Rehabilitation 2014

Functional Restoration

Creation of the CCGs will bring opportunities for new services

and new providers

Early intervention leadsto reduced costsand strong RoI

Getting NHS Spinal Services ‘back on track’

NHS now recognisesthe need for Trauma

Rehabilitation services

MSK costs the economy£9-12 billion each year

Rehabilitation; the ‘perfect storm’

Employers have a growing ‘health & wellbeing’ agenda

NHS Restructuring

NHS Restructuring

Liability InsuranceLiability

Insurance

The cost of Back Pain

The cost of Back Pain

Trauma Injury RehabilitationTrauma Injury Rehabilitation

Corporate employeesCorporate employees

DWP BenefitsDWP Benefits

Health Services

HealthCare Funding

Welfare State Budget 2014

Total£302 billion

£154 billion

£106 billion

Acute Trustsand CCGs

£98 billion

Three National Clinical Directors advising on Rehabilitation and MSK outcomes

These NCDs were appointed in March 2013 The world-famous

Headley Court

NHS now focused on

outcomes not outputs

Each year, over 300 thousand people go on to sickness benefits

Every year 140 million working days are lost to sickness absence, much of which ends in a swift return to work. However, a significant number of absences last longer than they need to and each year over 300,000 people fall out of work

onto health-related state benefits. Before reaching this point, many have been long-term sick off work

[Dame Carol Black and David Frost CBE:Health at Work – an independent review of Sickness Absence, November 2011 ]

Management Intervention?

HR Intervention?

‘Normal’Absence record

Bradford Score = Total days absent x (Number of absences)2

eg: a Score of 300 = 12 x 52

RehabilitationIntervention?

Health & Work Service from late 2014: early intervention is key

Sickness Absence

reduction

Independent Assessment

Service

Tax relief on Vocational

Rehabilitation

Abolition of

Payment Threshold Scheme

Public Sector:

Review of Sick Pay

Job Brokering

Service

Changes to Employment and Support Allowance

Government accepted Dame Carol Black recommendations, December 2012

MOTOR; 0

ACCIDENT & HEALTH; 0

PROPERTY; 0

GENERAL LIABILITY; 0PECUNIARY LOSS; 0

Each year in the UK there are as many as 250,000 motor vehicle crashes which result

in some degree of whiplash neck injury. £8.8 million was paid to customers each day for accident & health claims, in total costing

£3.3 billion in 2013[ABI Report: UK Insurance, Key Facts]

Total insurance premiums of £31 billion in UK in 2013

“Day in and day out, we see the benefits of early access to rehabilitation. [This

report] demonstrates how vital it is that everyone has access to quality care as early

as possible in their recovery. It’s good for the patients, and it’s good for the NHS.”[Colin Ettinger; Partner, Irwin Mitchell,

Claims Solicitors]

Early intervention is now recognised by the Insurance

industry as the key enabler of recovery and return to work

Cost model Inflation 4%        Year 1 Year 2 Year 3 Year 4 Year 5  

No intervention by Spring  

  Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4  

Support costs  

Clinical-initial £2,000  

Clinical-MRI/Surgery £487 £12,979  

Physiotherapy and CBT £1,500 £1,515 £1,530 £1,545 £1,561 £1,577 £1,687  

Case Manager £2,700 £1,515 £1,530 £1,545 £1,561 £1,577 £1,592 £1,608 £1,624 £1,641 £1,657 £1,674 £1,690 £1,707 £1,724 £1,741 £1,759 £1,776 £1,794 

Vocational Rehab £6,083  

Other  

   

Insurance  

Accident compensation £30,416 

"Loss of Earnings" £3,750 £3,788 £3,825 £3,864 £3,902 £3,941 £3,981 £4,021 £4,061 £4,101 £4,142 £4,184 £4,226 £4,268 £4,311 £4,354 £4,397 £4,441 £4,486 £36,243 

Internal administration £63 £63 £64 £64 £65 £66 £66 £67 £68 £68 £69 £70 £70 £71 £72 £73 £73 £74 £75 £76 

Other        Totals £5,813 £8,051 £6,919 £6,988 £7,058 £7,129 £7,200 £5,680 £6,223 £18,773 £7,539 £5,910 £5,970 £6,029 £6,090 £6,150 £6,212 £12,357 £6,337 £68,529 £210,957

        Year 1 Year 2 Year 3 Year 4 Year 5  

Intervention by Spring  

  Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4  

Support costs  

Clinical-initial £2,000 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 

Clinical-later £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 

Physiotherapy £0 £1,500  

Case Manager £0 £2,700 £1,515 £1,530  

Vocational Rehab £0 £0 £0  

Other £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 

  £0  

Insurance £0  

Accident compensation £0 £0 £0 £0 £0 £0 £0 £27,040 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0  

"Loss of Earnings" £3,750 £3,788 £3,825 £3,864 £3,902 £3,941 £3,981 £4,021  

Internal administration £63 £63 £64 £64 £65 £66 £66 £67  

Other  

   

Spring  

Assessment fee £750  

3-week programme £9,250  

Follow-up cm £750  

Vocational input £3,500  

On-going conditioning £900        Totals £5,813 £8,051 £15,404 £10,608 £3,967 £4,007 £4,047 £31,128 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £83,024

Return on Investment

RoI 11.90to 1

Reduction in costs 61%

Return on Investment > 10:1

Cost benefit modelling shows Rehabilitation achieves excellent R0I for Insurers

Spinal surgery

Rehabilitation

Significant cost and time savings

Rehab £83k; Surgery £210k; Rehab 24 mths; Surgery 60 mths

NHS has proposed a new pathwayand prescription

for trauma rehabilitation services...

