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Response to the British Orthopaedic Association

In a recent statement, the British Orthopaedic Association (BOA) criticised general practitioners (GPs) for their management of patients with knee problems and seemed to be blaming GPs for high rates of inappropriate arthroscopy in the UK. The statement was subsequently revised after criticism from GPs. The BOA seemed to be unaware that GPs refer patients to specialists for an opinion on further management. The decision to proceed to an intervention such as arthroscopy lies with the specialist - in consultation with the patient who has to agree to a procedure being carried out. The BOA also seemed unaware of how services for musculoskeletal problems are delivered in the NHS, both in primary care and in specialist settings, which is very worrying if true.

Where I practise in London, referrals for musculoskeletal problems are made to an Integrated Musculoskeletal Service in which the initial assessment is made by a physiotherapist. Most patients are generally then referred for physiotherapy and self-directed exercise. Only a minority of patients are referred on to a rheumatologist or orthopaedic surgeon. We do have direct access to MRI scans but this is not something we use often (in the last year, I have only referred one patient for an MRI scan of the knee). Because of the referral pathway we have locally, it has been some time since I have made a direct NHS referral to an orthopaedic consultant. Private referrals are a different matter and in my practice there is a steady stream of private referrals to orthopaedic surgeons (many of our patients have private health insurance). I note that I have never had a private referral to an orthopaedic surgeon returned to me on the grounds that the patient should have had a course of exercise or physiotherapy before referral.

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