Organisational capabilities, outcomes, and benefits of trigger finger release surgery in primary care: a service evaluation study

Rationale

The service was designed to leverage the existing expertise in primary care and simultaneously aimed to reduce waiting lists at the local acute trust. Indeed, a 2015 review by Hussenbux and coworkers considered the potential as well as output impact of interdisciplinary triage-and-treat services at the primary care interface for musculoskeletal conditions.¹⁴ Across the 23 studies identified, ≥72% of patients could be managed at an earlier stage through intermediate care pathways, leading directly to a 20%–60% reduction in orthopaedic referral rates. Furthermore, there have been further references to such interfacial services for the reduction in orthopaedic outpatient waiting lists, specifically in consideration of the shifting policy landscape within the UK NHS.¹⁵ Ferguson and Cooke¹⁵ assessed the NHS Bath and North East Somerset Orthopaedic Interface Service, where an intermediate service resulted in only 21% of patients being referred to secondary care, the remainder being successfully managed within primary care settings.

The setting and integration within the integrated care model

At the time of the study, the referral areas were Leicester City clinical commissioning group (CCG) and East Leicestershire and Rutland CCG, covering more than 1.2 million patients. The caseload described within this study accounted for 50% of the cases, where the remaining 50% of referrals were undertaken by secondary care. All referrals were made by the referral service scheme, which is a standard NHS practice where this offering was integrated into the opportunity. Furthermore, patients were referred to the service as part of the standard clinical pathway including previous iterations of corticosteroid injections before surgical referral.

The approach

The methodology was based on the concept of GP retraining where a number of clinicians in primary care had sought additional training in specialty fields that they are able to leverage. In this instance, a GP with surgical specialism and qualifications collaborated with a local consultant hand surgeon in the acute care trust in order to establish this service. The local GP surgical specialist and consultants working in the primary care setting were allocated 250 procedures per year in order to achieve the availability described.

Surgeries were carried out in existing, purpose-built minor surgery units in primary care, with ≥15 air changes per hour. The facility benefitted from a Service Level Agreement with the local CCG at the time. Operationally, the service was able to run at just above half the current NHS tariff for such procedures, as the economies of scale within the primary care units allowed for savings on porters, multiple theatre assistants, large administrative teams, and estates and overhead costs. Indeed, the current NHS tariff to secondary care for such procedures is marginally over £1000 per case, whereas the service described within this study was able to deliver such procedures at a 40% cost-saving, thereby £600. In comparison, the team used to deliver this service consisted of the following: GP specialist or consultant, theatre assistant (mid-band nurse), district nurse (for follow-ups), and an administrative colleague to arrange appointments and additional clerical tasks.

Patients were called at the surgery slot and in most cases would be discharged from the surgery within 30 minutes of arrival, thereby avoiding unnecessary waits, overcrowding, and patient anxiety. Follow-up was carried out by the district nurse team for stitch removal and benfitted from open-access patient initiated follow-up appointments (PIFUs) for any concerns or queries relating to the service. This avoided patient anxiety concerning additional clinician contact and reduced likelihood of emergency department visits given the open-access nature of the PIFUs as an alternative.

Evaluation and postoperative care

Patients received a hand evaluation questionnaire 6-weeks post-surgery in order to assess their recovery and capture any concerns, with the option of scheduling a follow-up appointment. On patient-initiated follow-up, the surgeon would receive an automated email with any additional information, such as wound photographs or patient notes, and scheduled a slot to call the patient. This would be carried out as a same-day service either by audio or video call. The surgeon would discuss with the patient their preference and a face-to-face appointment would be set up if clinically required or requested by the patient.

The development of this service — with demonstrable ease of access for patients, as well as the open and accessible follow-up opportunities, in addition to the improved time and financial considerations — indicated an overall benefit for implementation. Indeed, of all the referrals triaged to primary care, locally 90% of trigger-release interventions were carried out in primary care with 10% referred to the acute trust as the presentation was not commensurate to trigger finger, instead being a related condition such as Dupuytren’s contracture, flexor or extensor injury, ganglions, and arthritis.