NWL JOINT COMMITTEEDECISION MAKING FRAMEWORK PROPOSED NWL POLICY FOR CERVICAL AND THORACIC FACET JOINT INJECTIONS

This decision making framework is designed to facilitate Policy Development discussion and agreement by the North West London Collaboration of CCGs. The framework sets out the relevant items for debate including the key evidence base, the patient impact, the economic impact and the affordability.

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Executive Summary:

This paper provides the NWL Joint Committee with a summary of the recommendations from the Policy Development Group (PDG) with regards to the development of a new policy to decommission cervical and thoracic facet joint injections and therapeutic medial branch block injections. These injections are occasionally used for patients with chronic facet joint pain in the cervical and thoracic spine. Activity data shows that only a small number of patients (100-120) receive these injections per annum across NWL. This costs the NWL CCGs about £80,000 per annum.

As part of the wider NWL MSK Transformation Programme, the proposed policy is seen as an addition to NICE 2016 guidance which recommended not to routinely commission lumbar facet joint injections. As these injections are outside the scope of NICE 2016 guidance, it could not be included in the new NWL low back pain policy and hence a separate review was necessary.

The paper highlights that together with the low number of these injections being carried out across, there is also very little published data supporting their effectiveness.

Consultant feedback recognised the lack of evidence base for these interventions and also noted the importance of physical therapies for this group of patients.

The paper also includes the other factors for Joint Committee decision making including financial implications/commissioning impact and assumptions.

The Joint Committee are asked to consider all the factors presented in order to discuss and agree the following recommendations: Discuss and agree the methodology, rationale and evidence base of the final recommendations made by the PDG To agree with the PDG recommendations to decommission cervical and thoracic facet joint injections and therapeutic medial branch

blocks To agree to serve notice on the trusts currently providing these interventions

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Category/Measure/Definition Input/Owner

Policy Development Group Review

Policy Proposal andStrength of EvidenceHow strong is the evidence and therefore likelihood that this is going to work and evidence the potential outcomes

In April 2017, NWL Collaboration board agreed a Low back pain policy that had been developed from NICE guidance published in 2016. NICE recommended that facet joint injections for chronic low back pain should no longer be offered due to lack of clinical effectiveness. The PDG agreed to also review the effectiveness of spinal injections for cervical and thoracic facet joint pain, given the lack of evidence of effectiveness of similar injections for lumbar facet joint pain.

Review of Evidence Base for Cervical and Thoracic Facet Joint InjectionsA PUBMED search was conducted to review all published meta-analyses, systematic reviews and reviews.58 relevant articles were found, of which 4 articles were of clinical relevance and in English.A systematic review by Manchikanti, Pain Physician 2015 evaluated clinical utility of therapeutic cervical, thoracic and lumbar facet joint injections in managing chronic spinal pain. Their primary outcome measures were based on pain relief. The results included 6 randomised controlled trials for cervical facet joint pain, 4 of which were observational studies. Evidence was graded between I and V, where level I is of the highest grade of evidence found. For long term improvement level II evidence was seen for cervical radiofrequency neurotomy (denervation) and cervical facet joint nerve blocks. Level IV evidence was seen for cervical intra-articular injections.One RCT and one observational study were found describing thoracic facet joint injections. There was level II evidence for thoracic facet joint nerve blocks and level IV evidence for radiofrequency neurotomy for long term improvement.The review commented on the limitations of the systematic review due to the overall paucity of high quality studiesAnother review by Kiroalani looked at 45 references to review the management of cervical facet joint dysfunction. Again, there was very limited information to determine effective treatment of this condition (Kiroalani, 2008)One systematic review, published by Falco in Pain Physician in 2012, carried out a systematic review of the literature of cervical facet joint injections. Their review noted the specific lack of evidence for cervical facet joint injections and paucity of clinical trials and data in this area. There was little evidence to show any effectiveness of this procedure. The review was an update to a previous review carried out by the same authors in 2009 and included 2

IFR team

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randomized trials, with one high quality randomized trial which showed negative evidence. This is summarised below:

