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Buckinghamshire Healthcare Trust

Primary Care Brief Intervention Physiotherapy Pain Programme

The SIP has enabled the service to

…. produce better patient outcomes …. increased productivity…. and all for less cost!

The Physiotherapy department in the community division of Buckinghamshire Healthcare Trust (BHT) is responsible for delivering this service to an average of 18k patients a year.

StarTback tool has improved our understanding of our patients’ needs and has enabled us to use our resources more efficiently.

This ensures that all our patients receive the most appropriate assessment, treatment and long term support that they require as individuals, and deliver robust patient outcomes of which can be can be measured in QUALYS.

In addition to the improved use of clinical resources, the use of StarTback assists workforce development.

Our core purpose is to provide Physiotherapy for musculoskeletal pain and/or dysfunction to the residents of Buckinghamshire.

This service sits between primary care GP’s and ICATS or secondary care services and is well placed to prevent unnecessary secondary care referrals.

The service is entirely evidenced based. There are a substantial number of peer reviewed papers, NICE guidance and other met analyses which inform and support our practice.

We place a strong emphasis on patient empowerment. We encourage working in partnership and self management. We do this not only in the context of managing musculoskeletal pain but emphasize the importance of movement and activity.

We have a skilled workforce - our staff are trained in basic CBT and Motivational Interviewing.

…. being active not only improves outcomes for musculoskeletal disorders but is a critical component in the successful management of nearly all the long term conditions….

We believe in supporting patients to adopt more active, healthier lifestyles.

Our improvement aims were ambitious

… but were essentially driven by wanting to deliver better care.

The site in Aylesbury takes approximately 25% of the patients in this service. In addition to the volume of patients, it is also a less affluent area and therefore sees more complex patients. The links between health and income are well established.

Low staffing levels for a short period of time at Brookside in 2009 resulted in long waits for primary care Physiotherapy. (Waiting time was up to 24 weeks). We believe that patients should wait a maximum of 4-6 weeks for the service to be most effective. In addition to the effects on patients, long waiting lists demoralise and de-motivate all the staff.

There was an opportunity to do things differently. There were two key aspects of this project which were fundamental to its success.

The first is the use of StarTback 9 question tool for either LBP or generalised musculoskeletal pain. So that in addition to a thorough 1:1 subjective and physical assessment including a general health screen; time and opportunity to discuss their problem etc. our patients were also asked to complete the StarTback tool. This simple but effective tool enabled all the staff regardless of experience to identify patients who were at risk of developing longstanding pain and disability. Once identified the patients were then offered “Moving Forwards”.

Moving Forwards is a brief intervention pain programme which offers patients a cognitive behavioural rehabilitation programme as part of primary care Physiotherapy. By managing these patients in groups we are able to offer the most effective patient centred care and yet still maintain excellent productivity. MF also takes place at the beginning of the patients’ pathway and will for the majority of patients completing the group result in less onward referral.

More about StarTback ….

For more than 20 years there has been an scientifically undisputed understanding amongst clinicians working in this area - that the barriers to recovery from simple musculoskeletal are associated with psychosocial factors NOT biomedical.

For many years there has been an understanding that a ‘one size fits all’ approach to back pain does not work. Keele University has developed and evaluated this tool over the last 5 years; it is a brief screening tool which integrates physical and psychosocial factors. It allows the identification of sub group characteristics in the patients.

StarTback has allowed us to identify patients at risk of developing chronicity and do something about it early on in the pathway.

We now have a better chance of getting it right first time and reducing avoidable costs of secondary care referrals.

The current waiting time for treatment at Brookside is 6 weeks from 24 weeks

Whilst this cannot all be put down to Moving Forward and use of the StarTback tool it is clearly

An effective combination….

The use of StarTback has also ensured that we are now able to reduce variability across all the sites as the research from Keele demonstrates – clinicians are not accurate assigning patients to the different risk groups.

An additional and unexpected bonus is that in addition to identifying patients at risk – we can also identify those that aren’t.

We are able to target our resources more accurately. The research from Keele shows that a patient scoring 3 or less will achieve a successful outcome with or without treatment. Following assessment - Information and reassurance is all that is required.

We were anxious that staff and patients engaged with theses changes to our practice and in the early days wanted to ensure that patients were happy. Working with our stakeholders, we have transformed our service. The key stakeholders in this project in addition to the patients have been our staff.

Much of what we have achieved and will continue to achieve is due to a paradigm shift in thinking and in many instances clinical practice.

…As with all change we have had champions within the peer group but there have also been those who resist change and the challenges that it represents.

Staffing …The last six months has produced many challenges, the SIP lead left to take up a temporary post as a clinical fellow with the SHA, this combined with low staffing levels made the development of the programme difficult. Data collection and IT is different across the county. The service has also been subject to a service re- design and put out to tender in the autumn in addition to being phased onto a new IT system. There have been many challenges for the Moving Forwards team! It has felt like phoenix emerging from the ashes but Instead of a single SIP lead we now have a SIP team! The mix of individuals and their individual strengths has injected the process with new vitality and believability with respect to the 2nd and 3rd adopters and as such there has been a significant shift in the willingness of staff to engage with the changes.

Patients….The patient engagement began with a Tent Event in the summer. One of the Communications team carried out exit interviews at 4 of the 7 sites and carried out semi structured interviews with patients as they left the department. Their comments and opinions were sought with respect to their current experience of the physiotherapy and more importantly Moving Forwards.

