Saving time and space

Robert Millett speaks to two specialised paediatric physios about how their service changes have improved patient outcomes 

Changing pathways
Nikki Shack, a clinical specialist paediatric physiotherapist, and Claudia Backhaus [David Harrison]

Nikki Shack, a clinical specialist paediatric physiotherapist, and Claudia Backhaus, a highly specialist paediatric physiotherapist, are both based at the Royal Free Hospital in London.

Since 2019 they have been working closely with Camden’s health visitor team to run an innovative paediatric physiotherapy assessment clinic which sees patients five times a month in the local community. Their collected data, along with feedback from parents and staff, not only demonstrate clinical benefits, it also indicates how their service changes are saving space and time – for GPs, physios, health visitors and the families of the children they treat.

We spoke to Shack and Backhaus to find out more about their work and discover how other physio services might be able to learn from their new way of working.

From July 2020 to December 2021 53% of patients had one appointment of assessment advice and reassurance

What kind of work do you do?

We provide a regular, community-based clinic for under two years old in the London borough of Camden.

The patients we see are babies whose parents and health visitors have concerns with regards to their gross motor skill acquisition, as well as babies with undiagnosed torticollis and under twos whose parents may have concerns about how they walk or how their walking is developing.

How does your service work? 

We run five paediatric physio clinics a month for 0-2 year-olds, and the average number of bookings per clinic is six patients.

The appointments are booked directly by health visitors in Camden if they and the parents have concerns about a child.

Commonly we see infants with congenital torticollis and plagiocephaly, neonates with concerns regarding foot position, infants struggling to meet their developmental milestones and concerns about toddlers’gait.  

Each appointment is 30 minutes long and they take place in a community clinic alongside the health visitors’ clinics. We also provided video consultations when the clinics were closed due to Covid-19, but now we are back to face-to-face appointments.

26% of patients required a maximum of 3x30 minute sessions and a formal referral into physiotherapy

Where are the clinics held?

They are all held in a community health centre alongside the health visitors’ clinics, rather than in our physiotherapy space.

Treatment space is a massive issue for health care professionals, so having access to community clinic rooms for a half a day, five times a month is fantastic.

What happens during appointments?

We listen to the parents’ concerns and assess each patient. Our pathway then usually leads to one of three possible clinical outcomes. The parents are either reassured and the child is then discharged [if they require no treatment], or the baby or child is provided with a maximum of three further physiotherapy appointments in the health visitor clinic. Alternatively, when required, they start physiotherapy in the clinic and are formally referred into the service for a block of full physiotherapy appointments.

So is this pathway more efficient?

Yes, we now save on appointment time. Over the time period that we collected data we had 365 appointments that were attended, out of a total of 442 appointments booked. Each appointment was 30 minutes long. If all of those had been referrals into our physiotherapy service they would have amounted to 365 hours – instead we had 182.5 hours of clinical time. By offering shorter appointments we are able to determine early on if patients need further physiotherapy or if they just need advice and reassurance.

This model is time efficient, and we’ve had really good parent feedback, as they are seen quickly and they say they feel listened to.

How does your service differ from what was done before and what usually happens elsewhere?

One of the things that makes our service unique is our patients appointments are booked directly by health visitors, rather than GPs referring them to physiotherapy.

Our traditional referral route was via GPs. Families would book a GP appointment, which would usually involve a waiting time of maybe two or three weeks. The GP submitted a physiotherapy referral, and then the families might have to wait another three or four weeks before they saw a physio. So, it could take up to six weeks from the initial GP referral for a child to be seen by a physiotherapist.

For parents, who are concerned that something is wrong with their child, that’s quite a long time of worrying. The current waiting time for our physiotherapy health visitor clinic is between one to three weeks on average. This means that families’ concerns are being addressed much earlier on and without over-medicalising their concerns.

Another advantage is that the health visitors don’t need to fill in lengthy referral forms to book appointments.

85% video consultation attendance

Now they share the same notes system as us, so they just have to write a sentence as to why they are booking and agree the appointment with the parent/ carer. Sharing the notes system also means we can easily see what they have written previously.

What have been some of the benefits for the children and for their families? 

For our patients and their parents it means that (if needed) they can start physiotherapy much earlier and receive early physiotherapy intervention.

Our clinics enable babies, for example with torticollis, to be seen before the age of three months, whereas previously the average age of infants formally referred to the service was four to five months. But by that point, the asymmetry of an infant with torticollilis is already established and treatment may be less effective – and there is strong evidence for better outcomes with early intervention.

