Chapter 11
Illustrative patient pathway
to self care: back pain

This chapter gives you an example of a practice team’s approach to the self care of back pain

Section 1 Self care for back pain

The start

We start with a patient’s perspective. You could:

work through the detailed scenario observing the sort of issues and discussion that the fictional practice team progress through here
discuss how your team would respond to the patient story given here
take an example case of a patient with back pain from your own practice (anonymising the patient’s identity in the team’s discussion as appropriate).

If you feel that you do not know enough about the management of back pain to complete the problem based learning, then learn more about the range of self care support options and clinical summary about back pain in the second section of this chapter before you start the problem based learning exercise.

Patient’s story 11.1

After four days of severe back pain, Barbara thought she should make an appointment to see the doctor. Unfortunately, Barbara was uneasy as the doctor hardly examined her. The examination consisted of a light touch to her side asking if it hurt and then before Barbara could explain any further he had turned away and started to prescribe strong painkillers.

Around two months later Barbara was still having back pain and decided that she would see a different doctor. This time blood tests were done and Barbara felt as though she had been looked after and listened to. Nothing more was discussed around Barbara’s back pain this time as the blood test showed a different problem that needed to be treated as a matter of urgency.

Barbara carried on taking the strong painkillers for her back pain prescribed by the first doctor and also rubbed in Ibuleve which she bought herself. She bought an exercise machine to help her with exercising but this did not help. Barbara will try visiting the doctor again, but doesn’t feel that she has had much help with taking care of her back pain so far.

Note: the patient in this scenario had tried awaiting resolution of her symptoms, and self care with Ibuleve for relief of symptoms, then prevention to some extent with the exerciser, and finally tolerating the back pain in some measure, though unhappily.

Your project team

Consider Tool 11 on team building

You might want a team to discuss alternative self care support options for back pain as in this example, to include:

reception staff
practice manager
GPs
practice nurses
health visitor
midwife
district nurses
patient and/or carer
physiotherapist
practice secretary
community pharmacist
practice-based pharmacist.

You could use a checklist as in Table 11.1 (see p. 141) to record who is involved and in what way.

Team discussion considering the patient story 11.1

Consider Tools 1, 3, 4, 5, 6, 8 or 10 for your teamwork and discussions

In this scenario, discussion between the fictional practice team members reveals:

GPs view many of the patients attending for back pain as a nuisance. They think patients should take care of their acute back pain themselves and tend to feel that many people with chronic back pain are trying to avoid activity or using it for secondary gain. But they are fearful of encouraging patients with back pain to do self care and missing something serious
management is inconsistent. Some doctors give codeine-based analgesics routinely, others think a combination of paracetamol and a non-steroidal antiinflammatory drug (NSAID) better. None feel that they can give enough time to explain how the patient can take care of the pain themselves, or how patients can decide when to consult with back pain. They are unsure how they would do this anyway. They would like to give patients a booklet but think copies of The Back Book are too expensive to give away1
the practice has some books, tapes and videos to loan to patients. Many of these have disappeared and there is no formal scheme for recording who has what. No patient information materials on back care are in stock
receptionists feel that patients with back pain are anxious and in pain and need to see the doctor. Receptionists would like to prioritise those patients who need to see a doctor
patients continue to attend with back pain because there is no consistent policy. They feel unsure how to take care of themselves and that they were right to see the doctor because they received a prescription or investigations
practice nurses always refer patients with back pain to the GP as they do not feel competent to advise them
the midwife, district nurses and health visitor have had specific training and education about how to prevent and advise on self care for mechanical lower back pain, and feel that the rest of the team is simply not up to speed
the physiotherapist reports that too many people with back pain, who really just need information, are referred inappropriately for physiotherapy. The long waiting list means that, by the time they are seen, most of them have either recovered, or are fixed in a pattern of avoidance of any movement that hurts
the community pharmacist reports that people often ask for ‘something stronger’ than simple painkillers, and options available OTC are limited because doses of codeine and dihydrocodeine are lower than in prescription medicines. The practice pharmacist wants to discuss the GPs’ prescribing of topical NSAIDs, for which she says there is insufficient evidence in most cases.

What you do next might include:

Consider any of Tools 2, 3, 4, 5, 6, 7, 8, 9 or 10 for your action planning

arrange a meeting between all members of the team to agree a common approach to promoting prevention and supporting self care for acute back pain
the health visitor agrees to lead the project team as she feels competent to advise on prevention and self care of back pain from her special training and education, and can act as a resource for other team members. Fortunately, she is based in the practice and is readily available. One of the district nurses with similar training agrees to act as her deputy
the practice manager agrees to consider whether a health care assistant might help the health visitor to free up some time
the practice manager will act as the convenor of meetings and training and ensure that any decisions and training are rolled out to all staff
the practice secretary will formalise the loaning of information to patients. Useful books,2,3 videos/DVDs will be purchased and the receptionists trained in how to record who has what and when loan items are taken and returned. The secretary will review the record cards each month and write to those people who have overdue items
the practice manager liaises with the local library to find out if there is a facility for dealing with enquiries about health, or any formal scheme with which the practice can link
the patient representative helps to draft and test posters and new information in the practice leaflet about the availability of advice about prevention and self care the receptionists decide to use the flow chart published byNHSDirect.4 The practice manager will scan this into the computer so that it can easily be accessed or printed out
the practice will apply to the PCT for extra funding for supplies of The Back Book so that all patients with acute back pain can collect a copy.1 Patients who are not happy with this will be referred to the doctor, health visitor or district nurse for telephone advice in the first instance
the doctors and physiotherapist agree to meet to examine the literature about the management of back pain and to put a guideline on the practice computer screen so that patients receive consistent care.5 They become aware of patients’ dissatisfaction in general with the amount and quality of information and advice they receive, particularly regarding diagnosis and treatment.6 While meeting they review websites they can recommend to patients as having sound advice about back care – including back exercises and equipment; the practice secretary prepares a printout for patients signposting these recommended websites
the physiotherapist agrees to run back care prevention and self care classes for all staff on two different days to ensure that all can attend.

What extra resources might this require?

Consider either Tool 8, 10 or 17 for determining resource and skill needs

Time for meetings and for training.
Protected time for the practice manager to arrange meetings and training, monitor and support the introduction of changes.
Training for the reception staff in the use of the flow chart and booklet.
Training for reception staff on the loan scheme.
Time for the practice secretary to chase up overdue items from the loan scheme and to audit referrals.
Time (and possibly training) for staff to implement, monitor and audit the project.
Additional staffing hours may be needed initially - through modifying the workload of existing staff, extending the hours of existing staff or employing additional staff. An additional health care assistant may be the most cost effective approach.
The back pain prevention and self care classes will be in paid protected time for the staff.

The outcomes might include:

Either of Tools 9 or 12 will help to monitor progress

better and more confident self care of back pain by patients and carers (A, R, T) (Prevent the condition, Await resolution, use self care for Relief of symptoms, learn to Tolerate symptoms) see Box 11.1, p. 142)
fewer episodes of back pain in those who have received information about prevention (P)
fewer requests for GP appointments from patients with back pain (P, A, R, T)
improvement in the care of acute, sub-acute and chronic back pain by GPs (A, R, T)
fewer inappropriate referrals to the physiotherapy service resulting in a more targeted service (A, R, T)
fewer referrals to secondary care orthopaedic or pain services because of more confident and expert management by GPs and self care by patients (A, R, T)
no failures to identify and refer those few patients requiring medical input for acute back pain (A, R)

part 2

Chapter 11 Illustrative patient pathway to self care: back pain