Level of evidence graded I to III (USPSTF) Evidence for therapeutic facet joint interventions is Level II-1 for medial branch blocks,

Level II-1 or Level II-2 for radiofrequency neurotomy. There is no evidence for effectiveness for therapeutic intra-articular cervical facet joint injections.

i.e. there is no evidence of facet joint injections, but some reasonably strong evidence for therapeutic medial branch and radiofrequency neurotomy

Lastly a paper titled ‘Task Force on neck pain and its associated disorders’ published in the European Spine Journal in 2008 concluded that there was lack of evidence to support intra-articular steroid injections or radiofrequency neurotomy. This task force paper was developed by advisory bodies in different countries.In summary very few published reviews were found. The systematic reviews which were identified did not show conclusive evidence of effectiveness of facet joint injections for cervical and thoracic facet joint pain, but demonstrated that there radiofrequency denervation may be effective

Diagnostic medial branch blocks and Radiofrequency Denervation

In a review article Manchikanti, 2016, looked at the effectiveness of diagnostic blocks in diagnosing cervical facet joint pain. It determined, after reviewing 11 studies, that the evidence was described as Level II. False positive rates ranged from 27 to 63%, and the prevalence of patients who gained at least 80% of pain relief from the diagnostic block ranged from 36% to 67%.The article also concluded that there was Level II evidence for the long-term effectiveness of radiofrequency neurotomy (denervation) and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections (facet joint injections).A Cochrane review published in 2003 by Niemisto looked at the effectiveness of radiofrequency denervation for neck and back pain. The review found 9 articles, of which 6 were deemed to be of high quality. Out of 275 randomized patients, 141 patients received active treatment. Although study sample sizes were small, and follow up times were short,

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there was some evidence to suggest that radiofrequency denervation provided some short term relief in neck pain. The authors concluded that further research was needed in this area.A systematic review by Engel et al, also concluded that there were some clinical benefits of thermal radiofrequency denervation. The systematic review found 8 trials, which looked studied the outcomes of about 200 patients. The evidence showed that a majority of patients were pain free at 6 months and over a third were pain free at 1 year. The number needed to treat for complete pain relief at 6 months was 2.It was also noted that complications of this intervention were very uncommon, and that the procedure was well tolerated.

Whilst there is little evidence for the effectiveness of these injections, there is some evidence that radiofrequency denervation is effective. Radiofrequency denervation is currently commissioned within contracted activity. Diagnostic medial branch block injections are required to ascertain whether radiofrequency denervation will be effective, and again these would continue to be routinely funded

Clinical Stakeholder Engagement

In September 2017, a clinical forum was held and was well attended by pain consultants across NWL. Key points of the discussion:

There was a mixed view about the value of these injections, but agreement in the lack of published evidence. There was concern that it would be difficult to apply results of clinical papers to patients who present with complex pain syndromes, and that a ‘one size fits all’ approach was not appropriate in treating many of these patients.There was wide agreement that physical therapies such as physiotherapy and lifestyle changes were probably more impactful for these patients with chronic pain than providing joint injections.

The consultants explained that cervical and thoracic facet joint injections are not commonly given in secondary care, and activity numbers varied across NWL trusts.

Further circulation of the final draft proposed policy was sent by email to the clinical e-group in

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December after the PDG met in November 2017.No further comments were received.

Sacroiliac Joint injectionsOf note, the PDG had originally recommended the decommissioning of sacroiliac joint injections, again due to the lack of data to support this intervention. However based on feedback from pain consultants, this proposal was dropped due to the lack of effectiveness of alternative interventions such as radiofrequency denervation. It had also been noted that under 50 procedures were carried out a year in NWL.

Patient experienceWhat is the debate for improving patient outcomes and how can you correlate this back to wider agenda

From the activity analysis a very small number of patients receive these injections (100-120 patients a year across NWL). The PDG felt that patient engagement would not be possible given the small numbers of patients and difficulty finding patients to engage with. It was suggested by the PDG patient representative and PDG Chair to use existing forums within the MSK transformational programme to identify relevant patients. However it was subsequently highlighted that the forums would have a wide range for patients who were receiving a variety of interventions and not necessarily thoracic and cervical joint injections.

