Background
Theoretical frameworks
Methods
Recruitment
Data collection
Analysis
Results
Patient participant characteristics
Patient ID | Age | Gender | Self-reported occupation type | Duration of current symptoms in months at time of interview (4-month follow-up) | Leg pain intensity over past 2 weeks (at 4-month follow-up) | Self-reported symptoms at 4-month follow-up compared to baseline |
---|---|---|---|---|---|---|
*For five patients, symptoms had resolved prior to being interviewed, as indicated below | ||||||
1 | 62 | F | Unemployed due to sciatica | 5–6 | 9/10 | Worse |
2 | 36 | F | Radiographer | Symptoms resolved prior to interview, following 3 month duration | 0/10 | Completely recovered |
3 | 53 | M | Compliance director | 7–10 | 4/10 | Better |
4 | 49 | F | Pottery worker | 7–10 | 7/10 | Same |
5 | 44 | M | Assistant manager | 9–12 | 7/10 | Same |
6 | 60 | F | Dining hall assistant | Symptoms resolved prior to interview, following 3 month duration | 3/10 | Better |
7 | 64 | M | Retired | 7–10 | 9/10 | Much worse |
8 | 42 | M | Builder | 9–12 | 10/10 | Much worse |
9 | 44 | F | Early years practitioner | 7–10 | 7/10 | Same |
10 | 57 | M | Pottery worker | 5–6 | 4/10 | Better |
11 | 66 | M | Ambulance driver | 6–8 | 3/10 | Better |
12 | 86 | F | Retired | Symptoms resolved prior to interview, following 4 months’ duration | 2/10 | Much better |
13 | 45 | F | Data claims manager | 5–6 | 7/10 | Better |
14 | 69 | F | Retired | 11–16 | 6/10 | Better |
15 | 55 | M | Machine driver | 5–6 | 2/10 | Better |
16 | 67 | F | Unpaid carer | 7–10 | 7/10 | Same |
17 | 70 | F | Retired | 5–6 | 6/10 | Better |
18 | 67 | M | Office manager | Symptoms resolved prior to interview, following 4 month duration | 2/10 | Much better |
19 | 46 | M | Police service staff | 5–6 | 5/10 | Better |
20 | 28 | M | Left skilled labour job due to sciatica | Symptoms resolved prior to interview, following 5 month duration | 1/10 | Completely recovered |
Clinician participant characteristics
Principal findings
Theme | Findings summary |
---|---|
Acceptability of the ‘fast-track’ care pathway | Both patients and clinicians found it acceptable for patients identified as needing spinal specialist assessment and consideration for more invasive treatments to be seen by those specialists sooner. Patients were pleased with the speed of their ‘fast-track’ referral; however, some clinicians expressed concern that patients with short symptom duration may be ‘fast-tracked’ too soon and that their symptoms could still resolve naturally. All clinicians expressed reluctance to consider invasive treatment options too early for these ‘acute’ patients. |
Perceived benefits of the ‘fast-track’ care pathway | Patients and clinicians perceived benefits from the ‘fast-track’ pathway in providing early patient reassurance based on MRI scan findings, particularly in enabling patients to understand the cause of their pain and assuring them that there was no serious underlying pathology. However, clinician views were mixed about the potential longer-term clinical benefits of the ‘fast-track’ care pathway. |
Waiting times for onward treatment following being ‘fast-tracked’ | Although patient management following ‘fast-track’ was not altered as part of the trial, patients highlighted the significant difference between the short timeframe for the initial ‘fast-track’ to MRI scan and spinal specialist opinion and the usual NHS waiting times after onward referral for more invasive treatments. This led to uncertainty about how long they would be waiting to receive further treatments, resulting in dissatisfaction. Clinicians similarly felt that not being able to influence the timing of the receipt of further treatments once patients joined the waiting lists was a limitation of the ‘fast-track’ pathway. |
Acceptability of the ‘fast-track’ care pathway
Extract 1
Clinicians reported finding it acceptable for patients identified as needing spinal specialist assessment and consideration for more invasive treatments to be seen by those specialists sooner than is usually the case in current practice. In particular, clinicians expressed positive views that for those patients who were suitable for invasive treatments, ‘fast-tracking’ them through the initial phase of the care pathway and onto NHS waiting lists sooner reduced the overall time period it took for them to receive these treatments, enabling the patient’s pain to resolve more quickly and allowing them to get back to work and usual activities sooner:Patient ID 4: I went for my scan more or less straight after [the SCOPiC clinic appointment]. I even commented how quick it was, because normally you wait and wait and wait, don’t you? I was shocked and pleased because … It seemed like I’d jumped the queue! (Female, aged 49)
Extract 2
Spinal physiotherapist 2: There was a patient I saw six or seven weeks down the line, and they were struggling. They were quite severe and their scan findings said they had a big disc problem and they went on to have a caudal epidural injection. They got that injection a lot quicker than they would probably for the normal route, and that helped them massively in the sense that they’ve got back to work.