...and a new way of paying for them,combining NHS and Local Government

funding

“It is wrong to assume that specialist rehabilitation techniques will be carried out

on a general orthopaedic or surgical ward in a district general hospital...”

[Professor Keith Willett, National Clinical Director for Trauma Care]

22 major trauma centres in England have been named

Back Pain affects over one third of the population in UK

7.8 million people in the UK suffer moderate to severe pain that has lasted for more than six months. It is estimated that those in chronic pain consult their doctor up to five times more frequently than others. This equates to almost

5 million GP appointments a year.Calculating the cost of chronic pain to the economy is difficult, but an estimate of

the cost of back pain alone is around £12.3 billion per year.

[Dame Carol Black “Working for a Healthier Tomorrow” 2008]

32 9 3 4 3 10 9 0.5 3 8 3 11 4 7

Health Services£106 billion pa

Burden of diseasesof modern lifestyle

Musculoskeletal

Local(CCG) Budgets£65 billion pa

Central Budgets£32 billion pa

Budgets are now largely controlled by GPs

There are many providers of MSK rehabilitation services in the healthcare sector

In 2012, approx 5% of all NHS services were outsourced to the private sector. This is expected to at least double over the next few years, to approx £10 billion pa, and 40-50% of this will be for MSK services

£4.5 billion pamarket

“NON- SPECIFIC SPINAL PAIN: Commissioners should ensure a properly

constructed Combined Physical and Psychological programme is commissioned (Fig 4.1 box 3). This is the most serious gap in current services and should be urgently

addressed. The type of programme recommended by NICE is available in their

guideline CG88” [Department of Health

Spinal Task Force, Dec 2012]

NHS Spinal Task Force recommends CPPs as safety net before surgery

Keele STarT Back assessment tool

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Pre Programme Activity

• Administering measures to complete before attendance on workshop via email/ post

• Collating these and scoring • Development of a personal profile for each participant for use

within the workshop activities- indicating areas for development of psychological strategies

Overview of programme components on a [Spring Active] high intensity CPP or Functional Restoration Programme

Staffing of programme includes:

Consultant in Rehabilitation Medicine Chartered Physiotherapist Exercise and Rehabilitation Therapist Vocational Psychologist Occupational Therapist Clinical Psychologist

Overview of the programme staffing

“A CPP is an intensive multidisciplinary programme,

based principally on group exercise therapy, with a strong input of cognitive behavioural therapy, and some input from

other specialities”

[NICE Guideline CG88/2009]

Overview of a [Spring Active] high intensity CPP programme

A typical Spring Active HI CPP is: Psychologist-led 10 to 15 days, residential, Monday to Friday client-centred

The programme includes: group exercise and individual therapy strengthening and mobilising activity personalised exercise prescription cognitive behavioural therapy recreational therapy group hydrotherapy coping strategies for the management of pain self-management techniques lifestyle education and ability awareness stress and relaxation techniques functional activity training work conditioning appropriate to need

“High Intensity CPP: these are typically multidisciplinary and

high intensity, may be psychologically led, and

delivered over 40 hours or more. In CG88/2009, NICE found the

best evidence was for programmes of at least 100

hours exposure.”

[NICE Guidelines CG88/2009]

Objective of a High Intensity CPP FRP

The objective of a High Intensity CPP Functional Restoration Programme is the restoration of physical function though

targeted increases in physical performance, and passing the locus of control back to the patient.

Further, it is to equip them with sufficient confidence, knowledge, pain relief, and commitment, to accept

responsibility for the ongoing management of their condition.

Psychological Workshops

Workshop 1 - What can I do?: Exploring your Self Efficacy• What is Self Efficacy and why is it important? • Examining different self efficacy beliefs (High & Low)• Interpretation of personal profile (Self Efficacy scores) • Identification of barriers to Self Efficacy • Looking at areas for development

Workshop 2 - Can I do More?: Developing Self Efficacy – Tools & Techniques• CBT Based • Identifying “unhelpful” thought patterns that reduce self efficacy beliefs • Challenging and rebalancing • Reinforcing positive thought processes that build self efficacy • Building Self Confidence & Self Esteem • Job Seeking Self Efficacy (if Relevant) • Revisiting Barriers indentified in Workshop 1 – looking how can overcome these

using techniques discussed

Workshop 3 - Is it out of my hands: Exploring your Locus of Control • What is locus of Control • Internal Vs External Locus – What do these look like • How does this affect Self Efficacy beliefs • Exploring your own locus of control (taken from personal profile) • What does this mean to the way we tackle difficult events • How can this be developed? • Revisiting Barriers Identified from Workshop 1

