ChallengeThe aim of the project was to implement a comprehensive, evidence-based care pathway from the GP surgery, through CCG commissioned services in primary care and secondary care, to services delivered under specialised commissioning arrangements.
The project would reduce delays, eliminate ineffective therapies and improve patient outcomes with reduction of disability. Associated savings, largely within secondary care, were expected for spinal activity. The pathway would apply right care/ right time/ right place principles, supported by a regional Public Health awareness campaign on the “normality” of simple back pain and self-help measures to prevent or limit the experience.
The 2010 Global Burden of Disease results estimates that musculo-skeletal diseases cause the third greatest loss of disability-adjusted life years after cardiovascular diseases and cancers, and that 71% of these result from back and neck pain. The majority of CCGs in Cumbria and the North East have above national average prevalence for back pain. Patient knowledge of back pain is poor, resulting in unrealistic expectations and demands on healthcare systems. This demand is met by variation in management across the healthcare system often resulting in expensive investigations and ineffective care leading to poor outcomes.
NECS Transformation and Delivery Team worked closely with lead clinicians to implement the pathway across primary and secondary care providers. This complex transformational change project was supported by a team of people across NECS with a range of skills and experience. The tasks included:
- Compact developed, agreed and signed by 11 CCG members of the Northern CCG Forum, to deliver the pathway at CCG Level. This was the first project agreed to be delivered at scale.
- Communications and Engagement Plan in place, including the development of a detailed ‘What’s in it For Me’ Stakeholder Map
- Identified Phase 1 and Phase 2 localities/CCGs through expressions of interest and readiness toolkit
- North East Quality Observatory Service commissioned to provide a regional baseline assessment on utilisation of secondary care services by CCG and provider. NECS Business Intelligence team collected primary care usage data and further analysis which is now used nationally
- Re-training of 70 health professionals across the region to “de-medicalise” simple back pain and introduce a biopsychosocial model ‘Normalisation’ campaign launched, which included posters, leaflets and social media with the development of a successful animation to inform the public on how to self-manage. These tools are now being utilised nationally.
- Pathway delivered within 2 CCG localities as part of Wave 1, through detailed delivery and engagement plans agreed with local commissioning managers Pathway delivered within 1 CCG locality and partially delivered in a further CCG locality as part of Wave 2, through detailed delivery and engagement plans agreed with local commissioning managers
- Roll out timetable agreed for Wave 3. Remaining CCGs to deliver the pathway by March 2019 as part of the STP priority areas
- Development of a robust data collection process, which involves the collecting of a range of Patient Reported Outcome Measures (PROMs) at various points of the pathway including 6 and 12 month post discharge, utilising digital technology. This is to support the evaluation of the pathway and to inform local commissioners that patients are continuing to receive quality advice and treatments.
- Introduction of an intensive Combined Physical and Psychological Programme, which is demonstrating excellent PROMs results. This NICE ng59 recommendation is still largely overlooked nationally.
As a result of our project group’s close links with the national back pathway team led by UK SSB and supported by NHS England, the original North of England pathway is indistinguishable from NHS England’s recently published National Low Back and Radicular Pain Pathway 2017
The project was delivered within the overall timescales and budget, despite the enormous and complex challenge the programme embarked on in delivering clinical guidance, across a pathway and across localities. It is well noted that the challenge of implementing back pain guidelines in clinical practice is substantial, and issues relating to implementation, largely due to existing contract arrangements and managing change within clinical teams.
Delivery was enabled through well-established governance and reporting structures, and collaborative working. It was also delivered through an experienced project manager, trained in transformational leadership and highly skilled supporting teams within Contract Management, Communications and Engagement, Business Intelligence and Service Planning Reform within NECS.
The project successfully delivered on a well detailed communication and engagement plan. This included a ‘What’s in it for me’ stakeholder map (clinical engagement adapted to individuals/groups on a need basis), posters, social media, local newspapers, newsletters, and an excellent animation that was commissioned by our Communications Manager. This linked all of our project materials together and has generated a lot of national interest with those areas looking to implement the pathway. Provider engagement and commitment is what has maintained the project’s momentum during times of uncertainty, contract issues and lack of data.
An area that has consistently been a challenge throughout the project’s duration has been evaluation and data monitoring, due to the complexity of the systems that the pathway was being delivered within. The new and additional data being collected across the sites was not refined enough to develop a regional dashboard and support evaluation. A digital solution was identified and supported to address these challenges. There is no precedent within the region or nationally for evaluating patient outcomes across a pathway and across localities utilising an integrated digital solution.
As a result of our project group’s close links with the national back pathway team led by UK SSB and supported by NHS England, the original North of England pathway is indistinguishable from NHS England’s recently published National Low Back and Radicular Pain Pathway 2017.
The National Pathway uses all of our tools and learning to make recommendations on how the pathway should be delivered. The National Low Back and Radicular Pain Pathway has recently received a NICE endorsement statement confirming that this care pathway supports the implementation of the NICE guideline on low back pain and sciatica’. We are recognised as being the earlier adopters of the full pathway and recently shared the learning at the first National Back Pain Pathway Clinical Network meeting in September 2017.
The Regional Back Pain Programme team have been supporting a number of regions and in a number of small groups of CCGs nationwide. Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines.