Patients with musculoskeletal problems are waiting over six weeks for physiotherapy in more than half of England’s primary care trusts (PCTs), despite evidence that the propensity for back pain patients to return to work falls rapidly after four to six weeks.
Freedom of Information requests made by Health Insurance, responded to by 123 out of 152 PCTs, have uncovered that nine have waits of over 18 weeks for physiotherapy to treat back pain and other musculoskeletal conditions. Over a quarter (36) reported waits of over three months.
The survey highlights the extent of variation in the provision of services across the country, with over 40% (54) of PCTs offering physiotherapy in less than six weeks and five reporting waits of less than two weeks.
GP referrals for physiotherapy are not currently included in the government’s target of a maximum 18 week wait from referral to hospital treatment.
A recent government-commissioned report on the health of the UK’s workforce warned that delays in intervention for people with back pain come at a heavy price. Dame Carol Black’s Working for a Healthier Tomorrow states that by the time physiotherapy has begun, patients may be unable to return to work for a multitude of reasons, including mental health problems.
Back problems are the second most common cause of sickness absence for UK manual workers and are within the top five causes across all businesses. The condition costs nearly five million working days a year in the UK.
It has been estimated that 1.6 million adults suffer from chronic back pain, at a cost to the economy of £12.3bn a year.
THE QUESTION WE PUT TO ENGLAND’S PRIMARY CARE TRUSTS
We asked England’s 152 primary care trusts – the organisations which hold NHS budgets at a local level and commission services – the following question under the Freedom of Information Act. A total of 123 responded. We asked: What is the waiting time for physiotherapy for treatment of back pain and other musculoskeletal conditions?
DR GORDON PARKER from the Society of Occupational Medicine said: “Occupational health specialists are very clear that early assessment of musculoskeletal conditions, and early referral for appropriate treatment, significantly reduces time lost from work and the financial burden on employers and individuals.
“Employers who provide access to physiotherapy through their occupational health services see real benefits. For example, the Worthing and Southlands Hospitals NHS Trust Occupational Health Physiotherapy Service achieved a reduction in sickness absence for musculoskeletal disorders of 25% in the first six months.
“In Doncaster and Bassetlaw Hospitals NHS Trust, a similar scheme produced significant benefits, including 64% of staff reporting that accessing the service had prevented them from taking time off work.”
SUE HAYWARD GILES, assistant director of practice and development at the Chartered Society of Physiotherapy, said:
“We know that waiting times are variable. Some patients [who wait for a long time] will find a private or independent provider or another professional; some patients will not need physio after so long or won’t be motivated to come into the service; some patients will deteriorate and the problem becomes more acute or more chronic and will take longer to resolve – drugs bills increase and GP time increases.”
PROFESSOR MIKE O’DONNELL, chief medical office at disability insurer Unum, said:“If you are sitting there, waiting for treatment, prevented from treatment, it becomes demoralising. You are going to become much more set in your ways. With back pain it’s the same as with mental health – the longer you are off sick the harder it is to go back to work. People have less than a 50% chance of ever getting back to work if off work for more than six months.”
PHYSIOTHERAPY: THE CHALLENGE FOR INSURERS
Physiotherapy is not just a problem for the NHS. Private medical insurers (PMI) have consistently battled with managing a relatively high number of claims. When Aviva launched its Back-Up proposition(see box right), 8% of its overall claims were for back pain. The challenge lies in determining the cause of musculoskeletal conditions which may not be physiological but the result of a complex interplay of psychosocial factors. Furthermore, tensions have arisen between providers of physiotherapy services and insurers who are keen to exert greater control over the flow of patients into this form of intervention.
WHAT IS THE RECOMMENDED TREATMENT FOR BACK PAIN?
The National Institute for Health and Clinical Excellence guidelines on the management of persistent or recurrent low back pain focus on helping people to self-manage the condition through the provision of support and information. Treatment options recommended include exercise programmes, a course of manual therapy or, controversially, a course of acupuncture.
