1. COPS Providing Quality Service in a Cost Effective Way

2. Department of Health Musculo-skeletal Services Framework A group of Chiropractors, Osteopaths, and Physiotherapists in Swindon (‘COPS’) was formed in response to a Government initiative to ensure that patients are seen, diagnosed, and treated within 18 weeks. (www.18weeks.nhs.uk)www.18weeks.nhs.uk

3. Who are COPS? COPS is an association of local professionals specialising in manipulation as their primary therapy. The association was formed to provide GPs with a fast referral service for patients with acute back pain. The service will provide :  For patients - 1º diagnosis, treatment, rehabilitation exercise programmes and advice.  For GPs – rapid access to an integrated package of evidence based care within CSAG (Clinical Standards Advisory Group) guidelines, in a 1° care setting.

4. Management of Low Back Pain “Manipulation provides better short-term improvement in pain and activity levels than other treatment options, resulting in higher patient satisfaction” Royal College General Practitioners (1999) “Spinal manipulation, in the form of chiropractic, osteopathy, or manipulative physiotherapy, followed by a programme of exercise, provides significant relief of symptoms and improvements in general health” UK BEAM (Back Pain Exercise And Manipulation) trial, Medical Research Council (2004)

5. Management of Low Back Pain “Consider manipulative treatment within the first 6 weeks.” “Refer for reactivation/rehabilitation”

6. GMC & BMA guidelines “… you must be satisfied that any health care professional to whom you refer a patient is accountable to a statutory regulatory body …” General Medical Council “… GPs can safely refer patients to practitioners in osteopathy …” British Medical Association

7. Quality & Governance Statutory regulation with GCC / GOsC / HPC 4-5 year BSc degree course Compulsory CPD. Approved by all major Private Health Insurers

8. Are we safe? Red flag aware 50,000 manipulations with zero serious adverse events; ~ statistically, at worst a risk of 1 per 10,000 cervical manipulations Transient impairment 1:50,000 (eg fainting, dizzy or lightheaded) Reversible impairment 1:3.7million (eg footdrop, sensory changes) Serious non-reversible impairment 1:5million.(eg CVA)

9. What are we proposing? To provide a specialised multidisciplinary acute back pain service within 1° Care. The service would be based on the successful Plymouth model.

10. Treatment Modalities Chiropractic or Osteopathic spinal manipulation, unless contra-indicated. Caudal Epidural steroid injection, specific joint injection with lignocaine and steroid, trigger point and peri-facet injection. Acupuncture or acupoint stimulation

11. Benefits to GPs Fewer consultations Reduced cost Prompt referral Structured case management Good communication

12. Patient Benefits Choice Prompt appointments Diagnosis, treatment and advice on initial appointment Care close to home Continuity of care Reduced progression to chronicity Facilities for disabled patients

13. Where’s the proof? 1 BEAM report Pilot Study into Cost Effectiveness of Chiropractic in Industry; Taunton Cider Study into Cost Effectiveness of Osteopathy in a Swindon Manufacturing Company.

14. Where’s the Proof ? 2 Study into Cost Effectiveness of Osteopathy in a Swindon Manufacturing Company. “ The statistics show that overall, the osteopath is having an effect on the workforce.” Occupational Health Advisor 30% of cases seen were acute for whom rapid attention generally meant an early return to work, or no lost time. Quantifying productive time gained through the use of an osteopath is difficult. However, a conservative estimate suggested that when all costs were considered, 38% of the consultations were ‘free’. Health and Safety Manager

15. Procurement “Any willing provider” model. “Choose and Book” Proposal to PCT to move funding from 2º care.

16. Ensuring value for money Value for money= Problem resolution= Reduced repeat GP visits Reduced referrals to 2 O care. Use of G.P. questionaire and Melzack analogue scale for patients.

17. Referral Criteria Symptoms ‹ 6 weeks Trials of adequate analgesia and mobility + one of the following: moderate/severe pain not making progress limited SLR neurological deficit off work restricted spinal movement or scoliosis

18. The Revolving Door Patient Multidisciplinary Sub-acute clinic to be considered in the future for non- improvers.

19. And Finally Never lend your car to anyone to whom you have given birth - Erma Bombeck