ● heather.cameron@ggc.scot.nhs.uk 

MSK Outcome Measure Proforma ● ● karen.glass@ggc.scot.nhs.uk 

17 





Self referral 




Injection 

Outcomes 




One Stop Rheumatology Foot Service – a partnership with Glasgow Caledonian University. ● ● ● ● ● mhairi.brandon@ggc.scot.nhs.uk 

Pain Services ● aline.williams@ggc.scot.nhs.uk 

Practice Development: laser, therapy, dry needling, deep enucleation, surgery 

and steroid injections 

● ● ● ● paul.higgins@ggc.scot.nhs.uk 

Practice Innovations: patient stories, videos, phone follow up and the CARE measure ● ● karen.glass@ggc.scot.nhs.uk 

Rehabilitation Service – Glasgow City Community Health ● ● ● ● paul.higgins@ggc.scot.nhs.uk 

Training for Financial Inclusion and Employability ● ● heather.cameron@ggc.scot.nhs.uk 

NHS Highland 

Easter Ross Orthopaedic Triage Pilot ● ● ● ● sue.king6@nhs.net 

Hand Therapy and Splinting Service ● karen.tolmie@nhs.net 

Hand Therapy for Orthopaedics ● lindacurrie@nhs.net 

Mid CHP Podiatry ● roderick.wells@nhs.net 

South East Highland CHP Podiatry Service ● michael.gates@nhs.net 

NHS Lanarkshire 

Extended Scope Practitioner Service in Orthopaedic Out-patients ● ● ● ● ● janie.thomson@lanarkshire.scot.nhs.uk 

Low Back Pain Physiotherapy Pathway ● ● ● ● ● christine.mccallum@lanarkshire.scot.nhs.uk 

Physiotherapy Assessment Line ● ● ● ● ● ● ruth.currie@lanarkshire.scot.nhs.uk 

Podiatry Biomechanics Service ● ● ● jim.logan@lanarkshire.scot.nhs.uk 

NHS Lothian 

East and Midlothian Physiotherapy Service ● ● ● ● ● brian.brockie@nhslothian.scot.nhs.uk 

Edinburgh Community Physiotherapy Service ● ● ● ● ● eddie.balfour@nhslothian.scot.nhs.uk 

Foot and Ankle, Orthopaedic Clinic ● ● ● ● ● colin.thomson@luht.scot.nhs.uk 

Podiatry Biomechanics Clinic (Edinburgh, East Lothian and Midlothian) ● ● william.mcmurrich@nhslothian.scot.nhs.uk 

Spinal Practitioner Support to Orthopaedic Spinal Service ● ● vivienne.boyd@luht.scot.nhs.uk 

West Lothian Musculoskeletal Service ● ● ● ● orla.crummey@nhslothian.scot.nhs.uk 

NHS National Waiting Times Centre 

Innovations in Orthopaedics ● birgit.clark@gjnh.scot.nhs.uk 

MSK Physiotherapist in Occupational Health and Orthopaedic Out-patients ● ● ● ● kathryn.macpherson@gjnh.scot.nhs.uk 

18 

mskscoping2011-rs.indd 18 03/11/2011 11:01



Self referral 





Injection 

Outcomes 



Elective Orthopaedic Surgery ● ● ● ● birgit.clark@gjnh.scot.nhs.uk 

NHS Orkney 

MSK Orthopaedic Triage Service ● ● paula.hemsley@nhs.net 

Musculoskeletal Pathways, Balfour Hospital ● ● peter.mackellar@nhs.net 

Occupational Health, pre-employment assessment and return to work ● ● lesley.platford@nhs.net 

Rheumatology Telemedicine Link Clinic ● ● lesley.platford@nhs.net 

Video Capture Gait Analysis ● ● richard.bailey2@nhs.net 

NHS Shetland 

Musculoskeletal Podiatry Service ● ● ● ● ● ● bruce.mcculloch@nhs.net 

Occupational Therapy Service ● ● ● duty.ot@shetland.gov.uk 

NHS Tayside 

Advanced Physiotherapy Practitioner and GPwSi, MSK Primary Care Triage Service ● ● ● ● janice.mcnee@nhs.net 

Injection Therapy Expansion ● ● ● ● ● ● janice.mcnee@nhs.net 

Musculoskeletal Out-patient Services – General ● ● ● ● ● angelamurphy@nhs.net 

Lower Limb Biomechanics Clinic ● ● mikeblack@nhs.net 

Orthopaedic Screening in Secondary care ● ● ● janice.mcnee@nhs.net 

Rheumatology ● ● ● ● ● alisonknight@nhs.net 

Trauma and Elective Hand Clinics ● ● ● sarah.dalgleish@nhs.net 

Virtual Ward (Community Rehabilitation) ● ● ● denise.connon@nhs.net 

Working Health Services ● ● ● ● ● ● cathy.grieve@nhs.net 

NHS Western Isles 

Musculoskeletal Physiotherapy, class-based exercise groups ● ● ● ● sheila.nicolson@nhs.net 

Self Referral Clinic at the Physiotherapy Department ● ● ● nico.groenendijk@nhs.net 

Physiotherapy Services across Western Isles ● ● ● ● ● ● ● ● nico.groenendijk@nhs.net 

Podiatry Musculoskeletal Service – Western Isles ● ● smacphee1@nhs.net 


19 



Service descriptions 

NHS Ayrshire and Arran 

AHP Board Lead on MSK Redesign 

Judith Reid 

judith.reid@aapct.scot.nhs.uk 

AHP Electronic Diary Management 

Billy McClean 

billy.mcclean@nhs.net 

01563 827197 

AHP Low Back Pain Pathway 

Judith Reid 

judith.reid@aapct.scot.nhs.uk 

AHP Orthopaedic Services 

Carol Kirk 

carol.kirk@aaaht.scot.nhs.uk 

01563 827126 

The MSK redesign board was established in October 2010. Phase 1, low back pain pathway 

was successfully implemented in April 2011, with hand pathway going live in November 2011 

and other pathways (hip, knee, shoulder and foot/ankle) through 2012. In line with the quality 

strategy, several measures will capture effectiveness, safety and patient centredness. EQ5D5L 

is being used as a continuous measure for all MSK conditions. The STarT tools help inform the 

management approach, with other measures, e.g. HADS, informing exit routes. Survey and 

focus group evaluation of both staff and patient perception is in place with snapshot evaluation 

using CARE measure. Project documents are available. 

Centralised management of MS Outlook diaries has been introduced across Physiotherapy 

as a stepping stone to a bespoke electronic patient management system. This has improved 

efficiency and productivity with a reduction of unfilled slots and reduction in assistant and 

clinical time used to manage diaries across peripheral sites. Trackcare PMS will be used to 

manage diaries centrally across AHP MSK services once the redesign is complete and IT solutions 

have been implemented. 

The low back pain pathway was implemented in April 2011 as the first pathway within the 

overarching MSK redesign in line with the Government vision. GPs refer electronically through a 

single point of contact to access community-based AHP services. A robust process of escalation 

utilises community-based MSK ESPs (who also work in orthopaedics) to access diagnostic 

investigations and refer directly to secondary care as required. 

OT and Physiotherapy provide services to those undergoing elective and trauma orthopaedic 

surgery. Elective THJR patients have a pre-admission visit by the orthopaedic TI and are reviewed 

by the TI on the ward post surgery. TKJR patients attend a pre-op joint school (Crosshouse only) 

as part of the Rapid Recovery Programme. The MDT ensure timely and safe discharge home. 

Outreach domiciliary visits are carried out where necessary. An OA knee pathway delivers OT 

and physiotherapy rehabilitation to avoid surgical intervention. These services will be reviewed 

as part of the MSK redesign. 

