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Exercise on GP Referral

Musculoskeletal Medicine training cost effectiveness: reduction in secondary care referrals.

Simon Petrides, Tom Saw
Blackberry Clinic, Milton Keynes MK7 7PB

Aim. To determine whether cost-savings result from postgraduate education for general practitioners in musculoskeletal medicine

Method. Three separate days of postgraduate education in musculoskeletal medicine were carried out for general practitioners, covering early diagnosis and management of common musculoskeletal disorders, with emphasis on clinical examination and aspiration and injection techniques. Following the course the practitioners were asked to keep a diary noting cases which did not need referral to secondary care as a result of the knowledge obtained and skills learnt from the training. These details were collected and costed by the commissioning group who had paid for the training.

Results. Figures were available from 17 of the 23 doctors attending the training. 226 referrals to secondary care were avoided, the treatments given including injections. The equivalent secondary care costings were calculated to be £64,952-£148,002, compared to the £50,413 cost of primary care treatment plus the cost of training. A minimum saving of £14,538 is calculated for 12 months practice, with a possible £97,615 over 3 years.

Discussion and conclusion. This self-reported observational survey suggests that simple postgraduate education in musculoskeletal medicine can be cost-effective. The cost savings may be multiples of the figures quoted as a result of more expensive care being applied in secondary care: other benefits may include improving the patient experience, expediting pain relief, prevention of chronicity, improving hospital efficiency and conversion rates, and improving patient (and general practitioner) satisfaction.

Keywords: Musculoskeletal; Postgraduate education; Cost-effectiveness; Injection; Primary care.

Twenty per cent of the United Kingdom (UK) population present to general practitioners (GPs) each year with a new onset or recurrence of a musculoskeletal problem;1 and 10% of the population are referred from general practice each year to community or secondary care with musculoskeletal problems.2 The costs and speed of delivery of care will depend on the GP's decisions: the least cost and fastest delivery are likely to result from the GP managing the case him/herself.

The journey through the Health Service for patients with musculoskeletal problems is often difficult, fragmented and confusing; it can also be less effective and expensive for the purchaser.The only musculoskeletal service many GPs can directly access is physiotherapy and the wait is often 12-18 weeks. Where no community musculoskeletal service is available, GPs often have to refer to secondary care specialist departments such as trauma and orthopaedics (T&O) or rheumatology.

The need for dedicated musculoskeletal services in the community is accepted.3,4However many patients do not need referral to these services and can be managed effectively in primary care by up-skilling local GPs. Doctors trained in musculoskeletal medicine have demonstrated that they are well-placed to fulfil that need,benefitting patients and with the potential to reduce costs.5However, poor confidence amongst GPs for diagnosing and managing musculoskeletal problems has been a continuing problem in the UK.6

It is evident that GPs are becoming more specialised in various fields within their own practice and that within each general practice there is a diverse range of specialised GPs offering consultations which up until recently would have been offered on referral to the more expensive secondary care services. More services are being offered in general practice under LES (Locally Enhanced Schemes) and DES (Directly Enhanced Schemes) to benefit patients and manage a wider range of problems in the community. This includes cardiology echo services, direct access endoscopy services, ENT clinics and a wide range of musculoskeletal services.

In recent years 'introductory' GP training in musculoskeletal medicine has been offered by the British Medical Journal's 'BMJ Masterclasses' 7 and the British Institute of Musculoskeletal Medicine (BIMM)'Roadshows'. The BIMM 'Roadshow' 8 consists of 3 one-day units arranged by the commissioning group (Primary Care Trust [PCT]/Clinical Commissioning Group [CCG]), where up to 24 GPs are trained, near their place of work, in early diagnosis and management of musculoskeletal disorders. The course days are entitled: soft tissue, joint examination & injection; back in a day; and advanced injection course. The entire course is practically-based and hands-on, including the use of latex models on which to learn injection techniques.

The continuing success of the BIMM 'Roadshow' courses over six years encouraged us to plan a study to judge the effect of training on later management, treatment and referral of musculoskeletal problems. Part of the course includes the involvement of the practitioners in a prospective survey to look at the alteration in their practice and referral habits based on the knowledge gained. This data is collected by the PCT/CCG and forwarded to BIMM. The PCTs and CCGs also provide cost data for current T&O and rheumatology referrals to allow cost savings to be calculated.

Materials and Methods
Although BIMM has been running these courses for about six years, the first course to be fully evaluated in this way was in 2012 and was provided to the Hastings and Rother PCT. GPs responded to the commissioning group's announcement that the three days of further musculoskeletal training was available, and were therefore self-selected to the group.

