Back and Neck Pain –helping you and your patients
Musculoskeletal disorders place a heavy burden on the NHS in the UK. Traditionally, treatment for these disorders has been confined to hospital outpatient departments, but this is likely to change with the announcement by the DH of an extension to the choice of provider of Musculoskeletal (MSK) services for back and neck pain, underpinned by the principles of extending patient choice, driving up quality, reducing cost and enabling innovation.
Chiropractors are well placed to deliver high quality evidence-based care for back and neck pain, as has already been illustrated by the highly successful, award-winning service in the NE Essex NHS Trust. Chiropractors from the British Chiropractic Association www.chiropractic-uk.co.uk have recently been working with the NHS and the DH to look at how commissioners can work locally with chiropractors and use chiropractors as Any Qualified Providers (AQP) for the treatment of back and neck pain.
The DH has recently undertaken a review of impact of Musculoskeletal (MSK) conditions in the UK and concluded:
There are over 200 musculoskeletal conditions affecting millions of people, including all forms of arthritis, back pain and osteoporosis. Looking at prevalence and impact:
- In Europe nearly one-quarter of adults is affected by long-standing MSK problems that limit everyday activity (DH, 2006. Musculoskeletal Services Framework).
- It is estimated that up to 30% of all GP consultations are about musculoskeletal complaints and GPs have reported that it is the top clinical reason for visits (with musculoskeletal pain the most common presenting symptom).
- MSK conditions have a significant social and economic impact, with up to 60% of people who are on long-term sick leave citing MSK problems as the reason and patients with MSK forming the second largest group (22%) receiving incapacity benefits. (CBI, in association with AXA, 2005. ‘Who cares wins: absence and labour turnover 2005’).
- Furthermore it is recognised that, whilst prevalent in all age groups, the incidence of MSK disorders generally rises with age, so the proportion of older ages in the population will further increase the demand for MSK Services.
- Musculoskeletal disorders are the fifth highest area of spend in the NHS consuming £4.2 bn in 2008/9 (ARMA 2010. Liberating the NHS: Transparency in outcomes – a framework for the NHS)
- In the UK 16.5m people have back pain (Clinical Standards Advisory Group for Back Pain. London, HMSO, 1994).
- 20% of the population present each year with a new onset or recurrences of an MSK problem (Clarke A & Symmons D. The burden of rheumatic disease. Medicine 2006; 34 (9): 333-335).
Back and neck conditions frequently have an adverse influence on health and quality of life for many individuals and can limit daily activities. While there is excellent care available in some places, in many areas the quality of care is variable with poor access and limited choice. Extending patient choice of provider for the treatment component of care will help to address these issues by offering people with back and neck pain the choice of a qualified provider that would best meet their needs, in a framework that delivers high quality.
In the UK traditional MSK services have been delivered from hospital outpatient physiotherapy departments. However, this is likely to change with the announcement by the DH to extend the choice of provider of MSK services for Back and Neck Pain (Operational guidance to the NHS: Extending Patient Choice of Provider, July 2011 ). This initiative of commissioning Any Qualified Provider to deliver services is underpinned by the principles of extending patient choice, driving up quality, reducing cost and enabling innovation.
Chiropractors are well placed to deliver high quality evidence-based care for back and neck pain.
Working with Chiropractors
Modern chiropractors in the UK are trained to treat a variety of MSK conditions however, in practise, treatment of back and neck pain constitutes a major part of their practice.
Chiropractic is a health profession that specialises in the diagnosis, treatment and management of musculoskeletal conditions, particularly those of the spine and their effects on the nervous system. Chiropractors may treat all the joints of the body, but more commonly the muscles, joints and ligaments of the spine, often with manual therapy and using their hands to perform a wide range of skilled, precise manipulation, mobilisation or soft tissue techniques.
BCA chiropractors provide a ‘package of care’ including a biopsychosocial assessment whereby they support their treatment with cognitive interventions such as individual counselling and advice about the patient's lifestyle, work and exercise, in order to help in managing the condition and preventing it from recurring. Some chiropractors are also trained in medical acupuncture/dry needling.