20 



AHP Pain Services 

Arlene Sloan 

arlene.Sloan@aapct.scot.nhs.uk 

Counterweight Programme 

Carolyn Paton 

carolyn.paton@aapct.scot.nhs.uk 

Occupational Therapy Hand Service 

Gillian Cowan 

gillian.cowan@aaaht.scot.nhs.uk 

01563 827126 

Physiotherapy Service 

Billy McClean 

billy.mcclean@nhs.net 

01563 827197 

Chronic Pain services across Ayrshire are managed through anaesthetics. An MCN is being 

established as part of the MSK redesign. Work has begun on development of a physiotherapyled 

Level 1 pain management programme. An initial programme of staff education is underway 

with delivery of service scheduled from April 2012. Collaborative working with Working Health 

Services, Mental Health and Leisure Services is ongoing and will further enhance management 

options. 

Dietetics provide support, education and advice to patients and clinicians through the Ayrshire 

wide Counterweight programme. The programme provides weight-loss support and nutritional 

advice to those who are overweight. This approach is embedded within the OA knee and spinal 

pathways and will be extended as part of the MSK redesign. 

Hand therapy (Crosshouse only) is provided to in/out-patients following trauma/elective 

surgery. An Extended Role Hand Clinic is held by the Senior Occupational Therapist to review 

patients post operatively. Hand therapy is also provided one evening per week. OT also 

provides a service for Rheumatology patients at Ayr & Crosshouse and attend a ‘one stop’ 

Multidisciplinary Inflammatory Joint Disease Clinic held at Heathfield Clinic and Ayrshire Central 

Hospital. 

Physiotherapy services across primary and secondary care, with specialist services in 

rheumatology, hands, hydrotherapy and extended scope roles in orthopaedics. Referral systems 

in place from physiotherapy to orthopaedic services. Injection therapy provided throughout 

the physiotherapy service and combined clinics (ESP’s and clinical specialists) enabling further 

investigation as required. Core contributor to low back pain pathway. 

21 



Podiatry Service 

Helen Jackson 

helen.jackson@aapct.scot.nhs.uk 

MSK Podiatry Service accepts self referrals, GP, physio, consultant and other AHP referrals. 

A team of specialists provide assessment, diagnosis and treatment for children and adults 

presenting with MSK conditions. Three team members carry out foot and ankle steroid 

injections and a further three staff input to the multidisciplinary inflammatory joint disease 

clinics. Special provision is made for diabetic patients who require ‘off-loading’ bespoke devices. 

Functional orthoses, both bespoke and off the shelf, are provided by clinicians with technical 

support. A foot and ankle MSK pathway is currently being developed which it is hoped will 

improve access to imaging, bloods and orthopaedics. 

Outcome measures: audit, VAS. Plan to start using the Manchester and Oxford foot pain scale. 

Service Redesign in Orthotics 

Colin Keith 

colin.keith@aapct.scot.nhs.uk 

NHS Borders 

Musculoskeletal Physiotherapy in 13 locations 

Maggie Stobie and May Sharp 

maggie.stobie@borders.scot.nhs.uk 

may.sharp@borders.scot.nhs.uk 

01896 826545 

Orthotics provide services across Ayrshire but currently can only be accessed through 

Orthopaedics. Referral pathways to Orthotics are being reviewed as part of the MSK redesign to 

allow direct access for GPs and other AHPs and an email triage system set up. Over 60% of the 

service caseload involves treatment of foot and ankle conditions. Joint working with Podiatry in 

treatment of diabetic and rheumatoid conditions has been established together with ongoing 

clinics in Paediatrics and LDS with Physiotherapy. 

Physiotherapy is delivered at 13 locations and all accept self referral. The orthopaedic ESP 

includes a multidisciplinary team providing effective assessment of the routine orthopaedic 

out-patient waiting list at the Borders General Hospital and creates effective management of 

non-surgical cases. The patient pathway through triage has run since 2008 with future plans to 

introduce the service into primary care settings. 

The Physiotherapy Spinal Service has implemented evidence-based guidelines for both primary 

and secondary care. They treat and manage complex spinal patients and those triaged from 

the orthopaedic waiting list. The recently launched hip and knee school is part of the enhanced 

recovery programme, set up to reduce patient length of stay in hospital. Patients are seen before 

their operation for an hour-long education and exercise class, the classes are run jointly with 

occupational therapy, enabling home requirements to be assessed and relevant equipment 

delivered prior to their operation. 

22 



Musculoskeletal Physiotherapy in 13 locations 

Continued 


Pamela Gordon 

pamela.gordon@borders.scot.nhs.net 

NHS Dumfries and Galloway 

Back Pain Service 

Ann Grant 

ann.grant@nhs.net 

Other services include dedicated physiotherapy time for MSK referrals from the Occupational 

Health Service and a multidisciplinary Rheumatology team working across primary and 

secondary care. MSK patients also have access to hydrotherapy. The chronic pain management 

team includes OT and Physiotherapy working on assessment and management of patients 

including education and self-management programmes. 

The Podiatry Service aims to deliver care to patients as near to their home as possible through 

basing staff in local health centres and all accept self referral. NHS Borders covers a large 

geographical area and provides a range of primary and secondary care and mental health 

services to a population of 107,000. The rurality of the area and the dispersed nature of the 

population are key issues in the delivery of healthcare. There is an MSK podiatry service and 

orthopaedic triage service based at Borders General Hospital five days per week. This service 

sees patients on referral from GPs, consultants and other healthcare professionals. 

The service was implemented to triage all patients referred to Orthopaedics with neck, thoracic 

and low back pain, directing them for appropriate treatment and investigations and providing 

GPs with options for future management of symptoms. The team is also working with Pain 

Association Scotland to establish a service for those with chronic pain. A knee pathway is under 

development. 

Improvements: reduction in requests for MRI for back problems and those referred for surgical 

intervention. 

Outcome measures: Oswestry Disability Index,VAS HAD scores and self-efficacy questionnaire, 

DAPOS. 

Dumfries and Galloway Royal Infirmary Physiotherapy Department 

Sheryl Reason 

sherylreason@nhs.net 

Assessment and treatment of all out-patients with orthopaedic pre- and post-operative 

conditions. Patients are referred via consultants, GPs or through self referral. Rheumatology 

conditions are assessed and treated in a one-stop multidisciplinary clinic. A joint podiatry and 

physiotherapy clinic is held for those with biomechanical problems. MSK rehabilitation is carried 

out in a gym setting. 

23 



Dumfries and Galloway-East Physiotherapy 

Amanda Hall 

amanda.hall@nhs.net 

01387 244402 

Accept GP, consultant and self referrals. Joint injection service provided by PT at three sites. 

Involved in shoulder pathway project. Services are co-located with GPs with well established 

partnership working, e.g. PTs attend weekly meetings with GPs at Lockerbie Health Centre. 

Links with sport and leisure services in parts of region – exercise referral scheme. 

4,812 new patients were seen last year and there has been a change in skill mix to provide an 

increase in administrative support in order to release clinicians’ time. 

Electronic Triage of orthopaedic GP referrals by lead podiatrist 

helps waiting times 

Neil Malcolm 

neil.malcolm@nhs.net 

01387 244414 

The Podiatry Department provides a region-wide lower limb musculoskeletal service in a variety 

of settings and is staffed by a lead MSK podiatrist and three part-time specialist podiatrists. 

Assessment and treatment is provided as near people’s home as possible. 

All podiatrists carry out basic biomechanical assessments and insole manufacture, and have to 

access the PACS imaging system. 

The service accepts referrals from all healthcare professionals but does not accept self referrals 

at this time. Joint assessments with paediatric and adult physiotherapists are available when 

necessary. 

The lead MSK podiatrist is able to triage orthopaedic referrals from GPs electronically. Patients 

see the appropriate clinician first time which helps to reduce orthopaedic waiting times. 

Treatments offered include advice, exercises, orthotic therapy and injection therapy. The majority 

of orthoses supplied to patients are manufactured in-house with a small number receiving 

preformed devices. 

24 



NHS Fife 

Fife Physiotherapy Service 

Grant Syme 

grant.syme1@nhs.net 

01592 717828 

The service operates across the two District General Hospitals and the three Community Health 

Partnerships. The musculoskeletal service is provided through consultant and GP referrals, 

both in hospital and in community locations throughout Fife. Whilst there are four discrete 

management units, the service aims to provide people with seamless access to physiotherapy. 

