Welsh Backs GP engagement Thank you. Good morning ladies and gentlemen. The focus of my presentation this morning the process of engaging GPs in the Welsh Backs campaign. However, before describing this process I thought that it may be helpful just to mention a little about the Campaign itself

Welsh Backs Campaign AIM To minimise the financial, personal, and psychosocial effects of mechanical low back pain in Wales by promoting the ‘stay active’ message Welsh Backs campaign aims to promote the ‘stay active’ message through effective engagement with

Information and support Public Multi - media campaign Website Patient information leaflets Employers Health and Safety Executive Health professionals Resources to support patient management The public, employers and health professionals. The NPHS has been given the lead in engaging health professionals – particularly focusing on GPs and it is this process of engagement that I am going to describe this morning. Before doing so I would just like to highlight the importance of working at the primary care interface in relation to meeting the aims of the Welsh Backs campaign

Importance of primary care interface Effective healthcare Improved health outcomes Appropriate use of scarce NHS resources Fitness for work Appropriate advice Health and well being Demedicalisation Empowerment We know that at any one point in time 40% of individuals with low back pain will seek advice from a GP. However, in terms of the population impact of low back pain this has a disproprortionate impact. Firstly this is how patients access NHS care – ensuring that they receive effective evidence based management not only improves health outcomes, but ensures appropriate use of scarce NHS resources. We need to ensure that GPs are aware of appropriate management and have the tools to support them in caring for patients appropriately Then of particular relevance to this event today, it is at this point that patients obtain advice regarding fitness for work and if, deemed unfit, access the benefits system via this route. Again, GP education and appropriate resources are vital to ensure patients are given correct advice. Finally, and of tremendous importance when considering health and well being of the population, it is at this interface that the is the re potential for directing patients away from the traditional medical model of care and to look outside the health service for the answer to their problems – demedicalising and empowering patients to self manage and take control of their health. The back pain is a common problem which creates a huge public health burden yet we know that 95% of cases that occur in the working age population are due to mechanical low back pain

Effective healthcare Triage Activity Therapy Exclude serious pathology Encourage normal activity – ‘Stay active’ Educate – ‘pain doesn’t mean harm’ Therapy Analgesia Refer for physical therapy if pain not settling And that appropriate management is, in effect, to promote the stay active message. Although this information is not new, the problem of inappropriate orthopaedic referrals continues as does sickness absence due to back pain. Hence the challenge in GP engagement to reorientate thinking towards self management, demedicalisation agenda to prevent back pain causing disability both at individual and population levels.

Engagement tools Free copies of the Back Book Educational resources Signposting documents So, building on this sound evidence base, what has been our strategy for engaging GPs across Wales. The emphasis has been on providing primary care professionals with tools to help them in managing patients with back pain – rather then telling them how they should be managing patients or adding work. The starting point has been the provision of free copies of the Back Book by Welsh Assembly Government. This is a patient educational booklet, which was originally produced for use with Royal College of GP guidelines for the management of acute low back pain. Improved outcomes associated with its use have been demonstrated in one randomised controlled trial and experts continue to recommend it. To support the appropriate use of the Back Book within the GP consultation we have coordinated the production of a number of educational resources highlighting the evidence based approach to the management of acute low back pain. Then, finally, to support the demedicalisation agenda and to provide GPs with local information on local healthy living initiatives and resources to address occupational health issues we are coordinating the production of local signposting documents by working with the 22 local public health teams. Key features of these tools are that they should be user friendly, simple, available in paper and electronic form.

Effective dissemination Early adopters Back book sent to all GPs in Wales Letter / e-mail with links to on-line order form Engaged GPs / pharmacists CPD package Audit tool Primary healthcare professionals Local CPD events Interface with practices – promote resources And now to our strategy for dissemination. It is well established that there are no ‘magic bullets’ for effective GP engagement and that a multifaceted approach must be adopted. Understanding this, we have undertaken a phased approach which builds awareness through multiple connections and hopefully, will embed the Welsh Backs message into primary care right across Wales. We started by introducing the campaign to all GPs across Wales by sending out a copy of the back book and links to an online order form to allow any who were interested to order more copies. We then worked with a well respected and well know organisation to facilitate the production of a CPD package which was sent to all GPs and pharmacists in Wales and invited voluntary participation. Finally, we are currently working on organising more direct contact with GPS through local CPD sessions and facilitating the promotion of the resources through direct or indirect interface with individual practices.

