What inspired you to make this pledge?
The request for the pledge was to focus on making a difference and having a goal to work to. This made me think of something I had been working on which was developing a spinal rehab programme, engaging commissioners in this and moving forward the plan of developing MSK hubs in Swindon.
When did you start enacting your pledge?
We started around the same time as the Physiotherapy Works event. We were looking at improving our spinal rehab programme. Karen Middleton mentioned during her presentation the importance of looking at the health profile for your area. Swindon has a higher working age population then national average. Due to this one of the priorities of the clinical commissioning group is to look at long term conditions. So, I did a small study looking at MSK caseloads at different sites and 50% of our caseload were spinal conditions. We were running two programmes, one of which was a back fitness group to give people confidence to exercise with back pain. This could be pushed out into the community as it needed less input of a physiotherapist. The other programme is ‘Back on track’, a psychologically led back rehab class. I wanted to look at developing this into a more comprehensive model.
We have a very poor chronic waiting list. We do see our most urgent patients within two or three weeks but the waiting list is 26 weeks. I thought we should be managing this in a different way considering we have such high numbers of patients with back pain. At the time I was in discussion with the commissioning group who requested we look at improving our spinal rehabilitation package and use the clinical conditioning guideline for lower back pain as a starting model. This is where we were at during the Physiotherapy Works event. We were starting to explore the clinical commissioning guidelines for back pain and looking at addressing the waiting list, creating a working model to try to address the proportion of patients with lower back pain.
What has the impact been?
It focussed us on what we would like to achieve. It made us prioritise when it was busy and there were various ideas on what to take forward. Could you tell more about communicatng with local authorities about your ideas? Karen Middleton mentioned the NHS Five Year Forward View published in October 2014 which looked at how the NHS would be moving on.
One of the points made was the use of green field sites. Swindon is a massively developing area and we have a tremendous population increase with green site developments. Reading the document made me aware that no one had ever approached us to inquire what we could do with these sites. I was not aware we could influence council and developers to give back to the community. Potentially we could create interdisciplinary buildings which would incorporate a MSK hub, including a physiotherapist, a practice nurse and people with advance roles but excluding GPs. We contacted the MP to discuss these ideas and there was a real interest. The council had been in discussions with the CCG but those discussions had focussed on collaborating GP leads. The MP suggested we contact the Council to share our ideas of how to use the green field sites to deliver services near to patients’ homes. We did approach Council and had initial conversations however it hasn’t moved forward since then.
Is there support that the CSP could have offered you?
After Karen Middleton pointed out above mentioned paper I used it to circulated information about the use of the green fields’ sites. I have used resources from the CSP on self-referral and circulated it to commissioners. Recently we had a meeting about an article in Frontline on GP Primary Care First practitioners.
Could you tell more about the proposed spinal rehab programme?
It has been a learning curve and it doesn’t feel like there has been much progress. When you are engaging with the clinical commissioners you need to have volition and tenacity. Sometimes there are preconceived ideas about what physiotherapy is capable of. They are not aware the profession has moved on to more diverse roles and our skill set has extended.
Next to this there is a lack of funding, common in all CCGs.
It was in our patients’ interests to work alongside the CCG within our own resources. On a few community sites we have set up a first phase piloting of an early prevention advice programme for back pain patients. Those on waiting list can go immediately in one of the advice classes. Patients receive exercises and reassurance and then have the opportunity to opt back in for a further intervention four weeks later (1-2-1 appointment). We are using EQ5D as an outcome measure. We had an 80% discharge rate after that first intervention and have improved by 30% in pain/discomfort and anxiety/depression. If we can see patients and discharge them early this will also help our waiting list. It’s a different way of working; a group setting rather than 1-2-1. Also because of our extensive load of spinal we decided to put on more of our ‘Back on Track’ programme, which is the second phase of the spinal rehab programme. It consists of a six weeks programme of nine hours with 10 patients. Again, we have been monitoring it with EQ5D and a functional test and it is working well. We have to wait with the third phase as there currently is no funding to progress it.
How has it developed you?
My negotiation skills have improved and it has given me the confidence to talk to commissioners. Karen Middleton’s leadership has helped. It’s getting the evidence and working alongside people, negotiating and showing good outcome measures. I have always collected outcome measures but it has made me more driven to audit data. This can be difficult when we all are under time pressures to get through a normal case load. I’ve encouraged the department to make it a priority. You need the data to evidence what you are doing. It allows us to be forthright in what we can deliver and what we are good at.
Is there anything you would do differently?
Maybe I wasted too much time on the business plan but didn’t know this until the CCGs changed the goal posts! The benefit from this work is that as a department we are more proactive in engaging the commissioners. As a result we have regular meetings with commissioners every eight weeks. It has been difficult. MSK solutions had previously been discussed with GPs but never with the ones that deliver it. I’m hoping now that has changed.
What message would you give to others that are considering to understating something?
Be patient, aim high but you remember you will have to compromise. You need tenacity and to make the case all the time.
Is there anything that hasn’t been covered yet?
As part of looking at reducing the waiting list we are trying to introduce MSK hubs. The aim is to get someone in each hub. This proves difficult as GPs work separately and it is met with resistance. We don’t have the real estate in the community. Most GPs don’t have spare room for us and health centres charge a premium for rent.
There is one good example of a physiotherapist who set up within a GP’s practice. It showed real benefits as 80% of patients did not need further referring and the number of prescriptions dropped, with a resulting reduction in the drugs bill. People are able to get back to work faster. It would be wonderful to see this implemented everywhere.