Whilst the comments were positive there is clearly work to be done around their expectations. It will be increasingly important that we all take more responsibility for our health, but we need to challenge the expectation of the role of the health services. Patients are happy having exercises to do and value highly having personalised exercise programmes, putting their name on the sheets/booklet is very important.

But there is still a strong belief, that improvement will take place if “something is done to them” rather than improvement coming from the changes that they make for themselves. This is in part maintained by other clinicians.

“My Doctor has asked me to come back for proper treatment.”

Of the 500+ patients that were referred to the MF group approx 50% have not complete the programme. We are keen to know why. A telephone audit is in place and there are clear themes emerging but is a yet too early to include in this paper.

Those that do finish have often exceeded our expectation of what we thought could be achieved.

Working in this way has improved access for all patients – older patients – often because they present with long-standing problems are often given a low priority.

Using StarTback has enabled us to evaluate need in a different way.

An example of this is the story of Mrs W who was a 69 year old lady who had been diagnosed as having a lumbar disc “collapse ”and by the time we saw her had been in a wheelchair for a month. She was seen within the department took part in the MF programme and started re gaining her confidence. She continued to progress and has gone on to attend the free gym sessions which we have negotiated with the local leisure centre where she was supported by a member of the team. She continues to use the gym independently and no longer uses her wheelchair. Now no one can say for sure whether she would have achieved this independently but her StarTback score of 8 suggests this is highly unlikely.

Those patients that have completed the 5 week course have very good outcomes. Most showing a minimum of 2 point changes some up to 5 point difference. A change of 2 with the before and after scores using StarTback is significant.

In order to increase the number of patients who finish MF we have started a telephone audit in conjunction with the communication team to try to establish the reasons for this. We know that in some instances the patients were not well, had other health problems which they felt were not compatible with the programme. We hope however to have the data in and analysed and available for March. This part of the project has been one of the casualties of the changes within the department in the last few months.

Our other stakeholders for this service, the primary care clinicians, secondary care consultants, senior management team, commissioners and other therapists such as the podiatrists and dieticians and Occupational health are all important and we need to communicate and work with them over time.

The original SIP lead spent a considerable amount of time with the MSK primary care trust commissioners to inform them about the opportunities within primary care Physiotherapy and how to jointly develop a vision for the service.

One of the SIP team was invited to do a presentation to our Occupational Health department who were very interested and we will hopefully follow this up over the next few weeks.

Outcomes….

….Here are some quotes from patients that have benefitted from our groups and better targeted treatment.

Mrs M “It was the best, most informative course I have attended –the experience was tremendous. Being in a group situation enabled me to learn from others’ experiences as well as my own”

Mrs E “Why has no-one ever spoken to us about this before – it makes so much sense”

Mr P “I am no longer worried about any twinges I may get as I understand they are not harmful – I have gained in confidence and I am able to pace my activities so I can achieve my goals”

Getting it right first time….

A study carried out at Keele and accepted for publication, shows that using StarTback to screen patients results could result in very significant benefits to the health economy.

They have shown that 49% of patients who could be identified by StarTback as being in the low risk category were given treatment. A conservative estimate for our population in Buckinghamshire - would allow us to see half the patients for a single appointment- this equates to 9,000 patients in Buckinghamshire. This would release further capacity in the likely event of diminishing resources.

The researchers at Keele have also been able to show that 40% medium risk and 35% high risk patients were not identified correctly. These are the patients that are likely to be over investigated, often resulting in costly yet poor outcomes with a reduction in overall health and wellbeing.

The results show that using StarTback can target resources where they are needed benefitting the patients and the health economy.

The workforce costs for Moving Forwards fell from £76 to £50 – representing a saving of more than 30%. This included the cost of 1 member of staff at B4 and another averaged as B6 therapist time. This is comparing the MF group to 1:1 treatment.

….The figures speak for themselves

Where are we going with this?

Continue using StarTback with all our patients before and after treatment to not only deliver the individual care that they need but to demonstrate meaningful outcomes for all stakeholders..

We will continue to audit the groups to raise the number completing the programmes from 50% to 70% in the first year.

We will achieve this through training and developing our staff in the principles of CBT and Motivational Interviewing and

Ensuring that we continue to audit the outcomes at the end of treatment and we make it part of normal practice to follow up patients that DNA.

BHT is undergoing a therapy review and we would like the opportunity to share our work with the other therapy teams in the acute trust. It would also be useful in the context of the enhanced recovery programme.

Communicate this to the general practioners and secondary care consultants.

Making more contact with the community at large about the role of Physiotherapy.

The next year will be challenging

Skill mix

Consistency – developing material for the patients

Other services can achieve what we have achieved by…….

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Establishing a SIT or Service Improvement Team recruiting clinicians from different sites (especially from sites where there was greater resistance) and different grades of staff – this has encouraged the feeling of inclusion throughout the Service,

Using the StarTback Tool has been key in this project –

Establish methods of data collection at the start and identify clearly who has the responsibility!

Regular feedback meetings to inform all staff of the progress of the project and more importantly the patients – at present it is only the clinicians running the programmes that see the outcomes and hear the patient feedback – this is vital to inform clinicians that the programme works and the patients enjoy it!