The National Back Pain Pathway

Back pain is the largest single cause of disability in the UK, with lower back pain alone accounting for 11% of the total disability of the UK population.

Referrals for spinal surgery are increasing year on year and a growing number of patients are waiting longer than 18 weeks from referral to treatment. Wide variations exist in surgical rates between centres, and there are a significant number of treatments with a poor evidence base.

From a review of the service it was clear that that there were three main issues impacting on this area of work:

  • The current pathway of management for low back pain is not planned, has little reference to the evidence base and contains significant delays at every step.
  • Rehabilitation of patients with back pain is poor and very variable.
  • Large variation in surgical indications and rates between centres, which is unexplained. This in turn drives large variation in activity and cost between CCGs.

In addition, we found problems with waiting list management and fragile clinical teams relying on one or two individuals working in isolation.

To tackle this, a clinical team of 30 specialists in the diagnosis and management of lower back pain and I devised a complete end to end pathway for the management of lower back pain, the National Low Back Pain Pathway.

The National Low Back Pain Pathway aims to:

  • Rapidly identify and refer potentially serious pathology.
  • Provide expeditious access to interventions such as nerve root blocks or surgical discectomy where indicated.
  • Provide effective and timely care for sufferers with acute low back pain to improve outcomes and reduce disability.

This treatment pathway is more evidence based and coherent, meaning management will be significantly less expensive. Savings from implementation are estimated to be £900,000 per million population.

The volume of spinal surgery is spiralling – the NHS in England spends £200m per annum on spinal surgery and there are currently approximately 10,000 adult patients each year that have elective spinal surgery. In an addition, there are large numbers of patients being given injections with low evidence of effectiveness.  Reducing these ineffective but costly injections alone would save the NHS £9m a year.

This new pathway is a complete end to end pathway for lower back pain and radicular pain which starts at the GP Surgery and moves through primary care and, if needed, through to secondary care.

All clinicians using this new pathway will be applying the right care, right time, right place principles, supported by a Public Health awareness campaign. The focus will be on improving understanding of how to manage, limit and prevent back pain. This will reduce on going pain and disability and in turn reduce the need for patients to be referred into secondary care.

To support the pathway, patient literature will be used in conjunction with retraining of healthcare professionals to de-medicalise simple back pain. Altering beliefs about back pain is a recognised highly effective way for reducing back-related disability.

Patients will experience a planned care pathway, including a high intensity combined physical and psychological treatment programme for those who need it. Only after completion of the whole pathway will patients be considered for surgery.

Next steps

Our Regional specialised commissioning teams will be working with the transformation team in each CCG commissioning collaborative to take this work forward. We are communicating with the Sustainability and Transformation Plan teams. We will also be inviting provider networks to take part in the peer review and design process on the future pathway of care.

I would like to see every Clinical Commissioning Group in the country commission through this pathway to reduce delays, remove ineffective treatments and help patients to lead a fuller more active life, reducing disability and chronic pain.

If you are interested in being an early adopter of the Improving Spinal Care project email:


Charles Greenough will be presenting a webinar as part of MSK Knowledge network webinar series: The National Back Pain and Radicular Pain Pathway, Wednesday 24 August 12:00-13:00.

If you are interested, you can register here.

Charles Greenough

Charles Greenough qualified as a doctor from Queens’ College, Cambridge and University College Hospital, London. He trained as an orthopaedic surgeon at the Royal Free Hospital, London and the Royal National Orthopaedic Hospital, Stanmore. Specialist spinal training was also undertaken at the Royal Adelaide Hospital, South Australia.

He is also a Consultant Spinal Surgeon, Professor of Spinal Studies at the University of Durham and undertakes lecturing work in the U.K and Internationally. He is Past President of the Spine Society of Europe. He is also Clinical Director of the Golden Jubilee Regional Spinal Cord Injuries Centre at the James Cook University Hospital, Middlesbrough.

In his previous role as National Clinical Director for Spinal Disorders in April 2013 – March 2016 his vision was to promote a seamless care pathway for patients with low back pain or sciatica across the NHS to reduce long term disability and multiple ineffective therapies. He is currently chair of the Improving Spinal Care Project, NHS England. The project aims to implement the National Back Pain and Radicular Pain Pathway, and to give effect to spinal surgery networks.

Principal research interests have been spinal trauma, spinal cord injury and low back pain.

Hobbies include fell walking and family life.

One comment

  1. GREG SHARP says:

    “Altering beliefs about back pain is a recognised highly effective way for reducing back-related disability”….I hope any reflection by future pathway groups on methodology will be towards applying Cognitive Reassurance taking the patient beyond the limited learning opportunities of Affective Reassurance which is still in common use.
    There is some evidence to suggest that Affective Reassurance risks sowing the seeds of Iatrogenic Confusion which leads the vulnerable patient deeper into long term pain.

    I find taking time to create a bespoke script for some of the more complex patient’s reitterating the conversation of the initial consultation to be of value towards reinforcing learning and as appropriate, giving family an insight as to why the patient suffers for so long. This also probably boosts placebo.