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ESCAPE-pain fundingapplication toolkit A guide for leisure providersand clinicians applying forfunding to deliver ESCAPE-pain Message
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 2 of 17 4 14Contents Introduction Overarching aims of the ESCAPE-pain programme Make the case for ESCAPE-painWhat is ESCAPE-pain? Programme objectives Where has the programme been successfully implemented in your region, or ina geographically close or socioeconomically similar region? What are the key benefits of delivering the ESCAPE-pain programme? Evidence the need What is the purpose of ESCAPE-pain in your region/ patch? Costs to set up and deliver ESCAPE-pain Scope statement Cost savings Return on Investment (RoI) Sustainability of impactOptions for delivery Risks, Issues and Dependencies 3 3 5 67910 11 12 16 1314 15 5
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 3 of 17 Introduction This toolkit has been developed to act as a guide to help clinical, leisure and communityorganisations applying for funding from healthcare organisations such as Integrated CareBoards (ICBs) - formerly Clinical Commissioning Groups (CCGs) - government bodies, as well aslocal authorities, charities and calls for local and national grants awards, etc. It highlights areas that funding bodies may require potential applicants to address, such asinformation about format and content of the programme; local need for ESCAPE-pain; thecosts of setting up and delivering the programme; facilities needed and available; likelysavings and benefits to the local health systems or leisure/ community organisations;strategies for implementation; ideas of how to sustain the programme. It uses examples from business cases that have been successfully used to obtain funding thatmight be updated, adapted and used. In the Executive Summary of your business case, provide a brief background making thecase for why ESCAPE-pain is needed using data, evidence and “local intelligence” tocontextualise the application for your locality. EXAMPLE: For example, one ICB used data from NHS RightCare to show the variancebetween themselves and comparators in health outcomes such as knee replacements, andhow initial levels of health reported by their patients before surgery was higher thancomparators, suggesting patients were being recommended for surgery too early in theirtreatment pathway. Once you have set the scene, describe what ESCAPE-pain is (e.g., what it is, who it is for, theprogramme’s content, format and delivery, etc), where the programme has been successfullyimplemented in your region, or comparable region, and the benefits and cost savings youexpect to achieve. Make the case for ESCAPE-pain
What is ESCAPE-pain? ESCAPE-pain stands for Enabling Self-management and Coping with Arthritic Pain usingExercise and is an award-winning group rehabilitation programme for people aged 45 and overwho have chronic knee and hip pain – often labelled osteoarthritis (OA) – or back pain. Itteaches people the value of simple self- management and coping strategies, and theyundertake an exercise regime that is individualised for each participant. There is a robustevidence-base showing the programme produces sustained improvements in clinicaloutcomes, reduces costs and is easy to implement. For more information about ESCAPE-pain, please see the below document: Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 4 of 17 These programmes consist of 12 x 90-minute sessions (twice a week over six weeks)delivered by a trained “facilitator” (physiotherapist, exercise professional). Each sessionconsists of a 20-25 minute informal discussion around a set theme, followed byapproximately 45 minutes of a circuit type exercise programme. Participants attend in groupsof about 10, so it is a very efficient way to treat the many people living with joint pain. There is also a smartphone app and website participants can use during and after completingthe programme. Education component (20-25 minutes): Each session starts with an informal themed discussion, rather than a formal lecture, which are led by a facilitator. The sessions cover themes such as simple anatomy ofthe knee joint, what causes pain, goal setting, rest-activity cycling, weight management, healthy eating, and simple relaxationtechniques. Exercise component (45 minutes): The programme uses simple, unsophisticated exercises that are easy to do and can be repeated at home using inexpensive, easily available equipment. These can include quadriceps over a block, bending and straightening the knee, sit to stand from a chair, step-ups, step-downs, using a staticbike, standing on a rocker board, standing on oneleg, shuttle walks, and squats. Description of ESCAPE-pain.docx
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 5 of 17 Programme objectives For people with knee, hip and/ or back pain ESCAPE-paincan: Overarching aims of the ESCAPE-pain programme ESCAPE-pain aims to improve physical, mental and emotional health and wellbeing of people with chronicknee, hip and/ or back pain, reduce healthcare costs, maximise the efficient use of healthcare resources andincrease partnership working between clinical, leisure and community organisations. Does your project align to the funders core objectives? Study their guidelines, strategies, andorganisational values. You could alsoreach out to funders to make sureyou are clear about their aims andobjectives. reduce pain improve their function and mobility reduce feelings of anxiety and depressionrestore their independence get them up, out and socialising again help them regain