Organisation develops an exercise plan to help improve orthopaedic surgeries and care, increasing patients’ self-reliance and saving £22m

Synopsis

10 million people in the UK suffer pain and/or disability from knee and/or hip osteoarthritis. Enabling Self-management & Coping with Arthritis Pain using Exercise, ESCAPE-pain, is a rehabilitation programme that combines education, self-management strategies and exercise. The programme:

• Reduces pain
• Improves physical function, activity and mental wellbeing,
• Reduces healthcare utilisation
• Is more cost-effective than usual care.

We have delivered training and support to enable NHS and leisure providers to transform care. Starting from just 2 sites in 2014, ESCAPE-pain is now delivered by physiotherapists and exercise professionals at 265 locations across the UK; 15,000 people have benefited from the programme.

Ambition

Osteoarthritis causes pain, reduced mobility, impairs physical, mental and emotional well-being, independence, quality of life and increases the risk of comorbidity and mortality. By 2030 the number of people with osteoarthritis will double, dramatically increasing the pressure on health and care services.

Despite its prevalence, osteoarthritis is managed poorly. NICE guidelines recommend people with osteoarthritis receive advice about weight control, exercise/physical activity, self-management and pain-coping strategies. Unfortunately, few people receive this advice, most are maintained on long-term analgesia, which is unpopular, often ineffective, expensive and risks serious side-effects. Joint replacement is invasive, expensive, has limited availability, and is unpopular and contra-indicated in many older people. Consequently, people endure many years of unnecessary pain and disability.

To deliver NICE’S recommendations we developed, Enabling Self-management and Coping with Arthritic Pain using Exercise, ESCAPE-pain. This is a rehabilitation programme integrating information, advice and exercise. It helps people understand their problem, dispels erroneous health beliefs, advises them what (not) to do and allows them to experience the benefits of exercise. Led by a trained facilitator (clinician or exercise professional), groups of 8-12 people, aged 45+ years with chronic knee and/or hip pain attend 12 sessions (twice a week for 6 weeks). Each session comprises:

• 25-minute information/advice component-themed discussions and shared-learning about causes, prognosis, self-management/coping strategies;
• 45-minute exercise component - supervised personalised, progressive, exercise regimen to increase strength, endurance and function;
• Behavioural change techniques (motivational interviewing, goal-setting, action/coping planning) are incorporated into the programme.

The blend of information-giving, shared-learning and experiential-learning challenges beliefs about joint pain and promotes healthier lifestyles, in particular the importance of regular exercise and maintaining a healthy body weight. Participants learn they can regain control of their lives and alter the course of the condition.

We developed an accredited, award-winning (UKActive ’Specialist Training Programme 2019) training programme to enable clinicians and exercise professionals to deliver a standardised, safe, effective programme in clinical and non-clinical community venues, ESCAPE-pain is aligned with efforts to prevent ill-health and promote self-management through provision of evidence-based interventions that maximise value.

The programme is support by NHS England (NICE, QiPP, RightCare, Innovation Accelerator, Accelerated Access Collaborative cited in the “Long-Term Plan”), Public Health England, Sport England, Versus Arthritis, Arthritis Rheumatism and Musculoskeletal Alliance, and professional bodies Chartered Society of Physiotherapy, British Society of Rheumatologists, Chartered institute for Management of Sport and Physical Activity.

Outcome

In the largest clinical trial of its kind ESCAPE-pain has been shown to reduce pain, improve physical function, health beliefs and general well-being, was more cost-effective than usual primary care and outpatient physiotherapy, substantial reduction in healthcare, with benefits lasting for up to 2 1/2 years.

Extrapolation of the economic evaluation suggests every 1,000 participants who undertake ESCAPE-pain could yield potential savings of £1.5m in total healthcare through reduction in GP, secondary care inpatient, outpatient and A&E appointments, investigations and interventions. A proportion of these savings are cash-releasing, but also save precious clinical time.

