Written evidence submitted by the Royal College of Chiropractors (PRI0062)

 

1. Executive summary

 

 

2. Introduction

 

2.1               The Royal College of Chiropractors (RCC) is a Royal Chartered academic membership organisation. Approximately half of the UK’s 3000+ statutorily-registered chiropractors are current members of the RCC. Its charitable objects include improving and maintaining standards in the practice of chiropractic for the benefit of the public, and promoting awareness and understanding of chiropractic amongst medical practitioners and other healthcare professionals and the public. The RCC fosters quality, safety and excellence by publishing quality standards, providing quality awards, administering safety incident reporting and awarding research grants.

 

2.2              Chiropractic is a profession, not a treatment or mono-therapy. Chiropractors are trained to assess and triage patients with MSK conditions, to formulate a diagnosis and prognosis, to provide a treatment plan taking into account the patient’s views and, where appropriate, to refer to other health care professionals. Chiropractors provide a wide range of interventions that may include, but are not limited to, manual therapy techniques (including spinal manipulation and mobilisation), exercise rehabilitation and self-care advice. Dry needling/medical acupuncture may also be offered. Chiropractors can deliver these treatments within psychologically-informed programmes of care. Chiropractic, like other healthcare professions, is informed by the evidence base and develops accordingly. Since chiropractors have a broad clinical remit in the field of manual therapy, the evidence-base for the care they provide is the same as that for the care provided by physiotherapists and osteopaths.

 

 

2.3              Low back and neck pain are the leading cause of disability in the UK contributing 23% of total years lived with disability (YLDs), and this level of disability is likely to increase due to population ageing, increasing obesity and lack of physical activity (Murray et al, 2013). The growing burden can only be controlled if sufficient priority and resources are focused on interventions known to be effective in addressing the problem.

2.4               The RCC is submitting this evidence because we believe a highly-trained chiropractic workforce that could significantly enhance cost-effective provision of MSK services in the community is being seriously underutilised due to inappropriate barriers to NHS commissioning.

 

3. Our evidence

 

3.1               Chiropractics are regulated by the General Chiropractic Council, established under the 1994 Chiropractors’ Act. More than 3000 chiropractors are registered to practice in the UK of which 2347 are registered to practice in England (GCC Registrations Manager, pers. comm., 25/08/15). Chiropractic students in the UK study for 4-5 years to gain their Master of Chiropractic degree.

 

3.2               The care provided by chiropractors has been shown to be effective for a wide range of conditions (Bronfort et al, 2010; Clar et al, 2014).

 

3.3               Taking low back pain as an example, The UK Beam Trial Team (2004a) estimated the effect of adding exercise classes, spinal manipulation or manipulation followed by exercise to “best care” in general practice. Exercise improved disability more than “best care” at three months and, for manipulation, there was an additional improvement at three months and 12 months. For manipulation followed by exercise, there was an additional improvement at three months and 12 months, although a related study found that manipulation alone provides better value for money than manipulation followed by exercise (UK Beam Trial Team, 2004b). A care package that includes spinal manipulation, as provided by chiropractors, was subsequently recommended in the evidence-based NICE guidelines for the treatment of persistent low back pain (NICE, 2009a). Tsertsvadze et al (2014) established that manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) are more cost-effective than usual GP care alone or with exercise, spinal stabilization, GP advice, advice to remain active or brief pain management for improving low back pain/disability.

 

3.4               In relation to low back and radicular pain, Santilli et al (2006) found that, compared with sham manipulation, active spinal manipulation is more effective at six months at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion. A recent network meta-analyses of the many different treatment strategies for sciatica found that spinal manipulation is one of the interventions that provides significant improvement compared to conservative therapy (Lewis et al, 2015).  In 2013, Peterson et al demonstrated similar effectiveness and a cost benefit of employing spinal manipulation as opposed to nerve root injections for patients with symptomatic MRI-confirmed lumbar disc herniation.