Self referral is available at one site. Back Pain Redesign reduced costs and found that 90% of 

patients could be independently managed by the consultant physiotherapist in the first instance. 

Outcomes in use: EUROQOL, Oswestry Pain Disability Index, Patient Satisfaction, Visual 

Analogue Pain Scale, Global Change Patient Rating. 

Fife Podiatric Learning Disability Service 

Karen Hutt and Dorothy Hathaway 

karen.hutt@nhs.net 

01383 565307 

The service provides a comprehensive MSK service to all patients with a learning disability who 

have a biomechanical need. This includes biomechanical assessment, gait analysis and recording, 

physical therapy treatments including laser and acupuncture, footwear assessments and referral 

to Orthopaedic as required, casting and supplying of appropriate orthotics. Carers are advised 

on exercise regimes and postural management. Joint team working is undertaken with the 

learning disciplinary team, in particular joint clinics with physiotherapy. There is a specific service 

for people with Down’s syndrome. 

All people with Down’s syndrome in Fife are offered an assessment at the clinic where 

representatives from the multidisciplinary team assess their needs. The team consists of podiatry, 

physiotherapy, occupation therapy, nursing, psychology, speech and language therapy and 

dietetics. Currently all individuals seen at the clinic with a podiatry biomechanical need have 

been supplied an appropriate orthotic device and are followed up as required. 

25 



Hand Therapy Team 

Sheila McLellan 

sheilamclellan@nhs.net 

01592 643355 ext. 23690 

Integrated Pain Management Service 

Melanie Hutchison 

melanie.hutchison@nhs.net 

01383 623623 

Orthopaedic Foot and Ankle Service 

Carolyn Todd 

carolyntodd@nhs.net 

Podiatry Musculoskeletal (Biomechanics) Service 

Carolyn Todd 

carolyntodd@nhs.net 

01592 645218 

The Hand Therapy Team consists of two specialist nurses, one full-time Advanced Occupational 

Therapist, one part-time specialist OT and one full-time orthopaedic physiotherapy practitioner. 

The team provides an out-patient service in both Queen Margaret Hospital (Dunfermline) and 

The Victoria Hospital (Kirkcaldy). Assessment, intervention and rehabilitation is provided for 

people who have either sustained hand/upper limb trauma, undergone hand/upper limb elective 

surgery or who have a hand/upper limb condition. Referrals are accepted from AHP colleagues, 

GPs and consultants. Services offered include thermoplastic static and dynamic splinting, sensory 

assessment/re-education, injection therapy, wound management, functional assessment and 

rehabilitation, strengthening programmes and pain management advice. 

The Occupational Therapy Service provides assessment, intervention, rehabilitation and complex 

case management for clients referred and triaged to the secondary care aspect of Fife Integrated 

Pain Management Service. The services are in a variety of settings throughout Fife including: the 

specialist out-patient unit in Queen Margaret Hospital, Victoria Hospital and Whyteman’s Brae 

Hospital in Kirkcaldy, clients’ homes and workplaces, and local community health clinics. 

The Foot and Ankle Team consists of two orthopaedic consultants, two registrars, two 

podiatrists (one Extended Scope) and one orthotist. Referrals are received electronically from 

GPs and triaged to the appropriate team member. There is access to diagnostic investigations 

and imaging. Treatments can include biomechanical assessment +/– orthotic management, 

insole management and footwear, exercises, steroid injections, acupuncture, onward referral to 

physiotherapy and pain services, and where appropriate surgical intervention. 

The Podiatry Department provides a comprehensive Fife-wide lower limb musculoskeletal 

service. This is delivered by specialists who provide the assessment, diagnosis and treatment of 

children and adults presenting with complex MSK conditions. There are combined clinics with 

physiotherapists and late clinics to accommodate working patients. Direct access to orthotist 

services has shortened the journey for patients who need footwear or modifications, with 

bespoke and off-the-shelf orthoses being an integral part of providing the service. Work is 

ongoing to introduce skill mix. 

Improvements and outcomes: audit, patient survey, VAS Care Aims with mean VAS scores 

improving following intervention. 

26 



Rheumatology podiatry 

Adele Osborne 

adele.osborne@nhs.net 

01383 722911 

The Rheumatology Podiatry Department provides a comprehensive Fife-wide lower limb 

musculoskeletal service which also includes acupuncture and steroid injections. This is delivered 

by specialists who provide the assessment, diagnosis and treatment of adults presenting with 

inflammatory conditions. There are late clinics to accommodate working patients. Work is 

ongoing to introduce skill mix. 

Improvements and outcomes: audit, patient satisfaction survey, VAS, Care Aims with mean VAS 

scores improving following podiatry interventions. 

Rheumatology 

Janet Harkess 

janetharkess@nhs.net 

01383 623623 

The service provides an OT assessment, intervention and rehabilitation service for individuals 

with rheumatological conditions, in clinics or patients’ own homes. 

NHS Forth Valley 

Extended Scope Practitioner Clinics in Orthopaedics 

Lesley Dawson 

lesleydawson@nhs.net 

01786 434061 

These clinics have played a significant role in reducing waiting times in NHS FV over the last 

eight years. They assess and treat 50% of all elective orthopaedic patients, with just over 

half of these being discharged at their first appointment, requiring only advice or referral to 

physiotherapy or appliances. 

All referrals are triaged to ensure appropriate streaming to ESP or consultant clinics. ESP see on 

average seven new patients per clinic and onward referral rates are low at less than 5%. 

A recent audit showed that only 2.8% of patients discharged from ESP clinics in 2009 were 

re-referred back into the system and seen by an orthopaedic consultant within twelve months of 

discharge. 

Outcomes measured: discharge rates and a patient satisfaction survey. 

27 



Forth Valley Back Pain Service and Exercise Classes 

Norma Turvill 

nturvill@nhs.net 

The strength of the service lies in its capacity to direct patients to the part of the service that 

can help them the most. Patients can refer themselves to the Physiotherapy Department where 

they will be thoroughly examined and talked through a treatment plan. Exercise is an essential 

part of back care and Forth Valley has classes to suit all abilities, these can be accessed by 

self referral or referral by the physiotherapist. A pain management programme is in place for 

patients with longer term problems and the service can also give advice about workplace issues. 

Patients who require a second opinion or further investigation can meet with an extended scope 

physiotherapist practitioner who specialises in back pain via the Orthopaedic Department. 

Improvements measured: outcomes from the orthopaedic clinic are recorded, e.g. discharged, 

exercise programme, pain management, investigations, onward referral, physiotherapy. 

Outcomes measured: before and after treatment by pain management programme – TSK, 

coping skills inventory, exercise programme – VAS, exercise options taken up. 

Forth Valley Physiotherapy 

Catriona Phin 

catriona.phin@nhs.net 

01786 434061 

Occupational Therapy for In-patients 

Rosina McGuire 

rosina.mcguire@nhs.net 

01324 567435 

Orthotic Services (Open Referral) 

Lynne Rowley 

lynne.rowley@nhs.net 

01324 616084 

This Forth-Valley-wide service includes a staff physiotherapy service, injection clinics, specialists 

in hands, paediatrics and women’s health. Close links with local GPs and orthopaedic clinics 

with ESP physiotherapists working in orthopaedic and rheumatology clinics 

Outcomes measured: WOMAC, KOOS, Roland and Morris, HAD, TSK, VAS, DASH, MYMOP, 

although outcomes not recorded with all patients. 

The OTs perform an assessment and then the rehabilitation of acute trauma and elective 

patients to enable a safe and effective discharge home. 

The service has an open-access referral system with clinics held in hospitals and health centres 

with ward cover at weekends when required. 

Improvements measured: audit of referral-to-treatment dates compared to standard orthopaedic 

pathway. 

Outcomes measured: the foot function index and pain scale being recorded before and after 

treatment where possible. 