Given the difficulties engaging with this small particular patient group, the PDG agreed that patient feedback post-policy implementation should be achieved through complaint monitoring and feedback received via Contract leads. It was proposed that this information could be sought from the Complaints team every 6 months.

Ethical ImpactAre there any published debates in terms of ethics – does this warrant sufficient rationale to agree this in replacement for something else of a lesser priority.

This policy is based on an evidence driven recommendations which are based on clinical papers based on patient outcomes

A completed EQIA form is attached in Appendix 3There are routinely commissioned alternatives for this small group of patients such as physical therapies and radiofrequency denervation which are effective interventions

IFR

Economical Assessment: There is no published cost effectiveness evidence for these specific injections. IFR/Finance

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Population benefit andCost Per QALYHow many people across NWL would benefit from this?

A quality-adjusted life-year (QALY) takes into account both the quantity and quality of life generated by healthcare interventions. It is the arithmetic product of life expectancy and a measure of the quality of the remaining life-years.

Economical Assessment: Impact on other areasWhat other areas can you determine VFM i.e. reduction in lengths of stay and out-patient attendance and other socioeconomic factors. How did you validate this and with whom.

The table below describes the activity of facet joint injections in the cervical and thoracic facet joints across NWL.

Financial YearCervical and Thoracic Facet Joint injections Cost

15/16 120 £86,835.0016/17 103 £73,433.0017/18* (M1-5) 22 £14,941.00

It is not possible to obtain the activity data for therapeutic medial branch blocks due to the limitations of its analysis in how it is coded. It is not thought that this activity is high.

Given the very small activity, it is unlikely that decommissioning will cause a significant pressure on services which will be providing other alternative treatment options for this group.

Finance/IFR

Financial Impact As above Finance

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What is the impact in terms of commissioning – provide a variety of scenarios (using local intelligence i.e. what’s the likelihood of this genuinely changing current activity, i.e. what’s the feeling that this activity is already taking place. Define the source and validation methods and who was involved in this part of the process.

Define whether this would be stepped change or FYE and rationale for assumptions

MonitoringIt is foreseen that activity will be monitored through the current PPWT challenge process which occurs monthly.

AffordabilityThe CCGs operate with a finite budget and as such affordability is a decision making criteria. The decision to commission a service will always result in either a decision to reduce another service in order to fund it or will restrict the ability to commission other services.

Not applicable Finance

Legal/Political Challenge CostIf you kept the status Quo what is the potential for legal challenge, and the justification for this assumption i.e. other

It is not anticipated that any legal or political challenges would occur if this policy was adopted. IFR/Legal

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CCGs or advice from legal team. Also Equality Impact.

What is the local political position i.e. Health watch/MP’s.

Next steps Action required/timeline Input/owner1) Collaboration Board review2) Int. stakeholder briefing3) Provider briefing4) Notice period5) Form/policy change6) Implementation

IFR

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Appendix 1 – Proposed NWL PPwT Policy for Cervical and Thoracic Joint injections and medial branch blocks

NWL policy for cervical and thoracic facet joint injections and medial branch blocks

NWL CCGs do not commission facet joint injections or therapeutic medial branch block injections for chronic pain in the cervical or thoracic spine.

Background

There is insufficient evidence for the clinical and cost effectiveness of cervical and thoracic facet joint or medial branch block injections and therefore these injections are not routinely funded by NWL CCGs.

NWL CCGs support alternative treatments such as manual therapies, pharmacotherapy and radiofrequency denervation for the treatment of cervical and thoracic facet joint pain.

Diagnostic medial branch blocks will be funded in order to determine whether radiofrequency denervation is a suitable treatment option.

