1. Managing Headache

2. 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:

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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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%

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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 or Dr Richard Wood, GP