Back and neck pain services

By offering people choice in health and care services such as back and neck pain services, in the years ahead we expect to see more services being offered by a much wider range of NHS, private and voluntary providers. The service already being provided in this way across North East Essex is described in the case study below.

Manual Therapies Back and Neck Service, NHS North East Essex

  • NHS North East Essex wanted to provide greater choice, easier access and shorter waiting times for patients suffering back and neck pain and at the same time address the unsustainably high demand on local spinal services.
  • In 2008, all existing providers were contacted and invited to bid to offer patients these services.
  • Patients can now choose from 20 different providers of chiropractic, osteopathy and physiotherapy based throughout the Colchester and Tendering area.  There are four chiropractic, five osteopathy and 11 physiotherapy providers to choose from and they all meet NHS standards and agreed prices. Patients are given an appointment within two weeks and receive up to four treatments.
  • During 2009/10, 2,810 patients used these services and 97% of patients were seen within two weeks of referral.
  • Providers are working to locally agreed common referral and clinical protocols and whilst there is competition, there is also cooperation between individual providers and disciplines to ensure service integration for patients.
  • Evaluation after the first 12 months of offering patients a choice of any qualified provider has identified improved patient access and choice meaning early treatment and improved outcomes; and reduced primary care consultations, imaging, medication costs and inappropriate referrals to secondary care.  Referrals to spinal surgeons have reduced by more than 25%.
  • In 2009, this approach to offering chiropractic, osteopathy and physiotherapy services to treat back and neck conditions was awarded the NHS Alliance ‘Acorn Award’ for alternative therapy.

Read the full case study

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29 Responses to Back and neck pain services

  1. Julie Yaxley says:

    I have spent many years promoting the benefits of self care which includes issues such as pain managment, i would be interested to know how supporting self care and personalisation fits within the total care pathway.

    • Mark Gurden, Chiropractor says:

      Hi Julie I am a provider working in the above service and I think you raise an important point. All patients entering this service were assessed and treated according to a biopsychosocial model. Treatment was pragmatic and individualized and there was an emphasis on patient education and establishing coping strategies.

      Patient reported outcomes were determined using validated pre- and post-treatment questionnaires that looked at variables such as pain and disability but also anxiety, depression, fear avoidance behavior and locus of control. The vast majority of patients were discharged with advice on self
      management of their condition.

  2. Alf Collins says:

    …I believe absolutely in informed choice.
    …I know that competition improves quality.
    …I know that there is no cure for long term musculoskeletal pain
    …I know (from 18 years experience as a clinician working with people with long term pain) that the greatest impediment to recovery is fragmented services that give contradictory and confusing messages to people with pain about what works and what doesn’t.

    I am utterly appalled at this announcement and believe that this is a dark day indeed for people who live with long term pain.

    • Alf, you are quite correct that fragmented services and mixed messages cannot be consistent with an effective, patient-centred approach to the management of back and neck pain. However, this initiative shows what can be achieved when providers of these services work together. It is entirely appropriate that highly qualified regulated healthcare professionals who specialise in the field of back and neck pain should be utilised, regardless of whether they have historically been part of the NHS. The reason why patients should have widened access to back and neck pain services via the Any Qualified Provider scheme is precisely because the current model is not working.

      The North East Essex experience is an excellent example of why chiropractors, osteopaths and physiotherapists should work together and why we must make this a model to be adopted by all PCTs, not just the lucky few (patients and clinicians alike) who have experienced the benefits of an evidence-based and collaborative approach.

    • Mary@DH says:

      Integration between providers is very important for our vision of the NHS and we recognise that a number of comments have been posted on this issue. Where the AQP model is used, Commissioners would determine the shape of services, including where services need to be integrated to improve quality. All providers will be required to work within local referral pathways and protocols and providers will have a contractual obligation to co-operate so that patient care is safe, transfers are co-ordinated properly, and patient experience is good.

      Regards, Mary Mulvey – Policy Lead, Any Qualified Provider

  3. Nick Pahl says:

    We would like to ensure that British Acupuncture Council (BAcC) members are part of the any qualified provider process for back and neck pain. We are the largest body in the UK for the regulation of traditional acupuncture. With over 3,000 members, it has a track record of delivering robust self-regulation (recognised in the Secretary of State for Health’s announcement on herbal medicine on 16 February 2011).

    We would like to be part of a national qualificiation process.The recent inclusion of acupuncture in the NICE guidelines on the treatment of lower back pain is a demonstration of how BAcC members can significantly and increasingly benefit the nation’s health in this area.

    We believe that the public should have the opportunity to choose acupuncture as part of their NHS provision, and be able to receive advice and treatment from professional acupuncturists.

