Back Pain care and NHS Community Interface Clinics: Towards a better model

1. Back Pain and the integrated community MSK Hub: Towards a better model Dr. Richard Collins Sport & Musculoskeletal Physician NHS Circle Bedfordshire MSK & Blackberry Clinic Group
2. Aims • Historical models of Back Pain care and the evolution of MSK services • Current status of Back Pain care within community MSK services • Improved model of Back Pain care • The place of SEM within this
3. Back Pain – the facts • Very common – 33% of adults/year • Mainly affects working age population 40-60 y/o But…… • Major cause of disability globally • Costs health services and national economies £££
4. Back Pain – the failures • Rarely serious or sinister • Very good evidence for functional restoration if given: • Advice & reassurance • Tailored activity & exercise • Supported self-care So what went wrong?
5. Old Model pre-1990s
6. The birth of ‘structuralism’
7. Careful Now!
8. Then….
9. And now…
10. Patient GP Physio Radiology Surgeons Rheum Pain High levels of invasive intervention High levels of Anxiety Structuralism Passive Treatments Traditional MSK Care
11. Patient Off work Physical Deconditioning Poor Mental Health Pain Sensitisation ‘Vortex of Chronicity’
12. Case Study
13. 1998 1999
14. 2000-2005
15. GP+ Level MSK Care Clinical Assessment & Treatment Services (CATS) 20062005
16. ESP Radiology Patient GP+ GPwSI Surgeons Rheum Pain High levels of invasive intervention GP Better evidenced care CATS circa 2005 (pre SEM as a Specialty) GPwSI (Prime Driver) • SEM/MSK (self funded CPD) • Local senior GP ESP • MACP/MSc • Local senior NHS Physio
17. Strengths • Focus for better practice • Rapid assessment • Improved pathways with local stakeholder engagement • Early MDT working with shared up-skilling Weaknesses • Few services nationally & small scale locally • Little improved access to other MSK services • Hamstrung by poorer practice in other services • Delays in onward referrals
18. However…the case was made: • ⬇ Referrals into secondary care • ⬇ MSK spend • ⬆ Patient satisfaction • No real focus on Pain Care though 2011
19. Upscaling • More CATS commissioned or re-tendered • Larger budgets linked to quality outcomes • Need for capacity to bid for and run such services: • Large NHS Partnerships • Circle MSK • Virgin Care • Care UK • Connect Health • 2012 Health and Social Care Bill - ends PCTs & PBC
20. How do we clinically staff these larger services? Facts: • 2006 SEM awarded Specialty status – Some SEM GPwSIs moved away • Reduced availability of suitably skilled MSK GPwSIs • Some of the ‘raw’ clinical functions of the GPwSI were being acquired by ESPs Model adopted: • Increased utilisation of up-skilled ESPs in favour of the older ‘GPwSI-Model’ • Bedford MSK: • 2 FTE ESP : 1 FTE SEM (older service) • 10 FTE ESP : 1 FTE SEM (up-scaled)
21. Consultant • 3rd view GPwSI • 2nd view Patient ESP – CATS • Physio • OT • Podiatry • Diagnostics • Injections Surgeons Rheum Pain GP CATS 2012+ (post SEM as a Specialty)
22. How are these services doing? Particularly with reference to Back Pain
23. BMJ Open 2016;6:e011735. doi:10.1136/bmjopen-2016- 011735 • 3500 patients seen by CATS in North Staffs annually (1125 would allow well powered study) • 2166 CATS attenders consented to be followed up by questionnaire at 6 & 12 months • Primary outcome was consultation in primary care with the same musculoskeletal problem within 12 months • Secondary outcome measures were: • Consultation at the CATS with the same musculoskeletal problem within 12 months • Physical function and pain (Short Form-36) • Anxiety and depression (Hospital Anxiety and Depression Scale) • Time off work • Healthcare costs • QALYs
24. • Over 12 months, 507 (38%) re-consulted for the same problem in primary care and 345 (26%) at the CATS • Primary care re-consultation in: • The first 3 months (57% of re-consulters) was associated with baseline pain interference and spinal pain • After 3–6 months with baseline assessment by a Hospital Specialist • Small mean improvements were seen in physical function and body pain at 6 months • Poor physical function at 6 months was associated with obesity, chronic pain and poor baseline physical function • Mean 6-month cost and QALYs per patient were £422.40 and 0.257 respectively Results
25. “While most patients are appropriate for a ‘one-stop shop’ model, those with troublesome, disabling pain and spinal pain commonly re-consult and have ongoing problems. Services should be configured to identify and address such clinical complexity.”
