NICE guidelines are often in the headlines when it comes to access to cancer drugs – but what do they mean when it comes to back pain and where do insurers stand on the issue? Emily Perryman reports
The media’s focus on the National Institute of Clinical Evidence’s (NICE) cancer guidelines in recent years has meant that less serious conditions such as back pain have received little attention. Although back pain rarely signifies a severe illness, it can result in individuals being absent from work or not being able to perform all of their duties.
It is estimated that four out of every five adults (80%) will experience back pain at some stage in their life. According to the Office for National Statistics, the greatest number of working days lost to sickness absence in 2011 was due to musculoskeletal problems. This accounted for just over a quarter of the days lost, or 34.4 million days. From an employer’s perspective, understanding the best ways of treating and preventing back pain is essential to their bottom line.
“In terms of the effect of back pain on the individual, it is clear that there is a lot of physical impact on them which can affect their ability to concentrate at work and in some instances stop them from performing their job role fully. This is especially true with people who are required to complete manual labour for their job,” says Sam Daplyn, physiotherapist at Physioworld, partner company of occupational health provider Corporate Health. “In terms of the impact of the individual’s back pain on the employer, it can only be assumed that the longer the person is unable to fulfil their normal work role, the more inconvenience that is caused.”
NICE guidelines cover the early treatment and management of persistent or recurrent low back pain, defined as non-specific low back pain that has lasted for more than six weeks but for less than 12 months. Mark Armour, clinical director at RehabWorks, a private medical company specialising in musculoskeletal and mental health problems, says the guidelines pose three challenges for rehabilitation providers. First, they advise that they provide people with advice and information to promote self-management of their low back pain.
“Not many patients take kindly to being offered the opportunity to embark on a self-help exercise programme to alleviate their symptoms,” says Armour. “For many individuals experiencing an episode of excruciating back pain, the last thing your mind is telling you to do is move about more.”
Second, the guidelines advise the following treatment options: an exercise programme of eight sessions over a period of up to 12 weeks; a course of manual therapy with a maximum of nine sessions over a period of up to 12 weeks; or a course of acupuncture up to a maximum of 10 sessions over a period of up to 12 weeks.
“Notably we are advised to consider offering another of these options if the chosen treatment does not result in satisfactory improvement,” continues Armour. “This could potentially result in the total number of sessions reaching 20, which I am sure would not fill our referrers with joy on receipt of such invoices. It would be exceedingly poor practice to reach the 10th session to discover that goals have not been met and further treatment is required.”
Third, practitioners are advised to consider referral for a combined physical and psychological treatment programme should patients have received at least one less intensive treatment and have high disability and/or significant psychological distress. Armour says there is a common misconception between referrers and providers that in the instances when physical intervention has not worked, psychology should be introduced.
“In many circumstances we are over medicalising – and over pricing – the clinical delivery of mild to moderate psychological issues such as fear of movement or low mood, which can be addressed using a common sense psychosocial approach,” he says.
Charlie Vivian, medical director of Corporate Health, agrees that providers need to understand how an individual reacts to their back pain, as well as looking at their physical symptoms.
“Whether low back symptoms are attributed to work, are reported as ‘injuries’, lead to healthcare seeking and/or result in time off work depends on complex individual psychosocial and work organisational factors,” he says. “The development of chronic pain and disability depends more on individual and work-related psychosocial issues than on physical or clinical features.”
INSURERS AND BACK PAIN
Insurers use the NICE guidelines to inform their approach to managing back pain, but they do not follow them word-for-word. Some have adopted the psychosocial approach when determining how to treat employees. Jan Vickery, lead physiotherapist in the Health Services division of AXA PPP healthcare, says she will always consider the individual’s beliefs about back pain and any barriers that might hinder their recovery.
“The employee might face a lack of support from their colleagues or believe that working will make their back pain worse,” Vickery says. “We can work through these issues one by one. The message then is to get moving and keep active, once we have screened for red flags that indicate a more serious condition,” she says.
Having private medical insurance (PMI) in place is comforting for employees who have back pain because they can be referred to a specialist much faster than via the NHS. It can also save employers money by reducing the amount of sickness absence.
“PMI is highly beneficial in these times; some employers have staff who do not have PMI cover and are faced with long NHS waiting times,” says Vickery. “In some such cases, there is a cost benefit to the employer funding private treatment in order to prevent the knock on costs of having that person go off or not work to their full capacity.”
AXA PPP healthcare has a ‘Back to Health’ service which it introduced as a way of extending fast-track treatment to staff who do not have PMI. If an employee complains of back pain, the employer and their occupational health adviser will assess whether the condition is preventing them from doing their job. They will then decide whether treating back pain via the NHS would result in a protracted wait and, if so, whether private treatment would be more cost-effective. If the employer decides to proceed, their occupational health team can book treatment directly with providers or the employer can use AXA PPP’s fast track booking service. Back to Health is cheaper than PMI because it only pays for the treatment of medical conditions where the employee is prevented from undertaking their normal work duties and it does not cover employees’ dependants.
Aviva UK Health, meanwhile, has a ‘Back-Up’ service which focuses exclusively on back pain. An employee can phone Aviva and speak to a physiotherapist within a couple of hours. The physiotherapist will ask a series of questions about the level of pain, how much the individual is struggling, their previous medical history, their perceptions of back pain, whether they want to return to work, and so on.
“Some people will have a very low level of back pain which needs online or telephone advice, about 80% will require face-to-face time with a physiotherapist, and a small percentage will have significant symptoms needing specialist treatment,” says Mark Sharpe, clinical lead for Aviva’s Back-Up service. “We will look after all back pain, from mild to severe. The focus is on getting the individual better quickly so that corporates spend their money effectively.”
Back-Up is part of Aviva’s core cover for large corporates who can also upgrade to Back-Up Plus, which covers all musculoskeletal conditions. The plan is optional for SMEs, but Aviva is planning to look at its SME proposition this year.
“SMEs have different budgets and working environments so we need to ensure Back-Up meets their needs,” says Sharpe. “We will be making an announcement on how we plan to roll out the service to SMEs later this year.”
The recent product launches by Cigna HealthCare Benefits and Bupa – condition-specific or stripped-down PMI plans which target musculoskeletal and mental health conditions – will hopefully lead to even more progress in treating and preventing back pain.
Back pain and cash plans
Cash plans can be a good way of treating back pain for employers who cannot afford PMI. The therapies benefit typically includes physiotherapy, acupuncture, osteopathy, chiropractic and homeopathy.
“In some respects cash plans are better than PMI. An employee with PMI would need a GP referral which can cause delay and the excess might also put them off. With a cash plan there is no excess, the employee can arrange treatment at any time and all pre-existing conditions are covered,” says Paul Shires, executive director at Westfield Health.
Back pain facts and figures
* Low back pain affects around one-third of the UK adult population each year.
* It is estimated that four out of every five adults (80%) will experience back pain at some stage in their life.
* Forty per cent of GPs have seen an increase in the numbers of patients with musculoskeletal issues in the last year.
* The greatest number of working days lost to sickness absence in 2011 was due to musculoskeletal problems.
* The most common claims made by all of Aviva’s PMI customers are, in order, knee pain, lower back pain, shoulder pain, neck pain and abdominal pain.
Source: NICE, Office for National Statistics, Backcare.org.uk, Aviva