Extract 3
GP 7: My cut-off is if things are no better after six to eight weeks then it’s looking more like a chronic issue that’s maybe not going to resolve easily or quickly. So I would say patients are being fast-tracked for a scan earlier than I would [normally]. Potentially you may be seeing people that would have gone on to just resolve in another two or three weeks.
Extract 4
In line with the views in Extracts 3 and 4, above, several clinicians felt that ‘fast-tracking’ may be more beneficial for patients who have had symptoms beyond a certain duration, e.g. 6–10 weeks:Spinal physiotherapist 5: If you had a DVD (i.e. video) that went through everything, then that would have been just as good as me being there. As long as they were getting better at that point, I don’t really feel they needed to be seen by me really, in terms of a spinal specialist opinion.
Extract 5
Spinal physiotherapist 7: The only place where it [the ‘fast-track’ pathway] maybe falls down is them being referred into that service too soon. I saw a lady who had only had a two-week history of symptoms and for me, that’s too early to refer into that kind of service. But the ones that are a little bit later down the line, then it’s great to be able to assess them and have all the investigations done relatively rapidly because then you can make a decision quickly for that patient. It’s just where the starting point begins, and making sure the patients don’t come into it too early … I’d say anyone that’s coming through [for spinal specialist opinion] with less than two months or even up to ten weeks’ worth of symptoms, I’d like them to have longer to settle conservatively beforehand.
Extract 6
Spinal surgeon 4: I don’t think getting MRIs done earlier would be a bad idea. Patients like to have that reassurance. So I think the MRI scan is more of a tool to address their mental state rather than to decide treatment from that point of view … I don’t think it will change my surgical plan or decision making or time to treat.
Extract 7
Spinal surgeon 1: Even if I see patients privately, I tell them to wait for two to three months anyway; even if they are paying me I will say wait two or three months so that is our standard approach, that's what we follow.
Interviewer: So if a patient did come to you earlier would you still take that conservative view point of ‘let's see if it settles down by itself’?
There was a concern expressed by the GPs that if spinal specialists continue to adopt this conservative ‘wait and see’ approach for some patients, this may result in spinal surgeons repeating the patient’s original MRI scan:Spinal surgeon 1: Yes, we always do that.
Extract 8
The extent to which the ‘stepped’ care model is strongly embedded within usual care for patients with short symptom durations was also reflected in how some patients understood the treatment options available to them following ‘fast-track’:GP 5: The difficulty is sometimes if the spinal surgeons see people at too early a stage they will just want to try conservative management anyway … and then repeat the scan.
