Docstoc

A primary-care-led pain service for patients with low back pain

Document Sample
A primary-care-led pain service for patients with low back pain Powered By Docstoc
					A primary-care-led pain service for patients
with low back pain
This review describes an initiative that WiPP has identified to reduce workload in general practice.

Summary
The Integrated Back Pain Service (IBPS) was set up to transfer the management of patients
presenting with low back pain to a dedicated primary-care-led service.

The service was led by an extended scope physiotherapy practitioner (ESPP). The ESPPs worked within a
multidisciplinary team comprising physiotherapy, osteopathy, counselling, dietetics and podiatry. The ESPPs
had referral rights to a range of diagnostics, including X-rays, blood tests and magnetic resonance imaging
(MRI). This new pathway has resulted in:
 • reduced GP workload
 • reduced patient waiting times
 • increased patient access to care
 • improved outcomes for patients.

Previously, patients presenting to their GP with back pain had to wait approximately 18 weeks for an
out-patient appointment in order to be assessed and diagnosed by a consultant or up to 14 weeks to be
assessed within the physiotherapy department.

Each month, 200 patients are referred into this service, 97% of which are managed in primary care.
Previously, many of these patients would have contributed to the workload of their GP who would have
provided interim care and pain management pending an out-patient appointment.



  About the Working in                                   About the reviews
  Partnership Programme                                  The reviews are intended to assist the spread of
  The Working in Partnership Programme (WiPP)            good practice by highlighting initiatives that have
  was established under the new General Medical          helped to reduce workload in general practice.
  Services (GMS) contract to develop and implement       This review is one of a series of accredited
  a strategy for general practice that addresses         reviews that has been assessed to fit with the
  effective use of clinicians’ time whilst improving     aims and objectives of WiPP, and to have the
  the availability of services for patients. Workload    greatest potential to have an impact on workload
  management in general practice is an essential         in general practice.
  element of the expansion of the primary-care sector.
                                                         Find out more
  Good Practice Project                                  If you would like to find out more about the
  The Good Practice Project was established to           Good Practice Project or about the work of WiPP
  identify, evaluate, signpost and support the           then please visit: www.wipp.nhs.uk.
  mainstreaming of existing good practice in
  keeping with the WiPP remit.




                                                                Good Practice in Workload Management
Patients are referred by their GP to the service for assessment, diagnosis and appropriate management. All
clinicians within the multidisciplinary team can refer directly to another speciality within the team, meaning
patients follow the pathway of care that is best suited to them.


   From a sample of 150 patients referred to the IBPS:
   • 109 patients reported an 80–100% improvement in their condition
   • 29 patients reported a 60–80% improvement.



A total of 93% of patients surveyed in one quarter (n=67) indicated that they were satisfied or very satisfied
with the service and that they were happy with the speed of access to the service.

What was the issue?
Patients presenting to their GP with back pain had to wait approximately 18 weeks for an
out-patient appointment in order to be assessed and diagnosed by a consultant. This waiting time
meant that GPs continued to be involved in the interim management of the patient, providing,
for example, pain control and answering patient queries regarding a likely appointment with a
consultant. This was contributing to an increased workload for GPs and discomfort for patients.

Aims and objectives
The aims of this initiative were to:
 • develop and test new referral pathways
 • develop local services to provide quicker access to a primary care specialist and diagnostics
 • reduce waiting times and time to diagnosis
 • improve patient access and choice, and test the factors that influence patient choice
 • target referral into secondary care more appropriately and accurately
 • improve patient health outcomes
 • increase communication with GPs regarding the management of patients with low back pain so that
   they are more able to make an appropriate intervention
 • investigate both patient and GP satisfaction with the model of care
 • develop robust clinical governance arrangements to support the new ways of working.