26. Summary 62% didn’t re-consult in Primary Care ESP staffed model fairly effective How can these services evolve? What new models are emerging? Where should the SEM clinician sit in this?
27. New Model of Back Pain Care – Core Concept Supported Self-Care Evidence Based Treatment Information Screening Lifestyle Modification Navigation to Resources HCP Patient ‘MECC’
28. GP Patient CATS HCP Patient Physio Patient Networked
29. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Overview of these areas…
30. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening …and what value could SEM bring? Care Provision Pathway Design Stakeholder Engagement Education Service Leadership
31. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Screening
32. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening
33. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership SEM What value added?
34. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership Medical Knowledge & Competency SEM
35. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Treatment Guidelines
36. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening • Core Treatment • Positive messaging • Literature & online resources • Judicious analgesia • Activity modification • Exercise prescription
37. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening • CBT & MDT Pain Team • Homerton Locomotor Pain Service • Pain ESP (Prescriber) • Pain Pharmacist • Pain Psychologist • Royal Berkshire IPASS
38. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening • Spinal Interventions • Steroid Epidural if disabling neuralgia from prolapsed IVD (may reduce discectomy rates) • Facet Joint medial branch blocks leading to radiofrequency neurotomy of medial branch (if persisting and severe facetogenic pain) • Surgical discectomy (for severe radiculopathy with progressive neurology or failed steroid epidural)
39. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening • Core Treatment • Positive messaging • Literature & online resources • Judicious analgesia
40. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Information & Positive Messaging
41. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening ‘Back Pain is really common’ ’It’s rarely anything serious’ ‘With time and gentle activity it often settles’ ‘Prolapsed Discs often settle by themselves’ ‘Your back is healthy and wants to get strong’ ‘Your back is ageing normally just like your skin & hair!’
43. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership SEM What value added?
44. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership • GPs • Consultants SEM
45. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening • Core Treatment • Activity modification • Exercise prescription
52. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership What value added? SEM
53. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership Everything! SEM
54. Finally!
56. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening • Spinal Interventions • Steroid Epidural if disabling neuralgia from prolapsed IVD (may reduce discectomy rates) • Facet Joint medial branch blocks leading to radiofrequency neurotomy of medial branch (if persisting and severe facetogenic pain)
57. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership What value added? SEM
58. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Care Provision Pathway Design Stakeholder Engagement Education Service Leadership Why not? SEM
59. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Spinal Injections – why not? • Variability in compliance to NICE Guidelines • Spinal Intervention Society (SIS) Guidelines not always followed • Poor access to Steroid Epidurals (might ⬇ surgical referrals) • Blackberry Clinic demonstrates competency Barriers? • Access to fluoroscope • Training & Mentorship • Politics and turf war • Vision? Compare with diagnostic and interventional US 10 years ago….
60. Supported Self-Care Evidence Based Treatment Navigation to Resources Lifestyle Modification Information Screening Summary SEM • CATS are growing • Pathways are improving • ESP front-facing model can be effective • Back Pain care needs to be better • Early models emerging to meet this need • Medical complexity • Education & engagement • GPs & Consultants • Commissioners & LAs • Pathway design • Higher level interventions ‘Service Leadership’
61. Thank you

