Improving Spinal Care Project
Below is information relating to the ISCP, the National Lower Back and Radicular Pain Pathway, and the Regional Spinal Networks
National Low Back Pain and Radicular Pain Pathway
North East Low Back and Radicular Pain Pathway Report
Charles Greenough, National Clinical Director for Spinal Disorders
Back pain is the largest single cause of disability in the UK, with low back pain alone accounting for 11% of the total disability of the UK population. Referrals for spinal surgery are increasing year on year and a growing number of patients are waiting longer than 18 weeks from referral to treatment. Wide variations exist in surgical rates between centres, and there are a significant number of treatments with a poor evidence base.
A clinical team of 30 specialists in the diagnosis and management of lower back pain and I have devised a complete end to end pathway for the management of lower back pain, the National Low Back and Radicular Pain Pathway. The objective of this pathway is threefold: firstly to rapidly identify and refer potentially serious pathology; secondly to provide expeditious access to interventions such as nerve root blocks or surgical discectomy where indicated and thirdly, and most importantly, provide effective and timely care for sufferers with acute low back pain to improve outcomes and reduce disability. I would like to see every Clinical Commissioning Group in the country commission through this pathway to reduce delays, remove ineffective treatments and help patients to lead a fuller more active life, reducing disability and chronic pain. And by making the treatment pathway more evidence based and more coherent, this management will be less expensive than the current management.
The volume of spinal surgery is spiralling – the NHS in England spends £200m per annum on spinal surgery and there are currently approximately 10,000 adult patients each year that have elective spinal surgery. However there is a large variation in practice with inconsistent indications. In an addition, there are large numbers of patients being given injections with low evidence of effectiveness. Reducing these ineffective but costly injections alone would save the NHS £9m a year.
Reviewing current practice
From a review of the service it was clear that that there were two main issues impacting on this area of work.
• The current pathway of management for low back pain is not planned, has little reference to the evidence base and contains very significant delays at every step.
• Large variation in surgical indications and rates between centres, which is unexplained. This in turn drives large variation in activity and cost between CCGs.
In addition, we found problems with waiting list management and fragile clinical teams relying on one or two individuals working in isolation.
How can we overcome these problems?
1. Commissioning to a unified pathway of care.
The National Low Back Pain Pathway
This is a complete end to end pathway for lower back pain and radicular pain which starts at the GP Surgery and moves through primary care and, if indicated, through to secondary care. All clinicians using this new pathway will be applying right care/right time/right place principles, supported by a Public Health awareness campaign. The focus will be on the promotion of self-management and improving understanding of how to manage, limit and prevent back pain. This will reduce ongoing pain and disability and in turn reduce the need for patients to be referred into secondary care.
To support the pathway standardised patient literature will be used in conjunction with retraining of healthcare professionals to de-medicalise simple back pain. Altering population beliefs about back pain is a recognised highly effective way for reducing back-related disability. Patients will experience a planned care pathway, including for those who need it a high intensity combined physical and psychological treatment programme. Only after completion of the whole pathway will consideration be given to surgery for axial back pain (e.g. fusion surgery). Disability and chronicity will be reduced and ineffective therapies such as injections will be addressed. It is calculated that this managed pathway will also be less expensive.
Pathway – Future Proof
The pathway is a vehicle for implementation of evidence based care. It is a modular construction, and provided by a uniform, highly skilled workforce (Triage &Treat Practitioners).
This will allow new evidence based therapies to be “plugged in”, or other treatments to be discontinued as research and reviews are undertaken.
Our Regional specialised commissioning teams will be working with the transformation team in each CCG commissioning collaborative to take this work forward. We are communicating with the Sustainability and Transformation Plan teams. We will also be inviting provider networks to take part in the peer review and design process on the future pathway of care.
If you are interested in being an early adopter of the Improving Spinal Care project email: ENGLAND.firstname.lastname@example.org
NICE Endorsement Statement:
“This care pathway supports implementation of recommendations in the NICE guideline on low back pain and sciatica.”
National Institute for Health and Care Excellence, June 2017
A list of the documents available from NHS England for any organisations wishing to implement the pathway.