Introduction

Disorders of the musculoskeletal (MSK) system are the main cause of disability and lost working days worldwide, and in the UK, it is estimated that one in four general practice (GP) consultations are related to musculoskeletal disorders [1, 2]. In Ireland, one third of bed days used and one third of acute surgery results from MSK injuries each year [1]. In 2015, orthopaedics was the speciality with the highest volume outpatient activity within the Irish Health Service [3]. Osteoarthritis affects almost half a million people in Ireland, and this number will continue to rise as a result of increased life expectancy and obesity rates [4]. Therefore, appropriate access and resourcing of general practice and orthopaedics is a necessary measure for the provision of a safe and efficient health service.

One area that remains particularly challenging in Ireland is that of outpatient waiting lists with current Health Service Executive (HSE) policy being to see routine first time patients in an outpatient clinic within 9 months and urgent cases within 12 weeks [1]. In Ireland, orthopaedic outpatient waiting lists have increased by 26% from February 2016 to January 2017 and orthopaedics has the highest median patients waiting across all outpatient specialities [3, 5]. There is an increasing amount of evidence to support the use of standardised protocols for referrals and triaging and within the HSE the Outpatient Services Performance Improvement Programme (OSPIP) has established a working group to develop a set of referral guidelines [1, 3, 6,7,8,9]. Furthermore, it is estimated that one third of patients on orthopaedic outpatient waiting lists do not require consultant review with increasing evidence to support the safe and effective treatment of this cohort via alternative care pathways and allied health professional (AHP)-led clinics [1, 10,11,12,13].

The purpose of this study was to assess the attitudes and experiences of general practitioners in the Irish midlands with regard to orthopaedic services and to evaluate these in the context of national strategies and international best practice.

Methods

A survey was sent to 147 general practitioners contained in the midlands Primary Care Centre Database at Saint Loman’s Hospital, Mullingar. The survey looked at five main areas: elective services, trauma services, allied health services, patient access and practice demographics. Eighty-three surveys were returned representing a response rate of 56%. Of these, 5 were incomplete, leaving a total of 78 fully completed surveys that were processed for our results. The survey used was a Likert scale–based questionnaire which is one of the most widely used, accepted and validated methods of scientifically measuring attitudes [14, 15].

Results

For the purpose of displaying the results in an accessible way, we have divided them into the five main areas of the survey: practice demographics , elective services, trauma services, allied health services and patient access.

Practice demographics

Of surveyed GPs, 80.8% had an average patient population of > 2000 as shown in Table 1. Just under half of GPs surveyed described their practice as urban with the remaining quarters described as rural or mixed (see Fig. 1). All GPs except for one stated that the Midlands Regional Hospital Tullamore (MRHT) was their main orthopaedic referral centre.

Table 1 Frequencies of average patient population
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Fig. 1
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Practice demographics

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Elective services

In terms of access to elective orthopaedic outpatient clinics, 97.4% of GPs surveyed either disagree or strongly disagree that it is adequate as shown in Table 2. Of GPs surveyed, 98.7% either agree or strongly agree that there is a significant difference in terms of access between public and private services (see Table 2). The average waiting time for an elective orthopaedic outpatient clinic is more than 1 year as per 92.3% of GPs surveyed (see Fig. 2). Of GPs surveyed, 89.7% stated that the average waiting time for an elective private outpatient appointment is between 0 and 3 months as shown in the bar chart in Fig. 3.

Table 2 Access to elective orthopaedic outpatient clinics
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Fig. 2
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Average waiting time for an elective orthopaedic outpatient clinic

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Fig. 3
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Average waiting time for an elective private outpatient appointment

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Trauma services

Figure 4 is a bar chart illustrating the approximate distance of the nearest trauma centre to the GPs surveyed with 86% stating that it is within 50 km. Over a third of GPs stated that they encountered acute orthopaedic injuries once a week with half stating that they either strongly agree or agree that they are confident in dealing with them (see Fig. 5 and Table 3).

Fig. 4
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Bar chart illustrating the approximate distance of the nearest trauma centre to the GPs surveyed

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Fig. 5
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Frequency of encountering acute orthopaedic injuries

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Table 3 Frequencies of “Would you say you are confident dealing with acute orthopaedic injuries?"
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Allied health services

Over three quarters of GPs surveyed either disagree or strongly disagree that there is adequate access to physiotherapy services in the community with nearly 80% stating they have no physiotherapist attached to their practice (see Fig. 6). Three quarters of GPs surveyed either disagree or strongly disagree that there is adequate access to occupational therapy services in the community with 93.6% stating they have no occupational therapist attached to their practice (see Table 4).

Fig. 6
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Adequate access to physiotherapy services in the community

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Table 4 Frequencies of “Do you have an occupational therapist attached to your practice?”
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Patient access

The majority of GPs surveyed either agree or strongly agree that there is adequate access to diagnostic imaging for private patients. The majority of GPs surveyed either disagree or strongly disagree that there is adequate access to diagnostic imaging for public patients. Regarding public patients who have difficulty accessing services: 85.9% of GPs refer these patients as self-payers to private services; 48.7% of GPs urge them to use the National Treatment Purchase Fund (NTPF); 62.8% of GPs urge them to use the treatment abroad scheme (see Table 5).

