Managing Headache Headache is an increasing problem - PowerPoint Presentation

Managing Headache

Headache is an increasing problem Figures for specific CCGs available at: https:// www.gov.uk/government/publications/neurology-services-hospital-activity-data 24% increase in those in treatment for headaches and migraine in the past 5 years

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

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

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 Neurology outpatient clinic Emergency presentation

Most primary headache disorders and medication overuse headache are more appropriately diagnosed and managed within the community Neurology outpatient clinic Community headache clinic Faster access Closer to home

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

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.

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 clinicImaging without outpatient appointmentGeneral neurology out patient appointment Specialist headache clinic

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% Likely result of triage of headache referrals (based on case audit in Oxford)

Triage of referrals Self-management of simple headache More disabling headache More complex or headache plus presentations GP Specialist Support Support to population from education, GP advice, pharmacist, practice nurse, Headache Clubs, patient meetings, access to resources Support to GP from education, specialist advice Headaches, co-morbidities, psychological concerns, frequent attenders to reduce crisis and enable management by GP or self-management

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

Patient education and advice from Pharmacy GP Headache consultant triage Neurology outpatient clinic Specialist Headache clinic MRI without outpatient appointment Advice Referral GP management A and E Headache pathway Community Headache Clinic Emergency referrals including symptoms of brain tumours have their own dedicated 2 week pathway

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)Cost of appointments

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 appointmentAdvising 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

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 savingsThere are many factors the CCGs need to consider as outlined on the following slidePotential savings

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 nurseCosts 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 Setting up a new headache pathway

Benefits In Oxfordshire the revised headache pathway will: Provide a more efficient local service Enable faster access to the right supportImprove patient experience and skills for self managementImprove knowledge and skills in primary carePay for itself Reduce referrals to acute sector which can be managed locallyReduce emergency admissions and attendances Speed up access to specialist support For further details on the Oxfordshire experience contact: Dr Zam Cader , Consultant in Neurology zameel.cader@ndcn.ox.ac.uk or Dr Richard Wood, GP Richard.Wood@oxfordshireccg.nhs.uk