control of their lives For NHS Commissioners and providers ESCAPE-pain can: improve the health of patients as above reduce joint pain related healthcare costs by reducing GP, hospital and physiotherapy consultations,investigations, and interventions provide an alternative to medication and may delay or avoid surgery provide an effective intervention for people on surgical waiting lists maximise efficient use of resources by treating people in groups deliver evidence-based intervention recommended by NICE and the NHS RightCare programme(ESCAPE-pain is recommended by RightCare for Long Term Conditions) fulfil the NHS Long-Term Plan of making it easier to access effective care for people in theircommunity rather than needing to attend hospital appointments enable people to self-mange long term conditions, prevent ill health and support people to livehealthier lives For leisure providers and local authorities, ESCAPE-pain: supports their local community to self-manage chronic joint pain, become more active and improve quality of life enhances and increases their health and wellbeing services forms collaborative partnerships with local health providers (GPs, Nurses, Physiotherapists), exercise on referral, social prescribers and increases self-referrals upskills their workforce by training them to deliver the programme generates revenue by increasing membership, footfall, attracting untapped and underrepresented market of older, inactive people, using their facilities during quiet off-peak times supports people in retaining the programme’s benefits by providing classes and programmes that helpthem remain active generates revenue to make the programme sustainable Tip
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 6 of 17 Where has the programme been successfullyimplemented in your region, or in ageographically close or socioeconomicallysimilar region? Funders like to see where the programme has been implemented and what they have found. it is verycompelling to provide an overview of where and how ESCAPE-pain has also been delivered by yourorganisation or across your region and any outcomes. (Input relevant info/data into the [X]). You canuse the example statement below to provide an overview of where ESCAPE-pain is currently beingdelivered, how many places have previously been funded in what time period, and completion rate.Alternatively, you can state which other leisure providers or ICBs have adopted the ESCAPE-painprogramme. It may be useful to get in touch with a couple of these organisations for more informationabout how the programme has been successful across their patch. “The programme is delivered widely across the UK in over 200 physiotherapy, leisure, and community centres. ESCAPE-pain for hips and knees/ backs has been available in [X region] and [X] places have been madeavailable, of which [X] participants have accessed between [X month/year] and [X month/year]. [X%] havecompleted the programme.” View our interactive maps: For hips/knees sites For backs sites
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 7 of 17 What are the key benefits of delivering the ESCAPE-pain programme? Tip EXAMPLE: Successful ESCAPE-pain Business case submitted by North West London ICB The estimated cost (from previous ICBs who have run these classes) is £163 per patient. Previous ICBs using ESCAPE-pain have found the following benefits per 1,000 patients: - reduction of 230 bed days - reduction in 90 outpatient consultations - reduction in 110 GP consultations - reduction in medication costs of £20,280 - reduction in community-based care estimated at a value of £59,000 For the leisure and community sector The outcomes and benefits observed when ESCAPE-pain was delivered in physiotherapy departments have been replicated where the programme has been implemented in the leisure and community sector. Leisure providers are becoming increasingly interested in the programme as they try to attract older people to join as members and rebrand their gyms as “health centres”. Key benefits for leisure providers: form partnerships with local health providers provides the opportunity to deliver an evidence-based, award-winning intervention skills up the workforce as instructors complete training to deliver the ESCAPE-painprogramme and support people living with chronic OA and back pain Use this as an opportunity to sell the benefits of delivering ESCAPE-pain. You can evidence outputs fromyour own organisation (if looking tosustain ESCAPE-pain) or fromcomparators in your region, e.g., otherICBs or leisure providers. We haveprovided a couple of examples here. For NHS OrganisationsAbout 90% of people with OA are managed by GPs. OAaccounts for 2 million GP consultations and ~150,000 knee/hip replacements, making it the third largest NHSexpenditure. In addition, it causes 36m lost working days andaccounts for ~£480/ person/ year out-of-pocket expenses.The total health, social welfare and societal costs is £3.2billion, ~1% of GDP. ESCAPE-pain can reduce the number of GP consultations andreduce prescriptions of painkillers for this group.Furthermore, the programme is a more efficient way to deliver effective rehabilitation, as people are seenin a group rather than having individual physiotherapy. Moreover, the programme can be delivered byjunior physiotherapists or rehabilitation assistants thereby upskilling, expanding, and using the workforce. The programme facilitators give great feedback on the ESCAPE-pain programme as it provides a positive experience where they know they are delivering evidenced-based care, and they also see the benefit that it gives to participants.
