The Bedfordshire MSK Service, part of Circle Integrated Care, is a single point of access for musculoskeletal conditions.

All patients over 18 years old with an MSK condition registered with a Bedfordshire GP should be sent to the Circle Hub for triage (preferably via E-Referral).

Referrals will be triaged by specialist MSK Extended Scope Physiotherapists to the most appropriate treatment pathway and patients will be offered a choice of provider, where available. Patients will be monitored and supported across their pathway.

Clinical triage will be performed within 24 hours. If referrals have insufficient information, Circle staff will contact the practice to request additional information.

How do I refer patients to the service?

The preferred method of referral is to E-refer. This is a more secure referral method and ensures we have quick and easy access to all patient information. However, other methods are referral are through:



Circle Integrated Care
Regent House
Wolseley Road
MK42 7NY

What specialties should be referred to the MSK service?

The following specialties are covered by the MSK service:

  • Orthopaedics
  • Pain management
  • Physiotherapy
  • Rheumatology
  • Podiatry (MSK)
  • Podiatric surgery
What are the potential pathways within the MSK service?

Patients will be triaged to either:

  • Physioline. Patients will have the opportunity to speak with a physiotherapist who can assess their condition over the phone and can suggest exercises and other management techniques with reference to leaflets and online video demonstrations. If, after assessment, the problem is more complex, face-to-face physiotherapy will be arranged.
  • Physiotherapy. Patients will be referred for face-to-face physiotherapy.
  • Community MSK. Patients will be assigned to either an ESP or a GP with a Special Interest in MSK medicine, for a detailed assessment and work-up.
  • Secondary Care. Our Patient Choice team will offer patients a choice of provider, and our Shared Decision Making team will contact patients with certain conditions such as hip and knee osteoarthritis to discuss treatment options.
What happens when patients leave the service?

When a patient has completed their course of treatment, the Bedford MSK Service will discharge the patient back their GP with a clear discharge plan.

Should a patient’s condition require further treatment, and/or onward referral to another allied service, this will be arranged through the Circle MSK hub, and should not require further input from the patient’s GP.

If a patient did not attend (DNA) a hospital MSK appointment for whatever reason, will we have to send through the MSK service again rather than re-referring? Or can they phone the MSK service to reorganise?

If a patient has DNA-ed a hospital attendance, Circle will accept a direct contact at the Integrated Provider Hub from the patient so they can establish if their condition has changed and if the same pathway is still appropriate or if a new or different service is available, and to book them an appointment. The patient will also be able to access the service via the self-referral route.

A patient wants to go to a specific hospital for a certain condition. How does the patient exercise choice?

The Circle Bedford MSK team will advise the patient on their choice of provider.

If a patient has a particular preference for a hospital, the choice team will discuss this with them and arrange onward referral. Once it has been agreed with the patient they will be referred to secondary care a conversation with a choice adviser will be arranged.

Do I need to obtain permission from Individual Funding Request (IFR) panel before I refer to the MSK service?

No, you do not need to obtain permission from the IFR for Procedures of Low Clinical Value (PLCV). Circle Integrated Care holds the budget for all MSK conditions that are not within the exclusion criteria. We will manage the patient according to the clinical need and evidence based guidelines. These include the Bedfordshire Surgical Thresholds and the Evidence Based Interventions document published by NHSE in November 2018.


If you have any queries regarding a referral please email for advice.

Where can I find guidelines on Procedures of Low Clinical Value?

A link to evidence base for Procedures of Low Clinical Value can be found at the link below

Exclusion criteria: What MSK conditions should I not refer to the MSK service ?


Patients under the age of 18 years old at the time of referral. The MSK service is an adult service only

Red flags 

  • Fracture; Please refer to the local fracture clinic
  • suspected Cauda Equina; refer to local A&E is suspicion
  • Undiagnosed lumps and bumps
  • Suspected cancer; Please use 2ww pathway

Non-MSK conditions

  • Neurological disorders
  • Falls
  • ENT disorders e.g. vertigo, TMJ
  • Gynaecological referrals e.g. women’s health, Incontinence
  • Non-MSK podiatry e.g. corns, toenails, orthotics, callouses (MSK podiatry is included)
  • Chronic Fatigue Syndrome
  • Domiciliary physiotherapy

Clinical effectiveness

  • Acupuncture only referrals
If a potential cancer is found by Circle clinicians during the course of investigation, what is the process for referral under 2 week wait (2WW) ?

