Headache, migraine, chronic pain: making a difference in just 100 day

The NHS Long Term Plan commits to removing the need for up to a third of face-to-face outpatient appointments over the next five years.This is an opportunity to redesign the way specialist neurology services are delivered.

Nationally, waiting times for neurology first outpatient appointments are growing while activity is decreasing, suggesting a significant capacity problem. As well as transformation of outpatient services, the NHS Long Term Plan also presents opportunities for neurology services to:

    • think differently about workforce and maximise the role of specialist nurses
    • involve patients more in their care by building shared responsibility with clinicians and providing more support for self-management through digital solutions.

The national Elective Care Transformation Programme, run by NHS England and NHS Improvement, recently published a handbook sharing best practice, expertise and learning from transformation of neurology elective care services.This was developed as part of two years of specialty-based transformation, when the programme supported frontline health and care systems to transform elective care services in 14 high-volume specialties so patients see the right person, in the right place, first time.

Systems identified their issues, planned their interventions and implemented them in just 100 days – the 100 Day Challenge.

In neurology elective care services, the challenge was undertaken by whole system teams in Liverpool, north east Essex, Salford and south west Hampshire between October 2018 and late January 2019.

For those who are embarking on the journey, the conditions wheel (right) shows what, in our experience, is essential to successful transformation of outpatient elective care services, namely:

• strong support from the leadership team across organisations: they need to absolutely understand and back the change, invest money and staff time in planning and implementation, be there to unblock any barriers, give teams permission to get on with it, and ensure transformation is an urgent priority for all involved, with a clear delivery timescale.

• whole system working: it’s about re-thinking how services work, what they do, and who does what. This will only achieve the desired results if the team includes the right people from across the organisations involved, along with patients or patient representatives, and other potential service providers – such as community pharmacists. A new way of working for many, it requires new approaches to team communications and support, including coaching. This may be face-to-face or remote. For instance, Advice and Guidance – specialist support to GPs in primary care often provided through the NHS e-Referral Service – is a key component of work to transform outpatient services.

• measurable goals,supported by real-time data and evaluation, so teams can see what is working, and revise or expand their approach to ensure delivery.

We have found that with these in place, change is clinically-led from the front and owned by those involved, which results in sustained and embedded improvement.

During the neurology 100 Day Challenge, north east Essex, Salford and south west Hampshire focused on improving services for headache and migraine.Rising demand for consultant appointments for headache was causing long waits for patients.Yet many were discharged with advice at their first appointment, which suggested that a different approach could improve patient experience, quality of care and efficiency.

In north east Essex, the team implemented a new and improved headache pre-referral form and provided GP education on the existing headache and migraine pathway,which included an underutilised GP with Special Interest (GPwSI) provided community clinic. Not one of 30 people surveyed in outpatients had been offered a community appointment first.The team also increased responsiveness to GP telephone Advice and Guidance requests by working with Consultant Connect.The connection rate for Advice and Guidance calls increased from 43.4% to 78%, with 72% of calls avoiding a referral. Local Consultant answer rates also improved. Five months after the 100 days ended, waiting times to see a neurologist had dropped from 28 to 23 weeks.

The Salford 100 Day Challenge team introduced a community migraine clinic delivered by a specialist headache nurse, offering patients access to extended specialist appointments and prescribing without a long wait. It was digitally enabled, receiving electronic referrals, and accessing primary and secondary care records and the e-prescribing system. A portable fundal camera enabled the specialist nurse to view optic discs and email images to the supervising consultant.

At University Hospital Southampton (UHS), a four-week manual audit found 28% of the 43 patients referred required further investigations or could benefit from Advice and Guidance. During the 100 days, a new referral form was developed to support GPs to direct patients to a specialist headache pathway, away from general neurology.They also developed a patient toolkit to improve the understanding of waiting patients, and a GP Advice and Guidance toolkit.

The Liverpool team’s focus was improving the management of chronic pain patients in primary care to reduce opioid prescribing and patient waits. The team included a GP, pain consultants, pharmacists, pain psychologist, physiotherapist and managers from the CGG, acute trust and The Walton Centre, a major neurology hospital. They piloted a multidisciplinary team (MDT) for chronic pain in primary care, reviewing the notes of patients from 17 GP practices waiting for a specialist

appointment. Of the 51 patients reviewed, 27% were deemed appropriate to be discharged to their GP with treatment advice, and 41% able to benefit from a community MDT appointment. Seven patients were seen by the MDT during the 100 days.All gave very positive feedback. This work provided the foundation for a redesigned referral pathway with MDT triage and the offer of a community MDT appointment.The team also undertook a survey of GP confidence in managing chronic pain and delivered a GP education session.This informed new chronic pain guidance for GPs, including referral pathways and prescribing.

The neurology handbook has an overview of all the tested interventions with their benefits and opportunities, top tips, considerations for implementation, and advice on evaluation.

The handbook, supporting webinars, case studies from pilot sites, further resources and useful information are on the Elective Care Community of Practice online collaboration platform.To join the Community of Practice, please email ECDC-manager@ future.nhs.uk


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