  4. This is a small step in the right direction. However, only allowing 4 treatments is woefully inadequate to provide lasting change in most cases.
    Also, musculoskeletal care by its nature is an active process, meaning that patients have to take some responsibility and do their bit too. In my experience, those who are not paying for services tend to expect more and do less.
    For both reasons, patient satisfaction will likely be compromised and the NHS may end up dropping the idea.
    I hope this does not happen though, and that ultimately NHS patients will have access to the FULL services of these therapists, without prejudice, so they may experience the true benefits, rather than just being teased with a temporary taster.
    Who knows how much the NHS could save over the long term if everyone had much healthier spines and not just ‘less back pain’?

  5. jacqueline Scott says:

    Can anyone tell me where evidence based practice comes in to all of this ?
    Has anyone looked at NICE guidelines or the strong evidence on exercise groups for back pain sufferers .
    Where do patients in Essex go if they have not improved after 4 sessions ?
    If patients who saw the chiropracter are no better do they then get the choice to see the physiotherapist ?
    What information is given to patients on making their choice ? Is it only location and time taken to be seen ?

    • Hester Wadge@DH says:

      Thank you for your questions. For each of the eight initial services including back and neck pain, we will be working with the NHS to develop evidenced based implementation packs, to support commissioners.

      Part of this work will involve thinking about what information patients need to make an informed choice of qualified provider in the service area. If a Doctor has assessed that their patient needs a certain treatment, then it is for the Doctor, in discussion with their patient, to refer the patient for the treatment that is clinically necessary – this will not change.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

    • Nick says:

      I completely agree with the above post. There has been talk on self management and the only intervention I have noted so far is advice and maybe a leaflet. Has anyone read the Health Foundation’s self management guidance regarding the efficacy of different self management approaches. Quite commonly 4 sessions for someone living with centrally maintained pain is not sufficient. The ‘biopsychosocial’ model is mentioned and used with undoubtedly limited knowledge of what it entails. Chronic pain requires a multi modal aproach according to the driving factors of the patient’s presentation, whether that is anxiety/depression/fear or physiological factors as part of a disease process. Often this takes time to fully ‘unravel’ as a rapport is established between a therapist and patient. Currently I am sceptical as to whether or not factors such as this will be accounted for, or if (as I suspect) cost and number of sessions will take precedence…

    • Heather says:

      I agree with Jacqueline’s concerns, but i also reply to Hester’s comments. I think it demonstrates a lack of understanding about the expertise and role of Musculoskeletal practitioners of any discpline to say that:

      “If a Doctor has assessed that their patient needs a certain treatment, then it is for the Doctor, in discussion with their patient, to refer the patient for the treatment that is clinically necessary – this will not change.”

      As a physiotherapist, and I’m sure Osteopaths and Chiropractors will agree, we have trained long and hard to become autonomous practitioners who assess and advise our patients on the best treatment for their condition based on the evidence and our knowlegde and expertise. With all due respect to our medical colleagues most are not experts in MSDs and what physical therapy modalities may be suitable. Long gone are the days when doctors prescribed what physiotherapy treatment modalities were to be given.

      Are we set to turn back the clock and resort to being driven by the medical model and directed by the medical profession), rather than the evidence based, holistic, biopsyhosocial stepped approach to the management of MSDs as described in the literature?

  6. David Shortt says:

    I have been referred twice by the NHS to private providers – once for chiropractic and once of acupuncture. In both cases the first couple of appointments were free but then I had to pay. I also doubted whether the “free” treatment I received was as good as the fully paying customers. The new system would positively encourage providers to undertake “loss leaders” which in the short term would under-cut the NHS but in the long term would threaten NHS services which would become progressively unsustainable.
    Many large providers such as US healthcare firms or british supermarkets have the money to absorb short term loss (5 years??) in order to cash in for the longer game.

  7. Marion Keates says:

    I am currently seeing a physiotherapist at a local private clinic, having been sent there by my GP. I was given no choice, and thought I would be going to the nearest NHS clinic. When I enquired when I would be seen I was told I would have to join the waiting list, then six weeks, but some of their patients choose to have one or two sessions privately whilst waiting to get their NHS appointment! They also said that their physiotherapists had lots of experience, and that they were considered better than the NHS. I have been left in no doubt that the PCT only funds a certain number of appointments (6). I don’t see how this can be in the patient’s best interests.

    As my next visit will be the sixth it will be interesting to see whether that’s the end of my physiotherapy.

    A couple of years ago in a bid to reduce a huge waiting list for hearing aids, I was referred to a private provider. I was told that if I had been paying I would have been supplied with a better more modern aid than that sanctioned by the NHS. The days on which I could be seen were limited, and I could only leave messages on an answerphone and wait for them to call me.

