For National Health Service (NHS) services and commissionersSurgical decision support for NHS musculoskeletal (MSK) services
This page is for people who run NHS MSK services, and for commissioners and integrated care boards (ICBs), who plan and pay for them. It answers the questions we are asked most about evaluating Orwyn, and says plainly what is not yet decided.
Designed for first contact MSK clinicians.
For commissioners and integrated care boards
The Arthritis and Musculoskeletal Alliance (ARMA) looked at the joint forward plan of every integrated care board (the local NHS bodies that plan and pay for care). It found that 1 in 3 plans do not properly mention musculoskeletal health, and 2 in 3 do not mention chronic pain services. ARMA recommends a joined-up approach across the whole system, with clear outcomes for the services being bought. It says services should be measured on how well people function and take part in daily life, not on how many appointments they provide.
Orwyn is designed for one moment in care that already happens, and is already paid for. That is the point where the clinician seeing the patient first decides whether that patient needs a surgical opinion. Get that moment right, and patients who need an operation are found sooner. Patients who do not need one get a clear answer, instead of a long wait to be told so. In the demo, Orwyn records its plan and the clinician’s decision, with the reason for any change. Records for real patients are planned, as is recording what happens next, so that it can be counted. This is the work NHS England calls MSK referral optimisation. It is judged in both directions, not on the number of referrals alone.
A first evaluation would measure any change in both directions, against a baseline taken first. See what a first evaluation looks like, and who provides what.
Insurers and employee health providers: see MSK decision support for insurers.
Better decisions. Better care.
- Designed to find surgical patients sooner: built to identify people who need specialist review earlier.
- Fewer waits that change nothing: give patients a clear, credible non-surgical plan.
- Less uncertainty: intended to reduce avoidable waits and improve experience.
- Know what happened: structured outcome data to improve pathways.
Design intentions, not results. Orwyn has not yet been deployed.
How Orwyn fits NHS priorities
- Referral optimisation. NHS England’s referral optimisation guidance (October 2023) aims for people to be seen by the right person, at the right time and in the right place.
- Specialist advice. The same guidance recommends specialist advice before or instead of a referral, ideally within two working days. Orwyn puts a consultant knee surgeon’s written judgement into the first consultation.
- Community MSK waits. NHS England’s improvement framework to reduce community MSK waits asks that no priority patient waits more than two weeks. It also asks that no patient waits longer than 52 weeks.
- First appointments that change nothing. Getting It Right First Time (GIRFT) published its orthopaedic outpatient guidance in July 2023. It asks systems to review how they work when more than 20% of patients are discharged at their first orthopaedic appointment. The focus is on making best use of MSK practitioners in primary and community care. That first contact decision is the one Orwyn supports.
- The 18-week clock. The national waiting time rules say when the 18-week referral to treatment clock starts. It starts when a patient is referred to an interface or assessment service that may refer them on to a consultant-led service. So time in a community MSK interface service counts towards the 18 weeks.
- GIRFT’s knee replacement pathway. GIRFT’s knee replacement pathway (July 2026) asks that a referral shows the non-surgical care tried and the effect on daily life. The referral should say whether the patient is considering surgery, and include weight-bearing X-rays with a skyline view. It should also show support to stop smoking and manage weight, and health conditions optimised. Orwyn’s referral for a knee replacement opinion carries the non-surgical care tried, the effect on daily life and whether the patient would consider surgery. Every knee X-ray Orwyn asks for includes the skyline view. The referral also records the patient’s body mass index (BMI), smoking and the support offered, with the pathway’s advice on health conditions. This does not hold up the referral, in line with guideline NG226 from the National Institute for Health and Care Excellence (NICE).
Where Orwyn sits in the MSK pathway, and who uses it
Orwyn is designed to sit inside the first contact MSK consultation. That may be in general practice, a community MSK service, or an interface or triage service. It is for first contact clinicians: first contact practitioners, advanced practice physiotherapists and MSK physiotherapists. We explain where triage happens, and what NHS England asks of services, in NHS MSK triage, and where Orwyn fits.
Orwyn is for use in the room, while the patient is in front of the clinician. It is clinician-facing decision support, not a patient questionnaire and not something the patient fills in at home. It is designed to fit inside a normal appointment. A first evaluation would test this.
Orwyn does not check, approve or oversee anyone's work. It carries a surgeon's judgement into a room the surgeon is not in. The clinician assesses the patient and decides.
General practice
General practice still sees most musculoskeletal problems, in ten-minute appointments, alongside everything else. The hardest cases are often patients already waiting, who keep coming back. The honest question is whether anything has been missed, and whether the plan should change.
Orwyn is designed and tested for first contact musculoskeletal appointments rather than for a ten-minute general practice appointment. We are now talking to GPs (family doctors) about whether it is useful in general practice, and what would have to change. If you see these patients, we would like to hear from you.
