Managing Headache

Headache is an increasing problem 24% increase in those in treatment for headaches and migraine in the past 5 years Figures for specific CCGs available at: https://www.gov.uk/government/publications/neurology-services-hospital-activity-data

Headache accounts for 1 in 3 referrals to neurology outpatients* * Data based on Oxfordshire CCG analysis

66% of all headache referrals to general neurology could be managed more appropriately This enables the remaining 34% of rare, intractable and headache plus conditions to be treated faster in secondary care outpatient clinics

Neurology outpatient clinic Presence of primary headache disorders within outpatient clinics delays access for patients with other neurological conditions causing overspill into emergency presentations and deterioration during long waits Emergency presentation Neurology outpatient clinic

Community headache clinic Neurology outpatient clinic Most primary headache disorders and medication overuse headache are more appropriately diagnosed and managed within the community Community headache clinic Closer to home Neurology outpatient clinic Faster access

What is needed to make this happen? Improvement in primary care recognition of primary headaches including migraine and medication overuse headache Triage process to reduce hospital outpatient appointments Development of community headache clinic

What is needed to improve primary care recognition of primary headaches including migraine and medication overuse headache? Supportive comprehensive guidelines for GPs on what can be tried pre referral with specific info around medical management of migraine and medication overuse headache Patient education Supporting local pharmacists to provide patient advice (especially around medication overuse) GP education for those qualified and in training and advice/comment from specialists regarding referrals Support for anxiety/depression – although not fully understood a study in the Journal of Neurology, Neurosurgery, & Psychiatry of 107 patients with Chronic Cluster Headaches, 75 percent were diagnosed with an anxiety disorder and 43 percent with depression.

Triage of referrals Neurology consultant to perform triage, provide advice to referrers, interpret imaging reports, provide clinical oversight and support to the community clinicians After a GP referral a headache specialist could manage in the following ways: Advice back to referrer Appointment at Community Based Headache clinic Imaging without outpatient appointment General neurology out patient appointment Specialist headache clinic

Likely result of triage of headache referrals (based on case audit in Oxford) Advice back to referrer 10% Community Based Headache clinic appointment 50% Imaging without outpatient appointment 6% General neurology out patient appointment 18% Specialist headache clinic 16%

GP Triage of referrals More disabling headache Self-management of simple headache Support to GP from education, specialist advice Support to population from education, GP advice, pharmacist, practice nurse, Headache Clubs, patient meetings, access to resources Triage of referrals More complex or headache plus presentations Specialist Support Headaches, co-morbidities, psychological concerns, frequent attenders to reduce crisis and enable management by GP or self-management

Community Headache clinic For primary headache disorders and medication overuse headache where more support needed than referrer can give Mostly migraine, medication overuse headache, tension-type headache, cluster headache, chronic post-concussion headache Could be run by headache specialist nurse or GP with special interest in headache Imaging or investigations not normally needed in this clinic

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

Cost of appointments The Oxfordshire pilot shows that the tariff for a first appointment in a community health clinic (which is set to cover costs and triage) 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)

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 Includes cost of time for referral triage, ordering and interpreting MRIs, advice to GP, supporting community clinic, and pathway oversight Community clinic tariff for 30min appointment is £110

Potential savings The actual saving for a CCG will depend on the current local negotiated charges and the costs of setting up the triage and clinic If the released appointments in the neurology clinic are used for seeing patients rather than decommissioned this will obviously impact on any potential savings There are many factors the CCGs need to consider as outlined on the following slide

Setting up a new headache pathway CCGs need to consider: 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 Costs of running weekly clinic (30 min first appointment slot for each patient) 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

Benefits In Oxfordshire the revised headache pathway will: Provide a more efficient local service Enable faster access to the right support Improve patient experience and skills for self management Improve knowledge and skills in primary care Pay for itself Reduce referrals to acute sector which can be managed locally Reduce emergency admissions and attendances Speed up access to specialist support For further details on the Oxfordshire experience contact: Dr Zam Cader, Consultant in Neurology zameel.cader@ndcn.ox.ac.uk or Dr Richard Wood, GP Richard.Wood@oxfordshireccg.nhs.uk