“The STarT Back tool represents a high-value tool – this is what we need more of in the NHS.”

Sir Muir Gray, Department of Health

What was the problem?

Back pain is the most common reason why middle-aged people visit their GP, representing an estimated annual cost of £4.2 billion to the NHS. It is the second most common reason for sickness absence from work, and for persistent disability and work loss in the under 65s.

Current approaches mean that a substantial proportion of patients are over-treated, while a significant number fail to get the right care. Current guidelines promote a ‘one size fits all’ approach where, after the small minority of patients with potentially serious causes for their pain have been identified, the rest are managed as a single group under the label of ‘non-specific low back pain’.

While most cases of back pain resolve regardless of the course of therapy, some do not get better no matter what is done. Current treatment approaches therefore mean that a substantial proportion of back pain patients are over-treated in the NHS, while a significant number fail to get the right treatment and go on to suffer long term pain and disability.

What we did and why

The challenge for practitioners, patients and policy-makers is to be able to classify back pain patients according to their risk of persistent pain, and then to target them to appropriate matched treatments.

STarT Back provides an example of stratified care for low back pain, where patients are screened for risk of chronicity. The STarT Back prognostic screening tool places patients with back pain into three risk groups (low, medium or high chance of persistent disabling problems). Matched pathways are put in place to target the right treatment to the right patient.

The West Midlands AHSN (WMAHSN) supported the wider adoption of STarT Back, where patients are screened for risk of chronicity and placed into three risk groups, with matched pathways to target the right treatment to the right patient.

STarT Back improves clinical outcomes, patient satisfaction and care pathways. It reduces disability, sickness absence, physiotherapy waiting times, GP consultations and referrals to secondary care and for imaging, saving £34 per patient and £675 in costs to society.

Currently, more than 18 community physiotherapy services across the UK have adopted STarT Back, with CCGs across England and health services worldwide adopting the tool. Three clusters of West Midlands GP practices with care pathways linked to physiotherapy centres are being identified as participants. New care pathways are being negotiated with local CCGs and provider trusts to support the roll out of this approach.

Through WMAHSN support, the STarT Back screening tool is being embedded into GP clinical systems so that it will ’pop-up’ each time someone consults with back pain.

WMAHSN supports unlocking barriers by creating the capacity for change management, establishing networks for NHS colleagues, releasing funding for training in the STarT Back approaches and developing IT solutions to support implementation. WMAHSN gave practical assistance to ensure that innovation was in place, and has supported the roll out of STarT Back in NHS clusters across the region, facilitated by local clinical champions and managers and knowledge mobilisation/ change agents from Keele University’s Institute of Primary Care and Health Sciences.

WMAHSN 36pp

Which national priorities does this work address?

  • NHS support to help people get and stay in employment
  • Out-of-hospital care needs
  • Patient integrated services
  • Faster learning from best practice
  • Evaluating new care models
  • Helping patients get the right care, at the right time, in the right place
  • A strengthened clinical triage and advice service

Results

  • STarT Back improves clinical outcomes, reduces back pain disability, improves patient satisfaction and improves care pathways.
  • STarT Back reduces sickness absence, physiotherapy wait times, GP consultations, referrals to secondary care and referrals for imaging.
  • STarT Back is cost-effective, saving £34 per patient and £675 in costs to wider society.
  • WMAHSN support means that more than 18 community physiotherapy services across the UK have adopted the STarT Back approach for the treatment of low back pain, in addition to the 28 services that signed up to the STarT Back website.
  • Clinical commissioning groups across the UK are also adopting this approach, including North Staffordshire, Stoke-on-Trent, Southend, Derby, Devon, Scotland, Cheshire and Sheffield.
  • The STarT Back tool has been translated into 12 languages.
  • Through raising the profile of STarT Back, the programme team is now actively working with services overseas that are adopting the stratified care approach for back pain, including in Australia, Denmark, Canada and the USA.
    • InterMountain Healthcare has implemented this for use in Utah and Idaho across 22 hospitals and 185 clinics.
    • Fair View Healthcare has integrated STarT Back into their electronic patient record and across their services in Minnesota, and is collaborating with Group Health Co-operative which has implemented the STarT Back approach in Seattle.
    • In Canada, the Ontario government and the Centre for Effective Clinical Practice has adopted the STarT Back approach into their guidelines.
    • In Denmark the government has approved the training of 1000 physiotherapists using translated versions of the training materials.
  • STarT Back has been adopted into several high quality clinical care pathways, including Allied Health Professional Musculoskeletal toolkit, Map of Medicine and the Royal College of General Practitioners’ e-learning module.

“As a GP, the most important thing for me when looking at a new treatment approach is whether there are benefits for patients. In the case of STarT Back, it was very clear that patient outcomes are improved, but also there is more efficient use of resources. In particular, I was attracted by the fact that it helps me decide which patients I refer, and those that I can confidently manage myself in primary care.”
Dr Simon Somerville, GP and Researcher

Tips for implementation

  • A short film has been commissioned to summarise the findings and to assist implementation.
  • The programmes has trained trainers to cascade stratified care for back pain.

Next steps and spread

  • Further clusters of West Midlands GP practices with care pathways linked to physiotherapy centres are being identified as participants.
  • WMAHSN is funding project management and implementation/ clinical expertise to support the engagement and training of healthcare professionals to adopt a stratified care approach to managing back pain.
  • New care pathways are being negotiated with local clinical commissioning groups and provider trusts to support the roll out of this approach.
  • The implementation team are working with proprietors of GP computerised systems to embed the STarT Back screening tool into the GP clinical systems. This will mean that the STarT Back tool will ’pop-up’ each time someone consults with back pain. AHSN funding is supporting this change management and the related training activity.
  • To establish clinical champions to support the change management process within local areas.
  • To develop resources to support healthcare practitioners/ commissioners in adopting stratified care for low back pain.
  • To support evaluation of the impact of this implementation programme in the NHS.

Find out more

Visit the West Midlands AHSN website.

Contact for help and advice

Rhian Hughes, Director at Keele University
r.w.hughes@keele.ac.uk
0121 371 8061

Sarah Millard, Head of Communications and Engagement WMAHSN
sarah.millard@wmahsn.org
0121 371 8058

Programme duration: November 2011 – present