September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom

Value? Outcomes + experience + safety Value= Cost

Multiple care pathways End points to specialist care? Doctor shopping Multiple access points Multiple services & providers High demand, fixed capacity, log jams, long waits Patient Experience?

Secondary Care Model Clinical decisions made by single clinician Patient given a treatment plan Principle: FIX THE PAIN (biomedical model)

Value? Outcomes + experience + safety Value= Cost Therapeutically ineffective referrals No legitimate clinical pathway

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

13 “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

Service Redesign 1Clinically led; appropriate clinical model 2Follow & control whole patient's journey or care p athway 3Involve all stakeholders 4Effective multidisciplinary team 5Focus on patient experience and optimising care outcomes

Biomedical Model

Clinical Management Biomedical trigger Biopsychosocial response

GP Referral Multidisciplinary Clinic Consultant Triage Biopsychosocial Assessments Investigations MRI etc Treatments Acupuncture, Physiotherapy, BPS Pain/Spinal Programmes, CBT, Diagnostic & Therapeutic Injections Spinal MDT ‘Virtual’ Clinic Spinal Surgery GP Prescribing & medication trials Discharge Combined Pathway for Spinal and Persistent Pain

Referrals per 1000

After initial assessment? Spinal pain patients – MRI 40% (55%) – Injection 30% (50%) – Physiotherapy 15% (35%) – Back team 20% (15%)

Monthly Clinic Activity

Value? Outcomes + experience + safety Value= Cost

Costs Less consultant time Low f-up : new ratio Low DNA rates Few secondary care referrals Pregabalin?

Spinal Surgical Referrals? 10% referred (10%) 65% had procedure (20%) 42% of those referred had surgery (10%)

NNE CCG

First Hospital OP Attendances n

All Secondary Care Pain Management Deprivation adjusted SAR

First Spinal Hospital OP Costs £

‘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.