The musculoskeletal service standards in practice

The following examples show how the musculoskeletal (MSK) physiotherapy service standards could be embedded into clinical practice within different MSK services and scenarios.

female physio instructing a patient on how to stretch

The standards do not need to all be used at the same time, but would depend on what has been identified as the main areas for improvement within a service.  

Standard 1: assessment, diagnosis, management planning and review and standard 4: communication  

A physiotherapist working within an MSK service within a large teaching hospital, is referred a patient for acute lower back pain and is asked to review for an initial assessment. 

The patient is accompanied by a relative and upon initial discussions with the patient, it is evident that the patient has a history of severe anxiety plus previous poor experience within healthcare. The patient is currently unable to work and is anxious about their financial income which has been impacted due to their current MSK condition.   

After providing a detailed initial assessment, the patient and relative are given the chance to ask questions about diagnosis and treatment, and the patient and family are actively involved in decision making and ongoing treatment for the MSK condition which is guided by the physiotherapist’s recommendations. The physiotherapist had taken into account the previous patient’s previous experience within a healthcare setting, and also the preferences of the patient with regards to communicating their referral options, ongoing advice and digital options for self-management. The physiotherapist had verbalised this within the session, but also offered to write down any information the patient wanted with regards to digital links. Referral options and self-management were also explained and offered in written form. 

What was the result?

Personalised planning with the patient and relative helped to put the patient at the centre of the decision-making process with appropriate guidance and management options. This included taking into account a patient's state of mental health, and in this case, attending hospital for an appointment, which was increasing the patient's anxiety. Having an awareness of other options available within the community that the physiotherapist could refer the patient into, certainly can help with overall management of the patient’s condition. It is also important to have an awareness of patient preferences for current and ongoing communication within the assessment, treatment and long-term management evident within MSK service 1 and 4.  

Standard 2: Personalised physiotherapy and standard 7: evaluation, audit and research  

The GP patient survey does not specifically identify when a patient has consulted a First Contact Physiotherapist (FCP). 

An FCP service used questions from the GP patient survey (questions 25 to 30) to collect data on patient experience of the FCP service. Data collection was undertaken for 1 month asking patients attending the FCP service to complete a brief questionnaire. It is planned to repeat this data collection on an annual basis, unless FCPs are included as one of the named primary healthcare professionals in the national GP patient survey.   

It also identified an opportunity to improve FCPs’ use of shared decision making as data from Q27 ‘During your last general practice appointment, were you involved as much as you wanted to be in decisions about your care and treatment?’ highlighted a gap in use of shared decision making.   

What was the result?

The results allowed comparison of the FCP service with national GP patient survey data on patient experience and demonstrated adherence to standard 7.  This also improved performance against the outcome for standard 2: People with MSK conditions are being involved in decisions about their care.  

Standard 3: Supported self-management  

An MSK service located in a rural town had a growing number  of patients who did not attend future appointments after the initial assessment.

A patient survey was sent to all patients who had accessed the service but not attended follow-up appointments in a 12-month period, and feedback collected over a period of 3 months. Specific questions included information on access to the service, including the option of virtual appointments and follow-ups, barriers to access and how they felt about self-management of their condition after their initial assessment with the physiotherapist.

The results of the survey revealed that a high percentage of patients were very satisfied with the initial consultation and advice, but had limited knowledge or awareness on how to access ongoing information or resources for self-management of their condition. The identification of this via the survey results helped the MSK service lead along with the MDT team, to develop a program of evidence-based resources and gain more awareness on how therapists can promote self-management techniques/options to patients. This was developed with opportunities to offer optional virtual follow up appointments, signposting to online resources and linking in to programmes within the community area.   

What was the result?

This improved the way in which patients could self-manage their condition, in relation to standard 3: Supported self-management and utilising technology where appropriate and evidence based self-management resources.   

Standards 5: integrated management pathways and Standard 6: population health  

Within an acute NHS hospital, an integrated pathway is needed for when patients who have attended fracture clinic, on occasions, would benefit from having direct access to physiotherapy MSK assessment/treatment.

This is instead of being referred on to MSK physiotherapy, knowing that waiting lists are over 3 weeks for urgent appointments.   

The integrated MSK fracture pathway was developed with input from the triage reception staff, orthopaedic surgeons, orthopaedic and MSK physiotherapy teams. Having a pathway that involved patients attending fracture clinic, followed directly by physiotherapy in one appointment, not only helped reduce waiting times, but on surveying patients, patient satisfaction increased. 

As part of the pathway design, patients with lived experience of fractures and follow-up physiotherapy were involved in pathway development. To reduce the time for follow-up appointments, a virtual follow-up appointment was offered as an option. This took into account patient communication preference and digital literacy. 

From within the MSK physiotherapy appointment, advice on healthy living and wellbeing, including smoking cessation and dietary advice was available as patient information and part of post-fracture healing information.  

What was the result?

The integration of acute services and pathway design in this case, not only reduced waiting times, but increased patient satisfaction. Furthermore, the quality of the assessment and management of the patient was not compromised. 5 and 6 promote the need for personalised care that is integrated and involves lived experience in pathway design across all services. It is also evident to factor in population health needs within a service and to promote the importance of lifestyle factors and address inequalities.  

Standard 8: Clinical governance

A private MSK service decided to develop its quality improvement process by developing staff member’s knowledge of audits and audit cycles in accordance with a previously agreed local policy.   

The MSK service developed a CPD day for all team members within their existing MSK service to allow for a better understanding of how service and quality improvement could be achieved. Led by therapy MSK leads, the audit day was planned in advance to give all staff within the team including support workers, the chance to take part in service improvement opportunities and learn more about clinical governance, including audit cycles. The development of the audit day also provided an opportunity for the staff to hear from other colleagues about individual audit and service improvement projects that were in progress or completed.  A policy for monitoring audits and service improvement had already been developed and was reviewed within the process.    

Staff were given time to plan their own audits leading up to the session with support from senior staff within the team, and dedicated non-clinical time. The audits and service improvement ideas were presented on the day and included amongst others, references to relevant NICE guidance.  

One particular example of service improvement audit focused on the lived experience of patients who had attended the MSK service over a 6-month period. The clinician demonstrated how the patient and carer experience contributed to improvements in planning of future patient appointments and follow-up treatment sessions.   

What was the result?

The inclusion of all staff within the therapy MSK team demonstrates a commitment to CPD for staff in knowledge and understanding of the importance of clinical governance and quality improvement within the service. Standard 8 promotes the need for staff to be familiar with clinical governance frameworks, but understand their own individual responsibility for service and quality improvement. Having a clear and planned programme of audits that all staff can take part in and learn from, along with clear policies and procedures on how this is monitored, are key aspects and show adherence with Standard 8.

Problem statement template

To support the identification of where the service standards can be used within practice, you may want to use this problem statement template.

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