Julia Tabrah has been given the task of slashing MSK waiting times across London. She tells Mark Gould how she never lets obstacles get in the way
Julia Tabrah says she enjoys the challenge of bringing people together to improve patient care. The consultant musculoskeletal physiotherapist has been appointed NHS England Community MSK Lead for London, with a brief to develop a capital-wide strategy to reduce waiting lists and improve accessibility.
Julia, also allied health professions advanced practice lead at Hounslow and Richmond Community Heath Trust in west London, rushes through an impressive CV of leadership achievements.
She cites a body of important clinical research work including a paper on degenerative cervical myelopathy and another which found that digital rectal examination is no longer necessary to detect cauda equina compression. ‘Getting this embedded in the
Getting It Right First Time (GIRFT) national suspected cauda equina syndrome guidance is one of the proudest achievements in my career,’ she says.
When not running weekend lectures on complex spinal triage she enjoys amateur dramatics, dancing and travelling with her husband and children.
Lancashire-born Julia admits to occasional thoughts of imposter syndrome – luckily overcome by a never-say-die attitude when it comes to tackling problems.
She only became a consultant two years ago, having paused her career while her children were young.
‘When they offered me the consultant job, I nearly fell off my chair. I thought little old me doesn’t get these jobs. I think I got it because I am really ambitious about pushing boundaries, willing to feel the fear and do it anyway.
'If I ever reach a wall, I always try to climb underneath or around it, negotiate through it or build a team to volley me over it. I still pinch myself when I get feelings of imposter syndrome, but it’s less of an issue now because I can see that I am adding value.’
A new challenge
The London role was advertised at a point when Julia was ready for a new challenge.
‘I saw the job advert and thought my odds were slim. I could only tick 70 per cent of the boxes on the job description, but by some miracle I got it – I was so shocked because I’m not great at interviews. They said I had bags of experience, but I was also super passionate about what I do,’ she says.
The London brief is a tough one with some areas reporting waiting times of over a year for non-urgent appointments. The target is to hit 12 weeks for routine appointments and two weeks for urgent by 31 March, which Julia says will be a ‘massive challenge’ for some services.
She is implementing some of the successes which has seen her current trust get waiting times down from 23 to eight weeks with a combination of blitz clinics, expansion of Patient Initiated Follow-Up (PIFU), Waiting Well and setting up community/secondary care MDTs.
‘I have been able to share a lot of things that have been successful here in Hounslow and Richmond, but also share the lessons of what didn’t work.’
Under the traditional PIFU model (previously known as SOS), patients were discharged with an open ticket to come back within six or 12 weeks if problems persist without having to endure a new referral process.
Now with the help of a stakeholder group, PIFU has been extended up to six months which she says ‘massively reduces re-referrals’.
‘If you give someone a six-week safety net and they flare up two months down the line then they end up having to be re-referred and re-assessed which is very time consuming.’
The dashboard would allow clinicians and managers to compare and contrast services and learn from each other, identify pockets of excellence but also services that are struggling and need support
A self-management resources dashboard is also being created around the Waiting Well model to help patients manage their condition while they wait for treatment. Work is also underway to develop a ‘how to guide’ to setting up multidisciplinary arrangements across places with best practice case studies.
Once waiting times have been improved Julia outlines objectives around improving accessibility, reducing health inequalities, developing a first contact practitioner clinical governance scorecard, looking at workforce expansion and creating a London-wide MSK data dashboard.
‘The dashboard would allow clinicians and managers to compare and contrast services and learn from each other, identify pockets of excellence but also services that are struggling and need support.’
Chiming with the CSP’s work on raising awareness and reducing microaggressions, Julia has also developed a ‘difficult conversations framework’ to help tackle regular but unintended discrimination. It came about as a result of a WhatsApp group in which a physio mentioned the colour of a patient’s skin when it bore no relevance to the consultation.
Created in partnership with a range of stakeholders, the six-stage framework sets out how to prepare for the conversation, deciding the appropriate person to initiate it and how the subject will be broached, coming to a solution and more support after the conversation.
‘As a result, we can constructively challenge unintentional discrimination, so people are given the time and space to realise where they went wrong and reflect and change their behaviour. The framework was launched in pilot form last year and is hoped to be available London-wide.’
Julia is passionate about improving how clinicians pass on bad news to patients. It comes from painful personal experience when her father was critically ill.
‘A medical registrar just happened to tell my dad that he had a massive tumour in his throat. Dad was on his own, none of the family around and the registrar launched that hand grenade at him on a busy ward round without any kind of TLC or empathy.
'That is not the fault of the registrar, it’s a failure of the system in not giving professionals good difficult conversations training. It’s absent from physio degrees and just not well done in medical and nursing degrees. It’s something you are expected to learn on the job.
We had an issue where our local GPs asked us to lead on breaking bad news to patients, when MSK imaging unexpectedly shows cancer or suspected cancer. This is not traditionally ‘within scope’ for physiotherapists, so there was a lack of confidence and experience in the team.
Julia led a scoping review to understand what other MSK triage services were doing across the UK and built a stakeholder group of GPs, physios, cancer nurses and oncologists.
She led negotiations and was able to agree a case-by-case pathway, with shared decision-making based on the best interests of the patient. She worked with a nursing colleague to design and deliver a bespoke training package on breaking unwelcome news to the advanced practice physiotherapists, and this boosted their confidence enormously. The cancer pathway has now been running successfully for nine months and is hands down one of her proudest achievements to date.
Julia admits that it can be difficult to satisfy the competing interests of her role.
‘Sometimes my job is to make people realise the truth is somewhere in the middle. Sometimes I have to make difficult and unpopular decisions for the greater good. It’s not always easy but I do love a challenge and this role is no exception.’
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