Back pain - can a physio app cut NHS waiting lists?

The Flok app first tries diagnose your back problem

Back pain - it won’t kill you but it can make your life a misery. Yet the NHS does not seem to take it seriously, with waiting lists so long that I suspect many of those who can afford it turn to the private sector for treatment.

I have to confess I was one of them. I have had recurring problems with lower back pain and when I had a serious flare-up last autumn, one which meant I could barely walk, I was referred by my GP to an NHS musculo skeletal (MSK) clinic, with no indication of how long the wait would be.

I went to a private consultant, who sent me for an MRI scan in his clinic straight after my appointment. He took me through the options for treatment, starting with neuropathic pain medication, moving on to an injection in the spine, and as a final and drastic option, spinal surgery.

We went down the neuropathic pain medication route, and then after a couple of months on the tablets I finally got an appointment at the NHS MSK clinic. The advice I got there was excellent - and of course free - but by then I was on the mend.

Now a relative who is also a carer is going through even worse back pain than I suffered and his GP has warned him that he could wait a year for an appointment. He too is considering going to a private orthopaedic service. More evidence then that the NHS is letting down people with back pain, but in Cambridgeshire and Peterborough radical experiment offering patients physio via an app from a private sector supplier may show the way forward.

When Cambridgeshire Community Services NHS Trust (CCS) launched a twelve week pilot with Flok Health’s app in February, waiting times for an appointment with the musculoskeletal service stood at 18 weeks. Patients seeking a referral to the MSK clinic were told they could either join that waiting list or opt to use the Flok app straight away.

At first sight, the app doesn’t appear too sophisticated. You see a real live physiotherapist on screen but there is no direct interaction with her, or even a chatbot experience. Instead you answer a whole series of multiple choice questions so that your back issues can be diagnosed. Then you start a treatment programme with the same physiotherapist taking you through some physical tests and then asking more multiple choice questions before presenting you with a series of exercises designed to fit your capabilties.

During the pilot two thirds of patients chose to use the Flok app rather than join the queue to see a physiotherapist in the standard way. And at the end of their app based treatment programme just two percent asked for a face to face appointment and 80% rated their experience as equivalent or superior to the standard service. The result was that the waiting time for that service came down from 18 to 10 weeks.

What this says to me is that the way we run these kind of services in the NHS is hopelessly inefficient, a one size fits all solution that leaves nobody satisfied. Finn Stevenson, co-founder and CEO of Flok Health, puts it like this: “Regardless of what you need, if you need some care, you're being added to the same waiting list. And that's nowhere near granular enough to deal with even clinical need, let alone patient preference.” A minority of people will need more than an exercise programme - perhaps a steroid injection or even surgery - but they all end up on the same slow-moving travelator as the people with less serious issues.

A spokesman for CCS said: “We’ve learned that by offering the right patients the right options, we can ease pressure, improve outcomes, and offer a better service overall.”

While the pilot is now over, it sounds as though Cambridgeshire is minded to sign a long-term deal with Flok, which expects to have contracts with 20 NHS Trusts by the end of this year. Of course, the Flok app and service doesn’t come free - the company employs some physiotherapists to intervene with a videocall in certain cases where there is concern about how the patient is doing. But Finn Stevenson says that once Trusts restructure their service around the app it will save them money:

“To do a patient's full care pathway, so all their initial assessment, triage, treatment delivery, or the human telehealth provision as well, and then their follow up and discharge in the community ends up being about £50 a patient for the whole pathway. It's about five times cheaper than the current cost of delivery.”

Of course, many trusts will be tied into long-term contracts to do things the way they have always done them, and this may slow down the adoption of this kind of digital service. There are all kinds of other clinical services where new technology is challenging the old inefficient model where, in Finn Stevenson’s words “you are given an arbitrary appointment on a Tuesday morning, on a day that you're busy already, and then have to travel to a clinic that's running late..”

Yet, as with the Parkinson’s Home Based Care service trialled in Devon and Cornwall, local NHS managers sometimes seem reluctant to embrace this revolution. On top of that the UK Treasury, sceptical about the whole idea that you need to spend now to save later, is a major brake on change.

But if there is any project that embodies the principles of Wes Streeting’s 10 year plan for the NHS, with its emphasis on moving care out of the outpatients’ department and into the community, it is Cambridgeshire’s experiment with app based treatment for back pain. Just how quickly such ideas spread across the health service will be a measure of how likely Mr Streeting’s plan is to work.