28 




Gordon Mclay 

gordon.mclay@nhs.net 

01786 431133 

Rheumatology ESP Clinics 

Anita Carr 

anitacarr@nhs.net 

01786 434061 

Rheumatology Occupational Therapy 

Rosina McGuire 

rosina.mcguire@nhs.net 

01324 567435 

The service operates throughout the Forth Valley in a number of settings. Patients can be 

referred by any healthcare professional, and receive a full podiatry and medical assessment to 

determine the appropriate course of action. The services provided include: 

Acupuncture, Rheumatology, Joint podiatry/physiotherapy (paediatric and adult), Occupational 

Health, Biomechanical specialist service and a podiatry technician orthotic manufacturing 

service. The Occupational Health podiatry service has had an immense uptake with demand 

outstripping supply and provides a more local service to members of staff. The amount of days 

saved to the organisation in absence figures cannot be calculated. 

Fast access self referral clinics for patients already within the rheumatology service, requiring 

assessment for injection. Initial screening by phone then assessed in clinic and further 

investigations / onward referral completed if required. 

The team provides assessment and intervention for people with rheumatological conditions 

this includes giving advice, splinting, obtaining any necessary equipment, and supporting them 

within their employment. 

NHS Grampian 

Elective Orthopaedics Occupational Therapy 

Eve Cruickshank 


01224 556044 

This OT service provides input at a pre-admission clinic in order to prepare patients for surgery 

and allow liaison with community OT colleagues to deliver necessary equipment. It also provides 

assessment, treatment and additional advice once the patient is admitted to hospital and after 

their surgery including rehabilitation following hip/knee replacements or back surgery. 

Outcomes measured: goal setting before and after treatment. 

29 



Grampian Physiotherapy Services 

Lynn Morrison 

lynn.morrison@nhs.net 

01224 555466 

Musculoskeletal services are provided at several different settings – GP practice, Community 

hospital, District General hospital and Acute hospital. Self referral is available at some but not 

all sites. There are plans in place to make self referral into MSK physiotherapy services available 

throughout Grampian in May 2011. 

Staff work as a team across a locality, providing sickness and annual leave cover. Triage issued 

and based on knowledge of demand and capacity. There is a pilot of different assessment times 

(20/30/40 minutes) and local research funding has been obtained for this. 

Moray Occupational Therapy 

Judy Fairburn 

judith.fairburn@nhs.net 

01343 567245/559461 

Orthopaedic Rehabilitation Unit 

Eve Cruickshank 


01224 556044 

An integrated OT service between NHS and Council. Moray Occupational Therapy has a duty 

system for all new referrals. There is an open referral system – self referral or anyone else 

representing the patient. Anyone can access the service by telephone, email or letter. 

The unit provides a service to patients from 16 onwards with orthopaedic trauma or elective 

orthopaedic conditions who require specialist in-patient rehabilitation. The unit also takes 

patients who have had amputation following orthopaedic surgery. 

Improvements measured: patient satisfaction questionnaire. 

Outcomes measured: goal setting takes place throughout treatment. 

Orthotics Services 

Steven Lindsay 

steven.lindsay@nhs.net 

01224 556843 

Orthotics clinical and technical services are provided in Woodend Hospital and in some 

satellite clinics within Grampian. Currently, initial referral can be made by any medical or AHP 

professional, with self referral available for existing patients. The orthotic service along with 

the prosthetics and wheelchair services are ‘housed’ in the primary care setting, although a 

significant volume of work takes place within secondary care. 

30 



Rheumatology 

Fiona McCurdy 

f.mccurdy@nhs.net 

01224 554751 

Supported Discharge Service Stroke and Trauma Orthopaedics 

Beth Thomson 

beththomson@nhs.net 

01224 556401 

NHS Greater Glasgow and Clyde 

Call Centre Access and evening clinics popular with patients 

Paul Higgins 

paul.higgins@ggc.scot.nhs.uk 

0141 211 142 

Community Physiotherapy Services. Out-patient musculoskeletal 

services – Renfrewshire CHP 

Elizabeth Lightbody 

elizabeth.lightbody@ggc.scot.nhs.uk 

01505 821621 

The service provides specialist assessment and intervention to both in- and out-patients. The 

occupational therapy team has input into the Rheumatoid Arthritis Management Programme 

(RAMP) as well as the Adolescent Transition Service, to assist patients as they move from 

paediatric to adult services. The service is part of a multidisciplinary team, it offers an 

education programme for chronic fatigue management and provides specialist information 

for OTs working in community rehabilitation services. The service’s consultant uses a range of 

standardised measures. 

The service provides rehabilitation from OTs, physiotherapists and SLT within the patient’s 

own home for up to six weeks after early discharge from acute or specialist rehabilitation or 

intermediate care. 

Outcomes measured: individual professional measures, goal setting, service users rating own 

achievements. 

All podiatry primary and community care services use self referral or referral by another 

healthcare professional. All new patients referrals are by telephone using a single call centre. 

This operates daily from 9.00 am to 5.00 pm in the old Glasgow area (and some areas of Clyde). 

The model is used in some places for return patient appointments. It has proved to be popular 

with patients and was highlighted at a recent patient feedback day as top priority. This cannot 

be rolled out across the board area at the moment due to IM&T capability and capacity issues at 

the call centre. Evening clinics are also available where the DNA rates are close to zero. Access 

to services will be further simplified as part of a general AHP redesign. 

This service covers 30 GP practices and offers out-patients physiotherapy for most postsurgical 

and musculoskeletal problems. Patients are referred via their GP or other healthcare 

professionals. 

Outcomes measured: EMS, Tinetti. Record before and after completion of treatment in 

domicilary service. MSK use VAS etc. Injection-service-specific proforma and outcome. 

31 



ESP Orthopaedic Foot and Ankle Triage Service 

Paul Higgins 


0141 211 1425 

MSK Physiotherapy Service Review 

Heather Cameron 

heather.cameron@ggc.scot.nhs.uk 

0141 211 8562 

ESP orthopaedic foot and ankle triage services were set up in the community in 2004. 

Orthopaedic waiting times were around 18 months and the surgical conversion rate averaged 

30%. The service received the national AHP award for best innovative service in 2007. 

The service continues with a surgical conversion rate for foot and ankle patients of 90 – 95%. 

Permanent funding for the two whole time equivalent (wte) posts was secured in 2008. Patients 

wait a maximum of six weeks from referral to being seen. The service contributes to reduced 

orthopaedic waiting times, frees up consultant time, ensures patients are seen by the best 

person and provides a local service to the community. 

Over 72,500 patients are seen each year in the NHS Greater Glasgow and Clyde (NHS GG&C) 

physiotherapy musculoskeletal services. Currently delivered in 30 community sites and nine 

acute sites including clinics, health centres, hospitals, leisure centres, and other community 

centres throughout NHS GG&C. The MSK physio service employs 154.4 wte physiotherapy staff 

(75.19 wte in CH(C)PS and 79.21 wte in acute sector). 

A redesign of MSK services is currently underway, due for implementation early 2012 which will 

streamline services and improve accessibility and efficiency. 

Patients can access physiotherapy via a number of routes: self, GP or consultant referral. The 

majority of sites offer self referral – most patients use the telephone but some sites also offer 

drop-in sessions. 

Extended Scope Physiotherapists (ESPs) work across GG&C in acute hospital settings; the ESPs 

triage orthopaedic referrals and have a key role in patients pathways, ordering investigations 

and listing for surgery where appropriate. 

Glasgow Back Pain Service (GBPS) has a well established pathway for people with low back pain 

providing speedy access for those who may require it to specialist physiotherapy advice and/ or 

investigation / onward referral. This service has also recently been extended to include Clyde. 

32 



MSK Outcome Measure Proforma 

Karen Glass 

karen.glass@ggc.scot.nhs.uk 

Many MSK clinicians were only recording VAS pain scales as an outcome measure. Impact of the 

service on service users in any improvement in function, work or physical activity could not be 

demonstrated. 

Validated outcomes of pain VAS and function (from ‘patient functional scale’) were combined 

with non-validated outcomes related to work status and medication consumption and a record 

was kept of health improvement discussions: physical activity, alcohol intake, smoking and 

weight. 

