Headache Pathway Case for Change

Transcription

1 Headache Pathway Case for Change November 2017

2 Table of Contents Executive summary... 3 Background... 4 Introduction... 5 Epidemiology of headache... 5 National strategic context and drivers for change... 6 Local Strategic Context... 7 The vision for Headache management Improvement in primary care recognition of primary headaches including migraine and medication overuse headache Specialist triage of referrals Development of a community headache clinic Cost savings Cost of the new service in your area Summary... 19

3 1 Executive summary There are significant opportunities for the patient, the NHS, and the economy through the improvement of the management of headache. England has one of the lowest ratios of neurologists per population and case numbers are rising so it is imperative that their time is used for the maximum value to the patient. This Case for Change alongside a short summary document and a presentation forms part of a pack for commissioners which provides detailed information to help consideration of the development of a community headache pathway. This Case for Change has been developed by assessing the current situation in Oxfordshire but the methodology for consideration can be replicated in any area and the document includes links to specific CCG data sets which are useful when a CCG develops their own case. Oxfordshire CCG have undertaken a pilot and subsequent audit of the proposed pathway and have plans to move to the new service in early Current management of primary headache disorders and the challenges that are being faced are described along with future projections and detail of the local and national drivers for change. This document outlines a number of opportunities for improvement in the way that headaches can be managed in order to deliver the benefits listed below: Improved patient experiences and health outcomes Care provided more appropriately Reduced health system costs and pressures on the acute sector Care closer to home improving patient experience and reducing inequality Improved access times to health services Better, more efficient use of the limited resources of the NHS Reduced costs to the NHS through inappropriate or delayed care Reduced burden of disability and social care costs Reduced variation 3 of 17

4 2 Background The following key points highlight why focus on the headache pathway is important. Headache accounts for 33% of all new referrals to neurology although the majority of cases can be treated in primary care. It is the most common neurological reason for A&E attendance, and A&E admissions for headache have continued to increase steadily. i In the year 2013/14 there were 17.4m A and E attendances in England for headache, resulting in emergency admissions, were for migraine It is estimated that 4% of primary care consultations are related to headaches Improved community care for neurological conditions can improve care coordination for the individual, optimise self-management and focus specific resources on those with the greatest need Data on hospital activity related to headache shows a steady increase in activity between The system is overstretched and the increase in neurology referrals is causing pressure on outpatient clinics and patient delays. Numbers of neurologists are at critical levels in many parts of England leading to delays in provision of care so use of other skilled clinicians such as GPs with special interest or nurse specialists is key Most of the health and social burden of headaches is caused by primary headache disorders and medication overuse headache. The traditional model is process driven and not patient-centred Local analysis in Oxfordshire shows 66% of primary headache and medication overuse headaches referred to neurology outpatients could be successfully managed in the community Across England the total hospital admissions and costs for headache have increased over the past four years. The shift in services from the acute to the community/primary sector is expected to be a key enabler in delivering around 4.3bn of a total 22bn efficiency savings by 2020 National direction offers an opportunity and a requirement to reform and considerably improve community care of long-term neurological conditions 4 of 20

5 3 Introduction Through review of current healthcare usage in Oxfordshire, this case for change highlights that a significant part of the activity and financial pressure on the neurology pathway is caused by primary headache and medication overuse headache. It shows a clear argument for treating these types of headache in the community where clinically appropriate. This aligns with the national policy direction around developing more integrated approaches to care delivery, improving quality and efficiency of services and moving care closer to people s homes from acute hospitals to community services. The Transforming Community Neurology project report produced by the SCN in June 2016 aimed to encourage the adoption of community-based care models in order to improve person-centred coordinated care and improve the quality of life for people with long-term neurological conditions. This case for change focuses on a community-based proposed solution for the specific management of headache. 4 Epidemiology of headache Headaches are one of the most common neurological problems presented to GPs and neurologists. They can be painful and debilitating, an important cause of absence from work or school, and a substantial burden on society. Headache is a painful and disabling feature of the primary headache disorders including migraine, tension-type, and cluster headache. Headache may be a presenting symptom for many disease processes and is then termed as secondary headache. Headache affects 90% of the population at some time. They are among the most common disorders of the nervous system and can be the cause of significant and long-term disability. 4% of adults consult a GP each year for headache or migraine. ii (Latinovic et al. 2006) Whilst tension-type headache is the most common primary headache disorder (experienced by 70% of the population), the most frequent headache seen in general practice is migraine. Migraine is classed by the World Health Organisation as one of the top 20 leading causes of disability amongst adults. 80% of migraine sufferers have disabling attacks that interfere with life at work, home, and socialisation. iii There are approximately 6,720,000 people living with migraine in England. 5 of 20

