HEADACHE SERVICES IN ENGLAND FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST.

HEADACHE SERVICES IN HEADACHE SERVICES IN ENGLANDENGLAND

FAYYAZ AHMEDFAYYAZ AHMEDCONSULTANT NEUROLOGISTCONSULTANT NEUROLOGIST

HULL AND EAST YORKSHIRE HOSPITALS HULL AND EAST YORKSHIRE HOSPITALS NHS TRUSTNHS TRUST

HEADACHE DISORDERS ARE UBIQUITOUS, HEADACHE DISORDERS ARE UBIQUITOUS, PREVALENT, DISABLING AND LARGELY PREVALENT, DISABLING AND LARGELY TREATABLE, BUT UNDER-RECOGNISED, TREATABLE, BUT UNDER-RECOGNISED,

UNDER-DIAGNOSED AND UNDER-TREATED UNDER-DIAGNOSED AND UNDER-TREATED

Steiner et al J Headache Pain 12(5);501Steiner et al J Headache Pain 12(5);501

YOUNG OR OLDYOUNG OR OLD

HEADACHE DISORDERS IN ENGLANDHEADACHE DISORDERS IN ENGLAND

Population 51.5 million (Adult 16-65 = 33.5 million)Population 51.5 million (Adult 16-65 = 33.5 million)11

Headache in generalHeadache in general22 90%90% MigraineMigraine33 15% (M=7.6 F=18.3)15% (M=7.6 F=18.3)

80% disabling80% disabling Chronic Daily HeadachesChronic Daily Headaches44 1.5-4%1.5-4%

OROR 5.02 m adult migraineurs of which 4.06 disabling5.02 m adult migraineurs of which 4.06 disabling 1.38 m adults with Chronic Daily Headache1.38 m adults with Chronic Daily Headache 5.44 m in need of headache care5.44 m in need of headache care

1. Census 2008 2. Latinovic, 2006 3. Steiner, 2008 4. Lipton 20021. Census 2008 2. Latinovic, 2006 3. Steiner, 2008 4. Lipton 2002

BURDEN OF HEADACHE BURDEN OF HEADACHE DISORDERSDISORDERS

1 IN 10 GP CONSULTATIONS1 IN 10 GP CONSULTATIONS11

30% OF ALL NEUROLOGY REFERRALS30% OF ALL NEUROLOGY REFERRALS22

20% OF ALL ACUTE NEUROLOGY 20% OF ALL ACUTE NEUROLOGY ADMISSIONSADMISSIONS33

IN THE TOP TEN CAUSES OF DISABILITYIN THE TOP TEN CAUSES OF DISABILITY44

IMPACT SIMILAR TO ARTHRITIS, DIABETESIMPACT SIMILAR TO ARTHRITIS, DIABETES55 WORSE THAN ASTHMAWORSE THAN ASTHMA66

MORE YEARS LIVED WITH DISABILITY MORE YEARS LIVED WITH DISABILITY WORLD-WIDE THAN EPILEPSYWORLD-WIDE THAN EPILEPSY44

1. ABN 2011 2. Sending J, 2004 3. Weatherall, 2006 4. 1. ABN 2011 2. Sending J, 2004 3. Weatherall, 2006 4. WHO, 2001 WHO, 2001 5. Solomon, 1989 6. Terwindt et al, 2000 5. Solomon, 1989 6. Terwindt et al, 2000

IMPACT OF HEADACHE DISORDERSIMPACT OF HEADACHE DISORDERS

PATIENTSPATIENTS 160,000 attacks / day160,000 attacks / day33

75% can’t function 75% can’t function during an attackduring an attack11

50% need help from 50% need help from othersothers11

50% impacts on social 50% impacts on social lifelife11

33% headache 33% headache controls their lifecontrols their life22

15% cant get 15% cant get promotion at workpromotion at work33

1. Clarke CE, 1996 2. Lipton, 20031. Clarke CE, 1996 2. Lipton, 2003 3. Steiner TJ, 2003 3. Steiner TJ, 2003

ECONOMY ECONOMY (indirect)(indirect)33

83,000 miss work or 83,000 miss work or school every dayschool every day

20 million lost days / yr20 million lost days / yr £ 2 billion / yr£ 2 billion / yr 95,000 DALY95,000 DALY

(direct)(direct)33

£ 125 million for £ 125 million for migrainemigraine

£ 210 million for all £ 210 million for all headache disorders headache disorders

NEUROLOGICAL SERVICES IN NEUROLOGICAL SERVICES IN ENGLANDENGLAND

A Neurologist / 117,000 (514) [Holland 1 in 20,000]A Neurologist / 117,000 (514) [Holland 1 in 20,000]11

Acute Neurology seen by Non-NeurologistsAcute Neurology seen by Non-Neurologists Services based on out-of-date ‘Hub and Spoke’ modelServices based on out-of-date ‘Hub and Spoke’ model Commissioning only for scheduled servicesCommissioning only for scheduled services Unrestricted and Unregulated OP referral systemUnrestricted and Unregulated OP referral system Lack of ExpansionLack of Expansion

Difficult to recruitDifficult to recruit Changes in immigration ruleChanges in immigration rule

Next decade; call forNext decade; call for Expansion mainly in DGH’sExpansion mainly in DGH’s Commissioning for Unscheduled servicesCommissioning for Unscheduled services 1. ABN; Neurology for next decade, June 2011 1. ABN; Neurology for next decade, June 2011

HEADACHE SERVICES; WHERE WE HEADACHE SERVICES; WHERE WE ARE?ARE?

