Skip to main content
Bevan Exemplar Cohort 1 Projects

Advancing Healthcare: Patient Pathway Transformation (Carpal Tunnel)

Catrin Hawthorn

Hywel Dda University Health Board

A Therapy-led Carpal Tunnel Clinic in a primary care setting, supporting the government’s modernisation agenda for the shifting of boundaries between different professional groups to meet changes in healthcare delivery. Providing a patient focused service, reducing waiting times, and improving cost effectiveness.

The unique setting of the Powys LHB, as well as the freedom to develop innovative service provision to a rural community resulted in a service that meets the strategy set by the Welsh Government (Setting the Direction).

In response to growing concerns about the size of orthopaedic waiting lists, and waiting times, Welsh Government announced a multi service strategy to deliver an innovative Orthopaedic Service (Delivering Orthopaedics through Muscularskeletal (MSK) Transformation). The Clinic aimed to reduce the pressures on secondary care orthopaedic out–patients, providing patients with early access to specialist opinion in a community location. With all District General Hospital provision in Powys commissioned from neighbouring providers, the Clinic has enabled repatriation of orthopaedic services releasing funds back into the health board.

A review identified Powys patients who presented with carpal tunnel were waiting in excess of 20 weeks to see the Consultant, and in excess of eight weeks for a nerve conduction test (NCT). This led to pressures on referral to treatment (RTT) and long waits for patients.

The patient journey and feedback was mapped to experience “referral to surgery”. The distance travelled for the NCT, prolonged waiting times, and lack of clarity regarding a lead clinician, were key factors highlighted.

The data suggested a significant number were travelling out of county for treatment. The finance department were included in the project as there was recognition of a cost to new pathway whilst emphasis on quality would need to have a cost neutral or cost benefit. We applied the methodology using five quality domains resulting in a pathway transformation that met the demands placed upon it, not just from a patient’s perspective but also to comply with NICE guidelines and the prudent healthcare agenda.

This Project Supports Prudent Healthcare:

Effective: NICE systematic review does not recommend electrodiagnostic testing if symptoms were well defined some patients may be referred unnecessarily for tests when clinically their presentation would lead to an outcome of surgery.

We provide information and advice by a specialist clinician to improve self management strategies and quality of life whether surgical treatment is indicated or not. The NCT if relevant is explained, as are the treatment choices for the patient.

Timely: Reduction of waiting times for listing of surgery to a maximum of 8 weeks. Proven to shorten and streamline the journey to symptom resolution for the patients. Providing early access to specialist opinion in a community location.

Avoid waste and variation in the patient’s journey.

Efficient: Direct referral from GP/senior physiotherapist to the clinic, an appointment no later than 8 weeks after that, NCT, clinical assessment and pre-op happen on the same day. Improved the capacity of orthopaedic consultants to manage complex patients.

Equitable: All patients receive the same level of assessment and treatment with time from referral to assessment being equal for all referrals. There is no longer a dual access pathway for this condition.

Safety: Clinical governance comes from our upper limb specialist, training was received by the company providing the equipment, as well as linking with special interest groups within the profession.

Acknowledging the standard needed in the clinician, we utilise an evidence based approach to assessment and treatment.

We still have a referral path to the NCT service at Hereford, and their Orthopaedic team.

Anticipated Benefits:

Our aim was to provide a community based service for the assessment and treatment of carpal tunnel where a streamlined approach is required to achieve optimum outcomes for patients.


  • An emphasis on therapeutic management and supported self care.
  • Improve patient experience, health outcomes and general well being.
  • To improve Consultant capacity by reducing new patient and follow up attendances for this condition.
  • To reduce the waiting times at WVT – Orthopaedics nationally is high volume/long waits and this is particularly evident in Mid-Powys.
  • To improve the management of clinical pathways to ensure patients receive the most appropriate assessment and intervention in a timely way.
  • From a patients perspective their previous pathway was disjointed, using multiple clinicians, departments and localities. This resulted in long delays for assessment and decisions regarding the outcome of their assessment.

In comparison From 4 steps, in up to 3 different hospitals before outcome treatment was decided, over a maximum of 36 weeks until surgery.

The new pathway resulted in 3 steps in one hospital, on one day, lasting a maximum of 20 weeks until surgery.

Patient Outcomes:

  • Treatment closer to patients home;
  • Reduced travel costs – approximately £100 per patient;
  • Reduced travel time – max one hour;
  • Referral to Consultant – 16-20 weeks;
  • Referral to CMATS carpal tunnel service – four weeks;
  • Patients receives improved information;
  • Improved wait for clinical diagnosis;
  • We now accept patients from Machynlleth.