Table 5 Public patients who have difficulty accessing services
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Discussion

The results show that nearly all GPs surveyed feel that there is inadequate access to public elective orthopaedic services and that there is a significant difference between both private and public health sectors in terms of patient access. The Special Delivery Unit (SDU) which is part of the OSPIP outlined the following targets for the maximum waiting time for a first outpatient (OP) visit in 2013: < 12 months for a first time OP appointment by 30 November 2013; < 26 weeks for a first time OP appointment by 30 November 2014; < 13 weeks for a first time OP appointment by 30 November 2015 [16]. This is in stark contrast to the actual waiting times revealed in the results with the majority of GPs stating a waiting time of more than 1 year for an elective public outpatient appointment and shows a reality that differs greatly from the objectives and principles outlined by the OSPIP Strategy for the Design of Integrated Outpatient Services 2016–2020:

  • “to provide fair, equitable and timely access to a quality, safe health service that people need”

  • “access to outpatient care is equitable and based on clinical need, not ability to pay” [3].

The current situation is not in line with national strategies but also falls significantly short of international standards with current evidence suggesting that patients waiting time should not exceed 180 days from the time of GP referral to elective joint replacement surgery due to the deterioration in patients’ quality of life, physical function and increased joint-related pain [17].

Over a third of GPs surveyed encounter an acute orthopaedic injury every week, yet only half of those surveyed agree or strongly agree that they are confident in dealing with them. This suggests that GP trainees may benefit from formal orthopaedic teaching during their training and may offer an opportunity for the relevant training bodies to liaise regarding appropriate tutoring.

The use of AHP-led clinics is becoming increasingly widespread across the UK and Ireland with growing evidence revealing it to be a safe and efficient way of treating patients with MSK disorders in both primary and secondary care settings [1, 2, 10,11,12,13]. At a regional level, the introduction of a MSK Clinical Specialist Physiotherapist (CSP) led triage programme in University Hospital Limerick proved to be very successful [10]. Moreover, the introduction in 2011 of a joint initiative between the National Clinical Programme for Trauma and Orthopaedic Surgery and the National Clinical Programme for Rheumatology has led to a reduction in waiting lists of over 50,000 patients [1]. In the trauma setting, there is also increasing evidence to support the safe and cost-effective use of occupational therapist–led hand clinics with appropriate specialist supervision and access [18,19,20,21]. In the community setting, occupational therapists reduce the risk of falls in the elderly, thereby reducing fracture risk as well as having an impact on patient quality of life [22, 23]. We can see from the results that three quarters of GPs surveyed stated they disagree or strongly disagree that there is adequate access to physiotherapy and occupational therapy services with 80% stating they have no physiotherapist and 93.6% stating they have no occupational therapist attached to their practice. Inadequate capacity at general practice level results in rising referrals to secondary centres, but this burden on GPs and outpatient waiting lists could be removed by appropriate investment in resourcing AHP-led clinics.

With regard to patient access, the majority of GPs state they agree or strongly agree that there is adequate access to diagnostic imaging for private patients but disagree or strongly disagree with regard to adequate public patient access. Furthermore, almost 90% of GPs refer public patients with difficulty accessing public services to private entities as self-payers, with almost half urging patients to use the NTPF and almost two thirds urging their patients to use the treatment abroad scheme. This current situation reveals that a significant challenge awaits with regard to the introduction of the government’s planned Universal Health Care [24]. Increased investment and resources in primary care along with guideline-controlled direct access to imaging for GPs could have a substantial impact in terms of improving outpatient waiting lists and MSK disorder management overall [1].

Another issue requiring attention is that of orthopaedic consultant surgeon staffing levels which are gravely below par when compared to international norms. If one takes the orthopaedic unit at MRHT as a regional example, there are 5 consultant orthopaedic surgeons serving a catchment area of over quarter of a million people compared with Barnsley District General Hospital in the UK, which serves a similar population but has 17 surgeons with activity recorded in the National Joint Registry for April 2016 to March 2017 [25]. On an international level, Ireland has the lowest ratio of consultant orthopaedic surgeons per head of population in western Europe at 1:54,000 with many countries having a ratio less than 1:15,000 [26]. The Irish Institute of Trauma and Orthopaedics (IITOS) has produced a set of “Safe Clinic Guidelines” to be endorsed nationally with recommendations on adequate staffing levels and projects that requirements for expansion in consultant numbers to 2025 will require an additional 120 to be appointed which would still only result in a below international ratio of 1;24,000 [26].

The authors also feel that expanding this study to other regions would be an invaluable undertaking to provide a more macro representation of the national status quo.

Conclusion

MSK disorders are a significant burden on our health service, and inadequate investment in general practice, AHP-led facilities and orthopaedic services remains a serious challenge that requires considerable attention to insure adequate patient care, safety and best practice.