Fortunately, it is rare for a potential malignancy to be found. If a positive result is received it has been agreed with the Bedfordshire CCG that the referral should be immediately referred back to the GP for onward referral to the hospital of their choice under the 2WW pathway. The reason this was agreed was to ensure the best patient pathway. The MSK service will endeavour to contact the patient first to inform them of the abnormal result but will also contact the GP without delay by phone to ensure a smooth transfer of information and responsibility.

Will the service support GPs?

Yes. The service is designed to support GPs and create integrated working. Initiatives include:

    • MSK Practitioners (First Contact Practitioners). Experienced physiotherapists will be offered to provide front-line clinics, free of charge, in GP surgeries. They will work side-by-side with GPs by assessing and treating, or triaging to further MSK services, at the first point of contact.
    • Continuous Professional Learning. Circle will provide education and training opportunities on MSK conditions, based on specific conditions, diagnostic methods and examination techniques. Further information can be seen below.
    • Clinical Steering Group. GPs, Consultants, Physiotherapists and other MSK professionals will have the opportunity to meet and discuss pathways and ways to improve the service.

Educational events

Primary Care Rheumatology & Musculoskeletal Conference 

An educational programme of lectures and workshops for GPs, trainees and other members of the practice team to help develop core skills in musculoskeletal care.

14-16th November 2019 – Park Inn, York

A friendly hands-on conference for GPs, Trainees and all members of the practice team. Discounts available for Trainees and Registrars.  Full programme and application form at or contact Helen Livesley on 01609 744794 or email

  • Temporal artertitis and PMR – Dr Sarah Mackie
  • Osteoarthritis what’s new and what’s coming? – Professor Philip Conaghan
  • Ehlers-Danlos Syndrome – Dr Emma Reinhold
  • Primary Care Networks – Dr Raj Patel
  • Joint Injections – using models
  • Core Skills
  • Podiatry – Dr Heidi Siddle
  • Osteoporosis – Dr Zoe Paskins
  • Keele Pain Recorder App and Opioid Withdrawal – Dr John Bedson
  • Ultrasound – Dr Lucy Douglas / Dr Tony Mitchell
  • Promoting improved services for IAPT for Long Term Conditions – Ms Sue Brown, ARMA
  • National Institute for Health Research – Mrs Kay Stevenson
  • Health Policy – Dr Alistair Dickson (x1 workshop)
  • Paediatric Rheumatology  Dr Graeme Denman
  • Evidence based guidelines for managing MSK conditions – Dr Graeme Wilkes

Clinical Steering Group

This is an evening for clinicians with an interest in MSK to meet and discuss pathways and ways to improve the service.

If you would like to attend, please contact us at

You can also send issues or topics you would like to be addressed at these meetings.

Clinical Steering Group meetings are held every other month and are located at Flitwick Manor, Church Road, Flitwick, MK45 1AE – 0330 028 3406.

The dates for 2019 are as follows:

  • Thursday 31/01/2019
  • Thursday 21/03/2019
  • Thursday 30/05/2019
  • Thursday 25/07/2019
  • Thursday 26/09/2019
  • Thursday 28/11/2019
National guidance on MSK is increasingly being issued. To assist you in keeping up to date with MSK matters and to act as a reservior for useful guidance we are providing links to MSK documents which we hope you will find useful.

Useful MSK related links

Document Published Web link Description
Spinal GIRFT January 2019 This document looks at evidence based commissioning for spinal services and forms the basis for our referral pathways for spinal conditions
Evidence Based Interventions Consultation Document July 2018 Provides a guideline to evidence based management of a number of commonly commissioned procedures including knee arthroscopy, injections for back pain, shoulder arthroscopy and a variety of hand clinicians
Musculoskeletal Conditions Update on MKS conditions with a link to Arthritis and MSK Alliance (ARMA)
Everybody active every day October 2014  Update on MSK conditions with a link to Arthritis and MSK Alliance (ARMA)

If you have any questions, please contact our team on 01234 639000 or by email at for general queries or for clinical queries