The document summarizes the evolution of back pain care models in the UK from a structuralist model pre-1990s to the current community MSK hub model. It finds that while most patients are appropriately managed in a "one-stop shop" model through CATS services staffed by ESPs, some with complex or disabling back pain frequently reconsult. The document proposes a new integrated model of back pain care centered around supported self-care, evidence-based treatment, lifestyle modification and navigation to resources. It argues that sports and musculoskeletal physicians can provide valuable leadership, education and clinical skills to these services, including competency in spinal interventions and helping ensure compliance with treatment guidelines.
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Back Pain and the integrated community MSK Hub
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?
18. 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
19. However…the case was made:
• ⬇ Referrals into secondary care
• ⬇ MSK spend
• ⬆ Patient satisfaction
• No real focus on Pain Care though
2011
20. 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
21. 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)
22. 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)
23. How are these services doing?
Particularly with reference to Back Pain
24. 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
25. • 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
26.
27. “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.”
28. 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?
29. New Model of Back Pain Care – Core Concept
Supported
Self-Care
Evidence
Based
Treatment
Information
Screening
Lifestyle
Modification
Navigation to
Resources
HCP
Patient
‘MECC’
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)