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By involving patients with lower back pain in a project redesign, an innovative service in north west England sped up access to treatment. Robert Millett reports

Patients with lower back pain are reaping the benefits of early treatment, thanks to an innovative and time-saving service.

The initiative allows patients to access a spinal drop-in service, available at 13 sites across the trust, at their own convenience, either following a GP visit, or as self-referrers.

Introduced by East Lancashire Hospitals NHS Trust in 2009, the service aims to improve the access and quality of service for patients with low back pain.

The service is run by experienced physiotherapists who offer patients early assessment, advice and reassurance.

Patients who attend following GP visits receive invitation slips, giving clinic locations and times. They can then ‘drop in’ without an appointment, when it suits them. Doctors don’t have to submit written referrals unless they wish to do so for complex cases.

‘That’s been popular with GPs, as it saves them time, and they like the fact they can do something empowering and proactive,’ says Lesley Harper, an extended scope spinal physiotherapist at the trust.

‘It means that as soon as a GP passes on the invitation the patient can receive a targeted treatment that prioritises them as urgent or routine – rather than being placed on a waiting list.’

At the clinics patients receive a subjective 20-minute assessment in which they are screened for red and yellow flags, before being directed along the most suitable care pathway.

As part of their assessment, patients fill in body charts and complete Roland Morris disability questionnaires, which help to determine the level of their disability.

Post-assessment, the physiotherapy team can then order diagnostic tests or, if necessary, immediately refer patients on to other specialists.

The drive for early assessment expedites the entire pathway of care, explains Gillian Rose, the trust’s acting general manager for diagnostic and clinical support.

‘The spinal drop-in service allows patients with low back pain to be seen quickly, without an appointment, by specialist physiotherapy staff in community settings,’ says Mrs Rose.

‘This reduces pressure and cost for GP and hospital services, speeds recovery, and allows safe fast tracking of serious pathology.’

The success of the re-designed and enhanced patient pathway was formally recognised when the service won the NHS North West Regional Health and Social Care Award for Improving Services in 2010.

The win was largely based on the findings of an audit that revealed that 90 per cent of the service’s patients were being successfully treated and managed with physiotherapy.

The audit also showed that waiting times had become minimal, duplicate referrals and that unnecessary diagnostics were vastly reduced.

Meanwhile, patient outcomes and productivity had both greatly improved.

Service redesign

Previously the physiotherapy service had been run along traditional lines. Written referrals were taken from GPs and individual appointments were booked in general physiotherapy clinics.

But patients often waited up to 20 weeks and the patient pathway was far from clear.

Physiotherapy assessments had been carried out by generic outpatient physiotherapists, which sometimes led to patients being miscategorised or being re-referred back to their GP. Some missed out on the correct treatment at an early stage.

The long wait for physiotherapy meant GPs inappropriately referred patients on to specialist musculoskeletal services or secondary care.

Doctors were also requesting diagnostic tests to rule out serious conditions – but in most cases these referrals proved unnecessary.

Additionally, some patients endured long and frustrating waits for physiotherapy only to be told later that their conditions required referral to other specialist services.

This chain of events was, of course, proving clinically and economically inefficient.

As a result staff, patients and referrers joined forces and developed an evidence-based solution.

Patients were asked to identify their preferred service model and to take part in ‘dummy runs’. They also helped to evaluate pilot sites and presented their experiences to staff. It was agreed that a drop-in service was the solution.

‘One of the reasons for developing this service was that we were finding that GPs were giving out different messages in response to lower back pain,’ says Ms Harper.

‘By offering a drop-in service we thought we could provide a consistent message as to how back pain should be managed across east Lancashire.’

The concept flourished because it offered an instant solution to the problem of waiting times.

By removing appointment times, the ‘queue’ of passively waiting patients was transformed into a group of individuals who could decide where and when to be seen.

The idea also offered an elegant way of addressing the psychosocial concerns of patients.

Research shows that patients with lower back pain who have to wait a long time for assessment are more likely to become psychologically distressed. As a  result, they have a higher risk of developing a chronic condition.

‘The biggest predicator of a patient’s poor outcome with lower back pain is their level of psycho-social distress,’ says Ms Harper.

‘We decided that we would offer them early access so we would be in a situation where we could screen them, offer them reassurance and put them on the appropriate pathway for their kind of presentation – and that would ultimately stop them developing in any chronic pain patterns.’  

The new service began as a local pilot with the involvement of both patients and commissioners.

Physiotherapy staff had to work hard to make this happen, as no additional funding or staffing was available for the project. As a result, the existing service still had to be delivered while the new drop-in model was piloted.

Patients can now be seen weeks earlier than previously and are likely to require less treatment in the long run.

The patients are happier, staff are more satisfied and costs are down by £24,000. ‘It is an excellent example of how quality can be improved without any additional cost,’ says Mrs Rose. fl

A Patient’s experience

Professor Peter Hogg injured his lower back in October 2009. The damage was so bad that his mobility was severely affected and he was initially unable to walk.

A GP visited him at home and let him know about the lower back pain drop-in service.

‘The GP explained that it would be easier for me simply to present at the drop-in clinic than for her to refer me,’ says Professor Hogg.

‘This turned out to be true and importantly it came at a timely moment. If my understanding is correct then failure of the therapy to be conducted at that stage would have quite significantly hindered my recovery rate and ultimately my physical ability.’

He added that, following his initial assessment, he was impressed by the physiotherapist-managed approach to his treatment – which he found to be motivational, bespoke and sensitive.

‘Throughout my treatment I was pleased with the holistic approach to my health and well-being which took into account pain management, my exercise regime, my progress and how I was coping with my reduced mobility,’ says Professor Hogg.

‘I was also pleased to see the GPs held the physiotherapists in very high regard and the GPs played their part in helping to regulate my pain, through medicines, in accordance with the need to comply adequately with the set exercises.’

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Robert Millett

Issue date

21 November 2012

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