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APPENDIX 2 – Cervical and Thoracic Facet Joint injections Activity Analysis

Treatment Name 2015/16 2016/17 2017/18 (M1-5)Activity Cost Activity Cost Activity Cost

Cervical and Thoracic Facet Joint injections 120 £86,835 103 £73,433 22 £14,941

Brent 11 £8,111 16 £11,286 1 £631Central London 13 £9,644 12 £8,279 3 £1,996Ealing 19 £14,615 21 £16,053 2 £1,269Hammersmith & Fulham 8 £5,846 7 £4,187 1 £669Harrow 17 £11,731 7 £4,627 3 £1,956Hillingdon 30 £21,041 20 £13,808 5 £3,190Hounslow 12 £8,461 9 £7,324 5 £3,211West London 10 £7,386 11 £7,869 2 £2,019

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Appendix 3 - Equality & Inequalities Analysis Screening

Title: Planned Procedures with a Threshold Proposed Cervical/Facet Joint injections

1. What are the intended outcomes of this work?

Background

The NHS is required to improve the care and health of local populations within a limited and increasingly challenging financial envelope. As part of ensuring the most effective use of resources, standardisation of clinical practice and equity in access for patients the 42 Planned Procedures with a Threshold (PPwT) portfolio of policies are commissioned across the 8 CCGs in North West London. The key underlying principles for the PPwT approach are:

An evidence-based set of criteria are met so that the outcome of the procedure is effective and of benefit to the patient There is an opportunity for local clinical stakeholders to input into changes in policy supported by evidence. Commissioners are commissioning those procedures that have the highest benefit in terms of outcomes. In some instances, including for this policy recommendation, may result in offering some procedures as not routinely commissioned

The NWL Policy Development group were asked to review the effectiveness of cervical and thoracic facet joint injections and sacroiliac joint injections and consider whether a NWL wide policy should be developed – in particular to consider the effectiveness of:

- Cervical and thoracic facet joint injectionsAs a result of the review the recommendations that the NWL Policy Development Group are asked to consider are:

Consider decommissioning the use of cervical and thoracic facet joint injections on the basis of lack of clinical effectiveness and that there are other alternative effective treatments available

Continue to commission the use of radiofrequency denervation for chronic neck pain Recommend that radiofrequency denervation for cervical and thoracic pain, should be monitored and audited on an annual basis.

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Review of Evidence Base for Cervical and Thoracic Facet Joint Injections

A PUBMED search was conducted to review all published meta-analyses, systematic reviews and reviews for each of the search criteria below

‘Cervical facet joint injections OR thoracic facet joint injections AND clinical effectiveness’

cervical"neck"[MeSH Terms] OR "neck"[All Fields] OR "cervical"[All Fields]

thoracic "thorax"[MeSH Terms] OR "thorax"[All Fields] OR "thoracic"[All Fields]

facet joint "zygapophyseal joint"[MeSH Terms] OR ("zygapophyseal"[All Fields] AND "joint"[All Fields]) OR "zygapophyseal joint"[All Fields] OR ("facet"[All Fields] AND "joint"[All Fields]) OR "facet joint"[All Fields]

injections "injections"[MeSH Terms] OR "injections"[All Fields]

clinical effectiveness "treatment outcome"[MeSH Terms] OR ("treatment"[All Fields] AND "outcome"[All Fields]) OR "treatment outcome"[All Fields] OR ("clinical"[All Fields] AND "effectiveness"[All Fields]) OR "clinical effectiveness"[All Fields]

58 relevant articles were found, of which 4 articles were of clinical relevance and in English.

A systematic review by Manchikanti, Pain Physician 2015 evaluated clinical utility of therapeutic cervical, thoracic and lumbar facet joint injections in managing chronic spinal pain. Their primary outcome measures were based on pain relief. The results included 6 randomised controlled trials for cervical facet joint pain, 4 of which were observational studies. Evidence was graded between I and V, where level I is of the highest grade of evidence found. For long term improvement level II evidence was seen for cervical radiofrequency neurotomy (denervation) and cervical facet joint nerve blocks. Level IV evidence was seen for cervical intra-articular injections.

One RCT and one observational study were found describing thoracic facet joint injections. There was level II evidence for thoracic facet joint nerve blocks and level IV evidence for radiofrequency neurotomy for long term improvement.

