UKSSB Quarterly eBulletin
June 2016





Improving Spinal care Project

Reports from Improving Spinal Care Project workshops held at BritSpine, on Friday 8 April 2016, in Nottingham. The workshop included clinicians and commissioners from around England


How to implement Pathfinder

Workshop summary by lead David Cumming

The key elements identified to help implement pathfinder were:
   Identifying the key stakeholders for the implementation process.
   Identifying the current resource and system, what could be utilised and what changes would be needed to implement.
   Engagement of AQPs is essential. Engagement between private providers in primary care and secondary care providers is essential in any new system.
   Co-commissioning agreements between providers to ensure patients have the best possible care.
   Provider led commissioning may help implementation in certain areas. Block contract with the provider being given the responsibility to organise services.
   Identifying the key people clinically and in commissioning who will be committed to delivering implementation
   Make it someone’s responsibility to implement


Annual spinal care implementation meeting and Governance

Workshop summary by lead Elaine Buchanan

1/ Annual Improving Spinal Care Implementation Meeting

Would be best twice per year initially, possibly funded by relevant CCG
Linked to another meeting: preferably an MDT
? a National Implementation Day before BritSpine 2018.
? Questions were raised about how this would be funded


   Networking opportunity: sharing practice
   Opportunity for problem solving
   Case presentations
   Sharing outputs.

2/ Communication

   Modern Media should be explored
   Target Key Players and link via UKSSB
   Clinical Travel fellowships
   National Network should be developed to share good practice

3/ Governance

Key Performance Indicators
   % Imaging
   Conversion to surgery: Initial benchmark should initially be set as 70% of patients who attend for a surgical opinion should convert to surgery.
   % referred for an emergency opinion.
   Friends and Family Test
   Open reporting of late diagnosed serious pathology

   Training of Triage and Treat Practitioner (TTP) Workshop summary by leads Diarmaid Ferguson, Steven Vogel
Essential role of Triage and Treat Practitioner (TTPs) as pathway gatekeeper of the transition of appropriate patients from primary to secondary care.


Issues and challenges raised by the group

   Cultural change needed by some surgeons to accept TTP’s , to understand and respect the TTPs role and to delegate responsibility on interventions prior to surgical opinion.
   Consultants /MDT must continuously review work to build confidence of the TTP team to develop the ability to cast ‘a surgeon’s eye’ on the clinical presentation/scans.
   TTPs need specific radiological and clinical training and to build over time within a MDT.
   Senior experienced TTP practitioner should mentor less experienced TTP practitioners.
   The surgical team must also make time for regular ( minimum monthly ) MDT meetings with TTPs to discuss clinical/professional issues to develop trust and mutual understanding.
   In order to ensure effective TTPs, surgical teams should be encouraged to develop consistency of surgical opinion and explicit criteria for referral. Intra consultant variability would cause unnecessary challenges for the TTP team as inconsistency will foster doubt in the referral process and affect the confidence of the TTP to act as gatekeeper.
   The group were unsure of appropriate staffing mix-ratio of TTP: surgeons.
   The TTP role should mean surgeons only give opinion on those appropriate for a surgical opinion, ie radicular symptoms and not axial back pain as per new guidance. This should equate to higher consultation conversion rates to surgery.
   It was felt that the TTPs working in the community rather the hospital sites would help de-medicalise the back pain experience for many patients.
   Development of clear guidelines and entry criteria (which may change with the updated NICE guidance ) to the CPP Programme is desirable.

Positive feedback from the group

   TTPs should have the time for biopsychosocial (BPS) interventions and information giving when triaging as surgeons do not have time to do this. Exposure to training in BPS interventions is not felt to be enough to ensure high quality implementation. Continuous mentoring and evidence of BPS fidelity will be key in the effective application of BPS approach.
   Networking between peers and amongst the MDT was seen essential in ensuring consistency in use of the pathway and between clinicians. A senior TTP could take responsibility for new members of the TTP team to help ensure this.
   All primary care access to surgeons should be made via the TTP team (apart from patients with clear red flags); this will enhance the status of the TTP’s gatekeeper role. Surgeons should have confidence to send inappropriate referrals back to the appropriate pathway – be brave and positive in actions.


Regional Spinal Networks project and Specialised Spinal Services (Ashley Cole)

Summary by Ashley Cole

   Regional Spinal Networks
The concept of Regional Spinal Networks was presented at Britspine and thanks to all those who visited the NHS England stand. For those who want further information please contact d.waddingham@nhs.net or for more information about any clinical issues ashcole9@gmail.com. Please view the Regional Spinal Network template.

   Complex Spinal Surgery Clinical Reference Groups
All the CRGs were disbanded at the end of April and after consultation, NHSE is restructuring and reducing the number of CRGs. Spinal Surgery and Spinal Cord Injury CRGs have been merged to form the Spinal Services CRG. The position of CRG Chair (1 PA allocated) and the 8 Regional Advisors (voluntary posts funded by local Trust) are in the process of appointment.
There has been no official information given to the current CRG but we understand that members will lead on:
   Research priorities through the National Institute for Health Research (NIHR)
   Data and tariff with the Health and Social Care Information Centre (HSCIC) and NHS Improvement
   Liaison with NICE
   Commissioning for Value
For those who have queries, please contact ashcole9@gmail.com for further information.

   Orthopaedic Expert Working Group (EWG)
The Orthopaedic EWG meets to consider applications for new OPCS codes and putting OPCS (procedure) and ICD-10 (diagnosis) codes into Healthcare Resource Groups (HRGs) of equal resource for tariff allocation. The group met with Monitor on 4 May to consider 2016/17 pricing for Orthopaedics and Spine.

Related Matters

National Audit Office (NAO) finds lack of strategy for specialised services
The National Audit Office (NAO) recently published a report on specialised services commissioned by NHS England. The report finds that NHS England still does not have an overarching strategy for commissioning specialised services despite taking on the responsibility three years ago.
The NAO warns that any overspend on specialised services will affect NHS England's ability to resource services such as primary care and non-specialised hospital and community services. The report highlights that the budget for NHS specialised services rose by 6.3% per year on average, from £13 billion in 2013/14 to £14.6 billion in 2015/16, compared to 3.5% per year on average for the entire NHS budget. Concerns are expressed around NHS England keeping within its budget for 2016/17, despite an increase of 7%.
Pressures on specialised services are identified as growth in costly new drugs and increasing demand for specialised services. The NAO warns that in attempting to control costs by reducing the tariff on these services, NHS providers’ financial sustainability may have been affected. NHS England is found to not have consistent information from providers on costs, access to services and outcomes, or the efficiency of service delivery.