The HSCIC hospital episode statistics 2014-15 showed that demand on outpatient services is increasing annually. Last year 107.2 million outpatient appointments were requested. Of these attendances 30.3% were new patient attendances. Trauma and Orthopaedic (T&O) appointments are at the top of this list with 7,520,882 of the reported attendances. With traditional face to face practice the total cost to the NHS is estimated at: £712.8 million.

The 5 Year Forward View published in October 2014 highlights the currently expanding care and quality gap, stating that:

‘unless we reshape care delivery, harness technology, drive down variations in quality and safety of care then patients’ changing needs will go unmet, people will be harmed who should have been cured, and unacceptable variations in outcomes will persist.’

In 2013 Orthopaedic consultant James Gibbs and Advanced Practice Physiotherapist Lucy Cassidy decided to evaluate the fracture clinic asking thisimportant question:

Is the current, widely used model for the new-patient fracture clinic the most patient-focused, cost effective, and evidence-based model that can be used at BSUH & nationally?

To evaluate this we first reviewed other practice across the UK and Scotland, including the Virtual Fracture Clinic in Glasgow led by Lech Rymaszewski. This model has a unique way of working that removes the need for patients with simple fractures and soft tissue injuries to attend the fracture clinic, instead they receive their diagnosis over the telephone. We used this concept as a base for our model, modifying it to meet regional needs of a growing demand on outpatient physiotherapy by integrating rehabilitation into the core of the service.

We then surveyed patients and staff in the fracture clinic and learnt that although patients did not mind the travel or the long time wait for a short appointment, they did report frustration that they had to take time of work and that they were not given any information about rehabilitation. Staff reported frustrations that clinics were too busy resulting in little time with patients and minimal capacity for training. They also reported that patients were often seen in the wrong clinic, at the wrong time, or completely unnecessarily.


Service Redesign

We redesigned the service based around the following objectives:

  1. Improve patient experience by bringing first-line treatment to them in the comfort of their own home.
  2. All management decisions to be made by an Orthopaedic Consultant and that any follow-up care is under the correct specialist, in the correct time frame.
  3. All patients to receive standardised, protocol-driven, evidence-based treatment to ensure a high standard of care for all patients, which is shared with their GP.
  4. To reduce the number of outpatient appointments with a knock-on effect to supporting services such as physiotherapy, imaging & administration.

Our aim was to establish a patient centred, standardised, safe and effective way of managing acute fracture and soft tissue injuries. This includes use of online resources so patients can self-manage their injuries with subsequent appointments only where clinically indicated and with the correct specialist.

This resulted in fundamental change in our patient care pathway:

Service Launch

The service was launched in August 2013 with just one Physiotherapist, Lucy Cassidy. It has now grown to a team of 4 physiotherapists and 4 hand therapists coving all aspects of fracture diagnosis, treatment and rehabilitation. Over the years the service has evolved to include videos and information sheets as the key way of providing diagnostic information and rehabilitation, therefore empowering patients to self-manage their injuries.

The service we have managed over 10,000 patients, reducing outpatient appointments by 57% and saving the NHS on average £250k per annum. The Virtual Fracture Clinic won 3 national awards in 2015, continues to receive excellent feedback from patients and glowing reviews in the press. Please visit our Media page for more information.

Our mission is to share this best practice model freely across the NHS so that more patients can benefit from the structured rehabilitation plans. In December 2016 we transitioned to our innovative patient portal which is designed to manage the whole patient pathway, from referral to rehabilitation. As well as recording patient satisfaction, it proactively reports patient related outcome measures (PROMS) for both individual tracking of progress and overall analysis of the recovery times for different injuries. We will be testing the system for 6 months after which it will hopefully be available to other NHS Trusts from July 2017.

For more information on how the Virtual Fracture Clinic work in practice please click here.