Dundee streamlines services

Lynn Eaton meets the Dundee physios who work together to provide an all-round service without wasted referrals

Jam, jute and journalism are, as anyone from Dundee will tell you, the three things the city is most famous for. But to that, historians may want to add another item: the physiotherapy department.

The city, built on the Tay, was once the centre of the jute manufacturing industry. Dundee marmalade is famous worldwide. The publishing house DC Thomson, which produces The Beano and The Dandy among other classics, still has its headquarters there.

And in Dundee’s Hilltown area, advanced physiotherapy practitioner Janice McNee is one of a team that has worked to build up an innovative community therapy centre in the grounds of a former isolation hospital.

After years in which physios were scattered around the city, the entire community physiotherapy team now works together from one dedicated building on the site of King’s Cross hospital.

The unit also houses a community dental team, audiology department, X-ray department and occupational therapy team. Crucially, it has a dedicated GP working there one day a week who has a special interest in musculoskeletal conditions.

Team work

Janice, who is deputy head of community therapy services at Kings Cross Health and Community Care Centre, Dundee, is keen to emphasise the wide range of work that is being carried out by the team.

One initiative, with the occupational therapy team, is a ‘virtual ward’. It’s the name given to a meeting held each week by key community staff. They decide what support is needed for older people in the area who have been identified as, for example, being at risk of falls.

They offer more intense support in a crisis, aiming to prevent hospital admission, or will step down if the person’s condition improves and high-level care is no longer needed.


Healthier tomorrow

Down the corridor, band 6 physio Cat Moulton has just seen a patient under the Scottish Centre for Healthy Working Lives initiative.

The service, offered free to local businesses employing fewer than 250 staff, was set up after Dame Carol Black’s 2008 report ‘Working for a Healthier Tomorrow’ revealed that many small businesses were struggling to keep people at work. Dundee took part in a trial set up in 2008 to provide an NHS service to support employers.

‘We get a lot of office workers and people who have back problems,’ says Cat. ‘The patients love it.’

The neurology department on site has a piece of equipment that enables staff to measure balance, but physios can also use it to check a patient’s gait and measure their risk of falling.

The physios can also offer their patients easy access to the X-ray department, just around the corner. Results can be available in 20 minutes and the patient will know immediately what the likely problem is.

‘The service we offer is not unique,’ says Janice. ‘What is unique is that we’ve got the backing of senior staff.’

The ethos of the clinic is that patients should not be drawn unnecessarily into a ping-pong referral process.

Previously, it was not uncommon for patients to be referred by their GP to an orthopaedic surgeon, who would decide it wasn’t an operation issue and refer them back to the physio department. Sometimes the physios might spot a red-flag issue and refer the patient back to hospital to see, say, an oncologist.

Appropriate intervention

Now, the streamlined process aims to reduce unnecessary orthopaedic-surgeon referrals and allow more appropriate, and earlier, intervention by physios. It has done this by building confidence among local GPs to refer patients to the community physio team instead of to the orthopaedic surgeon.

‘The GPs are generalists,’ says Janice. ‘They are not experts in everything. We are the experts in musculoskeletal issues.’

It wasn’t easy to persuade GPs to turn to physios rather than their doctor colleagues – and the physio team had to launch a huge marketing campaign to persuade them to try the new approach.

Triage on A4

Physio Freddie Warden was instrumental in setting up the one-stop clinic. He tells how, back in 2004, they went out and explained to local GPs how they could improve the service for patients. Then GPs started to ask more about how best to refer appropriately, and to understand MSK conditions more.

‘They wanted us to tell them about each condition, and who they should refer to us rather than to the orthopaedic surgeon,’ he says. ‘We designed a single A4 document to show them – triage on an A4 sheet,’ he jokes.

Second opinion

Having a GP with a special interest in MSK as a member of the team has been fundamental in making it work, Freddie  believes.

Dr Niall Elliott, who works the other four days of the week as the medical officer for Scotland’s National Institute for Sport, is able to look at patients when physios need a second opinion. This may be because the patient is taking a number of prescription drugs that may be interacting, or there is a potential red-flag issue. He can, of course, prescribe painkillers and carry out steroid injections, which the physios aren’t qualified to do.

‘The physios learn from the GP,’ says Freddie, adding that it’s a two-way process. ‘To see patients from a GP’s perspective has been incredibly helpful,’ he says.

The challenge now is to carry out an effective audit of the outcomes from the project, says Freddie, who’d like to see the service rolled out across Tayside, initially with clinics in Perth and Arbroath.

The fear was that they might just end up creating a demand on physios that could not be met, rather than just reducing the pressure on orthopaedic surgeons.

However, although initially the clinic saw an increase in the number of referrals from about 600 to 800 a month, that has now fallen back to the original level.

Dr Elliott, meanwhile, estimates he is currently seeing about 400 patients a year, although he doesn’t see all the referrals himself.

Dr Elliott initially volunteered for the post before his role was formally incorporated into the staffing structure. He comes in on a Thursday and sees patients whose conditions have given either their GP or one of the physios cause for concern.

‘Surgeons don’t have time or inclination to advise on issues that don’t require surgery,’ says Dr Elliot. ‘They want the cutting time.’ fl


'A very good service'

On the day I visit, a patient came to vist Dr Elliott for the first time, complaining of a pain in her hip. Jean Wilkie has had strong pain for more than ten months, particularly at night.

Her GP has tried to treat the condition, without success. Jean later tells me she was worried she might need a hip replacement. Dr Elliott is more concerned that the pain could be a red flag for something more serious.

After an initial consultation, Jean goes to have an X-ray done in the same building. Half an hour later she is back in the consulting room with Dr Elliott, who gives her the results.

The X-ray shows she has a slightly curved spine, which is causing other parts of her body to overcompensate. He suggests a course of four physio sessions.

‘Last year I thought it was sciatica, then this pain started up when I went to bed at night,’ says Jean. ‘I just thought it was my arthritis. My doctor sent me for an X-ray but they said it was fine.’

Clearly relieved by the results of her visit to the Kings Cross centre, she says. ‘The service has been very good.’ 

Lynn Eaton

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