 

3.5               NHS England’s national ‘Pathfinder’ Pathway of Care for Low Back and Radicular Pain (NHS England, 2014) provides a generic pathway for the management of low back and radicular pain, as agreed by all stakeholders. It specifically recognises the role of chiropractors in early clinical triage and initial treatment. It also defines the competencies and skills required for: ongoing intervention for low risk patients, identifying red flags, radiculopathy assessment and initial management, further ‘triage and treat’, delivering core therapy for back pain, specialist triage review following core therapies, provision of combined physical and psychological treatment plus subsequent triage and provision of conservative therapy for lumbar radiculopathy, and these closely match the core competencies and skills of chiropractors.

 

3.6               The RCC estimates that no more than ten chiropractic service providers are currently commissioned to provide NHS-funded MSK services. Such providers typically operate as part of an integrated MSK service that also involves osteopaths and physiotherapists.

 

3.7               A novel Manual Therapies Back and Neck (Any Qualified Provider) Service, which integrated 20 different providers of chiropractic, osteopathy and physiotherapy based in NHS North East Essex, was the subject of an NHS case study published in 2011 (Department of Health, 2011). During 2009/10, 2,810 patients used the service and 97% of patients were seen within two weeks of referral. During this period, improved patient access and choice, early treatment and improved outcomes were identified. The service also reduced primary care consultations, imaging, medication costs and inappropriate referrals to secondary care with referrals to spinal surgeons down by more than 25%. In 2009, this approach to offering chiropractic, osteopathy and physiotherapy services to treat back and neck conditions, received the NHS Alliance Acorn Award. The key findings of the study, that this multidisciplinary back pain service resulted in high satisfaction levels among patients and GPs, reductions in primary care consultations and reductions in inappropriate referrals to secondary care, has been further described by Gurden et al (2012).

 

3.8               Currently, the vast majority of chiropractic patients consult chiropractors in the private sector, but it has been shown that MSK patients are equally satisfied receiving care from a chiropractic service provider whether that care is provided privately or with NHS funding. A recent study was able to examine the outcomes of NHS patients presenting with MSK conditions to chiropractors under an innovative AQP commissioning pathway in the south of England, and compare the clinical outcomes of these patients with those presenting privately.

 

              The study found that, in terms of improvement, those presenting for chiropractic care either privately or via their NHS GP experienced excellent results across a range of patient-reported outcome and experience measures; more than 99% of patients were satisfied with their experience of chiropractic care. 95% of those receiving NHS-funded chiropractic care reported their expectations had been exceeded compared to 90.6% of private patients (Field and Newell, 2015a; Field and Newell, 2015b).

3.9               A recent analysis of the UK population’s attitudes suggests that people are open to a variety of providers when it comes to personal treatment, with nearly half the population indicating no preference when asked if they’d rather be treated by an NHS provider, an independent non-profit or a for-profit provider (Niemietz, 2015).

 

3.10               Barriers exist to the commissioning of chiropractic services by Clinical Commissioning Groups, which may include:

 

 

We have identified a specific barrier to the commissioning of chiropractors and osteopaths which does not apply to physiotherapists. The Service Restriction Policies of CCGs are specifically excluding the funding of ‘complementary or alternative therapies’ (see Appendix) and, in this context, chiropractic and osteopathy are being erroneously included in this category.  Such policies fail to recognise the distinct status of chiropractic and osteopathy as statutorily-regulated professions, that the care they provide for persistent low back pain is underpinned by sound evidence in the form of the NICE Guideline CG88 (NICE, 2009a), and recommended in the accompanying Commissioning Factsheet (NICE, 2009b), and that the Care Quality Commission clearly recognises that ‘Osteopathy and chiropractic…are not counted as alternative and complementary treatments’ (Care Quality Commission, 2010).

 

 

4. Recommendations

 

4.1               CCGs should be made aware that commissioning of chiropractic and osteopathy does not need to be excluded as a matter of policy (see paragraph 3.10) and that these professions represent a significant highly-skilled, untapped workforce providing evidence-based care recommended by NICE (see paragraph 3.3).