    I have great doubts about this privatisation, be it by the back or front door. I have experienced using the private sector with medical insurance, and there’s no doubt that when the patient actually has control over payment, by being the one who authorises payment, and indeed often gives the cheque, the attitude and service is definitely better.

  8. Tererenc Humphrey says:

    I agree with the choice being offerd, but is the full course and cost of the treatment fully explained. The need to carry on the treatment after your alotted period has expiered and who foots the bill. Can you try another course of treatment with a different provider, or are you limited to one choice.

    • Hester@DH says:

      Thank you for your question

      Under Any Qualified Provider, commissioners will need to establish clear referral protocols and thresholds. This means that a set of criteria is developed, outside of which providers will return patients to the referring clinician or GP. In the event that patients are treated outside of these criteria, the provider should not be paid. In previous posts I have referred to ‘implementation packs’. These packs will recommend a currency model based on an appropriate ‘course of treatment’ – this could might be a year of care, or longer for some patients.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

  9. Paul says:

    My question is how the scheme will be funded? Will there be a separate funding stream to implement the AQP scheme or will this be expected to come from the existing MSK PCT budget. In my experience PCT/Consortiums are reticent to dismantle or destabilise an existing service and as such I ill be interested to see ho many PCT/Consortia use this scheme.

    • Hester@DH says:

      Dear Paul,

      Thank you for your comment.

      However, we are not dismantling or destabilising services. Commissioners are currently determining which three or more services will be suitable for Any Qualified Provider in their local area, having engaged with clinicians and patient groups. We are, so far, encouraged by the level of support received on AQP – and we know that a number of PCTs have decided to extend patient choice of provider as soon as possible – before the 2012-13 deadline. The Department of Health has invested in resources to co-produce implementation packs so that AQP can be implemented as efficiently as possible. Any Qualified Provider is a tool commissioners can use to increase choice for patients, it is not the intention that this will drive up costs for commissioners in priority areas identified in guidance.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

  10. debbie Tomlinson says:

    The question still remains: if one specified and chosen treatment doesn’t improve the condition can the patient be referred to another provider?
    How do you make sure that preferrential treatment is not going to happen as it appears that the GP is going to make the choice where the patient is to receive treatment?In order to stay informed and be clear about the near future I would appreciate more clearity…..
    Many thanks Debbie

    • Hester@DH says:

      Debbie,

      Thank you for your question.

      It is important to note that, under Any Qualified Provider, patients will always have the option to choose which provider they prefer. However, GPs will retain their current role in helping patients navigate the system, and if patients do not want to choose, they may ask their GP to choose for them. More widely, commissioners and the NHS Commissioning Board will be under a duty to promote choice and it will be for commissioners to ensure that their patients are aware of the choices available to them.

      If a patient requires treatment that a provider cannot provide, we would advise that they go back to their GP to discuss their options. It is not for us to say what treatment is right for patients – that’s for them to discuss with their clinician.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

  11. Steve says:

    Is there a ring fence within this service to prevent the funnelling of patients from NHS to private care? If not I would have reservations about the incentives at work.

    How do this groups results compare to those in the following study
    Rheumatology 2010;49:2346–2356

  12. Austin says:

    I am a private physiotherapy provider and would like to find out how to become a provider for the Back and Neck Pain services.

    How do I become registered as an AQP?

    Regards,

    Austin

    • Hester@DH says:

      Dear Austin,

      Thank you for your comment.

      Initially, we are asking commissioners to identify which three or more community or mental health services patients feel they want more choice in – this might include MSK services. In July, we published guidance to the NHS and current and would-be providers of NHS-funded services on how patient choice will be extended from April 2012.

      At the moment, we are developing the qualification process, and more details will be published in the autumn.

      Meanwhile register on the Supply2Health website and look out for opportunities as they will be advertised there.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

  13. Helen says:

    The reality of this is that choice is limited by your GP. My husband was referred to the physiotherapy service provided by the the “group” of GP practices, he was given no choice. What he got was an extended waiting time, could only access 1 venue per week (a gp practice) and a service that didnt meet his needs. The NHS service was provided at a range of venues, offered appoitments 5 days per week, not every patient wishes to go to their gp for limited access but the risk of this is that there is a very definite potential for conflict of interest which i am not assured is/will be managed appropriately.

    • Hester@DH says:

      Thank you for your post, and apologies for the delay in responding.

      When a service is opened up to choice of provider, this means that the patient will have a choice of a number of different types of provider: NHS, independent and voluntary sector providers. The patient would be able to make the decision based on waiting times, appointment availability, venue or information on patient outcomes. You may wish to check our new Any Qualified Provider Resource Centre – nhs.uk/aqpmap – where an interactive map will show you which services your local commissioner has chosen to deliver using this model in 2012-13.

      GP practices can become qualified providers of services, provided appropriate safeguards are in place to ensure that patients have genuine choice, the process followed is fair and transparent; and any potential conflict of interest is managed appropriately.