The course was held on 3 separate days in 2012. As well as receiving a workbook of the common musculoskeletal conditions, tutored groups (maximum 6 participants) were taken through clinical examination and discussion of treatment options with demonstration of treatment methods including soft-tissue injection, manipulation, and joint aspiration and injection. They were asked to keep a diary starting from their first day of GP work after the first study day. They were asked to note how many injections they performed each month that they would not have been able to perform before the course and to note how many patients they managed themselves rather than referring on to secondary care. These returns were collected at 3 and 6 months.BIMM collected the data. The PCT followed up with encouragement to GPs to complete the survey. There was no sanction on the GP for incomplete forms, although the PCT were encouraged to help by receiving a refund from course fees from BIMM when all data was collected in a specified time frame. The PCT then ratified the data.

The commissioning group undertook to provide us with the all the actual costs to them for out-patient appointments, procedures and average total Trauma & Orthopaedics (T&O) referral costs; this included the local secondary care facilities for T&O and rheumatology charges for first appointment with and without injection being performed. The historic cost of unselected secondary care referrals (which might include further care including diagnostic imaging, blood tests and elective procedures was given as an average cost of a T&O referral in that period. The PCT provided tariff plus Market Forces Factor (MFF) costs for initial T&O, rheumatology and pain appointments along with the tariff for an outpatient procedure.

23 GPs attended the 'Roadshow' which was held on 3 separate days in 2012. Follow-up was received at 3 and 6 months from 20 of the 23 doctors and their data used. 3 GPs did not respond. From the course participants 3 further doctors felt they were not able to comment on the reduction in referrals: two doctors claimed inability or reluctance to record or recall the data, and one doctor was not confident of the reliability of his data. The data therefore reflects changes in referrals from only 17 of the 23 GPs trained on the 3 courses (73%). With regard to the complete non-responders we did not include them as having performed any injections.

At 6 months, 226 referrals to secondary care were considered by the GPs to have been avoided, by undertaking care in the practice. During the same period, 266 injections were performed that would not have previously been given.

The cost of providing injections in primary care under the DES tariff in Hastings & Rother at that timewas £43.52. The secondary care costings are taken from data provided by the Hastings & Rother PCT showing that a T&O first appointment costs £143.7 with the cost for a first appointment and injection in the outpatient department being £278.2. This rises to £257 for a first rheumatology appointment and £375 for a rheumatology appointment with an injection at the initial consultation. The historic average T&O referral cost is £1522 to include outpatient costs, diagnostic imagery and further management.


Provision in secondary care


1st appointment

Appt + injection

Historic average care

Trauma &Orth








Table. Local costs (£) in secondary care

The cost of providing the training course for the 23 doctors was £27000. Although the expectation is that the training will provide a continuing change in skills and referral pattern, for the purpose of calculating whether a cost-saving results, we have chosen to spread the cost over a 12 month period. We have therefore extrapolated the change in referrals to secondary care, and the number of injections carried out in primary care, to 12 months by multiplying those figures by two, to give 452 referrals 'saved' and 532 injections given.

Our calculation on costs and possible benefit is made by starting with the 12 month figure for secondary care cost of the appointments calculated to have been avoided, less the cost of injections carried out in primary care and less the cost of the training course. In table 2 three secondary-care cost options are shown, for first appointment only, for appointment and injection, and average historical unselected secondary care episodes. The latter is included in view of the possibility of further secondary care costs, such as further appointments, blood tests, imaging or onward referral.

Table of Yearly Savings

  Cost of outpatient appointments/referrals Cost of minor surgery ‘DES’( £43.52/injection) Cost of  BIMM course Total Saving
Minimum Saving
(If patients had 1 outpatient T&O consultation only)
£27,000 £14,538.6
Saving if 266 had an outpatient injection (266x2)x£278.2
£23,413.8 £27,000 £97,588.6
Savings based on historic average T&O referral cost. (226x2)x£1522
£23,413.8 £27,000 £637,530.2

Whichever extent of secondary care is used, the 12 month calculation shows a cost saving for the further training, ranging between £14,538 and £637,530.

This calculated minimum saving does not allow for the extra cost of any further appointments, onward referral, scan, blood test, imaging or operation. Unfortunately such costs which could potentially be calculated from historic expenditure data, were not quantifiable from the available information.

The 3 GPs who did not respond may or may not have been implementing their new skills. If all GPs had reduced referrals the savings could be up to 25% greater than calculated from the data available. With regard to the complete non-responders we did not include them as having performed any injections. The calculations shown suggest that even if only 75% of participants use the new skill-set the savings are considerable.

