GIRFT national report calls for short-term pain relief to be replaced with rehabilitation

Replacing short-term pain relief injections with long-term physical and psychological rehabilitation programmes could help tens of thousands more patients cope with debilitating back pain, according to a new Getting It Right First Time (GIRFT) report on spinal surgery.

Lower back or radicular pain (sciatica) is the primary cause of disability in the UK. It affects one-third of the population at any one time, and 84% of people in their lifetime.

The latest GIRFT national report found that, despite NICE guidance, a significant number of patients are still receiving facet joint injections (injections of local anaesthetic and/or steroids to block pain), which have limited clinical value. On average between 2015 and 2018, almost 6% of patients with back pain received three or more facet joint injections in a year, at a cost to the NHS of £10.5m.

Reinvesting this money in longer-term physical and psychological rehabilitation programmes – close to patients’ homes – is one of the key recommendations in the GIRFT report. This is in line with the National Low Back and Radicular Pathway, endorsed by NICE.

The spinal surgery national report – the eighth from the Getting It Right First Time programme –focuses on spinal emergency conditions such as spinal cord injury and spinal infection, in addition to the management of common conditions such as back and radicular pain (sciatica). It shows that in 2017/18 the NHS carried out 52,523 surgical procedures on the spine.

A series of 22 recommendations bring opportunities to improve the patient experience through earlier discharge from hospital, reducing cancelled operations and ensuring trusts are equipped to deliver the best care in the most-timely manner. It is estimated the recommendations could deliver cost efficiencies of up to £27m. 

Among the other key recommendations in the report are:

• Referral without delay to 24-hour MRI scanning in all hospitals for patients with suspected cauda equina syndrome (a spinal emergency which can lead to limb paralysis and permanent loss of bowel and bladder function if not treated quickly);
• All major trauma centres to have the ability 24/7 to stabilise and decompress the spine in patients with fractured and dislocated spines;
• Suggested changes to the referral pathway of paediatric spinal deformity patients to enable children to be treated close to home where appropriate but at a centre with the shortest waiting time;
• Better recording of implants, their use and patient outcomes.

The report’s author, Mike Hutton, a consultant spine surgeon at the Royal Devon & Exeter Hospital, visited 127 spinal units across England in his review.

Mr Hutton said: “During my visits, I have been repeatedly struck by the passionate commitment of the clinical staff towards the NHS as a force for good in society. The majority of units expressed pride in their work, a sense of ownership of their unit and a loyalty to the communities they service. They do so, however, under significant increasing demand on their services and financial constraints.

“I am excited to put forward the recommendations in this report. I firmly believe they offer the potential to achieve significant improvements in patient care and to create significant financial opportunities.”

Health Minister Stephen Hammond added his support. He said: “This is a significant step forward in the way the NHS cares for people living with spinal conditions, focusing on rehabilitation rather than just relief to improve patient experience and lead to better treatment outcomes.

“These clinically-endorsed recommendations could have a major beneficial impact on the quality of life for tens of thousands of patients a year. This reflects a wider drive in the NHS Long Term Plan to reduce variation in treatment and deliver exceptional patient care at the best price for our taxpayers.”

Dr Kathy McLean, Executive Medical Director and Chief Operating Officer at NHS Improvement said: “As the Long Term Plan states, we are committed to supporting NHS trusts to learn from one another and to make changes that will both benefit patients and free up funds that can be invested back into frontline care.

“The recommendations in this report are based on what clinical teams have found to work most effectively in managing lower back pain, and so we encourage trusts to review their own practice without delay as this could improve the lives of thousands of people across the country.”

The recommendations in GIRFT’s spinal surgery report are endorsed by the UK Spine Societies Board, the British Association of Spinal Surgeons, the Society of British Neurological Surgeons, the British Orthopaedic Association and the National Back Pain Pathway Clinical Network. They will be implemented in partnership with NHS Improvement and NHS England, as well as directly with hospital trusts and Sustainability and Transformation Partnerships.

Patrick Statham, chair of the United Kingdom Spine Societies Board, said: “The many visits that have been made to individual trusts have provided new insights and have been a powerful stimulus for improvements in patient care. “Bringing these insights together in this national report shows where progress has already been made, gives examples of organisations that are leading the way in driving further improvements, and gives focus to areas where more work is needed.”

Professor Cliff Shearman, vice-president of the Royal College of Surgeons said: “Chronic back pain and spinal conditions can cause serious physical discomfort and be very distressing for patients.
 
“The Royal College of Surgeons fully supports this GIRFT report, which makes recommendations on how the NHS can better manage patients with back pain and spinal conditions to improve their outcomes. We urge hospitals to read the report and examine whether they could enhance the treatment they offer patients with chronic back pain and spinal conditions.”