Editor's Notes

I chose, as my talk, a fairly wide ranging topic (as I don’t like to be too constrained!) but to focus this into some key aims I intend to explore….
Read points

Next slide:

So let’s get going and start with a summary snap shot of Back Pain..
Read slide

Next slide: ‘the failures’
Read slide

Next slide:

To answer that we need to look at the history of Back Pain care….
Don’t read slide – allow to sink in

Next slide: although Back Pain is as old as humanity itself, there was a definite shift in thinking in the late Victorian era

This was the birth of structuralism
The discovery of X-Rays allowed early pioneers to image the spine and detect structural changes.

The assumption was that all Pain could be explained by visibly altered structures.
This was accompanied by popular theories centered around:

Disc fragility
Vertebral deformity & instability
These theories naturally fed into various management strategies.

When I was a med-student in the 90s it was fairly common to see the above…

Note the corset on the outside!

We may laugh at these images but…
….as a Doctor in 2017, it’s fairly common to see the above too….

There may have been a move away from some structural models (although much remains) but the newer theories aren’t necessarily more accurate.

Next slide: What part did the health system play in propogating these models?
Read through slide

Next slide:

This system funnels patients far too easily into the….(Vortex of Chronicity)
Read through slide

Next slide: A good resource to explore some of the underlying tensions that suck people into this vortex is the….
…Physio matters Podcast (S. 39)

Give overview

Next slide: So this is how the deck was stacked against patients (and continues to be stacked against them in many areas).

But there was a sea change occurring…
…in the 1990s with a number of individuals and organisations coming together in the birth of Evidence Based Medicine in the UK
These were a few of the key levers for change:
Gordon Waddell
BMJ Clinical Evidence
NICE

Finally, cherished theories and behaviours were being put under the critical spot light

Next slide: This new wave of critical thinking was pump primed by unprecedented investment in the NHS during the early 2000s
Explain slide

I make no comment on the long term financial wisdom or planning for this investment but there is no denying it had an impact

Next slide: This impact found it’s way into new ideas for MSK commissioning
Practice Based Commissioning
MSK Services Framework

….was taken up by some entrepreneurial GPs with an interest in SEM/MSK
PGDip SEM
MSK Diplomas
working in partnership with local physio departments

Financially supported by PCTs!
This produced a new model of community MSK care which harnessed more primary care expertise

Talk through slide

Next slide: Looking at this model…
What were the strengths and weaknesses?

Read through slide

The main detractors were the Acute Trusts (for various reasons) but ultimately….
The case was largely made and central policy makers started to push for wider mobilisation

This document by the FSEM from 2011 highlights some of the CATS in which SEM Doctors were involved

However outcomes from Chronic Pain weren’t really part of the original scope

Next slide: this led to….(upscaling)
Read through slide

Next slide: These new services required staffing…
The shift to an ESP led model was partly driven by workforce necessity, partly by perceived cost savings and partly by a desire within the Physio Profession to grow its scope and role

Next slide: The new structure looked like this…
Talk through slide

Next slide: As with the GPwSI led model before it, these new services are being actively evaluated and must demonstrate value & effectiveness, so….(how are they doing?)
Do we have any emerging data on the impact of these newer CATS, particularly around Back Pain care?

Next slide: In 2016, BMJ Open published a study online….
….which represents the largest study to date of the outcomes for patients passing through a new CATS

Read through slide

What were the results?
Read through slide

The headline data table within the paper….
….shows the significant determiners of re-referral to Primary Care (a surrogate marker of ‘failed care’)

Point out Back Pain

The headline conclusion by the authors was….
Next slide: So what can we take from this emerging data?
Read through slide

Clearly there’s room for improvement (as ever!) and some CATS are pushing into the next level.

Next slide: What should better Back Pain (or any Chronic Pain inc. OA) look like?
It’s always easy to talk about ‘patient centered care’ but what does this actually look like?

- One approach is to see each and every encounter that the patient has with a Health Care Provider (HCP)
- as an opportunity to cover (and recover) certain key areas with the HCP acting as:
Care giver
Facilitator
Motivator

I’ll cover these areas in more detail. The concept I want to communicate is that of structured ’MECC’
Further more, each of these encounters forms part of a wider network of care.