Public Health England independently assessed ESCAPE-pain and estimated a return of £5.20 for every £1 invested. The York Economic Health Consortium estimated a return on investment of £1:£8.81 when a CCG commissioned a community organisation to deliver ESCAPE-pain in their community venues.

Gathering participant’s experiences of the programme have always been a priority to us, because it enables us to understand whether, how and why the programme is valued, effective and can be improved, and capture ESCAPE-pain’s wider benefits. We conducted formal qualitative evaluation in our original clinical trial and have continued to gather feedback form participants, facilitators and partner organisations as the programme was delivered in “real world” clinical departments and community venues.

Participants describe how ESCAPE-pain’s education component increases their understanding of their condition and how to manage it, while successful completion of the exercise regimen engenders a sense of achievement and they appreciate exercise is a safe, effective, self-management strategy they can use to help themselves.

They find everyday activities such as climbing stairs, sleeping, getting on/off a toilet, playing with grandchildren is easier, which has enormous effects on their quality of life, mental and emotional wellbeing. The programme not only encourages people to be more active, it enables them to get out, return to occupational, leisure and family activities they may be avoiding, which helps overcomes socialisation isolation older people often experience.

Overall participants feel better, more confident, positive, optimistic and in control of their lives. ESCAPE-pain increases their self-reliance, empowering them to use activity as an alternative to medication and surgery. This may explain the reduction in healthcare resources, and how participants describe their willingness to delay/avoid surgery. If 10% of ESCAPE-pain participants decline surgery, for every 1,000 participants completing the programme could save £1 m (assuming costs of £4,000/hip and £6,000/knee replacement).

Spread

Since 2014 we have been working to spread ESCAPE-pain across the UK. Until 2018 the programme was delivered by physiotherapists in outpatient departments. We recognised that NHS constraints (logistical and financial) seriously limited the number of people who could access the programme, so we adapted our training programme to enable exercise professionals to deliver ESCAPE-pain in community venues.

The one-day accredited training programme teaches facilitators the programme’s ethos, content, format, behavioural change techniques, data collection requirements and implementation resources. This increase fidelity to the programme, standardises delivery across a range of geographical areas and delivery models thereby reducing variation and helps quality assure the programme. It also allows us to incorporate feedback from facilitators and participants to improve the programme.

The clinical trial was vital for providing robust evidence for the programme’s benefits. We have continued to collect outcome data from our clinical and community partners to ensure the programmes benefits and facilitator and participant experiences are reproduced when applied in “real world” locations. Data is collated in a central database, shared with all our partners, but each venue is individually benchmarked so that they can see how they are performing, and can be offered support if needed. Data remains vital in quality assuring the programme.

We provide a range of implementation resources. Our website (escape-pain.org) is crucial for communicating with our partners and participants. It contains testimonies from facilitators/participants, background information and case-studies for people considering the programme, an interactive map showing where ESCAPE-pain is being delivered, with contact and referral details. We have developed an app replicating the programme as a complementary resource.

Learnings from implementation of the programme are shared through:

• An annual conference showcasing achievements of sites and participant’s stories;
• Quarterly face-to-face learning networks;
• Webinars
• Social media - Twitter, Facebook groups, email for ESCAPE-pain facilitators and participants can share their experiences;
• Presentations at local, national and international conferences and events
• Contribute to videos (featured alongside Lord Darzi and Simon Stevens highlighting NHSE’s new Accelerated Access Collaborative) and reports (Kings Fund, NIA, NIHR Dissemination Centre)

ESCAPE-pain is currently (December 2019) delivered in 265 centres across the UK, almost half of which are community centres, by 1100 trained facilitators, over 15,000 people have benefitted and saved health and social care systems over £22m.

We are currently piloting ESCAPE-pain for backs. The early results are very encouraging, and we are planning a controlled rollout across the UK from spring 2020.

Value

The ethos of ESCAPE-pain aligns with NHS England’s aim to improve supported self-management for people with Long Term Conditions. In particular, it promotes physical activity that can help tackle several common co-morbidities simultaneously (diabetes, cardiovascular conditions, obesity, etc.). The focus of care is shifted to early intervention, preventing ill-health and avoiding “turning people into patients”, by facilitating easier access to effective integrated health and community services in local communities.