The calculation using historic average costs is simplistic but cannot be made more accurate without data on expenditure following each referral in previous years with similar conditions, which was not available to us. Those average costs from unselected referrals will include many more complicated cases which could not be managed in primary care; but they are included to clarify that the other figures are minimum secondary care cost figures.

It is hoped that the skills and change in referrals would continue for years by the up-skilled GP. A projection can be entertained for minimum 3 year savings: a figure of £97,615 saving results from the initial course costs not being repeated in the following years but allowing for the DES payments to GPs i.e.(£14,538.6+£41,538.2+£41,538.2).

These projections are not proof of actual savings and this study should be regarded as a pilot for more substantive research. A control group of general practitioners with a similar catchment and workload, ideally in a nearby location would allow a true comparison to be calculated, both in the immediate months or year following the education, as well as over a longer time-period. A robust trail for actual costs, to be obtained by the commissioning group, would allow for avoidance of the observational bias which may be present in the current calculations.

The savings projections may be exaggerated by a number of factors. The referral pattern to secondary care might revert to previous levels in the projected 'second' six months and thereafter (or it might continue to decrease with increased experience and confidence). Another uncertainty is that some of the referrals 'saved' may only be referrals 'delayed', thus incurring similar costs but at a later date. With more musculoskeletal care in primary care, more x-rays and other imaging and blood tests might be undertaken in that sector; but also, increased confidence in clinical examination may reduce the use of imaging and other tests.

The comparison figures are with traditional secondary care: cost comparisons would be different with less expensive intermediary-care options such as community musculoskeletal clinics. If referral is to a 'see and treat' community service, the cost may be one-third less than if the case were managed in secondary care: a figure of £260-296 compared to £434 was quoted in 2009.9 Any referral system however implies delays to patient care, and removes the satisfaction from continuity of care to both patient and doctor. Neither these benefits, nor speed of delivery of care, were measured in this study.

The group of GPs on this course was self-selected, which implies that they not only had a need for further education in musculoskeletal assessment and care, but may have had a special interest in that area of medicine, which other GPs might not possess; the generalisability of these figures to all groups of general practitioners may therefore be limited.

With the advent of Clinical Commissioning Groups, local commissioners and purchasers should consider the cost effectiveness of training GPs in musculoskeletal medicine and service development in recognition of the Department of Health 'Musculoskeletal Services Framework' document (2006).3
Musculoskeletal Medicine training.

There are postgraduate modular training programmes in the UK which culminate in the ability to take a Diploma in Musculoskeletal Medicine.10-12 Organisations running these programmes include the British Institute of Musculoskeletal Medicine (BIMM), The Society of Musculoskeletal Medicine, Bradford and Middlesex Universities. These doctors may then work in Tier 2 (interface) musculoskeletal clinics in the community or enhance the services provision to their practice population. Doctors trained in musculoskeletal medicine, although not able to join a specialist register in the UK, do have a training based on European and International competencies,13 and more recently based on the 'Competencies for Musculoskeletal Medicine Practice' 14 approved by the Standing Committee for Musculoskeletal Medicine 5th on Dec 2012. BIMM has also developed a guidance document to aid assessment of doctors revalidating in Musculoskeletal Medicine.15 Guidance is also available to assist CCGs in determining the criteria for accreditation of a doctor as a Practitioner with Special Interest in Musculoskeletal Medicine.16

These figures suggest that there are significant savings to be made by Clinical Commissioning Groups considering community based musculoskeletal GP training courses, such as those run by the British Institute of Musculoskeletal Medicine. Important possible further benefits are of improving the patient experience, expediting pain relief, prevention of chronicity, improving hospital efficiency and conversion rates, and improving patient (and GP) satisfaction.
CCGs should now consider initiatives of this kind whilst contemplating the design and tendering of MSK services.

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Deena Niren of the British Institute of Musculoskeletal Medicine Roadshow for data procurement.
Dr Robert McNeilly and Nikki Brooker of Hastings &Rother Clinical Commissioning Group

Address for Correspondence
Dr Simon Petrides MB BS DM-SMed Dip Sports Med DO FFSEM (UK&I)
Musculoskeletal & Sports Physician, Clinic Director, Blackberry Clinic, Milton Keynes MK7 7PB
01908 604666
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

Dr Tom Saw MA MB BChir MRCS MRCGP Dip Sports Med MFSEM (UK&I) Dip Occ Med
Musculoskeletal & Sports Physician.