Best evidence for a better back (BE FABB) - A triage, assessment and education service for patients with low back pain with or without sciatica

The aim of this project was to improve the department’s compliance with updated NICE guidelines (NG59), improve patient experience and ensure the delivery of effective and efficient evidence based care to the local population. In addition, we also aimed to reduce waiting times and unwanted variation in practice, remove low value interventions (e.g. acupuncture) and increase access to evidence-based treatment to empower the patients to manage their wellbeing more effectively in the long-term.

We achieved this by implementing with our neighbouring healthcare trust a uniform pathway to manage patients with low back pain (with or without sciatica). The change involved the design and implementation of a new group education session, accessed from initial referral therefore avoiding the waiting list. The group session was designed as a comprehensive education session with an explanation of the NICE recommendations highlighting examples of supportive evidence, supported by provision of  printed information including, advice on activity and information on appropriate actions in the event of more serious scenarios such as symptoms of Cauda Equina. To further reinforce this important message, we adopted the tool kit cue card for “Red Flags” as developed by Sue Greenhalgh, (2017) to provide to patients.

In addition, the new model facilitated triage of patients using the STarT Back risk stratification tool along with a specifically designed subjective information sheet. The combination of the subjective form and the STarT Back score ensured that patients were offered the pathway most appropriate for them, whether it be group exercise classes, individual one-to-one care, possibly including manual therapy, onward referral for CBT, or a combination of these treatments.

Services are provided from Hillingdon and Mount Vernon Hospital. We employ over 3,300 staff and aim to deliver high quality healthcare to the residents of the London Borough of Hillingdon (273,906 people), and to those living in the surrounding areas of Ealing, Harrow, Buckinghamshire and Hertfordshire. We offer a range of inpatient and outpatient services including musculoskeletal (MSK) outpatient physiotherapy across both sites, as well as at a number of GP practices.

Back pain referrals currently account for 13% of the trust’s total referrals to MSK therapy services. The NICE guidelines (NG59) were an opportunity for us to re-evaluate and redesign our pathway to manage this group of patients. It was an opportunity to cut waiting times, remove low value interventions and improve patient outcomes using the latest back pain evidence.

The recommendations we highlighted for review were: 1.1.2, 1.1.3, 1.2.1, 1.2.2    

Prior to the change, the utilisation of the risk stratification tool (STarT Back) had not been routinely integrated as part of our initial assessment, although we were compliant with recommendations regarding exercise classes, self-management and education. Patients referred by their GP, consultant or extended scope practitioner (ESP) were triaged onto either the urgent or standard waiting list. Following an individual assessment, patients would have a course of physiotherapy which may have included education, manual therapy, acupuncture, home exercises and referral to an exercise class. Patients were assessed and treated by clinicians with varying degrees of expertise and experience. This variation led to differences in communication of key messages surrounding back pain.

Utilising the STarT Back tool would support clinical decision making and help optimise treatment. The NICE guidelines were seen as an opportunity to up-skill our clinicians, increase the understanding of back pain, provide consistency in information being delivered and as an opportunity to embed this within the culture of the department.

In order to meet the recommendations, we sought to change the way we assessed and triaged patients presenting with back pain.

In the 4 months preceding the changes, the average waiting time in the department was 76 days. In addressing this we believed that introducing a group session accessed directly from the initial referral would have the following benefits:

• The waiting time for physiotherapy would be reduced.
• Patients would have the opportunity for group facilitated discussion and peer support.
• A group setting would allow longer contact time with patients to help embed knowledge and understanding of low back pain, self-management and healthy behaviours.
• Reduce patient’s fear and anxiety about back pain.
• Ensure a consistent message from our physiotherapists.

To implement this project, key individuals in both trusts reviewed the NICE guidelines. We invited Dr Neil O’Connell (a member of the guideline development group) to present the guidelines within the department to increase clinician’s understanding. We also attended an event, hosted at Brunel University by the emerging Brunel Academic Healthcare partnership initiative, which focussed on implementation of the guidelines. This information allowed us to create a new pathway for managing this patient group.

The first goal was to create a presentation for the group session focussing on key areas including: anatomy, pain, prognosis, common questions and myths, the evidence behind staying active, the need to avoid bed rest, treatment options and when to seek help. Information was based on the most current evidence from the NICE guidelines, the Chartered Society of Physiotherapy (CSP), NHS England, and medical journals.