6 Migraine is more prevalent than diabetes, epilepsy and asthma combined. iv (The Migraine Trust) Patients with frequent headaches may overuse acute treatments such as codeine, paracetamol, ibuprofen or triptans. With medication overuse, the headaches can become chronic and intractable increasing the disability arising from the headache. There are many serious conditions that will present with headaches. Many patients may visit their GP or A&E because they are worried about an underlying sinister cause for their headaches. However most patients with headaches will have a primary headache disorder. 97% of headache is managed in primary care (Latinovic et al: 2005) and it is therefore essential to ensure that the correct management is initiated by GPs to avoid ongoing disability, medication overuse, and inappropriate emergency attendance and repeat GP attendance. The majority of patients who are referred to secondary care for headaches are seen once by a general neurology consultant; in many cases, this referral is to exclude secondary causes such as tumours. The direct cost to the NHS for headache is estimated at 1 billion per year (Ridsdale 2007), with GP consults and medications of 468 per patient per year. Costs may be substantially higher than estimated as headache patients have frequent co-morbidities. For example, depression is three times more common in patients with migraine than healthy people. The cost of headache to the economy in terms of lost productivity was estimated at 5 billion. Across Thames Valley the total hospital admissions and costs for headache have increased over the past four years. In 2012/13 total costs for those with a primary diagnosis of headache across the SCN area were 2,016,691 and for those with a secondary diagnosis were 5, The total cost burden to the Thames Valley SCN area was just over 7 million. 5 National strategic context and drivers for change This project supports the vision set out in NHS England s The Five Year Forward View (2014) to explore the potential of new models of care to deliver locally-provided, integrated care, organised around the patient. It offers an opportunity and a requirement to reform and considerably improve community care of long-term neurological conditions. Alongside improved patient experience and outcomes, it has the ambition to achieve 2% net efficiency gains each year for the rest of the decade. Arlene Wilkie, chief executive of the Neurological Alliance, said: Good community care services are crucial to people living with neurological conditions. They can 6 of 20

7 support improved wellbeing and better health outcomes for patients, help people to self-manage their conditions more effectively and maintain good mental health. There is great potential for better community care to reduce pressure on hospitals by helping people maintain their good health and independence for longer. The All Party Parliamentary Headache in England report noted in 2014 that The biggest opportunities to address the burden of headache exist within primary care, since this is where the majority of cases present to. Despite the NICE headache guideline and quality standards, the provision of good quality headache care and patient satisfaction within primary care is poor. Strengthening resources to improve the provision of care at primary care level will therefore yield good value for money for commissioners. Initiatives to provide support to headache patients outside of clinical settings will reduce the demand on busy GP surgeries. Approaches to support properly diagnosed migraine and tension-type headache patients through ongoing remote support from primary care specialists have the potential to save CCGs money by reducing clinical appointments. Partnerships with third sector organisations to deliver this care can ensure that patient outcomes are achieved 6 Local Strategic Context New models of Care Care closer to home STP priorities Increased activity RightCare Approach Cost pressures 6.1 Sustainability and Transformation Partnership priorities Many of the Sustainability and Transformation Partnerships (STP) across the country are focussing on moving care out of the acute sector and into the community closer to home. There is also a focus on initiatives which provide easier to access high 7 of 20

8 quality care whilst delivering savings through reduction of admissions and use of secondary care. 6.2 Care closer to home Currently many patients across the country have to travel beyond their CCG area to receive care. The development of community clinics will improve patient experience as care will be provided closer to home. Data in the Right Care Neurology focus pack shows that for shows that in England only 49.8% of neurology outpatient appointments (consultant) are seen in their home CCG. 6.3 Demographic pressures The population across England is predicted to rise by 16.5% in the period Error! Bookmark not defined.. A sustainable solution needs to be developed to deal with the additional capacity needed for headache management. AREA % increase England (All Ages) 54,317 56,062 57,634 59,135 60,524 61,800 62,992 63, % Specific CCG data on demographics can be sourced at the following link: ojections/datasets/clinicalcommissioninggroupsinenglandz2 8 of 20

