The Physiotherapy Low Back Pain Drop-in Service project was introduced in East Lancashire to improve access and quality of service for patients with low back pain, through a re-designed and enhanced physiotherapy service.
Staff, patients and referrers were involved in developing new 'Drop-in' clinics. These are run by experienced physiotherapists who offer early assessment, advice and reassurance. Waiting times are now minimal (as the service is not appointment based but patients are invited to 'Drop-in'), duplicate referrals and unnecessary diagnostics have been vastly reduced; and patient outcomes are good.
This example was originally submitted to demonstrate practice against NICE guideline CG88. The guideline has now been updated and replaced by NG59. The example has been reviewed and practice described remains consistent with the updated guideline.
Aims and objectives
- Reduce waiting times for low back pain patients through an innovative new model.
- Prevent development of chronicity though early identification of sinister pathologies and psychosocial distress.
- Deliver appropriately targeted high quality physiotherapy intervention.
- Develop a seamless pathway across organisational boundaries and between primary and secondary care.
- Increase efficiency by reducing resource use.
- Identify patients with serious spinal pathologies at an earlier stage.
- Provide early advice education and reassurance to facilitate self management and return to work.
- Provide targeted evidence based physiotherapy treatments for specific clinical subgroups.
- Reduce average number of physiotherapy sessions required.
- Refer to diagnostics from physiotherapy; reducing inappropriate diagnostic referrals.
- Reduce inappropriate referrals to specialist musculoskeletal services and secondary care.
- Reduce Pain Clinic referrals.
- Support 18-week target delivery.
Reasons for implementing your project
Originally, patients with low back pain were referred by their GPs to physiotherapy, for which the wait was up to 20 weeks. Evidence shows that during this wait patients may remain off work, become psychologically distressed, and start to develop a chronic condition, resulting in higher costs to health and social care.
Some GP's avoided the wait for physiotherapy by referring to specialist MSK services or to secondary care; or requested diagnostic tests to rule out serious pathology. These referrals were often unnecessary and costly. Physiotherapy assessment was by generic outpatient physiotherapists who sometimes mis-categorised patients (thus delaying the correct treatment), and who could not order diagnostics (resulting in re-referral back to the GP).
Some patients required immediate onward referral to specialist services; making their long wait for physiotherapy unnecessary. These issues further contributed to psychological distress, chronicity and overall cost. The new Low Back Pain 'Drop-in' clinics were an innovative way of improving quality by addressing these issues. No baseline assessment data was available prior to implementation, apart from waiting times and physiotherapy input.
How did you implement the project
The project began with a local study, which asked patients how they would like to receive Low Back Pain advice. 70% said they would prefer a drop-in service.
In 2008 a Spinal Working Group of key stakeholders was established which identified gaps, obstacles and best practice locally for Low Back Pain. Visits were made to national sites to explore best practice elsewhere; it was decided to introduce the Drop-in clinics.
Jan-Apr 2009: Implementation team members were identified and Project co-ordinator appointed (existing specialist physiotherapist).
May-Jun 2009: Initiation: Support gained from administrative staff and physiotherapists for new model via meetings. Numbers of clinics identified. Diagnostic pathways between physiotherapy, musculoskeletal service and radiology further developed to improve the patient pathway and prevent unnecessary diagnostics. Audit designed; data collected included diagnosis, pathway, and to ascertain if treatment being delivered in accordance with NICE Guidance (p.2 of attachment). At pre-implementation stage members of Physiotherapy Patient Focus Group (Public Foundation Trust members with patient experience of the physiotherapy services) took part in pilot Drop-in clinics and provided valuable feedback on their experience. This work influenced the final design of the clinics.
July 2009-Jan 2010: Implementation: Initially occurred on 2 sites; a prospective audit was undertaken for first 8 weeks to evaluate the new service, results were shared with all stakeholders and then implemented on 3 further sites. Following implementation an 'Expert Patient' delivered a presentation to staff on his and others' experience. This was a powerful motivator for staff to continue to get things right for service users.
Retrospective audit: Nov 2009-Sept 2010 to capture treatments offered in line with guidelines(see attached). No project funding was available so the new service was developed within current staffing and budgets.
Progress and evaluation was monitored via two audits; samples 174 and 856 respectively.
The main results were:
1). 20 week wait has been abolished; patients are able access the Drop-in on any of the 5 sites after visiting the GP at their convenience.
2). Patients with serious spinal pathologies were identified at an earlier stage.
3). 90% of patients were successfully managed within physiotherapy and do not require onward referral (5% referred to Musculoskeletal services, 4% back to GP,1% to 'Other' services.
4). 3% of patients accessing the service were referred for diagnostics by the ESP clinicians.
5). Staff report improved job satisfaction as patients improve quicker and require less follow-up sessions; 78% of patients were assessed and treated in 4 sessions, this could be attributed to early access and being triaged to the correct grade of clinician from Drop-in.
6). Reduced administration time as less telephone contact is required.
7). Results from the second audit indicate the service is offering and providing all the treatments proposed in the NICE guidelines but not to the level recommended. Data analysis has identified variances in treatments approaches on each site; highlighting the need for training to standardise the management in line with the guidelines.
8). The number of duplicate and inappropriate referrals to specialist musculoskeletal services and secondary care will be more widely realised following the decision to roll the model out across the whole health economy.
9). The success of the project has been formally recognised with the announcement of the Low Back Pain Drop-in service as winner of the North West Regional Health and Social Care Awards for the Improving Services category.
Key learning points
1). Ensure all groups of staff are involved from the outset when changing service provision.
2). Earlier involvement from the Practice Managers would have been helpful in educating the GPs about the new referral process.
3). Provide 'start-up' funding if possible as the existing model had to be delivered during the development of the new model.