A very small percentage of patients with torticollis who present to physiotherapy as older babies, require surgery to release the affected muscle, but the evidence shows that the earlier there is intervention with physio the better the outcome. We have found that starting treatment for torticollis early on also reduces the number of future appointments. So the clinic has improved the outcomes for those having early referrals and really changed our caseload.

Another example of the benefits is when we see babies who have talipes, which is a congenital foot condition. With those cases it’s ideal to start treatment at around two weeks of age, for both physiotherapy treatment and orthopaedics. Because we are now seeing and assessing those babies much earlier we are able to start their treatment sooner – and it’s much easier to do when they are at that age.

The booking system is now very easy, as parents can book an appointment directly with their health visitor when they see them, and the families we see feel listened to and are seen early on when they are really worried and want to engage with services.  Also, if a physio programme is needed, it can start immediately - so concerns are addressed straightaway.

Similarly, if a child’s care needs to be escalated to OT, paediatrics or speech and language therapy, if there are concerns about motor disorders or communication disorders, there is now a seamless referral route.

How does it benefit your physio service and other clinicians?

The appointments we offer are much shorter than full physiotherapy first appointments (which are usually one hour) as they last 30 minutes, which is particularly beneficial if the appointment is to provide reassurance only. This makes the service both cost effective and time efficient.

Our clinic also reduces the number of patients who are formally referred to physiotherapy, which reduces our waiting list. And we have seen a reduction of referrals into physiotherapy for patients who only need a brief assessment and advice instead of a formal referral.

On reviewing our data, we found that only 26 per cent of our patients are now formally referred onto physiotherapy. We are also now able to see more patients in a shorter time, as it’s much more efficient in terms of time, paperwork and saving GP’s time – as the GPs are often no longer part of the equation.

Since returning to face to face appointments our attendance rates have also improved. Between July 2020 to December 2021, 442 patients were booked with an attendance rate of 85 per cent. The attendance was very good, considering these were virtual appointments only. 

But we’re now back to face-to-face appointments and we’ve seen an increase in attendance, so we now have a 93 per cent attendance rate – which is much higher than you’d get in a normal clinic.

Treatment space is so difficult to find, but out clinics are booked by the health visitor and held in their allocated clinic space, which resolves space issues for paediatric physiotherapists.

It has also led to enhanced relationships with the health visitors - and their feedback about the service has been excellent.

And for us, as the physios running the service, it is a fast paced, enjoyable and varied clinic.

How has the service helped to reduce health inequality gaps?

This rapid access service is open to all families who engage with our health visiting team.

In Camden we have many transient families in homeless family/hostel accommodation who are moved on to other areas very quickly, and this can result in their babies missing out on support services.

21% of patients attended 1-3x30 minute sessions for assessment, advice and treatment

If these families have concerns about their under two year olds, they can now be seen quickly by our service and also be given advice about how to access other related services if they’re moving on and leaving the area.

Do you have any advice for other physios or teams who may want to adopt a similar model?

Yes. Talk to your local health visitor managers, as this clinic is easily reproducible. It’s not heavily resource based – all that is needed is a room, a desk, a computer, a mat and some age-appropriate toys.

If you are able to set up these type of clinics we would suggest if you work in a large borough, where there are many clinic locations, it may be useful to initially set up clinics in a variety of health centres, review attendances and then decide which locations are the most appropriate for service provision.

This clinic promotes joint working and opportunities to learn from one another. It improves communication between the services and we now have a really good relationship with our local health visitors. 

At each clinic the physiotherapists offer either:

  • assessment, advice and reassurance.   
  • assessment, advice and a maximum of 3 x 30 minute physio sessions to resolve the issue.
  • or assessment, advice, a maximum of three physio sessions and a formal referral into physiotherapy.

Feedback from health visitors team 

Emily Espley, specialist community public health nurse: ‘It’s absolutely brilliant! It helps with our learning and makes the referral process easy/less formal and likely helps with engagement.’

Maggie Waters, head of Camden health visiting service: ‘It’s an excellent example of joint working, meets a huge need, having specialist advice without medicalising. It is more successful than expected.’

Kirsteen McDonagh, specialist health visitor for homeless families: ‘It’s very useful to have a service without a huge referral form.’

Gina Miller, specialist community public health nurse: ‘Parents have found it useful and informative, and good to have a quick appointment.’

Lucy Briggs, specialist community public health nurse: ‘A positive experience for parents. Easy to access. Parents really like the quick appointments and they feel it’s easy and informative.’

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