9 6.4 Increase in activity The increase in neurology activity is marked and provides a clear case for the review of current management. The below data was published in August 2017 and individual CCG data is available at the following link: *Neurology services: hospital activity data - GOV.UK The data below shows that in England there is a 12.2% increase in ordinary (inpatient admissions) and 53% increase in day case admissions for Headache and migraines between which highlights the importance of managing referrals early in the community. Hospital admissions with a mention of a neurological condition, England, age /13 hospital admissions with mention of neurological condition 2013/14 hospital admissions with mention of neurological condition 2014/15 hospital admissions with mention of neurological condition 2015/16 hospital admissions with mention of neurological condition % increase Primary diagnosis on admission episode ordinary (inpatient) day case admissions admissions ordinary (inpatient) day case admissions admissions ordinary (inpatient) day case admissions admissions ordinary (inpatient) day case admissions admissions ordinary (inpatient) day case admissions admissions Total Total Total Total Total Headaches and migraine 65,252 8,223 73,475 69,136 10,561 79,697 70,664 12,163 82,827 73,189 12,612 85, % 53.37% 16.78% 6.5 Increase in Emergency Admissions Between in England there was a 10% increase in emergency hospital admissions with a mention of a neurological condition and 13% increase in emergency hospital admissions where the primary diagnosis on admission is identified as Headaches and Migraine. Emergency hospital admissions with a mention of a neurological condition, England CCGs total, age 20+ ( ) (By neurological condition group) Primary diagnosis on admission episode 2012/ / / /16 % increase Headaches and migraine 62,824 66,616 68,320 70, % Neurological condition total 186, , , , % *Neurology services: hospital activity data - GOV.UK(accessed 23 August 2017) 9 of 17

10 6.6 CCG specific data Specific Hospital Episode statistics data (HES) related to headache and migraine by individual CCG can help with development of the case for change. The following codes are relevant: Headache ICD 10 codes : G44- Other headache syndromes, G440- Cluster headache syndrome, G441- Vascular headache, not elsewhere classified, G442- Tension-type headache, G443- Chronic post-traumatic headache, G444- Drug-induced headache, not elsewhere classified, G448- Other specified headache syndromes Migraine ICD codes: G43- Migraine, G430- Migraine without aura [common migraine], G431- Migraine with aura [classical migraine], G432- Status migrainosus, G433- Complicated migraine, G438- Other migraine, G439- Migraine, unspecified. 6.7 CCG/STP performance against comparators Analysis of Right Care data in the Neurological focus pack published in 2016 enables CCGs and STPs to understand how they are performing against Right Care Comparator CCGs and the average performance across England. It highlights opportunities for savings and for improving outcomes. This data can highlight where prescribing or non-elective spend is more than comparator CCGs or where there are more admissions and longer length of stay compared to comparator CCGs. Neurology is highlighted as an area where outcomes can be improved and savings made in many STP areas as illustrated by the following information from the Frimley STP and Buckinghamshire, Oxfordshire, Berkshire West STP. 10 of 20

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12 7 The vision for Headache management To develop a headache pathway that allows patients with headache who need to be seen in secondary care to do so quickly, while keeping in the community those patients with headache who can be better managed there, through supporting GPs in their independent practice and providing community headache services that are cost-efficient, easier to access and care is delivered closer to home. Not only would this improve patient care but also release capacity in over-stretched neurology outpatient clinics. Dr Richard Wood, Oxfordshire CCG There are three key elements in the development of the optimal community headache pathway. 1. Improvement in primary care recognition of primary headaches including migraine and medication overuse headache 2. Triage process to reduce outpatient clinic appointments 3. Development of community headache clinic 7.1 Improvement in primary care recognition of primary headaches including migraine and medication overuse headache The following section outlines potential ways to support improved diagnosis of primary headaches in primary care. This can be supported as follows: Education and Support for GP management of headache Clear guidelines and proformas for diagnosis It is important that guidelines are provided to the GPs to show clearly what steps can be tried prior to referral and to describe those cases when referral is important. The NICE guideline v for Headache provides the framework but the specialist neurologist experience and learning can help interpret and enhance these. Urgent referrals that include symptoms of brain tumours should be treated outside the proposed headache pathway and have their own dedicated cancer pathway. They are not included in the proposal. Learning opportunities Opportunities should be found to educate qualified and GPs in training on what to look out for. When it is felt a referral can be handled by the GP it should be returned with comprehensive advice from the specialist for continued management. Structured Education and Support for Patients to self-care When people self care and are supported to do this, they are more likely to: experience better health and well-being 12 of 17

