Tier II Clinical Assessment Service

Appendix 1

Tier II Clinical Assessment Service

Examples amongst many, of appropriate referral include patients with:

Knees

·  OA knee with pain unacceptable despite medication and/or physiotherapy

·  Any persistent pain possibly from meniscal, osteochondral or ligament injury

·  Persistent knee swelling / bursitis of unknown cause

·  Instability of knee or patella

·  Anterior knee pain unresolved with physiotherapy

·  Patella tendon symptoms

Shoulders

·  Persistent shoulder pain despite physiotherapy

·  Persistent reduced range of movement despite physiotherapy

·  Instability of shoulder

·  Failure of shoulder injection in primary care

Upper Limb

·  De Quervains Tenosynovitis

·  Non-specific chronic wrist pain

·  OA of elbow/wrist/hands

·  Tennis or golf elbow, not responding to injection/physiotherapy

·  Referred pain from neck

Neck

·  Unresolved neck pain despite physiotherapy input

·  Referred symptoms to upper limb

·  Thoracic outlet syndrome

Spine

·  Thoracic spine dysfunction affecting trunk or upper limb

·  Low back pain not resolving with primary care management

·  Suspected lumbar disc prolapsed with leg pain

·  Lumbar canal stenosis

·  Back pain in young athletes

·  Sacro-iliac joint dysfunction

Hip & Groin

·  OA of hip non-surgical management

·  Groin pain for diagnosis, eg sportsman’s hernia, hip pathology

·  Trochanteric bursitis

·  Femoroacetabular dysplasia/impingement

·  Sportsman’s hernia

Foot & Ankle

·  Achilles pain

·  Heel pain

·  Ankle instability/persistent pain

·  Midfoot pain

·  Forefoot pain

·  OA of forefoot joint for injection

·  Shin pain

NB. The above are examples and not comprehensive

MSK TIER II Exclusions

Direct referral to secondary care by GP is appropriate for:

1.  Red Flags – Urgent

·  Suspicion of systematic inflammatory disease requiring medical management, e.g. morning stiffness present for > 30 minutes or more than 6/52

o  Refer directly to rheumatology

·  Suspicion of serious pathology (malignancy, infection), i.e. general malaise, weight loss, night sweats, loss of appetite

o  Refer directly to secondary care

·  Signs of cord compression/cauda equina syndrome, ie bilateral leg pain, bladder/bowel frequency or retention, saddle anaesthesia, gait disturbance, pins & needles, numbness, or worsening neurological symptoms.

o  Refer directly to neurosurgery/orthopaedics

·  Suspicion of recent fracture requiring intervention

o  Refer directly to orthopaedics

2.  Post-Surgical Problems

Where a patient has recently had an operation and has developed a complication of that surgery, they should be referred back to the surgery/department that performed the surgery. This should include:

·  Immediate post-operative complications

·  Later complications, e.g. prosthesis failure

·  Trauma to prosthetic joint

3.  Acute Trauma

Any acute MSK trauma should be referred to A & E for fracture clinic, e.g. suspicion of fracture or dislocation or major soft tissue rupture (muscle tendon or ligament).

4. Previously assessed patient requests surgery

Where a patient has been previously assessed as suitable for surgery, either in MSK Tier2 or secondary care, but has deferred this, on re-presentation may be referred direct

5. Previously assessed MSK Tier2 patient

Where a patient has previously been assessed in MSK Tier 2 and the discharge letter has suggested referral direct to secondary care if re-presents

6. Children

MSK Tier II does not see children. Any under-16 MSK problems should be referred to secondary care (paediatrics) or via A & E if acute

Your local contact in SW Essex - Cara Finnigan

Referral Form – NHS South West Essex MSK Service

Appendix 2

GP REFERRAL TO MSK TIER II

NOTE:

Use this service for more complex MSK patients who you think might need referring to secondary care or require investigation, ie specialist opinion

Waiting time for MSK Tier II is typically less than 2 weeks

Date of Referral / NHS Number
Name / Previous Name
DOB: / Age / Gender / Ethnic Code
Address / Telephone / Home:
Work:
Mobile:
Can a message be left at the above number?
Name of Patient’s GP / Surgery
Telephone.
Surgery Name &
Address / Surgery Fax
Practice Code
Hard of hearing? / Is the patient eligible
for hospital transport?
Does the patient require
hospital transport?
(eligible patients only)
Interpreter required?
Please specify language

I have attached GP Referral letter (GP referral should be comprehensive enough to allow an informed paper triage decision to be made): YES / NO

If no, GP should complete following sections:

Reason for referral:
History of symptoms and interventions / treatments tried to date (eg previous medications tried):
Has patient had previous physiotherapy: If yes, what was the outcome:
Examination findings:
Treatments tried to date:
What does the patient expect from this referral, eg diagnosis, symptom control, investigation, surgery?
Are there any particular issues you as the referrer would like addressing?
Any other issues or comments, eg significant issues that may impact on care, eg only carer?
Investigations to date and results: (Please include copies of results):
Last Consultation:
Medical History:
Current Medication:
Allergies:

Please complete form and send to Tier II with / without referral letter

i)  attach to URBN, or

ii)  e-mail to , or

iii)  fax to 01268 531227