Shared learning database

Liverpool University Hospitals NHS Foundation Trust
Published date:
August 2019

Our physiotherapy department provides a musculoskeletal assessment service and physiotherapy treatment service to patients in Merseyside across Liverpool, Knowsley and Sefton. Referrals to our services can be from local GP practices and from various departments in the main part of our hospital such as orthopaedics, A&E, rheumatology and ENT.

Our service has four satellite sites in the community in GP practices. Our services runs a number of therapeutic classes and we have hydrotherapy facilities in our department. We also have access to two gym facilities to cater for the various types of services that we provide.

NICE into Action 2019 Category, Chief Allied Health Professions Officer (CAHPO) Awards

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

My goal when starting this initiative was for our practice as a physiotherapy department to better reflect the latest evidence for the treatment of osteoarthritis of the knee. This goal had a few different influences. I had liaised with colleagues in our orthopaedic department who have the challenging job of managing patients with osteoarthritis of the knee and considering surgical interventions. These patients will often have been referred from our physiotherapy department following a period of conservative rehabilitation. Staff highlighted the concern that without a pathway in place there was the potential that patients may be treated differently by different practitioners.

I was also influenced by emerging level 1 research showing the benefits of education and exercise classes to patients with a diagnosis of Osteoarthritis of the Knee and how it has been successfully been implemented in other countries. We did not have such a class or pathway but certainly had a large volume of patients with this diagnosis.

We have successfully set up this pathway and class and I am pleased that it has been a big success for our patients and department. It initially ran once a week as a pilot but now runs three times per week.

Reasons for implementing your project

The specific challenge I wanted to address was maximising the quality of the conservative management our patients received when diagnosed with osteoarthritis of the Knee or a degenerative meniscal tear. Our old practice meant we did not have a specific pathway for these patients. The patients did not have dedicated time in our physiotherapy gym facilities, which may have been a barrier to their treatment and recovery. If patients felt their conservative management was suboptimal then they may have been more inclined to consider more invasive surgical treatment options. These options would inevitably be higher risk, more costly and be less safe for pationts in the first instance. Our old practice also meant that each patient was seen by a physiotherapist on a one to one basis. Most recent high level research suggests these patients can be managed effectively in a therapeutic class. This gives patients access to facilities they may otherwise not have access to or have the confidence to try. It also meant that a group for 10 patients could be managed by a single physiotherapist and one therapy assistant meaning the class has been cost effective for our department.

The overall aim of our initiative has been to maximise the quality of our conservative management of patients with a diagnosis of osteoarthritis of the knee or a degenerative meniscal tear.

Our objectives to help achieve this aim are:

  • Establish a gold standard pathway of patient care based on best available evidence with the assistance of expert staff.
  • Complete an audit to confirm a demand for a therapeutic knee rehabilitation class.
  • Set up an education and exercise class to help implement this pathway.
  • Monitor outcomes with use of standardised outcome measures to ensure qualitative and quantitative effectiveness.
  • Educate and train staff appropriately through in service training to ensure that the new pathway is utilised appropriately.
  • Create appropriate resources such as patient information leaflets, summary sheets.
  • Organise onward referral to local gym schemes to help facilitate patient compliance and adherence to home exercise plans.
  • Ensure use of our department exercise app Physitrack to again aid patients’ compliance and understanding.

How did you implement the project

The first step in implementing our project was ensuring that there was a demand for our service. I therefore complemented an audit with the help of our trust audit team. All physiotherapists working in our service were asked to use a questionnaire with patients with a diagnosis of osteoarthritis of the knee or a degenerative meniscal tear. This questionnaire asked if patients would be happy to attend a therapeutic class focused on education and introduction to exercise for their condition.

The audit was completed over three months and gave us the data suggesting that demand for such a class would be met. I then structured the educational talks for the classes, created learning resources such as posters, educational booklets, patient information leaflets and educational summary sheets. All of these were informed by NICE guidelines and latest research. Our first class ran as a pilot and following feedback from the class I discussed the findings with my manager. She was happy that the class should continue and demand has increased to the point that it runs three sessions per week in our department now. We have continued to gather feedback from our patients with outcome measures and questionnaires.

Key findings

The successful implementation of our knee rehabilitation class has meant that the quality of our care has been better standardised. I feel this reflects the commitment from ‘AHPs into Action’ to deliver evidence based/informed practice to address unexplained variances in service quality and efficiency.

We have had the opportunity to put NICE guidelines into practice and share this with our patients. We have been able to educate appropriately, give advice on helpful treatments such as weight loss and exercise. This again links with the commitment of improving the health and well-being of individuals and populations.

The establishment of our class has also helped efficiency in our department. As only two staff are required to run a class, we have made significantly reduced the therapist to patient ratio. The average volume of one to one sessions from our audit was approximately 3.75 sessions to manage these patients. The class is structured so patients attend 3 sessions. This implies that the class has been very cost effective. The knock on effect of this is that our department is better able to deliver on its key performance indicators as staff have more capacity to see other patients.

Key learning points

Developing and implementing this service has been a learning curve and particularly challenging while maintaining a full caseload. As detailed above I completed an audit to help inform the set up of our service. This involved gathering information from our satellite clinics and our main department. On reflection, I think I should have given staff more notice of this audit. This may have helped gather more helpful data.

Over the past few months we have also made the class an opt-in service. This has successfully improved our attendance rate and helped ensure appropriate patients are attending the class. We have learned from our feedback that this patient group can be successfully managed in a class environment. We are therefore considering whether we have capacity to extend this service to patients with a diagnosis of osteoarthritis of the hip.

As detailed above the knee rehabilitation class runs three times per week and is an integral part of our physiotherapy service. It is now the most popular of all classes that our service runs. We have had feedback from our orthopaedic colleagues who are delighted that the service can act as prehabilitation for those patients that may go on to have surgery. The service is now running for just over a year and we may be in a position to nominate for our Trust awards which are towards the end of the year.

Contact details

Raymond Healy
Liverpool University Hospitals NHS Foundation Trust

Secondary care
Is the example industry-sponsored in any way?