The review commented on the limitations of the systematic review due to the overall paucity of high quality studies

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Another review by Kiroalani looked at 45 references to review the management of cervical facet joint dysfunction. Again, there was very limited information to determine effective treatment of this condition (Kiroalani, 2008)

One systematic review, published by Falco in Pain Physician in 2012, carried out a systematic review of the literature of cervical facet joint injections. Their review noted the specific lack of evidence for cervical facet joint injections and paucity of clinical trials and data in this area . There was little evidence to show any effectiveness of this procedure. The review was an update to a previous review carried out by the same authors in 2009 and included 2 randomized trials, with one high quality randomized trial which showed negative evidence. This is summarised below:

Level of evidence graded I to III (USPSTF) Evidence for therapeutic facet joint interventions is Level II-1 for medial branch blocks, Level II-1 or Level II-2 for radiofrequency neurotomy.

There is no evidence for effectiveness for therapeutic intra-articular cervical facet joint injections. i.e. there is no evidence of facet joint injections, but some reasonably strong evidence for therapeutic medial branch and radiofrequency

neurotomy

Lastly a paper titled ‘Task Force on neck pain and its associated disorders’ published in the European Spine Journal in 2008 concluded that there was lack of evidence to support intra-articular steroid injections or radiofrequency neurotomy. This task force paper was developed by advisory bodies in different countries.

In summary very few published reviews were found. The systematic reviews which were identified did not show conclusive evidence of effectiveness of facet joint injections for cervical and thoracic facet joint pain, but demonstrated that there radiofrequency denervation may be effective

Diagnostic medial branch blocks and Radiofrequency DenervationIn a review article Manchikanti, 2016, looked at the effectiveness of diagnostic blocks in diagnosing cervical facet joint pain. It determined, after reviewing 11 studies, that the evidence was described as Level II. False positive rates ranged from 27 to 63%, and the prevalence of patients who gained at least 80% of pain relief from the diagnostic block ranged from 36% to 67%.

The article also concluded that there was Level II evidence for the long-term effectiveness of radiofrequency neurotomy (denervation) and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections (facet joint injections).

A Cochrane review published in 2003 by Niemisto looked at the effectiveness of radiofrequency denervation for neck and back pain. The review found 9 articles, of which 6 were deemed to be of high quality. Out of 275 randomized patients, 141 patients received active treatment. Although study sample sizes were small, and follow up times were short, there was some evidence to suggest that radiofrequency denervation provided some short term relief in neck pain. The authors concluded that further research was needed in this area.

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A systematic review by Engel et al, also concluded that there were some clinical benefits of thermal radiofrequency denervation. The systematic review found 8 trials, which looked studied the outcomes of about 200 patients. The evidence showed that a majority of patients were pain free at 6 months and over a third were pain free at 1 year. The number needed to treat for complete pain relief at 6 months was 2.

It was also noted that complications of this intervention were very uncommon, and that the procedure was well tolerated.

Cost effectiveness

No cost effectiveness evidence was found for the use of cervical and thoracic facet joint injections

2. Please outline which Equality Delivery System (EDS2) Goals/Outcomes this work relates to?

Better health outcomes1.1, 1.2

1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities

1.2 Individual people’s health needs are assessed and met in appropriate and effective ways

3. Who will be affected by this work? Provider Trusts contractually in terms of reduction in capacity required and skill mix in secondary care in terms of opportunities for

teaching – however because of the small number of patients this change impacts on this should be limited. There are alternative commissioned services in place such as radio frequency with more evidenced based outcomes.

Secondary Care Clinical Teams providing the existing service Patients and carers who will no-longer have access to the treatment decommissioned in secondary care and where there is limited

alternative provision. Community providers and general practitioners who will be expected to manage these patients with complex health needs. GPs that are no longer able to refer patients for this treatment into secondary – managing the patient’s anxiety.

Evidence

North West London Population Equality Profile

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The approach to the evidence base will be based on the following:

1. Population Profile: Consideration of population profile and whether there are any particular groups within the population that impact would be greater for each of the areas identified.

2. Current Policy: Consideration of the current policy itself and an assessment on whether there would be any impact in terms of health outcomes and improvement in the patient experience.

