31 March 2014
Over 70% of the population will experience a significant episode of back pain during their lives. Back pain is the most common reason why middle-aged people visit their GP, with one in 12 adults presenting each year with this complaint, representing an estimated annual cost to the NHS of £4.2 billion, and back pain is the second most common reason for sickness absence from work, for persistent disability among adults under 65 and for work-loss among the same group.
Current guidelines promote a ‘one size fits all’ approach in which, after the small minority of patients with potentially serious causes for their pain have been identified, the rest are managed as a single group under the label of ‘non-specific low back pain’. Yet we know that most cases of back pain resolve regardless of the course of therapy, while some do not get better, no matter what is done. Thus, current treatment approaches mean that a substantial proportion of back pain patients are over-treated in the NHS, while a significant number fail to get the right treatment and go on to suffer long-term pain and disability.
The challenge for practitioners, patients and policy-makers is to be able to classify back pain patients according to their risk of persistent pain and then to target them to appropriate matched treatments. STarTBack provides an example of stratified care for low back pain, where patients are screened for risk of chronicity. The STarTBack prognostic screening tool places patients with back pain into three risk groups (low, medium or high chance of persistent disabling problems). Matched pathways are put in place to target the right treatment to the right patient.
Funding through the WMAHSN has helped academic and NHS colleagues to unlock barriers to implementation – through creating the capacity for change management, establishing support networks for NHS colleagues, unlocking funding support for training in the STarTBack approaches and developing IT solutions to support implementation. The WMAHSN has provided funding to ensure the practical support required to support innovation is in place and has supported the rollout of STarTBack in NHS clusters distributed across the region, supported by local clinical champions and managers, and knowledge mobilisation/change agents from Keele University’s Institute of Primary Care and Health Sciences.
Three clusters of West Midlands GP practices with care pathways linked to physiotherapy centres are being identified as participants. WMAHSN is funding project management and implementation/clinical expertise to support the engagement and training of healthcare professionals to adopt a stratified care approach to managing back pain. New care pathways are being negotiated with local clinical commissioning groups and provider trusts to support the roll out of this approach. The implementation team are working with proprietors of GP computerised systems to embed the STarTBack screening tool into the GP clinical systems. This will mean that the STarTBack tool will ’pop-up’ each time someone consults with back pain. AHSN funding is supporting this change management and the related training activity.
For access to tools and resources to support implementation of STarT Back, please visit the Keele University website.
Early audit evidence has demonstrated increased utilisation of the STarT Back tool within general practice settings of up to 30% and a reduction in physiotherapy waiting times by up to six weeks; North Staffordshire CCG and Staffordshire and Stoke-on-Trent Partnership Trust showed an increasing in achieving the waiting times target from 52% to 80%. In addition to evaluating the impact at a service level, the STarT Back implementation team is collaborating with CLAHRC WM to evaluate the implementation strategy adopted and role of leadership within this, and further implementation clusters have negotiated the development of pathways for referral for low back pain according to risk stratification.
Early audit evidence from the cluster sites has demonstrated:
Further clusters are currently negotiating the development of pathways for referral for low back pain according to risk stratification as below:
As well as establishing regional cluster sites of implementation, this project has developed industry partnerships, established links with other AHSNs to support STarT Back rollout across networks and linked closely with national bodies to ensure that STarT Back is integrated into professional networks.
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