Cost Effectiveness: Reducing Demand on Mainstream NHS Services

“Many of Impact’s patients were frequent attenders to GP practices; some because they had many chronic physical conditions and others because of mental health issues…many frequent attenders decreased their burden on GP services.”
Independent academic Dr Shona Kelly

Commissioning Impact’s services is very likely to lead to savings in practice budgets. The cost of the recent service to the Radford Medical Practice has been £260 per patient for six sessions, or an average of £43 per consultation. Whilst there are no reliable estimates of the cost of a GP consultation, it is clear that a reduction in GP visits equates with savings for the practice. Likewise, reductions in prescribed medication also result in savings for the practice.

In their Practice-based Commissioning submission for funding for the Impact service, Radford Medical Practice described their reasons for wanting to commission Impact, and included the following points:

Many patients who have treatment at Impact experience improvements in their health and wellbeing, and are able to function much better in their daily lives. Some have been able to start or return to work, others have begun study courses. After completing treatment at Impact, many people also use fewer NHS resources than they did before;

1. Their work over the last few years has demonstrated that patients who complete treatment at Impact subsequently visit their GP less often, report taking less medication and have less need for referral to secondary care.
2. In this way, capacity can be freed up for our GPs and nursing staff to concentrate on priority areas.
3. Provision of acupuncture, chiropractic and homeopathy is a cost-effective way of managing patients with long term conditions, including mental health conditions.

Over the last six years, we’ve treated several hundred patients with long term conditions. Most of our patients have previously received a considerable amount of conventional primary and secondary care. However, after completing treatment at Impact, the users of our Waverley Health Centre service reported the following changes to their take up of NHS services:

1. 87% of patients taking medication reported reducing or stopping medication, as it was no longer required.
2. 76% went to see their GP less often, including patients who were previously frequent attenders.
3. Some patients no longer require secondary care, including spinal injections and orthopaedic surgery.

“I stopped having facet joint injections for back pain as I was not having positive results – the chiropractor has helped significantly”

Likewise, the patients who were referred to the Radford Medical Practice service subsequently reduced their take up of other primary and secondary care services. Following treatment, 75% of patients (31 out of 42) completed a questionnaire on changes in their usage of medication and the frequency of visits to their GP.

1. 71% (22) of those who completed the questionnaire were on medication before starting treatment with Impact.
2. 69% (21) of those who completed the questionnaire said they wanted to reduce or stop medication.
3. 63% (14) of the patients who were on medication before starting treatment with Impact reported reducing or stopping their medication since it was no longer required after treatment with Impact.
4. 46% (14) of those patients who completed the questionnaire reported going to see their GP less after treatment with Impact.
5. 56% (5 out of 9) of those patients who were receiving treatment in secondary care no longer needed it after treatment with Impact.

 

“At the start of treatment, anti-inflammatories and pain killers every day x 3 – now anti-inflammatories only once a week, if that, and painkillers once a week or less, depending on work load”

Of course, a reduction in referrals to secondary care certainly saves GP practices money – for example, the current tariff for pain management is either £160 or £231 for the first consultation (depending on whether the patient is seen by a single practitioner or a team), and £84 or £95 for follow up attendances.

Several patients from the Radford service referred to the preventative aspects of the Impact treatment, one commenting that the referral to Impact had prevented her needing stronger medication. Another patient commented on the way in which treatment had prompted her to consider lifestyle changes:

“Did make me think more about my general health in relation to headache e.g. links to body – back pain, diet, exercise etc. Thank you.”

The potential to save money by diverting referrals from secondary care to community based services is illustrated in the Department of Health (DH) document, ‘Exercising Outcomes: A Guide for Commissioners to Developing Musculoskeletal and Exercise Medicine Services’. The DH states that diverting referrals from secondary care to community based services can generate cost savings of around £44 per appointment. With the average cost of an appointment with Impact currently at £43 per appointment, it is possible that the savings generated could cover the cost of providing the service.

Analysis of by North East Essex Primary Care Trust of a manual therapies back and neck service provided by chiropractors and osteopaths in 2009/10 concluded that:.

1. Referrals to a spinal consultant had reduced by almost 30% since the introduction of the service.
2. 74% of the 2,810 patients had their condition much improved or very much improved.
3. 97% of the patients referred to the service were kept out of secondary care.
4. 70% of patients taking medication for their condition reported either stopping or significantly reducing their use of medication post treatment.

The PCT estimated the service as cost neutral.

Audits from complementary medicine services in other parts of the country demonstrate that they are cost-effective; a PCT audit of a chiropractic service in Wilmslow has found that for every 22 patients referred, £10,000 was saved – 8 out of 10 patients waiting for orthopaedic appointments no longer required them. A revaluation of the integrated health services supplied by Glasgow Homeopathic Hospital (which involved scrutiny by the Health Board and parliamentary committees) found that long-term demands on the NHS were reduced with significant reductions in GP visits, new investigations and drug use.

“Almost all of the patients I have referred to Impact have made a point of reporting to me the improvement in pain levels and mobility they have experienced, and clearly therefore improvement in their quality of life… The ability to refer into such a service has also added to my ability to offer holistic care to a wider group of clients. I do hope that the area which you cover can be widened so that more patients can experience the benefit and equity of care can therefore be achieved.”
Practice Nurse