Outcomes were recorded in discussion with the patient rather than strictly patient reported or 

therapist reported. The ‘new’ MSK outcomes proforma was piloted in February 2010 and with 

minor changes rolled out and audited in October 2010. The Clinical Governance Support Unit is 

processing the data and a draft report is now available. 

One Stop Rheumatology Foot Service – a partnership with Glasgow 

Caledonian University 

Mhairi Brandon 

mhairi.brandon@ggc.scot.nhs.uk 

The MDT foot clinic coordinates rapid investigations such as diagnostic ultrasound and gait 

analysis to facilitate treatment planning and evaluation. This clinic has been developed as a onestop 

shop, specifically for the management of patients with complex lower limb problems. The 

MDT foot clinic is linked with the Foot and Ankle Research Group based at Glasgow Caledonian 

University and provides the opportunity to undertake audit and facilitate research. The specialist 

experience gained by running this type of clinic will also provide the opportunity to develop 

capacity and capability in ultrasound imaging, injection therapy and research for AHPs. 

This one-stop approach resulted in 75% of patients not requiring any further input AHP 

input following that episode of care, 5% were fast tracked to Orthopaedics for a surgical 

intervention and 20% were sent for additional medical management relating to their ongoing 

rheumatological condition. 

Pain Services 

Aline Williams and Linda Sparks 

aline.williams@ggc.scot.nhs.uk 

Specialist physiotherapists work within the pain services in the acute division as part of a 

multidisciplinary team. In addition to providing specialist advice to patients they also deliver 

training and education to other MSK physiotherapists. A multidisciplinary pain management 

programme has been established. 

33 



Practice Development: laser, therapy, dry needling, deep enucleation, 

surgery and steroid injections 

Paul Higgins 


0141 211 1425 

Practice Innovations: patient stories, videos, phone follow up 

and the CARE measure 

Karen Glass 

karen.glass@ggc.scot.nhs.uk 

Orthopaedic Foot and Ankle Triage provides an alternative care pathway within the community 

for patients historically referred to hospital out-patient services. 

Dry needling is used as an adjunct to treatment for a wide range of painful foot conditions 

such as Hallux Limitus, heel pain, painful diabetic neuropathy, Plantar digital neuritis and Plantar 

Fasciitis. Particular benefit has been reported for those patients with podiatric conditions that 

have proved difficult to progress or resolve using traditional treatment methods. There are now 

26 podiatrists across NHSGGC trained in steroid injection therapy. 

The impact of projects using qualitative feedback from service users. Video, patient stories and 

telephone feedback of patient experience of self referral. 

Video and patient stories: patients were interviewed in their own home at a convenient time by 

the practice development physiotherapist and one of the service managers. Footage was edited 

down to approximately six minutes. This is a powerful tool for improvements but especially in 

explaining AHP services to non-clinicians and board members. 

Telephone feedback: a practical, relatively inexpensive way to get good quality qualitative 

feedback on a service. 

CARE: clinicians attended NES funded training on ‘empathy and engagement’. Following this 

300 measures were analysised. An opportunity arose to take part in a national reliability study of 

the CARE measure for AHPs led by the NMAHP Research Unit at Stirling University. 80 clinicians 

from the community are currently collecting CARE measures. 

Rehabilitation Service – Glasgow City Community Health 

Paul Higgins 


0141 211 1425 

The team was established in May 2011 and provides various aspects of MSK care via podiatrists, 

physiotherapists and OT staff. The rehabilitation teams were established to support integration 

of the current range of rehabilitation services. The team will provide a full co-ordinated 

assessment within the hospital or community. Treatment plans and reviews will take place within 

a patient’s own home, or other appropriate community or workplace setting. 

The aim is a single point of access, better pathways, local provision and patients seeing the 

right person first time. The service will deal with all levels of need, complexity and vulnerability, 

promoting self management and vocational rehabilitation. This will be underpinned by a full 

understanding of the inequalities and discrimination faced by patients and the wider public. 

34 



Training for Financial Inclusion and Employability 

Heather Cameron 

heather.cameron@ggc.scot.nhs.uk 

0141 211 8562 

Bespoke training was developed to assist AHP development and support staff working within 

acute MSK to signpost patients to appropriate services. The training aimed to: 

1 identify at assessment, people’s aspirations to stay in work, return to work or access 

employment 

2 develop a new focus on enabling the individual to achieve their employability goals 

3 effectively refer vocational rehabilitation and employability services. 

On evaluation, the training was well received with staff reporting increased confidence in 

their knowledge and skills. A resource manual was also developed to support sustainability of 

learning. 

NHS Highland 

Easter Ross Orthopaedic Triage Pilot 

Sue King 

sue.king6@nhs.net 

01349 852496 ext. 7398 

Easter Ross Orthopaedic Triage Pilot has been successful in meeting the original aims of the 

project: Improving compliance with the orthopaedic referral pathways and demonstration of a 

sustainable reduction in orthopaedic referrals from the GP practices. 

Funding to continue the Easter Ross Orthopaedic Triage service for a further six months was 

granted whilst Mid Highland CHP considers the long-term future of this pilot locally and its 

potential as a sustainable solution across the rest of Highland is evaluated. 

Other strands to the work were triage, Teach and Treat Clinic and patient-focused booking for 

physiotherapy. Project reports available on request. 

Hand Therapy and Splinting Service 

Karen Tolmie 

karen.tolmie@nhs.net 

01463 704293 

The Occupational Therapy Department, Raigmore Hospital in Inverness offers a hand therapy 

and splinting service to both in- and out-patients from throughout the Highlands. Patients are 

referred primarily by medical or allied health professionals. A range of conditions impairing hand 

function are treated including post elective or traumatic surgery and neurological conditions. 

Patients who are known to the service may initiate re-referral. The service offers specialist advice 

for AHP colleagues working elsewhere in Highland. 

35 



Hand Therapy for Orthopaedics 

Linda Currie 

lindacurrie@nhs.net 

01631 788971 

Mid CHP Podiatry 

Roddy Wells 

roderick.wells@nhs.net 

01397 709800 

South East Highland CHP Podiatry Service 

Michael Gates 

michael.gates@nhs.net 

01463 723250 

Provision of Occupational Therapy Handtherapy Services for orthopaedic clinic (LIH) and postsurgical 

therapy for patients discharged from NHS Greater Glasgow and Clyde Hospitals. 

Mid CHP Podiatry delivers services in nine locations. All referrals are accepted. There is a 

PEAK system for patient appointments and no electronic patient records. A New Activity and 

Waiting Times data collection system in place since February 2011 across all AHP disciplines. No 

recognised MSK specialist for Mid Highland CHP, but part-time post currently awaiting clearance 

by vacancy panel. All staff expected to carry out routine MSK assessments and treatments. 

MSK referrals continue to increase. 94% of new patients were seen within eight weeks of 

their initial referral. Most staff are trained in acupuncture and two staff to undertake foot and 

ankle steroid injections. There are plans to train staff up on x-ray interpretation as well as blood 

and biochemistry results. All staff have access to results reporting and PACs imaging systems. 

Functional orthoses are manufactured by clinicians on site and staff can refer on to the local 

Orthotic Department for footwear and the more palliative type of orthotic devices. All staff are 

able to refer directly to X-ray and Orthopaedics accept referrals. 

The plans for a dedicated MSK triage referral service are underway across Highland. At the 

moment South East Highland CHP is the only CHP without a recognised podiatric biomechanical 

/ MSK specialist. Other CHPs within Highland either have an individual already in place or have 

funding to put someone in place. 

NHS Lanarkshire 

Extended Scope Practitioner Service in Orthopaedic Out-patients 

Janie Thomson 

Janie.thomson@lanarkshire.scot.nhs.uk 

01355 585447 

A team of six physio ESPs, a podiatry ESP and one consultant physio provide assessment clinics 

for general MSK conditions which are unlikely to require surgery. These clinicians are able to 

request necessary investigations and are also qualified in injection therapy which can be offered 

as a treatment in both ortho and physiotherapy clinics. The same team provide complex case 

clinical reasoning clinics across Lanarkshire and also provide training and support on a one-toone 

basis with difficult physio/podiatry cases. 

