Improving patient journeys and utilisation of NHS capacity by re-designing referral pathways in total hip and knee arthroplasty


Aim: - Collaboratively explore new referral pathways and processes to utilise NHS hospital capacity and reduce waiting times by removing the e-Referral Service (ERS), formally Choose and Book, administrative timeframe for patients requiring total hip or knee arthroplasty in Staffordshire.

Objectives: - Encourage consistent, collaborative working across primary and secondary care in Staffordshire - Increase referral rate to local NHS orthopaedic services, offering appropriate patients meeting inclusion criteria, direct referral - Explore reasons patients did not wish to participate

agreed to direct referral for surgical consideration at the dedicated site.
Average wait of 14.9 weeks
from referral to surgery


Four musculoskeletal (MSK) services and an acute orthopaedic provider in Staffordshire co-created and agreed a list of clinical criteria for patients appropriate for direct referral into an orthopaedic arthroplasty clinic at a designated NHS Hospital, rather than referral via ERS. Inclusion Criteria consisted of; age 65 and over, previous unsuccessful conservative measures, severe osteoarthritis (OA) radio-graphically and symptomatically. Clear exclusion criteria were defined. All patients referred by MSK for consideration of joint replacement were included, those who met the criteria were offered direct referral. Data was collected between June 2019 - April 2020, using an online survey tool and patient journeys were tracked and analysed.


Results: Collaboration between MSK services, commissioners and an NHS orthopaedic provider was observed across a large geographic region, to co-create agreed clinical criteria, dedicated data systems and a project plan. 585 patients were included in the pilot, 64% had Knee OA and 36% Hip OA, for whom orthopaedic opinion was sought. 339 patients (58%) met the criteria, of these, 129 (38%) agreed to direct referral for surgical consideration at the dedicated site. In those who met the criteria, but declined direct referral, the main reason was distance to travel (66%), followed by the wish to be seen at a specific location. The main reason patients did not meet the inclusion criteria was age less than 65. The average waits for those who chose to be listed at the pilot site were 7.8 weeks from MSK referral to orthopaedic appointment and from referral to surgery14.9 weeks . The ERS administration time, which would ordinarily be in addition to the aforementioned clinical wait times, during the pilot was 6-10 weeks, meaning patient journey was reduced by this timeframe when compared to the normal referral processes. The data also demonstrates compliance with the 18 week pathway in the vast majority of cases.

Conclusion(s): Due to re-distribution of referrals in the local health economy, the rate of referral to the dedicated NHS hospital site increased three fold compared to the previous financial year. However there remained resistance to travel from patients, when other facilities were available more locally. Consistency in practice and collaborative working across MSK services in Staffordshire was demonstrated, along with integration with secondary care and commissioners.

Cost and savings

Costs were not calculated as part of this evaluation, but patient journey, and waiting times were observed. The Addition of a direct referral pathway to routine referral pathways in Staffordshire improved the utilisation of NHS facilities and reduced waiting time when for those who participated.


The process of design and implementation of project working across the MIS and orthopaedic network in Staffordshire has been a useful exercise that has set the background for further integrated working and system design. There is scope to increase direct access to local NHS sites and explore ways to further improve patient journeys.

Top three learning points

No further information. 

Funding acknowledgements

No funding was provided for the above project, but collaborative working.