What Orwyn does: musculoskeletal (MSK) decision support at first contactThe surgical question, answered at first contact.
Care goes wrong in both directions
First contact clinicians already make this decision every day, and the great majority of those decisions are right. The weak part is the system around them. A patient can be sent for a surgical opinion that was never going to lead to an operation, and wait months to hear it. Another can be managed for a year with a problem that needed surgery sooner. Neither is a failure of the clinician in the room. When they decide, they cannot see the thresholds specialists will use later. Nor can they see what happened to their past referrals.
Musculoskeletal means the joints, muscles, bones and soft tissues. First contact clinicians are the people who see these patients first, usually in general practice or a community service. Most often they are physiotherapists. Some are advanced practitioners who run triage clinics, which sort patients by need. GPs, osteopaths, podiatrists, and sports and exercise medicine doctors also see these patients. They are experienced, skilled clinicians. But the system does not routinely share the surgical end of the pathway with them. They do not see the thresholds surgeons apply, the reasoning behind them, or what happened to the patient afterwards. Nor does the system give them a way to reach a surgical opinion at the moment the decision is made.
How the most likely diagnosis is reached at the first appointment is explained in MSK diagnosis at first contact.
A surgeon's criteria, written down and shown
Most patients do not need it. An experienced clinician is certain about most of the people they see, and existing triage stays exactly where it is. Orwyn is for the referral decisions where surgery is a real question. In those cases, it makes the reasoning clear to the clinician and, through the clinician, to the patient.
It is designed for the clinician
Orwyn is not a patient app and not a questionnaire the patient fills in at home. It is designed to sit with the clinician while the patient is in front of them, and to fit inside a normal appointment.
It shows its reasons
Orwyn runs on rules written by a named consultant surgeon, Dr Arj Imbuldeniya. The rules are built from national guidance and research evidence. Their sources include the National Institute for Health and Care Excellence (NICE) and the Getting It Right First Time programme. They also include the British orthopaedic specialist societies, such as the British Orthopaedic Association and the British Association for Surgery of the Knee. Orwyn is being built to NICE’s latest standards for digital health tools. Its rules are being checked against current NICE guidance. Any departure from it is stated, and the clinical safety officer is responsible for it. These are our own checks: none of these bodies has assessed or endorsed Orwyn. Orwyn is not a computer model that hides its reasoning. Anyone reviewing a decision can be shown why it was made.
It works with you, not above you
Orwyn does not check, approve or oversee the clinician's work. It carries a surgeon's judgement into a room the surgeon is not in. The clinician assesses the patient and decides.
The surgical end has its own bias. Surgeons are trained, paid and measured on operating. The surgical clinic also sees a patient only after someone has already framed the question as a surgical one. Writing the criteria down, with the evidence behind each one, is a constraint on the surgeon as much as anything else. It means the threshold can be argued with.
What happens in the consultation
Seven steps, and the clinician decides at every one
Orwyn follows the same steps in every consultation, in the same order, with the safety questions always first. Each answer comes with its reasons in plain words, and the clinician can disagree at any point. The diagram marks honestly which steps work in the demo today and which are planned.
A decision is not enough on its own
The patient leaves with the plan In the demo
At the end of the appointment, the patient is given the letter: the plan the clinician has agreed with them, in plain words. It is printed or shown on screen. It says what was decided, why, and what would change the answer. Where a consultant has reviewed the case it says so. Nothing is asked of the patient in return. There is no app to download, no account and no diary to fill in. Nothing is collected back from them.
Some clinicians told us patients may accept the same advice differently depending on who stands behind it. We are testing this; it is not yet shown.
The difficult cases still reach a surgeon
No set of written criteria settles every patient, and the ones it cannot settle are usually the ones who most need judgement. Orwyn is designed to find those cases and prepare them for an existing multidisciplinary meeting, where specialists from different professions discuss them. It will show what was tried and for how long. It will list the X-rays and scans with their dates, and why the criteria did not settle the case. The decision, the reason and the clinician responsible will be recorded. The letters to the patient and the GP will be drafted from them.
Orwyn does not hold the meeting, does not schedule it and does not make the decision. It is designed to remove the preparation time that makes consultant sessions too expensive for most community services to justify.
The clinician finds out what happened Planned
When a first contact clinician refers a patient, the outcome letter goes to the GP and the patient leaves the community service. Nothing routinely tells the clinician who made the decision what happened. That is a strange way to run a system that depends on those decisions being good. For the terms behind this, see MSK referral optimisation, MSK triage explained, and who first contact practitioners are.
Orwyn is designed to return the outcome to the clinician who made the referral. It will be theirs and theirs alone. There is no league table, no ranking, no comparison against colleagues and no report to a line manager. The clinician will be able to see what happened to their own patients, if they choose. Comparison between clinicians is something else, and we have deliberately designed it so that it cannot be done.
It does not learn by itself
Orwyn records its plan and the clinician’s decision, with the reason for any change. Recording the outcome is planned, not yet built. None of it changes how Orwyn behaves. The rules change only when a named consultant surgeon changes them in writing, with a version number and a date. This means any suggestion can be traced to the exact rule that produced it. That is a deliberate constraint and not a limitation we intend to remove.
The tool the clinician uses
One screen shows the most likely diagnosis and the findings behind it. It also shows the recommended actions, what happens next and a way to disagree. It all fits inside a normal appointment.
See why, not just a number. Orwyn shows the chain from assessment to suggestion in plain language. For every finding, Orwyn gives a weighted score based on written rules and regularly reviewed evidence. The screen shows the reasons, not the number, and every rule is available to check.
- Clinical inputs: age 42; symptoms, anterior knee pain; red flags, none reported.
- Rule and reason: the findings suit the usual first treatment. Evidence link attached.
- Suggested next step: non-surgical pathway; load management and targeted physiotherapy; reassess at a dated review.
- Clinician decides: agree or disagree, with the reason retained.
Built together, from evidence and experience
Orwyn was designed from frontline practice in the NHS (National Health Service). It draws on decades of seeing and treating thousands of patients, with and without surgery. It also draws on more than ten years of detailed conversations about this problem. Those conversations were with physiotherapists, advanced practice physiotherapists, first contact practitioners, GPs, and sports and exercise medicine doctors. Radiologists, orthopaedic surgeons, NHS service managers, commissioners (who plan and pay for care) and patients took part too. The consensus, wherever the question was asked, was the same. Better decisions for patients are made together.
The criteria are built from the highest quality evidence available in published research and national guidance, combined with that clinical experience. When a consultant surgeon and a physiotherapist work side by side, patients reach the right decision sooner. Orwyn exists to make that working relationship available in every clinic, at a cost the NHS can afford.
Surgeon-governed decision support for first contact MSK clinicians.
The demo uses draft rules awaiting final sign-off, and example patients only.