Improvements measured: reduction in number of back pain cases seen in ortho clinics, reduction 

in ortho ESP waits, reduction in radiology requesting. 

36 



Low Back Pain Physiotherapy Pathway 

Christine McCallum 

christine.mccallum@lanarkshire.scot.nhs.uk 

01698 242615 

The lower back pain pathway was introduced in July 2010. All patients with LBP are either self 

referred or GP referred, they are assessed and treated according to an evidence-based, managed 

clinical pathway. There is a clear escalation policy for patients identified requiring further 

investigation or have complex needs. An orthopaedic spinal clinic run jointly by an ESP and an 

orthopaedic surgeon reviews all patients with more complex outcomes or who have had an MRI 

in order to provide a single point of exit from NHSL for surgical opinion if required. Exit routes 

to other services such as WHSS, pain clinic, and exercise classes are available with outcome 

measures assigned to each in order to evaluate the pathway and inform future service provision. 

Improvements measured: measurable reduction in inappropriate referrals to ESP ortho vetting 

system and reduction in waits. Resources were shifted to support the service through savings 

made. 

Outcomes measured: at present VAS, and clinical subjective and objective markers. STarT Back 

tool in use. Will shortly be using the EQ5D, Roland and Morris and HADS. 

Physiotherapy Assessment Line 

Ruth Currie 

ruth.currie@lanarkshire.scot.nhs.uk 

01698 723246 

The Physiotherapy Assessment Line (PAL) is a single-access telephone triage service for all 

adults living within NHS Lanarkshire with an MSK condition for which Physiotherapy advice or 

intervention may be of benefit. More than 60 experienced MSK clinicians have been trained and 

handle calls, with the service manned by up to 10 physiotherapists each morning. Calls last on 

average 15 minutes with the patient being thoroughly questioned and then managed in line 

with evidence-based treatment and local service pathways such as routine appointment, urgent 

appointment and emergency referral. 

Improvements measured: call data outcomes available from our database and telephone system. 

Outcomes measured: numerous outcomes are recorded including the call outcomes as 

mentioned above, the percentage of back pain referrals made, the percentage of patients asked 

to self manage, presenting conditions and demographics. A 22% increase in demand has been 

addressed with the same resource. 

37 



Podiatry Biomechanics Service 

Jim Logan 

jim.logan@lanarkshire.scot.nhs.uk 

01355 585447 

NHS Lothian 

East and Midlothian Physiotherapy Service 

Brian Brockie 

brian.brockie@nhslothian.scot.nhs.uk 

0131 536 8430 

2,500 new patients last year accessed the service by referral from GPs, Physiotherapy, Podiatry 

or other healthcare providers. No self referral. Patients are able to initiate a re-referral back 

into the system for an existing condition providing it is within an agreed timescale. Preassessment 

questionnaires are sent out prior to patients first visit. There are currently ten 

podiatrists providing biomechanics service across NHSL. A MSK foot and ankle pathway is under 

development and will provide direct links into orthopaedic services in NHSL. A change in stock 

procurement resulted in a 20% saving on the cost of orthotic devices. 

Provide a skilled, accessible and equitable musculoskeletal and rehabilitation service for the 

population of East and Mid Lothian, in a variety of settings. Provide users with timely and 

clinically effective care, including assessment, treatment and advice to elevate pain, maximise 

function and promote self management. Provide clinical education and specialist teaching to 

undergraduates and post graduates. 

Contributes to a hospital-based consultant out-patient clinic based in Roodlands by way of 

extended scope physiotherapy practitioners being part of a hospital multidisciplinary team 

consisting of orthopaedic surgeons, rheumatologist and MSK GPwSI to provide expert 

assessment and treatment. 

Edinburgh Community Physiotherapy Service 

Eddie Balfour 

eddie.balfour@nhslothian.scot.nhs.uk 

0131 536 9732 

Foot and Ankle, Orthopaedic Clinic 

Colin Thomson 

colin.thomson@luht.scot.nhs.uk 

Provide a skilled, accessible and equitable musculoskeletal and rehabilitation service for the 

population of the City of Edinburgh, in a variety of out-patient settings. To provide users with 

timely, individualised and clinically effective care, including screening, assessment, treatment and 

advice to alleviate pain, maximise function and promote self-management. To provide clinical 

education and specialist teaching to undergraduate and post-graduate physiotherapists and 

other healthcare professionals. 

This multi-professional clinic has access to diagnostic facilities including ultrasound, x-ray, MRI 

and bloods. Treatment may include exercises, referral for orthotic therapy or injection therapy. 

Some patients may require surgery. Manchester and Oxford foot pain questionnaire is used 

before surgery. 

38 



Podiatry Biomechanics Clinic (Edinburgh, East Lothian and Midlothian) 

William McMurrich 

william.mcmurrich@nhslothian.scot.nhs.uk 

0131 537 7463 

Spinal Practitioner Support to Orthopaedic Spinal Service 

Vivienne Boyd 

vivienne.boyd@luht.scot.nhs.uk 

0131 242 1946 

West Lothian Musculoskeletal Service 

Orla Crummey 

orla.crummey@nhslothian.scot.nhs.uk 

01506 522063/522057 

NHS National Waiting Times Centre 

Innovations in Orthopaedics 

Birgit Clark 

birgit.clark@gjnh.scot.nhs.uk 

0141 951 5193 

The podiatry service operates throughout Edinburgh, East and Mid Lothian CHPs. Patients 

may self refer or be referred by any healthcare professional. Initial assessment and treatment 

(including supplying orthoses) is provided in community settings. Further gait analysis, orthotics 

and injection therapy may be obtained from the in-house MSK/Biomechanics clinic. Orthotics 

are manufactured on site using Podiatry Department laboratory technicians. 

The spinal practitioner post supports the Orthopaedic Spinal Service by performing exactly the 

same tasks as the surgeon, providing the appropriate screening i.e. taking a history, clinical 

examination, ordering the appropriate investigations, making a diagnosis and arranging the 

appropriate management including putting the patient on to the surgical waiting list. 

This service incorporates a large physiotherapy department based in St John’s hospital at 

Livingston and physiotherapy centres in 12 outlying clinics in primary care (many of these are 

part-time clinics). St John’s offers hydrotherapy and a large rehab gym as well as one-to-one 

treatments. Two of the new-build health centres have larger departments with gym facilities. 

The service receives approx 12,000 new referrals a year and services a growing population of 

172,800. The population is increasing year on year (10% in the past 10 years). Referrals are 

from consultants, GPs and other health professionals. Self referral is possible in most centres. 

The patient caseload includes post-surgical, chronic pain, rheumatological, general MSK, A&E, 

and ENT (dizziness and TMJ) patients. 

The NHS National Waiting Times Centre in Clydebank is an NHS special health board which 

manages the Golden Jubilee National Hospital, the Beardmore Hotel and Conference Centre 

and the new Beardmore Centre for Health Science. It provides an elective service to help 

local NHS Boards meet their waiting time targets in key specialties. This service is available to 

patients across Scotland. The orthopaedic programme continues to grow year on year. From 

30 operations in 2002 the hospital performs 300 per month. The GJNH does 15% of all joint 

replacements in Scotland. It takes a lead in pioneering new techniques, e.g. computer-assisted 

orthopaedic surgery (CAOS) and The CALEDonian Technique (enhanced recovery) leading to 

four days length of stay following joint replacement surgery. 

39 



MSK Physiotherapist in Occupational Health and Orthopaedic 

Out-patients 

Kathryn Macpherson 

kathryn.macpherson@gjnh.scot.nhs.uk 

0141 951 5121 

Elective Orthopaedic Surgery 

Birgit Clark 

birgit.clark@gjnh.scot.nhs.uk 

0141 951 5193 

This is a split post between MSK physiotherapy in Occupational Health (90%) and Orthopaedic 

(10%) out-patients. It offers a dedicated musculoskeletal physiotherapy service and vocational 

rehabilitation for staff working at the GJNH and Beardmore. Staff can be referred or self-refer to 

the service. Staff who have their surgery at the GJNH can be referred through their consultant or 

GJNH physio. 