3. Clinical Evidence: A summary of the clinical evidence base and determine whether there should be any exclusions.

1. Population Profile (Deprivation)The proposal will apply to all patients regardless of their level of deprivation, and there is no evidence to suggest that this proposal will disproportionately applicable to this group. Therefore no patient will be disadvantaged on account of their socio-economic status.”

Central London CCG: There are significant differences within and between electoral wards as a result of varied levels of social and economic deprivation. For example, men living in the least deprived areas are expected to live 16.9 years longer than their counterparts in the most deprived areas. Pockets of deprivation are particularly focused in the northwest of the borough, Church St, and parts of Pimlico. Over a third of children under 16 (35%) live in poverty according to official definitions, which is higher than London and England.

Ealing CCG: Ealing has an overall employment rate of 70%, which is slightly higher than the London average. However, Ealing also has areas of concentrated unemployment, with significant income inequalities. The ward of Dormers Wells is amongst the 1% most income deprived in the country. Life expectancy is 6.2 years lower for men and 3.9 years lower for women in the most deprived areas of Ealing than in the least deprived areas.

H&F CCG: Life expectancy for men in Hammersmith and Fulham is lower than London and England. The difference in life expectancy between affluent and deprived areas in the borough – 7.9 years – is broadly similar to the national average. Life expectancy for women in the borough is lower than London and England. The difference in life expectancy between affluent and deprived areas is similar to the national average, at 5.4 years.

Hounslow CCG: Due to a growing ageing population and the improved awareness and diagnosis of individuals, diagnosis of dementia is expected to increase between 2012 and 2020 by 23.5%. The volume of younger adults with learning disabilities is also due to increase by 3.6%.

West London CCG: Life expectancy for men and women living in the area covered by West London CCG is higher than London and England averages. However, the north of the area covered by West London CCG has correspondingly worse health outcomes. The wards falling into the worst 20% in London for self-reported bad/very bad health, self-reported limiting long-term illness (LLTI) and self-reported working age LLTI are

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Golborne, St Charles, Notting Barns and Cremorne.

Brent: The population is relatively young with 43% of residents under 30 years old. Brent is ethnically diverse with 65% from black, Asian and minority ethnic (BAME) backgrounds Brent is ranked amongst the top 15% most-deprived areas in the country where children and young people are most affected with a third of children in Brent living in a low income household.

Harrow: has one of the highest proportions of those aged 65 and over compared to the other boroughs in North West London. More than 50% of Harrow’s population is from Black and Minority Ethnic (BAME) groups. The biggest of these is the Indian ethnic group who make up over a quarter of the Harrow population. Less than half of the children in the Borough speak English as a first language.

Hillingdon: By 2021, the overall population in Hillingdon is expected to grow by 8.6%. This future increase is mainly due to an expected 10% rise in population under 15 years and a 15.4% rise in the population of those 75 years and over. Hillingdon is an ethnically diverse borough with around 30% of the population from black and minority ethnic communities. The largest ethnic community is the Asian community, with the Indian community forming 13% of the total population.

The EQIA screening looked at if there was any evidence of prevalence, e.g.:

Age: Facet joint syndrome can be caused by a combination of aging, pressure overload of your facet joints, and injury.

Disability: Could a patient feel their disability is worsening due to lack of treatment as part of this policy

Race: Are there any specific racial groups who have a greater prevalence to seek such treatment? The same for Sex, sexual orientation and religious belief.

The conclusion was that the policy does not discriminate against those with disabilities or older patients (who are more likely to have facet joint disease). The clinical exceptionality clause is prudent to include.

Race: facet joint disease is not related to race, gender, sexual orientation or religious belief.

2. Summary of Current Clinical Thresholds:

Age

o 50% of people over 65 live aloneo 21% of the population in North West London are Children; of those, between 10% - 20% of children Live in households with no adults in

employment

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Disability

NWL STP outlines the following data

21,000 adults have severe physical disabilities 7,000 adults have learning disabilities 5,000 adults have advanced dementia 37,500 adults have serious and long term mental health needs

Gender reassignment (including transgender)

There is a dearth of information on gender reassignment. Using the national profile as a benchmark we know that there is no clear consensus on how to define and enumerate the trans-gender population. However, it is likely that transsexual people represent a small proportion of those who might be considered trans, estimates for the UK ranging between 1,550 and 5,000.