What they did

  The IBPS was set up to transfer the management of patients presenting with low back pain to a
  dedicated ESPP-led service. On seeing a patient with low back pain, GPs completed a service referral
  form that was faxed to the service. The referral was paper triaged by the ESPP and the referral
  was prioritised into urgent or routine. The patient was then directed to the most appropriate care
  pathway. In one of these care pathways, the patient was offered the choice of being assessed by
  either a physiotherapist or an osteopath. Should the patient require onward referral to secondary
  care, the ESPP offered the patient a choice of providers. They had direct referral rights to a range of
  consultant orthopaedic surgeons, rheumatologists, pain management teams and a neurosurgeon.
How they did it
Funding was secured from the ‘Choice at Point of Referral’ initiative to develop and establish the service so
that patients could be offered a choice at the point of referral from the GP.

Objectives were set at the beginning, and the process for referral and management agreed between the
stakeholders. The PCT set about recruiting staff and finding a suitable location for the service. Early in
the development of the service, a lead clinician was appointed to take forward the development work.
This included:
  • modelling demand to predict the resources required to deliver the service
  • planning the scope of the service, deciding which specialities to include and commissioning specific
    capacity from each speciality within the multidisciplinary team
  • securing commitment to support the service from secondary care consultants and senior trust
    management teams
  • documenting procedures, policies and referral pathways
  • briefing each practice on the service.

Rollout of the service took place one practice at a time so that volumes built gradually.

What did they achieve?
   The IBPS resulted in:
   • a reduction in GP workload
   • a reduction in patient waiting times for assessment and diagnosis
   • better patient health outcomes
   • increased patient satisfaction
   • increased GP satisfaction.


Specifically, the service has resulted in a reduction in the waiting time for an appointment from 18 weeks to
2 weeks for those patients with low back pain who are prioritised as urgent following triage of their referral.

During the period June 2004–October 2005, 1,145 patients were referred into the service. A total of 97% of
these patients were managed in primary care. Previously, many of these patients would have contributed to the
workload of their GP who would have provided interim management pending an out-patient appointment.

Evaluation
A range of audit measures were used within the service. One audit concentrated on evaluating whether
there was a correlation between the information on the referral form (from GPs) and the information
concerning the patient’s symptoms and clinical presentation following assessment by the ESPP. This was
important as the referral form provided the framework on which the triage process was based. The audit
found that the referral form in use at that time with the GPs was effective, and provided strong and
correlating information for the ESPP to work from.

Ongoing reviews measuring patients’ disability index measurements and health outcomes were useful in
evaluating the effectiveness of the IBPS. Patient satisfaction questionnaires were also used to audit and
review the service.

From a sample of 150 patients registered on the IBPS, 109 patients reported an 80–100% improvement in
their condition, whilst 29 patients reported a 60–80% improvement.

A total of 93% of patients surveyed in one quarter (n=67) indicated that they were satisfied or very
satisfied with the service and that they were happy with the speed of the service.

Key learning points


   • Stage the rollout of the service so that capacity can be managed effectively.
   • It is important to commission ‘ring-fenced’ capacity from each of the specialities within the
     multidisciplinary team so that patients can access each part of the service seamlessly.
   • Excellent communication throughout the multidisciplinary team and with all stakeholders is essential.
   • Involvement of the mentoring consultant through all stages of the development of the primary
     care service is important.
   • Rapid access to diagnostics is a prerequisite (blood tests, X-rays, MRI etc).
   • Presentation of the service at each GP practice allows GPs to meet the ESPPs and to iron out any
     queries with the service.



Costs
Costs included:
 • employing 1 full-time equivalent ESPP (£39k)
 • the costs of commissioning ‘ring-fenced’ capacity from each of the specialities included in the
   multidisciplinary team.



  Contact details
  Kim Rickard
  Service Redesign Manager
  Horsham and Chanctonbury PCT
  New Park House
  North Street
  Horsham
  West Sussex RH12 1RJ

  Tel: 01403 223285
   Email: Kim.rickard@hcpct.nhs.uk

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:8
posted:3/11/2010
language:
pages:4
Description: A primary-care-led pain service for patients with low back pain