Extract 9
Patient ID 8: They [the spinal physiotherapist] said ‘well this is the course of how we treat sciatica’. You wouldn’t go for the big drug [an analogy for the most intensive treatment] as a first option, you would go for the small one to see if it had any effect. The big drug would be the last option, because if that doesn’t work, where do you go from there? (Male, aged 42)
Perceived benefits of the ‘fast track’ care pathway
Extract 10
Patient ID 6: I was happy when I had the MRI because I knew what it was [causing the pain]; I think that’s half the problem, because you worry about it otherwise. You think ‘oh my god, what’s going on there?’ But he [the spinal specialist physiotherapist] showed me the MRI scan and showed me exactly where the disc bulge was so at least then you know exactly what was going on … I know what I’m coping with and I just feel easier now. That’s 90% of the battle really, that I know that it’s nothing too sinister. (Female, aged 60)
Extract 11
Spinal physiotherapist 1: With a lot of these patients it’s the first episodes of these types of problems that they’ve ever had and they can be quite dramatic. So there is a huge amount of anxiety … and one of the benefits of ‘fast-tracking’ them is at least we can show them, ‘yes, there is something’, because if they’ve had a scan that confirms the changes … there’s nothing sinister or nasty going on. So you can offer a level of reassurance.
Extract 12
Patient ID 4: I feel like I’ve got further with you this time than I’ve got with anyone else. In previous years I’ve been to so many people for help and everyone seems to close the door on me, basically, that’s how I feel. This time it just seems like I’m getting somewhere. (Female, aged 49)
Extract 13
Spinal surgeon 2: If the question is: a year down the line will they be better off if they’d been treated sooner rather than treated later, the answer is probably no. The long term outcome varies very little according to the speed at which they’re treated; but in terms of getting them back to work, the sooner we treat them, the sooner we will get them back to that happy situation.
Extract 14
GP 8: I think it’s preventing people from going down into that chronicity and all the other issues that go alongside that, with dependency, like Diazepam, health-seeking … the behaviour around being an invalid.
Waiting times for onward treatment following ‘fast-track’
Extract 15
Interviewer: And how quickly did you go from the clinic to the MRI?
Patient ID 9: Very quickly, that was a matter of weeks. But then waiting for the injection they said would be about a five week waiting list... So five weeks came, and six weeks came, which kept going on and on. And I was phoning them and I was still seeing my own doctor, and he was like “We need to get something sorted with this.” And I was phoning and phoning them and an appointment then came through as a cancellation … So after initially saying, it’s sort of about a five week wait, it was longer and it would have been even longer still. (Female, aged 44)
Extract 16
Patient ID 13: Because of the speed I went from the doctor to there [the SCOPiC clinic], to the MRI to the specialist; I thought ‘yeah there’s got to be something wrong here’, for them to have spent the 9 hours and so on, on treatment to get me to this point. And then for it to stop, you think, ‘well where do I go from here? Who can I talk to just to get things moving?’ (Female, aged 45)
Extract 17
Patient ID 10: The physio said, “Right the next step is physio and we'll wait for the injection”. We'll do that while we wait for that one [i.e. the epidural injection]
Interviewer: So they said have the physio while you're waiting?
Patient ID 10: While we're waiting, yeah.
Interviewer: To see if that can help in the meantime?
Patient ID 10: Yes, that’s right. (Male, aged 57)
Extract 18
Patient ID 5: I was offered the steroid treatment [i.e. epidural steroid injection] by the physio. I didn’t really want to take it on because she said there were risks involved; because I said at the moment I can tolerate it, it’s not that bad. If it got to the stage where it was crippling and I couldn’t get out of bed and stuff and couldn’t dress myself, I’d have to think about having something done. That would forfeit the risk involved then. (Male, aged 44)
Extract 19
Spinal surgeon 3: There’s no point in investigating these patients quickly if you then have to put them on a long waiting list before they’re allowed to have them [i.e. spinal injections]. It’s unfair to get patients’ expectations up.
Extract 20
Spinal physiotherapist 4: We can ‘fast-track’ it to a point but then we can’t then necessarily influence the speed with which the next step, the next intervention occurs. So if we do deem that person as being appropriate for having an injection, but then there’s a long waiting time for injections, that’s out of our hands. So whilst we can get them to this point [i.e. MRI scan and spinal specialist opinion] quicker we can’t then necessarily get them onto the next stage any quicker.