In common with medical practitioners, the profession has statutory regulation and all chiropractors must be registered under the terms of the Chiropractors Act 1994 with the statutory regulator, the General Chiropractic Council (GCC).
All British Chiropractic Association members are registered with the GCC.
The British Chiropractic Association is the largest and longest-standing association for chiropractors in the UK, requiring the highest standards of education, training and conduct from its members.
Evidence Based Practice
NICE Guidelines; In May 2009, The National Institute for Health and Clinical Excellence (NICE) published new guidelines to improve the early management of persistent non-specific low back pain. (www.nice.org.uk/CG88)
The guidelines recommend what care and advice the NHS should offer to people affected by low back pain. NICE assessed the effectiveness, safety and cost-effectiveness of available treatments and one recommendation is to offer a course of manual therapy, including spinal manipulation, spinal mobilisation and massage.
This treatment may be provided by a range of health professionals, including chiropractors because manual therapy and spinal manipulation is part of the package of care they routinely offer.
- Safety of Chiropractic Manipulation of the Cervical Spine, Bolton, Thiel et al, 2007
- Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders - Haldemann, Cassidy et al
- The Effectiveness of Manual Therapies – The UK Evidence Report – 2010 – Bronfort et al.
A Model Service
In 2008 NHS NE Essex initiated a service that utilised chiropractors and other manual therapists working in the independent sector to deliver treatment for back and neck pain. This approach was driven by a need to reduce waiting times, take pressure off existing spinal services and improve patient choice.
This pathway used strict referral criteria and measured clinical outcomes, using validated patient reported outcome measures (PROMs), patient experience and service delivery levels.
In the first year of this service some 2810 patients were allowed choice of provider following GP referral. During this period 97% of patients were seen within two weeks of referral.
An analysis of a subgroup (n=696) of patients using this service revealed that patients received and average of six treatments and approximately two thirds reported a clinically significant improvement in their condition and a reduction in medication usage.
Almost all (99.5%) patients were satisfied with the service. Similarly almost all (97%) patients were discharged from the service with advice on self-management; the remainder were recommended for secondary care referral.
Evaluation of the service by the PCT, after the first 12 months of offering patients a choice of any qualified provider, identified improved patient access and choice meaning early treatment and improved outcomes, as well as reduced primary care consultations, imaging and medication costs and, in addition, a reduction in inappropriate referrals to secondary care. Referrals to spinal surgeons reduced by more than 25%. This service was awarded an NHS Alliance Acorn award in 2009 and has subsequently been used as a case study by the DH.
To date this service has seen over 7,000 patients.
Commissioning Chiropractic Services
BCA chiropractors have recently been working with the NHS and the DH to look at how commissioners can work with chiropractors locally and use chiropractors as Any Qualified Providers (AQP) for the treatment of back and neck pain.
The DH launched an AQP implementation pack in December 2011 that offers commissioners guidance on the qualification process, service specification, use of clinical outcomes, provider engagement and future development of services. An interactive map of AQP Provider services is also available, from which it can be seen that between 30 and 40 Primary Care Trusts/Clinical Commissioning Group clusters are committed to inviting AQP interest in MSK services
The BCA is committed to the principle of extending patient choice and improving the quality of provision of back and neck pain services. We totally support the AQP initiative and anticipate that this, once implemented, will lead to better outcomes, reduced costs, improved patient satisfaction and better integration of the chiropractic profession into health care in the UK for the benefit of patients.
Referrals to professionals registered with a statutory regulatory body:
The GMC and DOH state that from a legal point of view, GPs can safely refer patients to chiropractors who are registered with the General Chiropractic Council (GCC), (Complementary Medicine, information for Primary Care Clinicians, DOH June 2000). Chiropractors are fully accountable to the Statutory Regulatory Body for their actions and the patient can seek legal redress against them in case of accident. The GCC monitors training and sets standards of proficiency for competent and safe practice.
Further information about chiropractic and the British Chiropractic Association
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