September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Value?
Outcomes + experience + safety
Value
=
Cost
Patient Experience?
• Multiple care pathways
End points to specialist care?
Doctor shopping
• Multiple access points
• Multiple services & providers
• High demand, fixed capacity, log jams,
long waits
Secondary Care Model
• Clinical decisions made by single clinician
• Patient given a treatment plan
• Principle: FIX THE PAIN (biomedical model)
Value?
• Therapeutically ineffective
referrals
• No legitimate clinical pathway
Outcomes + experience + safety
Value
=
Cost
ICATS
• Strong NHS support
• WHY? High referral rates, long waiting times,
low conversion to surgery
• Whole system approach
• Typically MSK
• Multidisciplinary team
• Triage – skills matching
ICATS
Paper triage, then refer to either
Physio
Back programme
Pain clinic
Spinal surgeons
(Back to GP)
Virtual spinal clinic
ICATS
•
•
•
•
•
Improves patient experience eg access
Control ‘up front’
Reduces referral rate to secondary care
Reduces initial costs
BUT
Sufficient depth of skills & expertise?
Truly integrated?
Medical ‘buy-in’
15-20% re-referral rate after initial referral?
Old services & models still exist
“We introduce the new by allowing the old to
continue …
… therefore the new only add cost.”
Professor Paul Corrigan, Kings Fund.
Reduce secondary care referrals
13
Service Redesign
1 Clinically led; appropriate clinical model
2 Follow & control whole patient's journey
or care pathway
3 Involve all stakeholders
4 Effective multidisciplinary team
5 Focus on patient experience and optimising
care outcomes
Biomedical
Model
Clinical Management
• Biomedical trigger
• Biopsychosocial response
Discharge
GP
Prescribing &
medication
trials
GP
Referral
Investigations
Multidisciplinary Clinic
Spinal
Surgery
Spinal MDT
‘Virtual’
Clinic
Consultant Triage
Biopsychosocial Assessments
MRI etc
Treatments
Acupuncture, Physiotherapy,
BPS Pain/Spinal Programmes,
CBT, Diagnostic & Therapeutic
Injections
Combined Pathway for Spinal
and Persistent Pain
Referrals per 1000
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Spinal
Other msk
FM
Visceral
Neuropathic
Headache
After initial assessment?
Spinal pain patients
– MRI 40% (55%)
– Injection 30% (50%)
– Physiotherapy 15% (35%)
– Back team 20% (15%)
Monthly Clinic Activity
100
90
80
70
60
50
Telephone
Reviews
40
30
20
10
0
Monthly Clinic
Attendances
Value?
Outcomes + experience + safety
Value
=
Cost
Costs
Less consultant time
Low f-up : new ratio
Low DNA rates
Few secondary care referrals
Pregabalin?
Spend on Pain Products (BNF 4.7.20) per head of population (2011/12)
12
10.06
10
UK average
8.49
8.76
8.20
8
7.13
6.31
6
4
2
0
Nottingham City
Rushcliffe
Newark & Sherwood
Nottingham N & E
Mansfield & Ashfield
Notts West
Spinal Surgical Referrals?
• 10% referred (10%)
• 65% had procedure (20%)
• 42% of those referred had surgery (10%)
NNE CCG
n
First Hospital OP Attendances
500
450
400
350
300
250
200
150
100
50
0
Principia
NWC
NNE
All Secondary Care Pain
Management
Deprivation adjusted SAR
250
200
150
--------------------------------------------------------------------------------------------100
50
0
All
Principia
NWC
NNE
M&A
N&S
First Spinal Hospital OP Costs
£
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Principia
NWC
NNE
‘If clinicians are not part of the solution, they
are part of the problem’
Clinical engagement
GPs, specialists and other clinical staff must be
engaged in managing budgets and with service
redesign to bring outcomes, experience and cost
together.