ESCAPE-pain offers a solution to many issues health and social care systems commonly grapple with. It is an effective alternative for older people who don’t want surgery, or for whom it is contra-indicated. It can help address the rising demand for orthopaedic surgery and the difficulties achieving the 18-week wait, reduce physiotherapy waiting times, the pressure on GP and primary care and the use medication, in particular use of opioids.

Matt Whitty, Deputy Director of Innovation and Life Sciences, NFIS England and NFIS Improvement: “…ESCAPE-pain is a great example of a proven, low-cost innovation that transforms lives. It will mean more people with chronic joint pain getting better care in their local communities and being able to live more independently with a higher quality of life. Responding to needs through this sort of cross sector working is crucial to how we will deliver the NHS Long Term Plan.”

Sarah Worbey, Health and Inactivity National Partnerships lead, Sport England: “…ESCAPE-pain fits perfectly into community and leisure settings…participants are making important lifestyle changes and becoming more physically active.”

David Rawlings, exercise professional: “…people love it and for some it literally is life-changing…Some of the participants had stopped going out and participating in family life or in their community. After attending the programme, they become more active, are able to manage their pain and their arthritis better and build the confidence to move and become more active again.”

Jenn Holeman, senior physiotherapist: “…it saves the NHS money because rather than 30-minute one-to-one physiotherapy sessions people are having group sessions. It relieves the pressure on GPs because it cuts down on the amount of patients seeking treatment for their symptoms.”

Sandra, 84 year old ESCAPE-pain participant: “…I feel much better in myself because I can do things again…I don’t think I need knee surgery. The pain is much less and it doesn’t bother me. I know how to cope now…”

Involvement

ESCAPE-pain evolved from rehabilitation programmes that were too long, expensive, and impracticable and delivered education and exercise separately rather than as a coherent integrated programme. Its content and format was informed by NICE clinical guidelines, but co-created with participants, healthcare professionals and commissioners to ensure it produced a programme that is safe, effective, deliverable and affordable. Our ongoing “Participant Engagement Strategy” is an important conduit for capturing participant, facilitator and organisational experiences, what’s not working, why and how to fix things.

We appointed an “Implementation Fellow” to systematically gather the experiences of NHS commissioners, managers and clinicians as they progressed through the stages of considering, implementing and sustaining ESCAPE-pain. We identified the important organisational facilitators (e.g. effective leadership) and barriers (commissioning models, impracticalities), and work with our partners to develop arguments, systems and processes to facilitate programme delivery.

To supplement the programme we developed a smartphone app, online programme and outcomes portal. These have all involved working closely with participants and clinicians to develop valued, useful and useable resources.

Delivering ESCAPE-pain in community venues has helped several NHS and community/leisure organisations work together more closely, addressing professional worries and sensitivities, establishing local referral pathways and innovating, with CCGs commissioning co-delivery of the programme outside clinical settings. The organisations utilise their staff and facilitates better, and they have identified tremendous possibilities in co-delivering health interventions in through leisure/community venues. For example, in:

• Cheltenham participants are referred from physiotherapy, physiotherapists and exercise professionals co-deliver the programme, leisure centres provide facilities free and cover cost by signing up participants as members or post-programme activities;
• Crewe and East Riding the local CCGs have contracted with a leisure organisation to deliver the programme
• Bury leisure provider is partnering with Public Health, charging a small nominal amount to cover costs.

Participants tell us that accessing ESCAPE-pain in their local community is more convenient, avoids travelling to hospital, de-medicalises their problems, and makes them feel more comfortable and less intimidated of community leisure facilities. Such cross-sector collaboration is one the chief aims of the NHS’s Long-Term Plan and Integrated Care systems. The community organisations are instigating a range of “exit opportunities” (such as exercise, swimming, dance, walking groups) to help people continue to be physical activity - habitualising exercise after completing the programme.

We capture and share people’s experiences, problems and solutions in our webinars, networks, etc, as described above.