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 8 of 17 EXAMPLE: ESCAPE-pain in the community North West leisure provider case study Of 175 people who completed the programme between 2018 and 2020: - 85% had less knee and hip pain - 75% reported better quality of life - 72% had improved mental wellbeing - 92% increased their physical activity levels - Customer satisfaction was 9.8 out of 10- 72% undertook other classes and programmes offered by leisure centres after completingESCAPE-pain - ROI £204,484 saved in the health and social care sector inexpensive to set up and run increased footfall generates revenue as participants join other classes, use cafés, shops and vending machines more efficient use of resources as classes can run in off-peak times For public health Increasing physical activity levels, particularly among sedentary audiences, has significant publichealth implications around reducing co-morbidities and managing other long-term conditionsthat these patients are at higher risk of. They also reported reduced social isolation and bettermental health and well-being. Public Health England made MSK a priority for 2018-19 and has promoted and supportedESCAPE-pain. Read more of our ESCAPE-pain in the community case studies here.
Once you have this information, you can pitch the relevant stats and figures based on what the funderwants to achieve (e.g., reduce NHS costs, prescriptions, co-morbidities, waiting lists for surgery,pressure on GPs), and hone your argument to fulfil the funders’ organisations remit and aims. Showcasing the evidence for the need of ESCAPE-pain is an important step in applying for grantfunding. Using secondary data is not enough to show the importance, therefore, capturing theevidence of need through primary data is key, for example, qualitative and quantitative data collectedthrough surveys, interviews, discussion groups or letters of support. One ICB used data from the Versus Arthritis MSK calculator to show the size of the patient problem in their area, and then data from NHS RightCare to show how much it currently costs to manage the population, the likely future projection of the size of local population, what that might cost, andpossible savings achieved by implementing ESCAPE-pain. Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 9 of 17 Evidence the need It is important to have a clear idea of what the funder is looking for so that you can evidence theneed. Questions to ask yourself Why does ESCAPE-pain need to be implemented? What is the wider benefit of the project? For example, if you are a leisure centrewith paying members, what is the benefit of this project on the wider community?Does the ESCAPE-pain programme align to the funders core objectives? Take alook at their guidelines, strategies, and organisational values (You can highlightthis in the ‘Programme aims’ and ‘Programme objectives’). What cause is this helping? Does the ESCAPE-pain programme solve a socialissue? How is it more than just a ‘nice to have’? Tip Use Versus Arthritis MSK calculator to find data on estimated number of people over the age of 45 living with OA or back pain in your region based on either your local authority or ICB. Use Secondary Users Services (SUS) data to determine how many knee/ hip or back operations there have been in your region.
