One-stop shop for back pain

A community pilot for back pain meant patients were treated earlier, says Dr Moheb Shalaby

A back pain management pilot  in Birmingham is demonstrating how the patient journey for those with chronic pain can be speeded up and simplified.

The six-month pilot is a ‘one-stop shop for pain’ and is running in Birmingham East and North PCT’s area until the end of this month. It was set up in conjunction with NHS Institute for Innovation and Improvement to focus on the care of chronic back pain patients and how treatment could be shifted into primary care. 

Off work in pain
Evidence from the Department for Work and Pensions states that 80 per cent of patients with chronic pain conditions who are off work for six months or more will never go back to work again.

Up to date figures are not available but in 1998, back pain cost the NHS £6,650 million. Typically, chronic back pain patients are assessed and treated by doctors, physiotherapists, clinical psychologists and clinical nurse specialists.

This often results in several referrals to hospital.

In contrast, our one-stop shop enables patients to see  different healthcare specialists at a single visit. Traditionally, GPs refer patients with chronic back pain to one of three secondary care specialities — orthopaedics, rheumatology or chronic pain clinics.

General orthopaedic surgeons and rheumatologists check there is no serious spinal pathology through radiological investigations and will re-refer most patients to chronic pain clinics or physiotherapists.

For such patients a typical journey can take between 18 and 24 months, during which they ‘yo-yo’ between their GP and different hospital specialities. This has an impact on the GP’s time, the practice’s prescribing budget and of course the patient’s time.

Ideally, back pain patients should be seen as early as possible and treated locally.

They should be assessed thoroughly with secondary care requirements identified and the need for analgesia dealt with as early as possible.

It is important to consider the psycho-social barriers that can delay patients’ recovery.

The number of referrals to secondary care and, consequently, the costs of referrals together with the number of visits the patient makes to the GP should be minimised.  Patients attending an appointment at the one-stop shop receive a multidisciplinary team assessment of chronic low back pain.

They are each assessed by a physician, physiotherapist and psychologist during their visit. They can attend at one of two local community settings near to their homes.

Serious pathology
My role for the pilot as a GPSI in chronic pain management is to identify patients with potential serious pathology through history-taking, triage and examination, and to refer them to secondary care.

I identify patients who need secondary care interventional techniques and refer them to a consultant in chronic pain. Optimising patient analgesia and prescribing accordingly is also part of my job.

Patients satisfied
The benefits to the patients are already clear. Those not requiring extensive treatment will be managed solely in primary care. Those who need secondary care treatment will see fewer and more appropriate secondary care specialists and receive an earlier diagnosis.

Patients whose lower pain problems are treated early are more likely to return to work.

By the end of January this year, of the patients seen at the one-stop shop, over 70 per cent were being managed in primary care and only 23 per cent referred to secondary care.

The waiting time for a first appointment averaged 17 days compared to 86 weeks for those referred to a secondary care pain clinic.

Significantly, 85 per cent of patients were satisfied with the action taken after their appointment and 95 per cent were satisfied or very satisfied with their clinic visit.

When the pilot has been evaluated, the NHS Institute for Innovation and Improvement plans to ensure that the lessons learnt from it and the other schemes in its long term conditions priority programme — Making the Shift, are used to develop appropriate local and national schemes for moving care from primary to secondary care settings.

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