Pregnancy and maternity

N/A

Race

The percentage of BAME residents in CWHHE and BHH CCGs are as follows:

38% of residents in Central London 46% of residents in Ealing 32% of residents in Hammersmith and Fulham 63% of residents in Hounslow 35% in West London 65% in Brent 50% in Harrow 30% in Hillingdon

Religion or belief

The percentage of population by religion in CWHHE is as follows:o K&C: 55% Christian, 13% Muslim and 26% No Religiono H&F: 54% Christian, 11% Muslim and 30% No Religion

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o Ealing: 45% Christian, 19% Muslim and 17% No Religiono Hounslow: 47% Christian, 15% Hindu, 14% Muslimo Westminster: 49% Christian, 19% Muslim and 24% No Religiono Brent: 38% Christian, 23% Muslim and 19% Hinduo Harrow: 34% Christian, 26% Hindu, Muslim 15%o Hillingdon: 46% Christian, 21% No Religion, 15% Muslim

Sex

Please refer to the following datasets:

London Data Set London Assembly Constituency Data Profiles 2016 Local Authority Profile – Nomis 2015

Sexual orientation

Not Available

Carers

N/A

Other identified groups

Homeless

Please Refer to the reports below. Given Homeless population in Westminster – and Inner North West London Borough, consideration needs to be given to working with homeless organisations to assess impact of proposals:

Tri-borough Public Health Report (2015-16) The Passage – to ending homelessness Sleeping Rough in Westminster: Health, Wellbeing & Healthcare. Report of the Homeless Health Task and Finish Group (December, 2013) Hounslow JSNA Supported Sousing Section (2014) Ealing JSNA – Housing, homelessness and rough sleepers (2015)

The screening asked could their ‘living environment’ make this group more susceptible to the conditions?

Also the high homeless population could mean that without GP registration they could be presenting themselves at Acute (primary care) and this

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was concluded as no.

Commissioning Impact- By Activity and Cost

Table 1 below shows the expected level of activity impacted by CCG. This shows that there will be an overall impact that base on FYE for 2016/17 there was 136 episodes with a cost of £123k.

Table1 below shows actual spend by CCG for year 15/16, 16/17 & 17/18 (M1-M5)

CCG Name2015/16 2016/17 2017/18

Activity Cost Activity Cost Activity CostCervical and Thoracic Facet Joint injections 120 £86,835 103 £73,433 22 £14,941Brent 11 £8,111 16 £11,286 1 £631Central London 13 £9,644 12 £8,279 3 £1,996Ealing 19 £14,615 21 £16,053 2 £1,269Hammersmith & Fulham 8 £5,846 7 £4,187 1 £669Harrow 17 £11,731 7 £4,627 3 £1,956Hillingdon 30 £21,041 20 £13,808 5 £3,190Hounslow 12 £8,461 9 £7,324 5 £3,211West London 10 £7,386 11 £7,869 2 £2,019

Grand Total 148 £118,293 136 £123,726 29 £18,441

Commissioning Impact – By Provider

Appendices1 below shows the breakdown of activity by provider. This provides an understanding of whether any particular providers will be particular impacted in the proposed service change. This shows that based on the data presented, Hillingdon Trust have a higher proportion of activity that any other providers commissioned by NWL CCG’s. However as the overall activity numbers are small it is deemed that there should be no significant impact in the overall service provided by Hillingdon by the pain management service as there will be alternative options for patients clinically, such as pain management programmes in primary care. The number of patients affected has also been endorsed by clinicians providing the service.

Engagement and involvement

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Patient, Service User and Population Engagement:

To date the proposals have not been discussed with any patient groups or engagement forums. It has been identified that as the population impacted is so small, it would be difficult to identify the particular patient group to engage with. It is also highlighted that as the driver for the change is clinical effectiveness that the alternative provisions for the patients would have better clinical outcomes.

Staff Engagement – Clinical

North West London consultants in pain medicine, radiologists and rheumatologists, were invited to a clinical forum held in September 2017.