This is an elective orthopaedic service, based at the Golden Jubilee National Hospital (GJNH) 

managed by NHS National Waiting Times Centre, offering hip and knee replacements, some 

spinal surgeries and minor surgeries including ACL repairs, arthroscopies, meniscectomies, hand 

surgeries and foot surgeries. The Rehabilitation Department consisting of physiotherapists and 

OTs, supported by generic rehabilitation assistants provide pre- and post-operative intervention. 

Very few patients require referrals for out-patient physiotherapy, by following strict criteria. 

Patients are offered follow-up physiotherapy at GJNH or will be referred to a facility accessible 

closer to home. 

All patients are reviewed by the Arthroplasty Outcomes Team for their post-operative check up 

at six weeks or three months dependent on type of surgery, one year, five years and 10 years. 

The enhanced recovery programme known in-house as CALEDonian Technique encourages early 

mobility of patients post-surgery and improved length of stay. 

Improvements measured by internal audit. 

Outcomes used: pain scores, Oxford knee/hip scores, range of movement, day of mobilization, 

referral rates for out-patient care. 

NHS Orkney 

MSK Orthopaedic Triage Service 

Paula Hemsley 

paula.hemsley@nhs.net 

This was set up in January 2008 and modelled on the Raigmor service which offered training 

and their existing clinical pathways. It took some time to embed but is now fully accepted and 

has recently been extended to reviewing all the post-op total hip replacements. It freed up 

consultation time and improved surgical conversion rates. Triage is now embedded in the core 

service as of March 2010 at 12.5 hours per week. 

40 



Musculoskeletal Pathways, Balfour Hospital 

Peter Mackellar 

peter.mackellar@nhs.net 

Occupational Health, pre employment assesment and return to work 

Lesley Platford 

lesley.platford@nhs.net 

Rheumatology Telemedicine Link Clinic 

Lesley Platford 

lesley.platford@nhs.net 

The Physiotherapy Service is wide ranging: General MSK Outpatients ,Woman’s and Men’s 

health. Cardiac rehab and the telephone based follow up road to recovery programme for 

patients that wish to carry out their programme at home, Pulmonary rehab ,Rheumatology, 

Occupational health, Orthopaedic triage, Fracture clinic. Consultant lead orthopaedic clinics. 

Lead by out moving moving and handling therapist who is in an excellent position to advise staff 

of preventative and back saving advice. Staff identified with MSK injury are offered same day 

physiotherapy or at their earliest convenience. Regular updates are given to occupational health. 

Other Occupational Health Services offered are: 

1 pre-employment occupational health assessments 

2 ergonomic work station assessments 

3 return-to-work programmes. 

Since July 2010 there has been a rheumatology video link service with the consultant in 

Aberdeen. It is run once an month by a senior MSK physiotherapist. Additional training in 

injection will extend the service. The patients are seen jointly by the therapist and consultant 

and booked for further treatment at this clinic and given exercise advice at the time of the 

consultation. 

Publication of the results of this model of care is awaited. 

Video Capture Gait Analysis 

Richard Bailey 

richard.bailey2@nhs.net 


A gait analysis assessment procedure is currently being developed. Using a video camera to 

cache to a memory stick all the patient assessments done on a treadmill. Using pre- and posttreatment 

gait analysis as an audit tool to assess objectively the effectiveness of treatment. This 

information can also be sent to other practitioners who may be involved in their care, giving 

an excellent visual account of the patient’s problems. Data can be re-examined via slow motion 

replay in order to help augment appropriate treatment plan. 

Gait analysis is offered as part of routine physiotherapy assessment. 

41 



NHS Shetland 

Musculoskeletal Podiatry Service 

Bruce McCulloch 

bruce.mcculloch@nhs.net 

01595 743202 

This service is based on a joint approach to patient care with physiotherapy, orthotics and 

medical imaging. Clinics take place in an out-patient physiotherapy department with access 

to plain x-ray to support diagnosis via direct referral to medical imaging. Our practitioners are 

qualified to prescribe appropriate medication for patients using the service. 

Improvements measured: suggestion made about the language used in the original leaflet and 

subsequent changes were made and approved. 

Outcomes measured: number of processes in the patient journey following the LEAN method, 

and a time and cost analysis. 

Occupational Therapy Service 

Occupational Therapy Service 

duty.ot@shetland.gov.uk 

01595 744319 

This service evolved when services were merged in 2009 because of lengthy waiting lists and 

duplication of processes. It operates an open referral system for patients suffering any condition 

resulting in a functional difficulty with performing daily living activities. 

NHS Tayside 

Advanced Physiotherapy Practitioner and GPwSI, MSK Primary Care 

Triage Service 

Janice McNee 

janice.mcnee@nhs.net 

01382 425668 

This service offers a twice-weekly clinic which can accommodate up to 15% of all patients 

who are referred to the Physiotherapy Department. The clinic demonstrates a successful 

multidisciplinary approach in that APPs, podiatrists and GPwSI all share knowledge ensuring a 

cost-effective service with an improved patient journey. If patients require onward referral all 

investigations have already taken place, therefore waiting times are minimized. With the ability 

to order diagnostics other conditions, e.g. ovarian cysts and brain tumours, have been identified 

enabling patients to access the most effective management sooner. 

Improvements measured: reduction in orthopaedic waiting times, number of referrals to 

secondary care. 

Outcomes measured: survey in 2008 showed health outcomes improved measurably with 95% 

of patients assessed saying that they had improved VAS recorded before and after completion of 

treatment. 

42 



Injection Therapy Expansion 

Janice McNee 


01382 425668 

Injection therapy has been used as a treatment option since 2001. The Patient Group Directive 

allows independent supply and administration of appropriate medication. Baseline information 

is recorded including medication name, dose and manufacturer’s number, and then forwarded 

to the patient’s GP for information. 

Improvements measured: reduction in orthopaedic waiting times and number of referrals to 

secondary care. 

Outcomes measured: VAS, and patients’ perception of normality. 

Musculoskeletal Out-patient Services – General 

Angela Murphy 

angelamurphy@nhs.net 

01241 822514 

Lower Limb Biomechanics Clinic 

Mike Black 

mikeblack@nhs.net 

01382 425668 

Orthopaedic Screening in Secondary care 

Janice McNee 


01382 425668 

Rheumatology 

Alison Knight 

alisonknight@nhs.net 

01382 425668 

General MSK out-patient services are provided across Tayside. Five departments in Angus (in 

each of the towns), two departments in Dundee (one in acute hospital and one in community 

health and care centre) and five departments in Perth and Kinross (in the city and towns). Each 

area accepts referrals from GPs, consultants, other healthcare professionals, and self referral. 

Biomechanical clinics are staffed by a podiatrist and physiotherapist, combining the knowledge 

and skills of podiatry and physiotherapy to assess and treat patients with lower limb disorders 

associated with changes in the functional structure of the ankle/foot complex. The aim is to 

improve the patient journey and reduce waiting times for each discipline by providing a holistic 

package of care. This service is based in Dundee but accepts referrals from all Tayside. 

Physiotherapists screen referrals coming into the Orthopaedic Department, provide assessment, 

diagnosis and treatment of patients referred to Orthopaedics by Tayside GPs. 

A one-stop multidisciplinary inflammatory joint disease clinic where patients are immediately 

assessed and treated appropriately. Patients can be discharged by physiotherapists and OTs 

thereby reducing consultant waiting lists and improving patient care. 

Improvements measured: reduction in rheumatology waiting times. 

Outcomes measured: VAS recorded before and after completion of treatment. 

43 



Trauma and Elective Hand Clinics 

Sarah Dalgleish 

sarah.dalgleish@nhs.net 

01382 425668 

These plastic surgery hand clinics are staffed by OTs and physiotherapists, who assess and treat 

patients appropriately and are then able to discharge them without consultant follow up. This 

enables waiting lists to be reduced and improves patient care. 

