East Lancashire Integrated MSK, Pain and Rheumatology Service

Improving access to co-ordinated musculoskeletal rheumatology and pain care in the community


The Integrated MSK, Pain and Rheumatology Service (IMPRS) in East Lancashire has brought all musculoskeletal (MSK), rheumatology, pain management and orthopaedics together with a single point of access. Since full roll-out in July 2015, the IMPRS has successfully diverted patients from secondary care to management in the community whilst maintaining patient satisfaction.
  • 8% reduction in patients requiring secondary care rheumatology 
  • 30% diversion from orthopaedic activity as patients referred into alternative services 
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The Challenge

  • Separate referral processes existed for individual community-based MSK services and hospital-based rheumatology, pain management and orthopaedics services; patients were often referred to multiple providers and the burden on secondary care was high.

The Solution

  • The Integrated MSK, Pain and Rheumatology Service (IMPRS) provides a single point of access to a range of services for common conditions such as neck and back pain, osteoarthritis, sports injuries, inflammatory conditions and long-standing pain conditions.
  • The integrated service is delivered across multiple sites, including in the community to reduce the need for hospital-based interventions by enabling more timely assessment, and is jointly commissioned by two Clinical Commissioning Groups (CCGs).
  • A co-design event was held involving commissioners, service managers, clinicians and patients. Commissioners, managers, clinical leads and service leads managed the development and roll-out of the new integrated service, and continue to monitor its implementation.
  • The IMPRS employed EMIS Health to monitor key performance metrics, with all stakeholders able to access the ‘MSK dashboard’ and therefore able to identify any problems for early discussion. GP practices can compare themselves against other practices, and the system records clinical activities, which facilitates audit.
  • The IMPRS has brought in some new initiatives for primary care clinicians, including GP educational forums, a GP advice line, MDT foot and ankle clinic, GP newsletters and spinal drop-in clinics.
  • The IMPRS is clinically led with a robust system of clinical supervision and peer review; there are regular clinical team meetings, scheduled case discussions, clinical audits, training opportunities for medical trainees and support for ongoing professional development.
  • The IMPRS provides web-based resources for patients (eg. exercise videos) and patient education programmes have been developed to meet the service aim of improving self-care.

Service Performance and Outcomes

  • The IMPRS was rolled out in July 2015 after a successful pilot triaging all orthopaedics referrals from a smaller locality’s primary care practices. The pilot demonstrated a ~30% deflection from secondary care into primary care MSK services, and met key performance targets of 24 hour triage turnaround and routine patients seen within 4 weeks and urgent within 5 days. There was also a high level of patient satisfaction, and the majority of patients were seen in the community.
  • The IMPRS has freed capacity within secondary care and reduced costs to the health economy, with an 8% reduction in patients requiring secondary care rheumatology and a 30% diversion from orthopaedics.

Financial Performance and Outcomes

  • Investment by the commissioning CCGs was required to set up the IMPRS. There were specific staff costs involved in implementing the co-design, as well as recruitment for new posts created for the IMPRS and IT infrastructure.
  • There have been no additional costs to rheumatology to manage referrals since becoming part of IMPRS with the single point of access.
  • Given the deflection away from secondary care, cost-savings to the CCGs are anticipated, although this has not been formally evaluated.

Patient Focus and Satisfaction

  • The IMPRS provides a more streamlined patient journey to the most appropriate specialist, preventing patients from needing to navigate complex clinical pathways in multiple departments and localities.
  • The service provides practical advice for patients through patient education sessions and via its website.
  • The services that have been integrated into the IMPRS have consistently high levels of patient satisfaction; 93.7% of patients were extremely likely or likely to recommend the physiotherapy service to friends or family if they needed similar care or treatment, for example.

Commissioning Implications

The East Lancashire IMPRS is an example of commissioning best practice in rheumatology and meets a number of priorities for commissioners, clinicians and patients:


  • Active support for self-management – IMPRS offers a number of patient education programmes, including one on inflammatory arthritis, and has a strong emphasis on educating patients in order to encourage self-management
  • Care coordination – IMPRS coordinates care across multiple specialties, addressing a wide variety of patient needs, and prevents unnecessary referrals into secondary care
  • Community-based care – the development of IMPRS was underpinned by guidance about delivering community-based care

The service has only recently been established and is considered an emerging best practice model for the integrated management of MSK, pain and rheumatology services. Based on the available data and forecasted outcomes, IMPRS has the potential to triage patients to the most appropriate care whilst reducing expenditure on secondary care.

Service diagram