Consistent urgency

by Fraser Ferguson [NHS 24] 

Over the Christmas holiday period I spent a lot of time and a considerable amount of money taking my accident prone dog, Jess to the vet. First with back pain and secondly for surgery on a very badly cut paw. Both times the overly anxious owners phoned for an urgent appointment. Both times an immediate intervention was offered. The process got me thinking about what would have happened to a human member of my family and just how urgent their back pain would have been managed by their local AHP  service – particularly as it was Christmas Eve and Hogmanay! Obviously the urgency of an NHS appointment decided by who can pay the most cannot happen. So how can AHP appointments be classified as urgent or not and can public and clinicians agree?

Everything we do is graded in degrees of urgency and these degrees will differ from person to person, task to task and also between different people involved in the same situation. Should a 77-year-old person with a thirty year history of knee pain be seen as any less of an urgent appointment than a 30-year-old with acute back pain? To get this blog posted is urgent to me even if the urge of others to read it will be less urgent.

AHPs are by and large a very caring grouping of healthcare professionals who I believe want to see their patients as soon as possible. However sometimes with MSK problems the prognosis can be poorer if you are seen too soon – medicalisation of an often benign condition – unnecessary investigations which either cause anxiety and takeaway appointments for those with a greater need.

I was dealing with a complaint last week from somebody who wanted to know when their physiotherapy appointment would be as they had been told by their GP it was to be dealt with urgently. The caller was in obvious distress and great pain with back pain. This had been bothering them for a week and to the caller seeing a physiotherapist was an urgent need.

Whether their symptoms were an urgent requirement was a different story. The difference between an urgent need or an urgent requirement is a key issue and can be clearly identified in the journey of a back pain patient.

Your average back pain patients journey will really just have one urgent step. The physio appointment. To the patient this is an urgent need and will probably be so for every one of the many back pain patients who access physiotherapy services in NHSScotland. If however they then become one of the 2% who go for an MRI or surgery then they would have a few more steps and these would be governed by local criteria and be due to an urgent requirement of the medical presentation. However the 98% of the people who will never need imaging or surgery often  find the urgency criteria used on their referral is more haphazard. 

I am just finishing off a piece of work that investigates if there is any consensus between public-patients and clinicians as to what factors should be considered when an MSK out-patient is prioritised for urgency.

As expected there are many factors where the two groups differ (full report to be published soon) – but positively there were a few areas where the groups found consensus that when one or all of the following were present – an MSK referral was more likely thought of as urgent if it affected: 

• Work
• Pain – constant severe
• Recent injury
• Functional impairment
• Worsening pain
• Sleep considerably disturbed by pain

The obvious follow on question from this finding is “are these used consistently then throughout NHSS?”  The finding would suggest they are not used everywhere.

I once read somewhere that the only non urgent medical appointment is one that doesn’t concern me.

I have always found that the two main pieces of information that nearly every MSK patient routinely expects from their healthcare professional is “will it get better” and “is it something serious?” If we are unable as yet to agree on just what makes one MSK appointment more urgent than another then the very least  patients should expect is a consistency in approach to how MSK services implement policies. Even when the four-week wait for access to MSK AHP services is live there will still be a need to determine urgency of referrals.

Could we not be using less traditional ways to help alleviate these fears has to be one consideration. Tele-health options such as telephone consultations – is a simple and cheap option in which we can move forward. For example a quick phone call, confirming receipt of referral – reviewing the information – providing specific reassurance – and engaging the patient with self management advice will all be much more beneficial to the patient – irrespective of condition, social or personal circumstances. Similar benefits from an email too. Better outcomes all round and consistent urgency whatever is wrong with you.

No dogs suffered any permanent injury in the making of this blog 🙂

Advertisement