It’s time to talk. What have we lost in the race to manage capacity and throughput?
I don’t have to repeat the stats. We’re spending more and more on the assessment, treatment and management of musculoskeletal (MSK) pains. We’re doing more scans, more innovative investigations, more new treatment ideas, more new ways to surgically improve our moving parts.
And all this spending and brainpower is having a good result? Is MSK care timely, appropriate and effective? Unfortunately, not. It doesn’t look like we have done, or are doing, a good job. Disability and costs climb in unison with the efforts to deal with the problem.
It’s difficult to tease out the correlations from the causations here but one thing is clear: we need to consider changing the paradigm we’re operating under. More of the same is not working.
Most consultations for pain in the UK occur with a GP and the average time spent in that appointment is seven to ten minutes.
Is seven to ten minutes enough? Well, that depends on what you are aiming to achieve. A doctor’s role is diagnosis and the diagnostic model has been astonishingly successful at keeping us alive against a number of challenges.
What’s the Diagnostic Question in a Spinal Assessment?
There are two questions here, both relatively quick to answer:
- Does the patient have a medically important condition and need treatment or referral to a specialist? This group is smaller than 5% in number and includes many medical conditions including inflammatory arthritis, infections and tumours.
- Does the patient have a specific spinal-related condition? This is again fewer than 5% in numbers and includes nerve root impingements and spinal stenosis.
Once those diagnostic questions have been answered by a doctor, there is little more to do under the diagnostic model. The patient has back pain or neck pain. Chasing after a closer diagnosis reaps diminishing returns as it has little or no effect on the choice of treatment given to that person.
This group makes up 85-90% of spinal pain sufferers, yet we concentrate on the specific conditions such as cauda equina which, although very important to identify, make up a very small part of the whole.
What Should We Assess in Spinal Pain?
Physiotherapists and doctors love the hard stuff. The stuff we can feel, the muscles we can test, the reflexes we can elicit, the movements and images we can see.
However, the aspects of a person which relate to severity of disability, likelihood of recovery and return to normality are all psychosocial. No physical parameter makes much difference unless it is severe in nature.
We assess spinal patients using the measures that don’t have relevance to their recovery. Yes, they’re quick and once you’ve learnt the techniques, not that difficult. You learn how to handle a patient as a physiotherapist, that’s what we do.
The Driving Forces Behind Musculoskeletal (MSK) Management
What drives MSK management across the country is numbers and capacity. The steadily increasing demand for help with back, neck and other pains puts continual pressure on NHS systems to cope with the numbers.
New initiatives invariably revolve around how to get larger numbers through the gate, how to reach targets so that this percentage of patients is catered for in that amount of time. Success is throughput.
Physiotherapy assessment times have traditionally varied from 30 minutes to an hour. In response to pressures new times have been suggested: 15 minutes or 20 minutes to assess, form a plan, record this and send the patient on his or her way. These look like responses to pressure rather than reasoned approaches. At these times our input becomes diagnostic rather than therapeutic.
What this all misses, and what questions the validity of the entire process, is any mention of outcome, any focus on whether the patient is better or not, any indication that the assessment and treatment have been successful. Even a 60-minute assessment is all very well, but what was the result in the patient’s life?
Upstream vs Downstream Costs
Musculoskeletal care is expensive. But we do have a choice about the amount, the timing and how much we can control those expenses.
At present, we do cheap MSK care upstream, closer to the initial presentation. A short GP consultation establishes the presence of non-serious back pain, a short course of 30-minute sessions of physiotherapy attempts to improve things.
A number of patients will resolve or not re-consult, but those who continue to request help begin to go towards secondary care. More expert physiotherapy, MRI scans, spinal injections, orthopaedic opinions and surgery are possibilities.
This process is much less controllable and, added to the costs in suffering, work loss and benefits paid, makes up the greatest proportion spent on this group of patients. Here are the uncontrolled, and at present mostly uncontrollable, downstream costs.
Assessment Takes Time & Can’t Be Rushed
If we are to assess the psychosocial parameters of relevance to a person’s spinal pain, it’s going to take time. Quite a lot of it. An hour to start with to tell their story and feel that they have been heard.
“No-one listened. No-one understood” are common themes from patients who go through the system. There is no substitute for extending the time to find what is driving the patient’s symptoms if we are going to have any effect.
By investing in upstream time we can target three main aims:
- We can find and address the drivers of a patient’s pain
- We can measure their outcomes to see if we’re doing anything useful
- We can try to limit the uncontrollable downstream costs.
This should lead towards what is lacking from present spinal care, effectiveness. Without a measure of effectiveness, all our targets, capacity and throughput have no meaning.