Workshop 4 - Next Steps • Revisiting Personal Profile • Looking at Barriers Identified – progress • Formulation of Next Steps • Repeat questionnaires completed at onset (Compare with baseline measures)

Psychological Workshops (2)

Type of individual who might benefit from 1-week FRP ‘Foundation’ Programme

For ‘Foundation’ FRP, consider deep seated impact and combination of:

• extended absence from employment• considerable time lapse since injury• involvement in litigation• anxiety/ psychological difficulty• complex social difficulties/ heavy reliance on others• significant state of physical deconditioning• use of walking aids/impaired mobility• multiple MSK trauma• markedly reduced self confidence and low self esteem• unhelpful self belief patterns of behaviour• very high scoring psychosocial flags screening

BSRM Basket of recommended outcome measures

Page | 7

1.3.What is a health state?Each of the 5 dimensions comprising the EQ-5D descriptive system is divided into 3 levels of perceived

problems:

Level 1: indicating no problem

Level 2: indicating some problems

Level 3: indicating extreme problems

A unique health state is defined by combining 1 level from each of the 5 dimensions.

A total of 243 possible health states is defined in this way. Each state is referred to in terms of a 5 digit code.

For example, state 11111 indicates no problems on any of the 5 dimensions, while state 11223 indicates no

problems with mobility and self care, some problems with performing usual activities, moderate pain or

discomfort and extreme anxiety or depression.

Note: Two further states (unconscious and death) are included in the full set of 245 EQ-5D health states, but

information on these states is not collected via self-report.

Mobility

Self-Care

UsualActivities

Pain /Discomfort

Anxiety /Depression

HealthState

Page | 9

3. Scoring the EQ VAS

The EQ VAS should be scored as follows:

To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0.

We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today.

Y o u r o w nh e a lt h s t a t e

to d a y

B e s t im a g in a b le h e a lt h s ta te

W o r s t im a g in a b le h e a l th s t a t e

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To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0.

We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today.

Y o u r o w nh e a lt h s t a t e

to d a y

B e s t im a g in a b le h e a lt h s ta te

W o r s t im a g in a b le h e a l th s t a t e

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For example this response should be coded as 77

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Even though the line does not cross the VAS this response can still be scored by drawing a horizontal line from the end point of the response to the VAS. In this example the response should be coded as 77

NB: Missing values should be coded as ‘999’.

NB: Ambiguous values (e.g. the line crosses the VAS twice) should be treated as missing values.

EuroQol group: EQ-5D and EQ VASQuestionnaires

Page | 15

Table 5: EQ-5D-3L index values before and after treatment

EQ-Index Before treatment After treatment

Mean 0,59 0,76

- Std error 0,012 0,015

Median 0,60 0,70

- 25th 0,50 0,65- 75th 0,70 0,80

N 120 110

Table 6: EQ-5D-3L index values for the total patient population and the 3 subgroups

EQ-Index All patients Subgroup 1 Subgroup 2 Subgroup 3

Mean 0,66 0,45 0,55 0,90

- Std error 0,010 0,013 0,015 0,010

Median 0,55 0,40 0,55 0,95

- 25th 0,50 0,30 0,50 0,80

- 75th 0,70 0,50 0,60 1,00

N 300 100 75 125

Figure 4: EQ-5D-3L index values before and after treatment: mean values and 95% confidence intervals

Figure 5: Mean EQ-5D-3L index values and 95% confidence intervals for the total patient population and 3

subgroups.

Page | 15

Table 5: EQ-5D-3L index values before and after treatment

EQ-Index Before treatment After treatment

Mean 0,59 0,76

- Std error 0,012 0,015

Median 0,60 0,70

- 25th 0,50 0,65- 75th 0,70 0,80

N 120 110

Table 6: EQ-5D-3L index values for the total patient population and the 3 subgroups

EQ-Index All patients Subgroup 1 Subgroup 2 Subgroup 3

Mean 0,66 0,45 0,55 0,90

- Std error 0,010 0,013 0,015 0,010

Median 0,55 0,40 0,55 0,95

- 25th 0,50 0,30 0,50 0,80

- 75th 0,70 0,50 0,60 1,00

N 300 100 75 125

Figure 4: EQ-5D-3L index values before and after treatment: mean values and 95% confidence intervals

Figure 5: Mean EQ-5D-3L index values and 95% confidence intervals for the total patient population and 3

subgroups.

EuroQol group: EQ-5D index

Group Average Reduction of BORG Pain Scale Group Average Reduction of Patient Health Questionnaire (PHQ-9)

Group Average Reduction of Generalised Anxiety Disorder Questionnaire (GAD-7)

Group Average Reduction of Oswestry Low Back PainDisability Questionnaire

Group Outcomes

Postscript

John Galsworthy, 1918

“A niche of usefulness and self respect exists for everyone, however

handicapped, but that niche must be found for them. To carry the process

of restoration to a point short of this is to leave the cathedral without a

spire.”