50% Headache sufferers do not consult50% Headache sufferers do not consult11

‘‘it is too inconvenient to see a doctor’ (53%)it is too inconvenient to see a doctor’ (53%) ‘‘there is nothing a doctor could do’ (22%) there is nothing a doctor could do’ (22%)

9% of those seen in primary care get referred9% of those seen in primary care get referred22

Vast Majority seen by General NeurologistsVast Majority seen by General Neurologists Many are discharged with reassurance ‘there is nothing Many are discharged with reassurance ‘there is nothing

serious’serious’ 31 Dedicated Headache / Migraine Clinics 31 Dedicated Headache / Migraine Clinics

Mainly at the Regional CentreMainly at the Regional Centre Neurologist with training in headacheNeurologist with training in headache General Practitioner with Special InterestGeneral Practitioner with Special Interest Headache Specialist NurseHeadache Specialist Nurse1. Steiner and Fontebasso 2002 2. Laughey et al 19991. Steiner and Fontebasso 2002 2. Laughey et al 1999

MIGRAINE CLINICS IN THE UKMIGRAINE CLINICS IN THE UK

HEADACHE SERVICES; THE UNMET HEADACHE SERVICES; THE UNMET NEEDSNEEDS

The services are inefficient, inequitable, inadequateThe services are inefficient, inequitable, inadequate No local or national targets for headache managementNo local or national targets for headache management Lack of awareness and headache education among Lack of awareness and headache education among

Public & Healthcare ProfessionalsPublic & Healthcare Professionals Lack of undergraduate training in headacheLack of undergraduate training in headache Post-graduate education in headache is driven by the Post-graduate education in headache is driven by the

Pharmaceutical IndustryPharmaceutical Industry Too many referrals to secondary care (Unregulated)Too many referrals to secondary care (Unregulated) Unnecessary investigations (wasted resources)Unnecessary investigations (wasted resources) Lack of Specialist Nurses and Therapists Lack of Specialist Nurses and Therapists

HEADACHE SERVICES; WHERE WE HEADACHE SERVICES; WHERE WE WANT TO BE?WANT TO BE?

A shift to Primary CareA shift to Primary Care Care closer to homeCare closer to home In line with the current Policy (intermediate care)In line with the current Policy (intermediate care) Better patient satisfactionBetter patient satisfaction11

Reduced secondary care referralsReduced secondary care referrals22

GPwSIGPwSI Expert GeneralistsExpert Generalists33

More complete care in a therapeutic fieldMore complete care in a therapeutic field Headache Specialist NurseHeadache Specialist Nurse

Integrating primary and secondary careIntegrating primary and secondary care Cost effectiveCost effective 1. Ridsdale et al BJGP 2008 2. Thomas et al, BJGP 2010 3. Baker, 20021. Ridsdale et al BJGP 2008 2. Thomas et al, BJGP 2010 3. Baker, 2002

HEADACHE SERVICES; PROPOSED HEADACHE SERVICES; PROPOSED MODELMODEL11

Level 1;Level 1; Primary Care Physician (90%) /35,000Primary Care Physician (90%) /35,000 Diagnose and Manage Migraine and Tension HeadacheDiagnose and Manage Migraine and Tension Headache Recognise and refer secondary headaches to level 2Recognise and refer secondary headaches to level 2 Theoretical postgraduate headache trainingTheoretical postgraduate headache training

Level 2;Level 2; GPwSI (9%) / 200,000GPwSI (9%) / 200,000 Diagnose and Manage more difficult but not rare Diagnose and Manage more difficult but not rare

headachesheadaches Refer the rare ones and those requiring in-patient care to Refer the rare ones and those requiring in-patient care to

level 3level 3 Affiliated with a headache clinic for sometimeAffiliated with a headache clinic for sometime

Level 3; Level 3; Headache Specialist (1%) /2 millionHeadache Specialist (1%) /2 million Neurologist with training in headacheNeurologist with training in headache In-patient facilitiesIn-patient facilities

1. 1. Steiner et al J Headache Pain 2011 Steiner et al J Headache Pain 2011

HEADACHE SERVICES; HOW DO WE HEADACHE SERVICES; HOW DO WE GET THERE?GET THERE?

Education Education Public and Professional meetingsPublic and Professional meetings Undergraduate headache educationUndergraduate headache education

Resource Allocation (re-allocation)Resource Allocation (re-allocation) Set up and training costsSet up and training costs Specialist Nurses freeing up Physicians’ timeSpecialist Nurses freeing up Physicians’ time Reduced mismanagement and secondary referralsReduced mismanagement and secondary referrals Reduced economic burden (indirect cost)Reduced economic burden (indirect cost)

GovernanceGovernance Evaluation processEvaluation process Integrated arrangementsIntegrated arrangements Stakeholders engagementStakeholders engagement

HEADACHE SERVICES; OUTCOME HEADACHE SERVICES; OUTCOME MEASURESMEASURES

Reduced referrals to secondary careReduced referrals to secondary care Timely access to serviceTimely access to service Equitable service based on needEquitable service based on need Increased patient satisfactionIncreased patient satisfaction Cost savingsCost savings Reduced burden of headache in generalReduced burden of headache in general

HEADACHE SERVICES; HEADACHE SERVICES; LIMITATIONSLIMITATIONS

ADDITIONAL RESOURCES ADDITIONAL RESOURCES Low overhead cost in primary care but more GP’s Low overhead cost in primary care but more GP’s

requiredrequired CHANGE RESISTANCECHANGE RESISTANCE

Patients’ perception of specialistPatients’ perception of specialist Savings mainly indirectSavings mainly indirect Lack of gold standard model of careLack of gold standard model of care

RECRUITMENT RECRUITMENT Interested General PractitionersInterested General Practitioners Specialist Nurses Specialist Nurses