 

 

4.2               CCGs should be made aware of the success of the NHS North East Essex Case Study (see paragraph 3.7) and encouraged to extend the role of independent practitioners, utilising their services in an integrated fashion as accommodated by the Pathfinder National Pathway (see paragraph 3.5).

 

4.3              Innovative commissioning of chiropractic and osteopathic care services in the community could immediately increase the number of NHS community-based, primary contact, MSK health professionals in England by up to 6000. Utilising this important and largely untapped resource would enable the NHS to offer patients the choice of a cost-effective and clinically-effective option for care.

 

References

 

Bronfort G et al (2010) Effectiveness of manual therapies: the UK evidence report. Chiropractic & Manual Therapies 18:3.

 

Care Quality Commission (2010) A new system of registration: The scope of registration. p.24

 

Clar C et al (2014) Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropractic & Manual Therapies 22:12.

 

Department of Health (2011) Manual Therapies Back and Neck Service, NHS North East Essex. http://webarchive.nationalarchives.gov.uk/20130805112926/http://healthandcare.dh.gov.uk/back-and-neck-pain-services/ (Accessed 25/08/15)

 

Field J and Newell D (2015a) Clinical outcomes in a large cohort of musculoskeletal patients undergoing chiropractic care in the UK: A comparison of self and NHS referred routes. Journal of Manipulative and Physical Therapeutics (accepted).

 

Field J and Newell D (2015b) Direct access to chiropractic services versus physician referral: Analysis of a large data set from the UK. In: Proceedings of the 13th World Federation of Chiropractic Congress & European Chiropractors Union Convention, May 13-16, Athens, Greece.

 

Gurden M, Morelli M, Sharp G, Baker K, Betts M, Bolton J (2012) Evaluation of a general practitioner referral service for manual treatment of back and neck pain. Prim Health Care Res Dev 30:1–7.

 

Lewis RA et al (2015) Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal 15, 1461–1477.

 

Murray CJL et al (2013) UK health performance: findings of the Global Burden of Disease Study 2010. The Lancet 381(9871), 997–1020.

 

NICE (2009a) Low back pain: Early management of persistent non-specific low back pain

https://www.nice.org.uk/guidance/cg88 (Accessed 25/08/15)

 

NICE (2009b) http://www.nice.org.uk/guidance/cg88/resources/cg88-low-back-pain-commissioning-fact-sheet2 p.5 (Accessed 25/08/15)

 

NHS England (2014) NHS England National Pathfinder Projects: National Pathway of Care for Low Back and Radicular Pain. http://spring-active.com/nhs-england-national-pathfinder-projects-national-pathway-of-care-for-low-back-and-radicular-pain/

 

Niemietz K (2015) A Patient Approach: Putting the consumer at the heart of UK healthcare. Institute of Economic Affairs Discussion Paper No. 64.

 

Peterson C et al (2013) Symptomatic magnetic resonance imaging-confirmed lumbar disc herniation patients: A comparative effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either high-velocity, low-amplitude spinal manipulative therapy or imaging-guided lumbar nerve root injections. Journal of Manipulative and Physiological Therapeutics 219, 36(4), 218-225.

 

Santilli V et al (2006) Chiropractic manipulation in the treatment of acute back pain and sciatica

with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal 6, 131–137.

 

Tsertsvadze MA et al (2014) Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomised controlled trials. Journal of Manipulative and Physiological Therapeutics 37(6), 343-362.

 

UK BEAM Trial Team (2004a) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 329, 1377.

UK BEAM Trial Team (2004b)  United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 329, 1381.

 

 

 

Appendix. Excerpt from the Mid Essex CCG Service Restriction Policy, September 2014

 

 

N.B. The typographical error that erroneously combines ‘Chiropractric’ and ‘Environmental Medicine’ has been reproduced in other CCG Service Restriction Policies.

 

7 September 2015