What happens in the consultation
The same seven steps every time, with the safety questions first. You can follow the demo step by step, with example patients, without a password.
What does not change
The clinician decides
The clinician assesses the patient, makes every decision and remains accountable for it, exactly as now. Orwyn offers a suggestion with its reasons, in plain words. The clinician can disagree and give a reason. In the demo, Orwyn records its plan and the clinician’s decision, with the reason for any change.
Nothing refers by itself
Orwyn does not send a referral, book an appointment or contact a patient on its own. Every letter is written for the clinician to check, change and send.
Existing pathways stay
Your triage, referral routes and local criteria stay as they are, unless the service decides to change them on purpose as part of an evaluation.
What a first evaluation looks like
Orwyn is being assessed for an NHS pilot. No pilot is under way yet. A first evaluation would run in one first contact MSK service, alongside the existing pathway, not in place of it. Only clinicians who choose to take part would use Orwyn. Before it starts, we would agree with the service which clinics take part, and for how long. We would also agree what counts as a good decision in both directions, and who reviews safety.
The evaluation would first measure how referral decisions are made today. It would then compare the same measures while Orwyn is in use, so any change can be shown, not just claimed. The results would belong to the service as much as to Orwyn.
What it would measure
These are the measures a first evaluation would collect. They are not results: Orwyn has not yet been deployed.
Process
Whether Orwyn fits inside a normal appointment, how often it is used, and where it is not.
Decisions, in both directions
Patients referred who did not need a surgical opinion, and patients held in non-surgical care who needed one sooner. Neither on its own; always both.
The pathway
Time to the right next step, re-attendance, imaging requested, and escalation.
User experience
What clinicians and patients say about the plan, the letters and the time it takes.
Safety
Every safety rule that applied, what was done, and any incident, reviewed against the clinical safety case.
A pilot should measure the clinical decision, the outcome and the pathway around it, not clicks or logins.
- Referral decision: what was decided, and why.
- Specialist outcome: what happened next.
- Patient pathway: time, reattendance, escalation.
- Service effect: activity, waits, variation, cost.
Designed for NHS pilot evaluation: a baseline first, then the decision, the outcome that followed, and the effect on the service.
Who provides what
Orwyn provides
- The software, and the clinical rules behind it, written by a named consultant knee surgeon
- The maker's clinical safety work under DCB0129: the hazard log and the clinical safety case report
- Training for the clinicians taking part, and support during the evaluation
- The evaluation reports, shared with the service
The NHS service taking part provides
- A clinical lead and the clinicians who choose to take part
- Its own clinical safety assessment, under DCB0160 (the NHS standard for organisations that use health software)
- Information governance approval, including the data protection impact assessment
- Agreement on what is measured, and access to the outcome information needed to measure it
Information governance and clinical safety
We carry out clinical risk management under DCB0129, as the maker of the software. Any NHS service that uses Orwyn would carry out its own assessment under DCB0160, and we would support it. Orwyn is being mapped against the NHS Digital Technology Assessment Criteria (DTAC) as it is built.
Some questions are not yet decided. They include how Orwyn connects to the record system, where the service's data is held and how clinicians sign in. We will agree each of them with the service before any evaluation starts. Our standards page shows where each standard stands today. Our evidence page shows what we have tested, and what a first evaluation would measure. Our safety page shows how Orwyn is built to be safe.
Background
The size of the problem
Musculoskeletal problems are one of the biggest things the NHS deals with. 20 million people in the UK live with a musculoskeletal condition. A fifth to a third of general practice consultations relate to one (NHS England; Keavy, British Journal of General Practice (BJGP), 2020). The NHS spends around £5 billion a year on them, and around 30.6 million working days are lost to them every year.
The Arthritis and Musculoskeletal Alliance (ARMA) brings together patient charities and professional bodies, and speaks for musculoskeletal health in the UK. It describes what good care needs: early assessment, rapid advice and the right triage, so people get support before problems get worse. Good care also needs strong links between community services and specialist care. ARMA notes that delays lead to avoidable decline, loss of function and more pressure on the rest of the system.
The GP consultation figure is published by NHS England. The remaining figures and the policy positions are published by ARMA. Orwyn has no affiliation with either and is endorsed by neither.
- 20m+ people in the UK live with an MSK condition. Source: ARMA 2026.
- A fifth to a third of GP consultations relate to MSK conditions. Sources: NHS England; Keavy, BJGP 2020.
- £5bn NHS spend estimated annually on MSK conditions. Source: ARMA 2026.
- 30.6m working days lost annually to MSK conditions. Source: ARMA 2026.
Surgeon-governed decision support for first contact MSK clinicians.
The demo uses draft rules awaiting final sign-off, and example patients only.