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 10 of 17 What is the purpose of ESCAPE-pain in yourregion/ patch? ESCAPE-pain contributes significantly to [input funding source key strategic objective(s)]. Thereare additional benefits to the health economy resulting from this in terms of community treatments,such as additional physiotherapy sessions, social care and reduced GP appointments, as well asmedication savings from reduced painkiller use, better mental health, increased physical activity andsocialisation. ESCAPE-pain also provides positive patient/participant outcomes: Cite any relevant ESCAPE-pain statistics andtestimonials from yourregion/patch [x]. quality of life improvement score increased by [x]%pain improvement score increased by [x]% function improvement scores increased by [x]%sustained over [x] months [X] have started the ESCAPE-pain programme with a completion rate [of/ exceeding x]%. Participants/ patients have told us how this programme has changed their lives; they have becomemore mobile, independent, physically and socially active, and less reliant on medication. Patient feedback includes: [List testimonials]
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 11 of 17 Costs to set up and deliver ESCAPE-pain Many leisure providers use their leisure centres, utilising gym spaces and/ or studios (which are easierto manage and offer more privacy for participants). Some offer the programme from community hallswhich may require a small venue hire charge. Delivering ESCAPE-pain only requires simple,unsophisticated, inexpensive equipment that can be found in any exercise location, meaning noadditional costs. However, all staff delivering the programme must attend the accredited trainingprogramme (costs are in the region of £300 per person). The decision to charge, and how much to charge, is at the discretion of the provider organisation and determined by its need to cover running costs and/ or break even. Where the programme is currently being charged to participants, costs range from £24 - £60 for the 12-session programme. Examples of funding models used by leisure/ community organisations include: local, regional or national grants to support programme facilitator costs and hall hire tosubsidise the programme deliveryESCAPE-pain charged as an upfront cost (e.g., a successful collaboration between localhealthcare providers, a local authority and leisure trust charged £36 per participant to coverthe programme costs)ESCAPE-pain charged as an upfront cost for people referred from local MSK clinic, but costsrefunded if a participant completes 80% of the programmeself-referrals are charged a non-refundable charge at the beginning of the programmeSubsidised membership of the leisure centreESCAPE-pain included in cost of leisure centre membershipprogramme charged as upfront cost but includes other benefits as part of the package suchas free-swimming membership for the duration of the ESCAPE-pain programme or reducedrate for refreshmentsreduced-price leisure centre membership after completing the programmeSome leisure providers work with their local health system to receive referrals from GPs, MSK teams,Falls Prevention Services and Community Physiotherapists, health trainers, Community HealthAmbassadors, local charities, Community Interest Companies (CIC), etc. To engage with these key stakeholders, establish referral pathways and encourage self-referrals,leisure providers have: promoted ESCAPE-pain as a programme that benefits patients of their health partners viaGP forums, TeleHealth, linking with Versus Arthritis, targeted promotions on social media,health and wellbeing events, directly targeting health professionals and local councilorsdirectly targeted the public to encourage them to self-refer themselves (via newsletters,events, target marketing)created a webpage on their website, providing all of the information people needed to know(what the programme is, eligibility criteria, how it works, how they sign up and refer to it)
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 12 of 17 The funding requested is £[x] to deliver [x] ESCAPE-painprogrammes over [X period] in [X location]. Theprogramme will be offered in [X e.g. leisure providercentres/ community halls/ centres and/ or virtually] toensure accessibility of ESCAPE-pain in local non-clinicalsettings for participants. To provide good access to theseprogrammes [x] courses will be required per yearproviding [x] places. Taking into account allowance fortraining, venue hire and promotional activity, this will cost£[x]. created social media graphics, posters, banners, leaflets, decorative bunting, and staff t-shirts with their key message “Do you have knee or hip pain?”, to attract the attention ofpeople with osteoarthritis, or people who may know someone that has osteoarthritis inGP surgeries, residential homes, hospitals, health centres, pharmacies, and communitycentresmade videos of ESCAPE-pain sessions in action collected testimonials from participants who had successfully completed ESCAPE-pain andwere keen to champion its benefits to others shared all this activity across social media and with their local press contacts charged a small fee that included a 6-week free gym membership as an incentive to makethe programme sustainable.These promotional activities may have a cost, but they are often small and may be non-recurring. Tip Provide realistic cost estimates for promotional activity and subsidised gymmembership costs (e.g., printing and labour costs, social media promotion - even downto the tea, coffee and biscuits!) Scope statement Outline here the fundingrequired and more informationabout the delivery of theprogramme (i.e., how long it willrun, how many programmes areexpected to be delivered, in whatlocations and venues). Add in therelevant funding and deliveryinformation [x]. Tip