13 reduce the perceived severity of their symptoms, including pain improve medicines compliance prevent the need for emergency health and social services prevent unnecessary hospital admissions have better planned and co-ordinated care remain in their own home have greater confidence and a sense of control have better mental health and less depression Patients need targeted education on headaches and when to seek medical advice and particular education around medication overuse headache. In some areas, clinics have been set up for those who have received a positive diagnosis of migraine, to provide education and effective treatment in a group environment which aims to reduce the patient s migraine related disability and improve their ability to manage their migraine independently, reducing reliance on medical services for management of migraine over the longer term. Support for Pharmacists Pharmacists play a key role in dispensing over the counter or prescribed medication to patients with headache and need to be supported in delivering targeted patient education especially around medication overuse headache. 7.2 Specialist triage of referrals In order to ensure that the optimum pathway is considered for each patient referred by a GP or from another consultant in the hospital it is important that a triage process is undertaken. The consultant can also be contacted for advice around patients attending Accident and Emergency with headache. The triage needs to be undertaken by a neurology consultant who will also provide advice to referrers, interpret imaging reports and provide clinical oversight and support to the community clinicians. There should be a robust mechanism (ideally electronic portal) for communication between the consultant undertaking the triage, the GP referrer, the community clinic and the hospital. After reviewing the referral the neurology consultant could manage the referral in the following ways: Provide advice back to referrer for continued management Where clearly a primary headache (such as migraine) Offer appointment at Community Based Headache clinic Where patient needs more support than GP can provide (mainly migraine, tension-type headache, and cluster headache but also medication overuse headache and chronic post-concussion headache) Where investigations are not required 13 of 20

14 Arrange Imaging without outpatient appointment If it is felt imaging is needed (typically structural MRI head without contrast) this could be arranged without a face to face clinic appointment If the scan is normal the patient can then be managed in the community clinic of by the GP or have an appointment at outpatients if further investigation needed Offer General neurology outpatient clinic appointment If patients have headaches with neurological signs or red flag symptoms that require an underlying pathology to be ruled out so further investigations are needed Offer Specialist headache clinic appointment Rarely the consultant may feel the patient should receive specialist consultant neurology assessment and management directly rather than through presentation at a general clinic Refer to Physiotherapist Rarely it may be appropriate to refer directly to physio (eg for those with clear cervicogenic headache) An audit of a cohort of 135 patients in Oxfordshire by 3 consultant neurologists suggested that the likely split between the above options is as follows: 14 of 20

15 Headache pathway Urgent referrals that include symptoms of brain tumours have their own dedicated 2 week cancer pathway. Patient education and advice from Pharmacy Community Headache Clinic Neurology outpatient clinic GP management GP Referral Advice Headache consultant triage Specialist Headache clinic A and E MRI without outpatient appointment 15 of 17

16 7.3 Development of a community headache clinic A community headache clinic could be run by headache specialist nurse or GP with a special interest in headache with the training and support of the consultant where needed. It would manage primary headache disorders such as migraine, tension-type headache, cluster headache, chronic post-concussion headache and can provide long term consistent care close to home if appropriate. It is important to select the locality of the clinic carefully with reference to the local population and likely number of referrals. Patient engagement and involvement of patient participation groups in the planning at an early stage is vital. The clinic will need a robust information sharing mechanism with the hospital and the GP practices to make referrals management and appointment booking effective and efficient. Ideally this will be through an electronic portal. Administration support to process bookings and arrange follow ups and maintain communication with the patient s GP is also important. There is also evidence of a link between anxiety/depression and headache. Although not fully understood a study in the Journal of Neurology, Neurosurgery, & Psychiatry vi of 107 patients with Chronic Cluster Headaches, 75 percent were diagnosed with an anxiety disorder and 43 percent with depression. The inclusion of psychological support within the pathway merits consideration. 7.4 Cost savings The savings from this community model come from the difference in the charges for appointments in the general neurology outpatient clinic and in the community headache clinic. The cost savings will obviously depend on local numbers and situations but the below Oxfordshire chart identifies how savings may be made if referrals are managed according to the expected triage as shown on page 13. The Oxfordshire pilot shows that the tariff for a first appointment in a community health clinic (which is set to cover costs of the clinic and triage and training) is likely to be 43% of the cost of a hospital first outpatient appointment The below table shows savings for those patients who are currently seen in outpatient clinic but could be seen elsewhere. It is based on a cohort of 1100 patients of which 6% could have imaging without appointment, 10% could be referred back to GP and 50% (550) could go to Community health clinic. The clinic costs are based on managing the cohort of 550 patients plus their anticipated follow-ups. They are based on 3 clinics for 42 weeks a year with 6 x 30 min appointment in each clinic (18 appointments x 42 weeks = total of 756 x 30 min appointments). Calculation of anticipated follow up rate is complex and will differ according to clinician involved but the chart below is worked on an estimate and an assumption that a follow-up appointment would take 15 minutes. 16 of 20