Patients were excluded from the group if:

• The referral was not for low back pain i.e. thoracic pain
• Requirement for an interpreter
• Overriding mental health problems affecting perception / compliance
• They were under 18 years old
• Any un-investigated red flags

Patients were referred via GP using the eRS system, or via Consultant / ESP using paper referrals. GPs would be able to refer directly via eRS to the group. Non-GP referrals were triaged based on ESP recommendation having already been assessed in clinic. We presented the pathway at the Hillingdon MSK Clinical working group and communicated the agreed changes to the GPs directly.

Therapists were concerned that the lack of 1:1 assessment could allow serious pathology to be missed. This was addressed by collaboratively working on a subjective information form to ensure screening questions were appropriate. Patient’s answers could then be used alongside the Keele STarT Back risk stratification questionnaire for appropriate triage. The MSK Health Questionnaire has also been adopted to monitor outcomes. A second challenge was that engaging staff from two Trusts increased the likelihood of differences in opinion on the new model with the potential to cause delays in modifying and implementing the plan. Our final barrier was that differences in the Trust’s computer systems meant we had to initially manually contact patients to re-book into the group.

This project has had a positive effect on the quality and consistency of care patients have received, reducing variation in pathways across neighbouring NHS Trusts. Furthermore, the quality of advice and education has been standardised and therefore, important messages about symptoms and their management are routinely and consistently communicated to patients.

This standardisation of information will not only allow the most accurate evidence-based recommendations to be widely disseminated, but will also enable the patients to better manage and facilitate self-management with the potential for decreased service use and adoption of healthy lifestyles in the future. Our service has now fully implemented the recommendations from the NICE guidelines (NG59). In addition, there has been an improvement in average waiting times for patient appointments (mean >30 days). Patients are now seen much more quickly and physiotherapy productivity has increased with over 100 additional new patients being seen compared to the previous 4 months before implementation.

Patient satisfaction has also been high with comments including that the group was ”informative and helpful”. We anticipate that this project will deliver further benefits as therapists gain more confidence in running the group and improve their ability to triage more effectively.

The priorities of ‘AHPs into action’ were considered throughout the implementation of this project. We feel that, by reducing the time between referral and initial appointment, this scheme will improve the health and well-being of individuals and the wider population of Hillingdon. Addressing a patient’s problems more promptly will also reduce the fears and anxieties associated with a lack of information on their condition and appropriate management. We have implemented evidence based practice to address variation in the messages patients receive and the quality of the education provided, have removed low value treatments and have stratified patient care to the most appropriate clinician and clinical pathway.

By collaborating with CNWL in creation of the project we have limited variance in care across the borough. The changes made to the low back pain pathway will support reduction of demand in general practice and urgent and emergency services through improved self-management.’

There have been some key learning points from running this project. Most notably, we demonstrated that it is possible to jointly collaborate with another NHS Trust running a similar service in order to successfully launch a project. Despite the obvious challenges of a wider set of views and opinions, the dedication and enthusiasm from staff across both Trusts allowed us to overcome these challenges and produce a great piece of work. In future, for collaborative work, meeting face-to-face to discuss amendments and adherence to agreed deadlines may help to streamline the process.

We have also found that redesign of the way in which we assess and triage patients can have a positive impact on both waiting times and productivity delivering high patient satisfaction. Utilising risk stratification tools and outcome measures has helped with the triage process, and has highlighted the importance of effective communication with patients in to support accurate clinical decisions. This is a key learning point as consideration had been given to triaging patients to pathways without initial contact.  

Another key learning point is that not all patients will fit this pathway and therefore flexibility must be built into it at design. Despite rigorous vetting and triaging, we are often limited by the quality of the information contained in the referral.

At times, patients have been referred to the pathway inappropriately (due to the need for an interpreter not being mentioned on the referral form) and this can cause disruption in the group setting, resulting in a negative experience for individual patients as well as other attendees. A key learning point is that clear education and guidelines on the model needs to be communicated to GPs, consultants and ESPs to optimise use of the service. Furthermore, the skill of the clinician running the group is paramount to ensure they are able to effectively recognise and manage situations where inappropriate triage has taken place.