It was an opportunity to discuss the clinical value of these procedures as well as the clinical pathway and indications for treatment.

There was a mixed view about the value of these injections, but agreement in that the evidence was limited. There was concern that it would be difficult to apply results of clinical papers to patients who present with complex pain syndromes, and that a ‘one size fits all’ approach was not appropriate in treating many of these patients.

There was wide agreement that physical therapies such as physiotherapy and lifestyle changes were probably more impactful for these patients with chronic pain than providing joint injections.

The consultants explained that cervical and thoracic facet joint injections are not commonly given in secondary care, and activity numbers varied across NWL trusts.

Sacroiliac joint injections were carried out even less frequently by pain clinics.

It was suggested that some activity was carried out by radiology and rheumatology departments who were not well represented at the meeting. There was concern that some injections were being carried out without a multidisciplinary review to determine whether or not a spinal injection was in the best interests of the patient.

Following on from the meeting, the IFR Team emailed a wider group of consultant rheumatologists and radiologists.

Consultant rheumatologists fed back that injections for inflammatory sacroiliitis were clinically effective

Summary of responses from Consultant Rheumatologists

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Are there any clinical indications for these injections?

Where in the pathway are they given? E.g. failure of conservative treatment, physio etc.

How often are these injections being offered?

How effective are they?

Cervical and Thoracic Facet Joint injections

Thoracic facet joint injections are used occasionally for individuals with vertebral compression fractures with persistent severe pain. Done by radiologists.

Rarely Prior trial showed efficacy equivalent to vertebroplasty

Risks/Possible Impacts

Policy Area Possible Impact Mitigation

Clinical Ownership in secondary care

There may be lack of clinical ownership and therefore compliance in secondary care if local clinicians feel that they are not engaged in the decision making

A workshop was arranged and on-going dialogue with a clinical e-group. Feedback has been reflected into the final proposal for consideration where supported by clinical evidence. The final recommendation that is going back to the PDG is to decommission cervical and facet joint injections only. There are also alternative treatments in place that offer a reduced risk of harm to the patients and are supported by stronger evidence base. These include radiofrequency denervation.

GP Engagement GPs may not know how to manage the patients in primary care who have been receiving this treatment on an on-going basis

Local commissioners need to ensure that alternative pathway provision is clearly communicated to GP. There are

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alternative treatments provided within pain management services

Patient Engagement Patients may be left in pain as alternative provisions are not clear

Ensure clear communication with general practice

IFR’s GP requests patient referred to secondary care outside of the decommissioned activity. This may result in higher number of IFRs being referred.

On-going engagement with GPs re terms of exceptionality and ensure clinical triage team are familiar on the parameters of the new policy.

Homelessness Given Homeless population in Westminster – and Inner North West London Borough are high

Although not a Protected Characteristic, Consideration needs to be given to working with homeless organisations to assess impact of proposals locally.

Monitor and Evaluation

4. How will you monitor and evaluate the effect of your work on Promoting Equalities and Reducing health inequalities?

Numbers of IFR’s receive post change will also be monitored to see if there are any patterns of exceptionality that may influence changes to the model.

Recommend that radiofrequency denervation for cervical and thoracic pain, should be monitored and audited on an annual basis

For your records

Name of person(s) who carried out these analyses: June Farquharson

Name of Sponsor Director: Diane Jones/Dr Lily Wong

Date analyses were completed: Feb 2018

Review date: 27 February 2018

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Reference

1. Healthier North West London: Borough Information Packs; https://www.healthiernorthwestlondon.nhs.uk/documents/borough-information-packs

2. North West London Strategic Transformation Plan; https://www.healthiernorthwestlondon.nhs.uk/documents/sustainability-and-transformation-plans-stps/stp-october-submission-2016

3. ONS Data on Religion and Belief: https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/religion/articles/religioninenglandandwales2011/2012-12-11#differences-in-religious-affiliation-across-local-authorities

4. https://books.google.co.uk/books?id=xubPt2ae4YcC&printsec=frontcover#v=onepage&q&f=false

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