      The Health and Social Care Bill provides for safeguards to manage potential conflicts of interest where GP practices wish to provide services that are commissioned by clinical commissioning groups.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

  14. Mike Ker says:

    I am a very well qualified remedial massage practitioner and Pilates teacher and feel that I have a huge amount to offer the back pain sufferer. However without HPC registration ( blame the infighting and prevarication of an assortment of Professional Bodies) I presume that I have no chance of being included as an AQP.

    I generally have very good outcomes with chronic back pain and I entirely disagree with Alf, above, that there is no cure for long term musculoskeletal pain. In many instances the basic causes of pain are tight, misused muscles; releasing that tightness and addressing the reasons for the misuse will often resore the quality of life so lacking in sufferers of long term pain. Of course this success depends massively on good patient compliance to change their posture and movement patterns. Ten years ago i was seeing Chiropractors on an almost weekly basis for back pain. After discovering what was wrong with my posture and with the way i was supporting myself and what i needed to do to address these factors I implemented these changes to my movement and posture and haven’t had a treatment since – and I no longer have a bad back. I know that, in many cases, one doesn’t have to live with pain.

    I would dearly love to be able to help many more of those who can’t afford my services to feel the same.

    • Hester@DH says:

      Thank you for your question. Apologies for the delay in responding.

      To find out more about Any Qualified Provider, please visit our Any Qualified Provider Resource Centre on NHS Supply2Health.

      Initially we have asked commissioners to listen locally to patients and select three or more community or mental health services in areas where patients have said they want more choice of provider, this may include musculoskeletal services for back and neck pain. You may wish to consult the implementation pack on NHS Supply2Health which contains an example service specification reflecting national guidance:

      Commissioners will begin to advertise opportunities on NHS Supply2Health soon, which will include service specifications which detail the type of service which the commissioner has decided is right for their local population. Providers can then apply online in response, describing how they will meet the requirements. Potential providers of NHS services will undergo a qualification process, which will ensure that all providers offer safe, good quality care, taking account of the relevant professional standards in clinical services areas.

      We do recognise that, in some cases, providers fall outside the scope of both CQC and professional regulation. Our qualification questionnaire and process will identify and verify these professionals. More information will become available on NHS Supply2Health in due course.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

  15. Kiran Sharma says:

    Hi I am a qualified physiotherapist and have been running my practice for 11 years. I have approached the Heartlands and Solihull Trust to provide a physiotherapy service and work with the NHS but every time I make enquiries I am told something to fob me off. I had a meeting with a key player who said the clinic and what we are doing was exactly what they are looking for as there is a very poor provision of service in our area which is rural. I was told that someone would get back to me but nothing and when I phoned to ask what is going on I was informed they are looking to keep it all uniformed and it looks I’m nudged out of the loop again. Can anyone help and tell me what is the best way to go about this and which person (title) in the Trusts to get in touch with, as I know and feel and have been told we provide an excellent service and I would like to increase the work for my staff but also provide a good quality service to those who would normally not be able to access it.

    Thank you

    Kiran

    • Hester@DH says:

      Thank you for your question. Apologies for the delay in responding.

      To find out more about Any Qualified Provider, please visit our Any Qualified Provider Resource Centre on the NHS Supply2Health website.

      Initially we have asked commissioners to listen locally to patients and select three or more community or mental health services in areas where patients have said they want more choice of provider, this may include physiotherapy. You may wish to contact your local PCT to find out which services they have selected. Alternatively, you may wish to use our interactive map. The map shows the services that will be delivered through Any Qualified Provider locally in 2012-13.

      Commissioners will begin to advertise opportunities on NHS Supply2Health soon and providers can apply online in response. Potential providers of NHS services will undergo a qualification process, which will ensure that all providers offer safe, good quality care, taking account of the relevant professional standards in clinical services areas.

      Regards
      Hester Wadge
      Policy and Briefing Manager, Any Qualified Provider, DH

  16. Pete Moore says:

    Just catching up with comments and have to agree with Alf Collins. This service will promote doctor/therapy shopping. Something similar was tried in South Essex in the mid 90′s. Yes it was a short-lived service with many patients returning to their GP’s saying their pain was worse.

    I do know one of the Chriropractors involved in this service and they told me many of the patients sent to see them need other pain management strategies.

    People with pain, whether back, neck etc just need some encouraging pain management support from there health care professionals.

    Alas looking at the Quality, Innovation, Productivity and Prevention (QIPP) and Reform Plan 2011 – 2015 for North Essex there is no mention of pain within it.

    Who am I. I used to be a doctor/therapy shopper and cost the tax payer around £375,000 in the 90′s. What helped me and other, and what really works? Yes, pain management.