17 Savings for the 66% of patients who are currently seen in outpatient clinic but could be seen elsewhere Savings come from: - Reduced tariff of CHC (for which 50% referrals now seen) - Sending 6% of referrals to MRI without appointment - Advising GP without seeing patient in 10% of cases Community clinic tariff for 30min appointment is 110 Includes cost of time for referral triage, ordering and interpreting MRIs, advice to GP, supporting community clinic, and pathway oversight 17 of 20

18 7.5 Cost of the new service in your area Each CCG will be paying different amounts for their outpatient first and follow up appointments and will incur different local set up costs but the principles of where savings can be made remain the same. Apart from the savings made through referrals which are: 1) returned to the referrer 2) have imaging and are then returned to the referrer 3) take place in the community rather than the outpatient clinic there may be additional savings from seeing follow ups, of the referrals which were initially seen in the hospital, within the community clinic It is important to highlight that If the released appointments in the neurology clinic are used for seeing patients rather than decommissioned this will obviously impact on any potential savings. However, the clear benefit of having hundreds of additional appointments available to see more appropriate referrals in the acute hospital clinic to support the 18 week pathway cannot be underestimated. The following areas need to be considered when setting up a new pathway: Cost of Consultant Neurologist time to triage referrals Training costs for Neurology consultant to train community clinic specialist (GP with special interest or specialist nurse Numbers of patients likely to be seen in community clinic (1 st appointments and follow ups) Costs of running weekly clinic (30 min first appointment slot for each patient plus follow ups) Cost of Clinician time in clinic plus admin time Cost of Management time Patient/PPG involvement and engagement in the design of the service Secretarial time (20 mins per patient for report) Receptionist/admin time for booking and attendance at clinic Service charge (rent clinic space, utilities etc) Governance and Indemnity premium (may be negotiated with acute Trust) Education programme costs Psychological support Information technology to ensure joined up service Key performance indicators/metrics 18 of 20

19 8 Summary The evidence from the Oxfordshire CCG community headache pilot has evidenced that cost savings can be made, patient experience and outcomes improved and pressure on hospital clinics reduced through the set up of community provision for headache. It is hoped that CCGs across the country will review their case for change and use some of the learning from the Oxfordshire experience in order to enhance the care and experience of local patients. In summary, it is anticipated that the following benefits will be realised: Provision of a more efficient local service Improved patient experience as faster access to the right support Improved use of finances to ensure cost effective and appropriate expenditure Improved patient outcomes as patients who need to see a specialist have quicker access Increased capacity in outpatient clinics reducing waiting times Increased communication between primary and secondary care supporting learning Increased consistency of care Appropriate care closer to home Improved knowledge and skills in primary care Transfer of care from the acute to the community Closer links with third sector support in the community Improved patient education and self management Reduction in number of referrals to secondary care which can be managed in primary care Reduction in A and E admissions and attendances due to easier access to support The community pathway is due to be set up in Oxfordshire in early For further information please contact: Dr Zam Cader, Consultant in Neurology zameel.cader@ndcn.ox.ac.uk Dr Richard Wood, GP Richard.Wood@oxfordshireccg.nhs.uk 19 of 20

20 References i Headache Services in England - A Report of the All-Party Parliamentary Group on Primary Headache Disorders Headache-Services-in-England- -Full-Report.pdf ii Latinovic R, Gulliford M, Ridsdale L (2006) Headache and migraine in primary care: consultation, prescription, and referral rates in a large population. J Neurol Neurosurg Psychiatry 77: iii WORLD Health Organisation factsheets iv Migraine Trust facts and figures on Migraine v NICE guidance on management of headache vi Donnet A, Lanteri-Minet M, Guegan-Massardier E, Mick G, Fabre N et al. Chronic cluster headache: A French clinical descriptive study.j Neurol Neurosurg Psychiatry 2007;78: of 20