Referral for a combined physical and psychological treatment programme comprising around 100 hours over a maximum of eight weeks should be considered for patients who have already received at least one less intensive treatment and who have a high disability and / or significant psychological distress.
AN INSURER’S APPROACH: SELF-REFERRAL
CIGNA HealthCare has recently announced that members will be able to self-refer for physiothearpy to Nuffield Health. The new benefit will mean that members do not have to wait for a GP referral before accessing treatment. Nuffield Health has more than 450 physiotherapy facilities throughout the UK.
Kirsty Jagielko (pictured), head of product management at CIGNA, said that some PCTs had already started using the self-referral model and that the gatekeeper model was now starting to be perceived as “old-fashioned”. One corporate client who has had the benefit in place for 18 months has seen the number of physiotherapy sessions halved.
Members contact a CIGNA nurse who will perform a triage over the phone and can then authorise an initial assessment and a maximum of three further sessions of physiotherapy. This can be arranged immediately. If more sessions are required a Nuffield physiotherapist will contact a CIGNA case manager to discuss the treatment plan.
However, Dr Albert Ferrante MB BS MRCS FRCP (UK), senior partner at occupational health provider Blossoms Healthcare LLP, challenged the self-referral model as “a dangerous move”.
He said: “Physiotherapy should be prescribed by the only group of people trained to diagnose conditions, which are doctors. Nurses aren’t trained to diagnose or physiotherapists. We are muddying waters here.
“If you have decided on a treatment process there is no reason to wait at all. There is no such thing as delayed physiotherapy.”
AN INSURER’S APPROACH: NETWORKS
Bupa launched a national network of more than 3,000 physiotherapy providers in July this year. It was fiercely opposed by physiotherapists who claimed it was a cost-cutting measure that would reduce patient choice.
However, Bupa claimed its review of physiotherapy services prior to the launch highlighted a variation of more than 200% in the cost of a physiotherapy session and that treatment was not always delivered consistently, with a significant difference in the number of physiotherapy sessions received by Bupa insured customers with similar conditions – varying from one to 16. It claimed this led to over-treatment in some instances and by introducing the network it would reduce the average cost of physiotherapy treatment by up to 10% over the next couple of years.
AN INSURER’S APPROACH: CASE MANAGEMENT
Aviva’s Back-Up service is based on a model of early intervention and a shift away from the traditional private medical insurance approach of treating back and neck pain as a high volume, low cost condition. Every member who contacts Aviva with a back problem is referred to a clinical case manager who will offer advice, support and, if necessary, referral to treatment. A personal rehabilitation plan is devised, based on the stepped care model, where the least intensive intervention is recommended at each stage. With the employee’s consent, the case manager can also work with their line manager to advise how the employee can be helped safely and effectively at work.
When trialled on Aviva’s own staff, physiotherapy sessions were reduced by 37.5% while 50% of employees said the service prevented them from going absent or restricting their duties. Of the 25% who were absent prior to using the service, 100% successfully returned to work through Back-Up.
MUSCULOSKELETAL PROBLEMS IN NUMBERS
|Musculoskeletal disorders are the most prevalent of the major diseases in the UK working population|
|There were 6.5 million cases in the working age population in 2008|
|Musculoskeletal disorders were the cause of 8.8 million annual working days lost in 2007/8|
|They cost employers £820m a year and society £7.7 bn|
|Low back pain affects 38% of adults in any one year of whom one in four experience significant disability|
|There is a 20% risk of long term disability for those off work for four to six weeks|
|Musculoskeletal disorders account for 49% of sickness absence from work, a higher proportion than any other condition, and cost the UK economy £7bn each year|
|Sources: Bupa Healthy Work report, 2009; Labour Force Survey, Health and Safety Executive; Office of Population Censuses and Surveys Social Survey Division; Waddell, G. The clinical course of back pain; The Work Foundation|