The Integrated Pain and Spinal Service (IPASS): A unique, integrated and collaborative approach to persistent pain management

The aims of the service were:

• To deliver high quality, safe, effective and consistent treatment approaches for patients with back and generalised persistent pain.
• To improve guidance for GPs to enable better pain management early on in primary care.
• To establish a multidisciplinary community pain service for rapid MDT assessment and treatment of patients with back and chronic pain.
• To improve communication between primary, community and secondary care to enable more co-ordinated care.
• To offer better support for patient self-management.

The objectives of the service were:

• To provide appropriate assessment and treatment earlier on in the patient journey, avoiding duplication, delay and inappropriate referrals.
• To provide access to specialist spine and pain services in the community closer to patients home.
• To offer a range of strategies including back and pain management classes to engage patients in exercise activities and promote self-management strategies.
• To reduce the number of attendances in secondary care, therefore making a cost efficient service.
• To release capacity to secondary care in order for ‘red flag’ patients and those requiring invasive procedures to be seen more quickly.

Key concerns were raised informally on the back of the original spinal service and then formally via workshops attended by the stakeholders of Berkshire West. These concerns indicated an increased number of patients with chronic pain of which 50% were thought to arise from back pain, increased waiting times for specialist pain services and increased associated costs.

A review of patients with chronic pain conditions undertaken by West Berkshire CCG highlighted that a significant number make multiple attendances within secondary care. Within a 5 year period the cost associated with patients attending multiple services totalled £2.1m. An analysis of the top 20 highest attenders within this group of patients revealed that they received 1035 attendances at a cost of £540,000 in a 5 year period. It was acknowledged that this was not financially sustainable and patients were not being given the adequate support they needed to self-manage their pain.

Existing specialised spinal services and musculoskeletal (MSK) physiotherapy were found to have inconsistencies in the type of care provided between clinicians and some treatments on offer were found to be outdated and / or absent. For example, some patients were given manual therapy alone and back classes still encompassed a large core stability element. Facet joint injections had also been decommissioned based on the previous NICE guidance and some patients with persistent pain needed an alternative option. Thus with only a very specialised pain service available in secondary care for very complex pain cases, it was recognised that there was an unmet need within the local area for those with less complex cases earlier on in their pain journey.

A stakeholder group was convened to review recommendations, formulate plans and ensure outcomes were being met once operational.

There were two stages to the project:

1. Establishment of a new community pain service and
2. Integrate the pain service with the existing spinal service.

A project plan was drawn up with various time scales and outcomes measures and various tasks were disseminated amongst the stakeholder group. The new community team worked closely with the secondary care team to provide training and ensure the service was up and running quickly. At the same time, the community MSK physiotherapists reviewed and amended their back classes in line with the new NICE guidelines i.e. less core stability focused and more general movement and cardiovascular fitness with an educational component.

Traditional conservative treatments such electrotherapy and acupuncture have been actively discouraged with dissemination of the evidence to physiotherapists whilst others have been highlighted as beneficial adjuncts to exercise classes i.e. manual therapy. The underlying message of all the treatments on offer is to empower the patient to self-manage through education, advice, support and increased physical fitness.

On review of the existing spinal service it was left largely unchanged: it was performing well against set outcomes and closely followed NICE guidance (NG59).

The whole project was underpinned by the latest evidence based literature and research from other services. At the time of initial development the latest NICE guidelines had not be released and to the best of the stakeholder’s knowledge there was no other service like IPASS to replicate. A multi-disciplinary team of consultants, psychologists and specialist pain physiotherapists were recruited and together they developed a range of treatment options including a community pain management programme (PMP), which was to be run by the MDT.

The new community team worked closely with the secondary care team to provide training and ensure the service was up and running quickly. At the same time, the community MSK physiotherapists reviewed and amended their back classes in line with the new NICE guidelines i.e. less core stability focused and more general movement and cardiovascular fitness with an educational component. Traditional conservative treatments such electrotherapy and acupuncture have been actively discouraged with dissemination of the evidence to physiotherapists whilst others have been highlighted as beneficial adjuncts to exercise classes i.e. manual therapy. The underlying message of all the treatments on offer is to empower the patient to self-manage through education, advice, support and increased physical fitness.

Prior to IPASS, facet joint injections were decommissioned and largely replaced by the secondary care PMP, although this was viewed mainly as a ‘last option’. Education sessions were held for GPs to help them support patients in the early stages of pain using the neuropathic pain guideline, the map of medicine and information to help sign post to services such as physiotherapy, IPASS, other healthcare facilities and on line resources. Communications were also sent out to GPs highlighting changes to the pathway and informing them of the new referral process.

Through the implementation of the best available evidence and integration of services across healthcare providers, IPASS has been shown to benefit patients, local healthcare services and the health economy of Berkshire West.

Waiting times for patients to access a first appointment for specialised pain services has reduced from more than nine months to four weeks, whilst routine spine appointments can be booked within six weeks. This has allowed patients to access community base spine and pain specialist services closer to home with early intervention and a reduction in risk of chronicity. A significant improvement in patient outcomes measuring quality of life, function and mental health have been measured in all patients and service feedback has been overwhelming positive with 90% of patients rating the service as excellent and 89% stating they would recommend IPASS to family and friends.

One patient was quoted as saying ‘if ever the NHS is doubted then look no further than IPASS’. Other comments received include ‘first class service’ and ‘very informative and empowering’. For further patient feedback please view the IPASS video which can be accessed on the IPASS NHS Berkshire West website.

Furthermore, a reduction in referrals to secondary care has been seen with 62% of all referrals relating to spine and generalised pain now being managed in the community. A reduction of a third in multiple secondary care outpatient attendances has also been reported between 2015 and 2017. Financially, this has equated to an overall saving of £260k between 2015 and 2017 and IPASS is expected to save £111,455 a year here-on-in.

The lessons learnt as well as the challenges faced with implementing the IPASS service have been shared regionally and nationally through a variety of network meetings and the compilation of a toolkit (a ‘how to guide’) commissioned by the British Society of Rheumatology. For the in depth learning please refer to the BSR website to access the toolkit.

Four key areas of learning have been identified with this project.

Collaboration and buy in of the wider stakeholder group was crucial to the set up and on-going success of IPASS. Stakeholders represented primary, community and secondary care and the patient cohort during the scoping out, development and operational phases of the service. This has ensured the projects sustainability from a financial point of view as well as the on-going delivery of high quality care using evidence based practice.

Steering group meetings occurred regularly leading up to and during the initial operational set up to update on progress. The MDT were responsible for developing clinical pathways and treatment options and shaping the service as it progressed using well researched validated outcome measures and feedback from patients. The clinicians were given time to research the evidence, practice in other services and hold regular meetings to discuss ideas, progress and plans going forward. The MDT is able to discuss patient cases meaning that knowledge and skills have developed beyond the traditional specialist roles.

Referrals have become more streamlined and patients are getting seen more quickly in the right place at the right time, which ultimately means fewer inappropriate or repeat secondary care referrals with a group of patients who are managing their persistent pain more independently.