Improvements measured: reduction in plastic surgery waiting times. 

Outcomes measured: TAM scores, VAS recorded before and after completion of treatment. 

Virtual Ward (Community Rehabilitation) 

Denise Connon 

denise.connon@nhs.net 

01382 425665 

The aim of the virtual ward construct is to provide a co-ordinated, multidisciplinary approach 

to identifying people living with long-term conditions and to intervene earlier in their disease 

trajectory to improve quality of life and reduce use of unplanned health and social care services. 

The principles of the Virtual Ward have been prioritised in NHS Tayside through Steps to Better 

Health and recently aligned within new overarching Integrated Community Services (ICS) work 

streams in each CHP. 

Four Dundee and three Perth practices are involved in the first wave. 

Working Health Services 

Cathy Grieve 

cathy.grieve@nhs.net 

01382 825100 

This new NHS service was launched in 2008, it aims to assist employees (who live and/or work in 

NHS Tayside) of small to medium-sized enterprises (SMEs) to remain in or return to work quickly 

after a period of absence. SMEs are companies with less than 250 employees and most do not 

provide access to Occupational Health services. The service offers access to a range of services 

including physiotherapy, case management, occupational therapy and counselling. 

Outcomes measured include: COPM, EQ5D and HADS, assessments are completed at entry and 

discharge from the programme. 

44 



NHS Western Isles 

Musculoskeletal Physiotherapy, class-based exercise groups 

Sheila Nicolson 

sheila.nicolson@nhs.net 

Self Referral Clinic at the Physiotherapy Department 

Sheila Nicolson and Nico Groenendijk 

sheila.nicolson@nhs.net 

nico.groenendijk@nhs.net 


Physiotherapy Services across Western Isles 

Nico Groenendijk 

nico.groenendijk@nhs.net 

01851 704704 ext. 2258 

Following an audit of the type of condition referrals to OP MSK Physiotherapy, class-based 

exercise groups have been initiated in the Physiotherapy Department, Western Isles Hospital. 

A Back to Fitness class was commenced in June 2009 for clients with chronic low back pain. A 

Lower Limb class was commenced in July 2010. Both of these classes are led by a physiotherapy 

clinical support worker. The classes are based on six weekly circuit classes, consisting of warmup, 

stretches, circuit-based exercise and relaxation. All clients are assessed prior to attending 

the classes, clients for the Back to Fitness class using the Roland-Morris Disability questionnaire, 

clients for the Lower Limb class, using both the KOOS knee survey or the Aggregated 

Locomotor Function (ALF) score. These classes are audited regularly and the outcome of 

attendance assessed. Overall the outcomes and feedback are excellent. 

There is a weekly self referral clinic at the Physiotherapy Department, Western Isles Hospital, 

Stornoway. This commenced in September 2008. This drop-in clinic allows patients to self 

refer to Physiotherapy without having to attend their GP first. The DIC operates every Thursday 

afternoon, from 3.00 pm to 5.00 pm. 

By July 2011 approximately 3,000 attendees had self referred via this route. Ongoing patient 

satisfaction surveys of DIC clients indicate that this service is well received, feedback has been 

very positive. 

NHS Western Isles Physiotherapy Department employ an extended scope practitioner, who 

works in the orthopaedic clinic and fracture clinic. The ESP currently vets the orthopaedic 

waiting list and is able to assess and treat patients directly from this list. He is also able to list for 

surgery, administer cortico-steroid injections, refer onwards to other specialised centres, request 

plain x-ray, CT and MRI and ultrasound. The ESP routinely reviews all post-elective arthroplasty 

patients and post-operative hip fractures in the orthopaedic clinic. This service has helped to 

reduce orthopaedic waiting times and provides a more streamlined service. 

There are discussions taking place as to how the ESP post could support a remote rheumatology 

service to NHS Western Isles in the future. 

45 



Podiatry Musculoskeletal Service – Western Isles 

Sarann Macphee 

smacphee1@nhs.net 

01851 704704 ext. 2289 

Western Isles Podiatry Service offers musculoskeletal services in a number of forms. The 

biomechanics clinic is based at the Western Isles Hospital and offers a specialised assessment 

service and management for lower limb musculoskeletal pathologies or gait dysfunctions. 

Referrals for the clinic may originate from the areas of rheumatology, orthopaedics, paediatrics, 

fellow podiatrists, allied health professionals, GPs and patient self referral. This clinic is 

conducted by the musculoskeletal specialist podiatrist. Joint consultations with fellow clinicians 

can be arranged to ease the burden of multiple visits on the individual and aim to improve 

clinical outcomes. This activity most frequently occurs with the paediatric physiotherapist. 

All clinicians in the department are specialist general practitioners as a minimum and as such are 

experienced in the management of general biomechanical and musculoskeletal complaints. This 

permits wide and frequent patient access through outreach clinics. There is a continuous audit 

cycle of orthotic provision and effectiveness. 

A specialised orthotic manufacturing laboratory is located at the Western Isles Hospital which 

allows clinicians to make, adjust or provide custom functional and accommodative or modified 

pre-made appliances, greatly aiding compliance, and the speed/ease of modification. This asset 

is also utilised by the visiting orthotist service. 

46 



Glossary 

ACL 

Anterior cruciate ligament 

MCN 

Managed Clinical Network 

AHP 

Allied health professional – a who’s who can be found at 

MDT 

Multidisciplinary team 

www.scotland.gov.uk/Topics/Health/NHS-Scotland/chpo/whoareahps 

MRI 

Magnetic resonance imaging 

CARE 

CH(C)PS 

The Consultation and Relational Empathy (CARE) measure, an 

outcome measure supported by Scottish Government 

Community Health (and Care) Partnerships 

MSK 

MYMOP 

Musculoskeletal (to do with muscles, bones and joints) 

Measure your own outcome profile – a patient-completed outcome 

measure 

CHP 

Community Health Partnership 

NMAHP 

Nursing, Midwifery and Allied Health Professions 

COPM 

Canadian Occupational Performance Measure 

OA 

Osteoarthritis 

CT 

Computerised tomography scanner 

OT 

Occupational therapist 

DAPOS 

DASH 

EMS 

ENT 

Questionnaire designed to measure depression, anxiety and positive 

outlook in people who suffer from pain 

A shoulder outcome measure 

Elderly Mobility Scale 

Ear nose and throat 

PACs 

PMS 

PT 

STarT Back 

Picture archiving and communication system 

Patient management system 

Physiotherapist 

Back pain specific screening tool developed by Keele University 

available at www.keele.ac.uk/sbst/ 

EQ5D, EQ5D5L 

ESP 

GPwSI 

HADS 

IM&T 

IT 

KOOS 

LBP 

Standardised quality of life outcome measures available from the 

EUROQOL group (www.euroqol.org) 

Extended scope practitioner 

Genereral practitioner with special interest 

The Hospital Anxiety And Depression Scale 

Information management and technology 

Information technology 

Knee and Osteoarthritis Outcome Score 

Low back pain 

STarT MSK 

TAM 

THJR 

TI 

TMJ 

TSK 

VAS 

WOMAC 

General MSK screening tool under development at Keele University 

Total active motion 

Total hip joint replacement 

Technical instructor 

Tempromandibular Joint 

Tampa Scale of Kinesiophobia 

Visual Analogue Scale 

The WOMAC® Index s self-administered score and assesses the 

three dimensions of pain, disability and joint stiffness in knee and 

LEAN 

A production practice that considers the expenditure of resources 

hip osteoarthritis using 24 questions. 

for any goal other than the creation of value for the end customer 

to be wasteful, and thus a target for elimination. 

47 


over 

1 million 

people each 

year see their 

GP for an MSK 

condition 

15,000 

people had hip 

and knee replacement 

operations in 2010 

7,000 more than 

in 2000 

5.2 

million 

people live 

in Scotland 

Over half a 

million people 

see their GP 

for back pain 

each year 

over 400,000 

referrals into 

AHP MSK services 

each year

Joint effects 2011 - An update of the involvement - 18 Weeks

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