This case study features in the NHS Innovation Accelerator’s year three research report, Understanding how and why the NHS adopts innovation.
ESCAPE-pain is a rehabilitation programme for people with chronic joint pain, that integrates educational self-management and coping strategies with an exercise regimen individualised for each participant. It helps people understand their condition, teaches them simple things they can help themselves with, and takes them through a progressive exercise programme so they learn how to cope with pain better.
ESCAPE-pain originated from clinical research and development undertaken by NHS Innovation Accelerator (NIA) Fellow, Professor Michael Hurley, at St George’s University of London and Kingston University. The local Academic Health Science Network (AHSN), along with the charity Versus Arthritis, has played an important role since 2013 by supporting a core team, including Professor Hurley, seeking to improve chronic joint pain management in the community, including supporting more widespread adoption of ESCAPE-pain.
Three successful adopting organisations were interviewed as part of this study. For each, awareness of ESCAPE-pain was via local clinical champions motivated to develop their own and their teams’ professional practice for better patient outcomes. They initially became aware of the research led by the NIA Fellow through their normal professional activities, e.g. reading published papers and attending conferences. Each became increasingly convinced of the potential benefits ESCAPE-pain could bring to the services they provided.
At one of the adopting NHS organisations, the lead clinician was in a sufficiently senior position to be able to adopt ESCAPE-pain within his own clinical and budgetary responsibilities. This contrasted with his attempts to adopt ESCAPE-pain at his previous Trust, where concerns had been raised about the impact of the service on the Trust’s income. In his new Trust, he had the autonomy to proceed, and no business case was required to adopt ESCAPE-pain.
In other organisations, forward-looking physiotherapy teams worked within a supportive, professional management structure which encouraged service improvement.
Once the decision to adopt ESCAPE-pain had been made, staff were trained in how to deliver the model. The core ESCAPE-pain team based at the local AHSN provided training and educational materials in how to deliver the service. Junior colleagues were also able to attend annual training courses run by the AHSN.
Attendance at an annual training event run by the NIA Fellow and the core ESCAPE-pain team led to further interest in the model. The training allowed local clinical teams to draw effectively on the evidence-base and tailor it towards preparing their own local business case and implementation plans. However, final decisions were made within the physiotherapy services without need for further approvals.
Adaption of location
Early learning whilst developing ESCAPE-pain highlighted that one of the possible constraints for some potential adopters was a lack of appropriate space in which to deliver group programmes. To help address this, further research was undertaken by the core team in order to build the evidence-base around delivering this model of care in partnership with leisure centres. This has helped to enable alternative delivery, including supporting the adoption of ESCAPE-pain by one of the NHS services where it is run in the local leisure centre and delivered jointly by a physiotherapist and a health trainer. The leisure centre allows usage of their gym facilities at no cost to the NHS.
Clinical champion with autonomy to adopt: At one Trust, the major enabler was the decision to implement being within the responsibilities of the adopting clinician. There were no wider financial or other organisational barriers.
Enabling culture: In one Trust, the supportive professional and managerial culture across the whole physiotherapy team encouraged and generated an enthusiasm for new ideas to improve the service, e.g. through monitoring relevant professional literature and attending conferences. This resulted in an early awareness of the opportunities ESCAPE-pain offered and supported their adoption activities.
Modification of an existing service: A common factor facilitating adoption in all three sites was that implementation of this new service did not require any major modifications to a service that was already in place. Rather, it represented a process of substituting one kind of training course with another, and – in the case of one of the adopting NHS organisations – a relatively easy modification to an existing partnership with the local leisure centre.
Local clinical champions at all three case study sites, supported by the innovator and core team, have now successfully implemented ESCAPE-pain into their routine service provision. Each are providing ongoing feedback on clinical outcomes to the core team so that the evidence base can continue to grow. Each site regards ESCAPE-pain as well embedded in routine service delivery, providing clear benefits to their patients. Each site has successfully delivered a full course of ESCAPE-pain to a number of cohorts, and patient feedback is very positive.
Wide-scale spread of ESCAPE-pain has been led by the NIA Fellow’s team, with the support of the local AHSN and Versus Arthritis. The promotional messages about the programme and the benefits to patients are evidence-based, have professional endorsements, and are supported by a wide range of organisations including national and third sector bodies. The core team provides a broad range of supporting activities which have been important in facilitating the spread of ESCAPE-pain across each of the case study sites.
Enabling adoption of complex healthcare interventions like ESCAPE-pain requires resourcing. The core team delivers a range of functions to those wishing to adopt ESCAPE-pain, however these activities cannot be readily commercialised. Routes to make these functions more sustainable need to be explored, which take into account the benefits associated with, for example, reducing reinvention and duplication of effort, and economies associated with centralised training, data collection and analysis.
1. Martha Cooke, Senior Physiotherapist, South West Yorkshire Foundation Trust, Barnsley District
2. Chris Davis, Leisure Centre Health and Wellbeing Co-ordinator, Cheltenham Trust
3. Dave Evans, Programme Manager, West of England AHSN
4. Professor Mike Hurley, Founder of ESCAPE-pain, NIA Fellow
5. Megan Kirbyshire, Senior Physiotherapist, Cheltenham General Hospital
6. Julie Knight, Lead Physiotherapist for Musculoskeletal Services, Gloucestershire Hospitals NHS Foundation Trust
7. Chris Moule, Advanced Practitioner Physiotherapist, Cheltenham General Hospital
8. Sharon Sweeting, Musculoskeletal Service Manager and Physiotherapy Professional Therapy Lead, South West Yorkshire Foundation Trust, Barnsley District
9. Darren Thorpe, Senior Physiotherapist, South West Yorkshire Foundation Trust, Barnsley District
10. Ben Wanless, Consultant Physiotherapist, St George’s Hospital