This is why a structured approach is needed. A ‘script’ (if you like) from which everyone must speak, so as to reinforce correct messages and eradicate wrong ones.

This also points to the need for some sort of ‘system control’ to ensure these encounters aren’t silo events
Let’s drill into this more and look:

At how each of these areas works out in the context of Back Pain care
What sort of role an SEM-MSK trained Professional might play within it
To explore the role that SEM-MSK has to play requires us to consider what skills that such a clinician uniquely brings to the system.

If we are to argue for a wider role within the CATS then we need to articulate our competencies.

I considered what, in my time as a MSK Physician within Bedfordshire, I brought to the party and came up with these 5 key skills

Explain Skills

Linking these areas and skills together we can start with….
Every HCP that sees a patient with Back Pain must be competent within their scope of practice, to assess patients for:
Serious pathology
Medical complexity
Psychosocial interplay
However, determining this can be tricky and ‘hard rules’ can lead to over interpretation:

History of Cancer?
Urinary symptoms?
Night Pain?
What value does a SEM clinicians, particularly a Doctor add here?
This is where a Doctor, appropriately trained and accredited by the GMC, has the:
Knowledge
Experience
Skills
To filter the finer detail, guide and education other members of the MDT and hold senior responsibility for discharge

The buck stops with the one who has the validity to carry that decision

Next slide: Once we’ve screened the patient we move on to treatment this is where…..
NICE has recently done a LOT of heavy lifting for us with treatment guidance that we can broadly divide into 3 levels…..

Next slide: (core level)
This are the basic level of care that every patient with Back Pain, or OA Pain (or any form of ongoing pain!) should receive

Read through slide
CBT and MDT working is an essential part of higher level care and may be necessary with a number of patients

We don’t have time to describe how these services work, but I would recommend studying these two services as they are award winning and are yielding good results (click)
Finally, there is the highest level of care which only a very few patients should need to access.

I’ll discuss these in a bit but it’s important to see that they are very much part of the evidence based ‘whole’.

So, coming back to core treatments….
We can divide these roughly into:

Information & advice
Tailored activity prescription

Let’s look at the first of this…
…..Information and Knowledge

What should this look like in Back Pain Care?
Well, in many ways, it’s the most foundational aspect of Back Pain care

As we saw, there are a lot of popular myths around Back Pain so the provision of positive messaging:
Early
Repeatedly
By everyone the patient sees

Will help start to correct these myths

Next slide: in support of this messaging there is a deluge of online resources…
Click through examples

We really don’t need to re-invent the wheel here. The main obstacle is getting clinicians and patients to realise they are there and access them!
What role can the SEM clinician play in support of CATS and their Back Pain care pathways?
Go through slide

Next slide: Now let’s look at the 2nd arm of the core treatments….
Namely exercise medicine….

Next slide: PHE One You
PHE initiative is aligned with this aspect of healthcare
We know which activities will contribute to rehab and wellbeing (as well as prevention!)

We also know that encouraging the patient towards this approach involves…
Stages of change….
Pre-activity participation screening….
The SMART methodology of goal setting….
….and the correct prescription of exercise

Next slide: SEM value
What value does the SEM trained clinician add here?
This is the role, par excellence, of the SEM clinician.

It is within the syllabus and competency set for SEM

A personal testimony is my own journey of discovery, not so much into the importance but into the mechanism to provide such care
Coming to the 3rd tier of NICE validated Back Pain care…..

Namely….(Spinal Interventions)
….Spinal Interventions…..
Talk through slide
What value does a SEM-MSK add here?
Is this an area of interventional practice that SEM-MSK Doctors could (or should!) be involved in?

Certainly not as a core competency but….
Read through slide

Next slide: So, to summarise…(click)
Read through slide

Next slide: Thank you

Back Pain care and NHS Community Interface Clinics: Towards a better model

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