Key partners Deanery Welsh Medicines Resource Centre Organisational Effectiveness Programme Welsh Medicines Resource Centre Module on acute low back pain Primary Care Quality and Information Team Audit tool Blaenau Gwent Local Public Health Team Pilot of signposting document Clearly this has been a collaborative effort involving a number of key organisations. The Post graduate deanery coordinates the appraisal system for all GPs in Wales. Appraisal is a necessary prerequisite to practice and therefore the deanery has contact details for all practicing GPs in Wales. I was enormously priviledged to be part of the Organisational Effectiveness Programme - a project based leadership programme organised by the Deanery. Welsh Back has been my project and, as a result, the Deanery facilitated the original e-mail cascade and continue to provide Welsh Backs updates in the quarterly appraisal newsletter. The Welsh Medicines Resource Centre which is well known and used by GPs as producing, among other things, on line and paper based CPD packages worked with us to produce a module on acute low back pain which was also sent to pharmacists across Wales for the first time. This is being supported by an audit tool produced by the PCQIT. This has recently been circulated to all GPs. Finally the concept of the signposting document has been taken forward by Blaenau Gwent Local Public Health Team who organised a workshop in CPD session with GPs to which representatives of various organisations - including job centre plus, condition management programme, expert patient, ex on referral and several others to discuss interface issues and way that they may work more effectively together. We are hoping to develop this model in other GP CPD sessions.

Progress to date 26,200 back books distributed Majority to GPs Initial mailing – one to each GP – Nov 2007 Second copy sent with WeMeReC bulletin – March 2008 69.4% practices have requested further copies So far 66.5% of all practices in Wales have requested further copies of the back book

Percentage of GP practices in each LHB which have requested ‘The Back Book’ up until September 2008 Local Health Board

Number of requests for ‘The Back Book’ between 19th November 2007 and 12th October 2008 Letter and email to GPs Email to practice managers via LHB Email to practice managers via LHB Evaluation questionnaire sent to all GPs

WeMeReC bulletin Case studies sent to 2,470 GPs 2,900 pharmacists (first time participated) Completed by 688 GPs (28%) 247 paper copy and 441 on line 103 pharmacists Bulletin and copy of back book sent to 2,470 GPs / 2,900 pharmacists The WeMeReC module has been really successful with 28% of all GPs participating in the full module. It is likely that many more will have read the educational bulletin, but not completed the case studies to complete the module.

GP responses to survey question “How well equipped do you feel you are to …” (from 200 of 688 responses to educational module on acute low back pain, 2008)

Ongoing work Production of signposting documents Local Public Health Teams Engaging with GP networks CPD and appraisal coordinators Engaging with LHB heads of pharmacy Work with individual practices Engaging with Trusts Physiotherapy departments Care pathways / Map of Medicine Our final and, perhaps most challenging phase, is to make direct contact with GPs in order to introduce the resources available to them to manage back pain effectively. This involves liaising with all local public health teams across Wales to produce the signposting documents and then connecting into GP networks to facilitate direct contact with GPs. There are many such networks mainly working under the Deanery, but there are also practices taking medical students, sessional GPs and GPs working in Out of Hours services. We are also working with LHB pharmacy teams in order the facilitate the promotion of Welsh Back Resources at practice visits if analgesic prescibing is discussed. Finally we will need to engage with Trusts across Wales to ensure that Welsh Backs is firmly embedded in care pathways for the management of back pain. A link to Welsh Backs has been included in the Map of Medicine

Conclusion Coordinated approach Collaboration Created networks Consistent messages Public and professional Collaboration Potential for further GP engagement Created networks Potential for further public health programmes (smoking cessation) The key features of this process are the coordinated approach and collaborative working across may different agencies. This has created networks through which the Healthy Working Wales Website will be disseminated. In addition, it demonstrates a model for delivering a public health programme through primary care – nationally coordinated and locally delivered. There is the potential to build on this model as we all work to promote the health of the population of Wales.

With special thanks to: Nicola John, Local Public Health Director for RCT and Merthyr Tydfil Leonie Roberts, Speciality Registrar in Public Health Wendy Bowler, Principal Health Promotion Practitioner Katrina Minton, Welsh Backs Project Co-ordinator Alexia Saunders, PA to Dr Sally Venn

Thank you

For further information Dr Sally Venn, Primary Medical Care adviser T: 01495 332216 E: Sally.Venn@nphs.wales.nhs.uk Katrina Minton, Welsh Backs Project Co-ordinator T: 029 20348777 E: Katrina.Minton@nphs.wales.nhs.uk