EXAMPLE: ESCAPE-pain in the community - Northwest leisure provider case study The estimated cost (from previous ICBs who have run these classes) is £163 per patient. Wewish to provide the programme to 610 patients. Total cost = £163 x 610 = £99.5k Previous ICBs using ESCAPE-pain have found the following benefits per 1,000 patients: reduction of 230 bed days reduction in 90 outpatient consultations reduction in 110 GP consultations reduction in medication costs of £20,280 reductions in community-based care estimated at a value of £59,000We believe the programme would generate following costs and savings. Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 13 of 17 Cost savings The economic evaluation of ESCAPE-pain (Hurley 2007b, Hurley 2012) suggests that for every1,000 participants who undertake ESCAPE-pain there are potential savings (2017-18 prices) of: £21,840 per/ annum in medication £64,140 per/ annum in community-based care (GP consultations, district nurse, social care contacts) £1.5m in total health and social care (hospital services – inpatients days; outpatients, A&Eand other consultations) over 30 months after completing the programme A proportion of savings are cash-releasing, but equally importantly save much needed clinicaltime. Number of patients completing course Cost of programme delivery Number not attending secondary care Number of procedures avoided Savings from first appointments Savings from follow up appointments Savings from procedures avoided Gross savings Net savings (-£99.5k) 610(610 x £163 = £99.5K)6131£7,930£2,288£212,585£222,803£123,303
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 14 of 17 Options for delivery The programme is currently being delivered in healthcare and in leisure settings, using a range ofcommissioning models. For ICB-commissioned activity, the most common arrangements are: the ICB contracts with the physiotherapy provider to deliver ESCAPE-pain in physiotherapyoutpatient departments. Some contracts are a locally agreed “group tariff”, others operate under a“block” contract that specify expected number of participantsthe ICB contracts with the physiotherapy provider as described above, but the physiotherapyprovider delivers the programme in a leisure centre. The leisure provider offers the venue withoutcharge, and benefits from increased footfall during the programme and when participants continueto use the facilities after the programme. The leisure provider may instigate other “paid for”programmes to support participants after they have completed the programme or offer incentivesto encourage participants to take up centre membershipthe ICB contracts with local authority to deliver ESCAPE-pain in a leisure setting and/ or communityhalls. The leisure providers use their own venue/ community halls and develop referral pathwayswith local physiotherapy departments, primary care services, Exercise on Referral (EoR) scheme andfalls programmes etc., to facilitate easy referralFor ESCAPE-pain commissioned by local authority, the most common arrangements are: the local authority contracts with the leisure provider to deliver ESCAPE-pain in leisure settings andcommunity halls. The leisure provider links with referral pathways from health professionals (GPs,nurses, physiotherapists), Exercise on Referral (EoR) routes, social prescribers and promotes self-referrals onto the programmeReturn on Investment (ROI)Based on Public Health England’s (PHE) return on investment tool for musculoskeletal conditions,PHE calculated that for every £1 spent, ESCAPE-pain offers a healthcare savings return of £5.20. PHE also released 'Return on Investment of Interventions for the Prevention and Treatment of Musculoskeletal Conditions' stating there is an estimated net saving of £1,309.78 per patient who attends an ESCAPE- pain course. This is based on health care activity savings. If this funding is available, it would enable [x] people to complete a course giving an overall return on investment of £[x]. Use Public Health England’s (PHE) return on investment tool to calculate potential ROIbased on funding available.
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 15 of 17 Sustainability of impact Funders want to know how the impact will be sustained following the end of the funding period. Questions to ask yourself How are you sustaining the impact of ESCAPE-pain post-programme? How are you linking ESCAPE-pain with continuing other physical activity opportunities? It is important that you establish an ‘exit strategy’ for participants “graduating” from the programme toensure the benefits gained are sustained and increase the return on investment. Some leisure operatorshave set up ‘post-ESCAPE-pain’ classes in response to demand from participants to help graduatesmaintain their physical activity or have offered subsidised gym memberships to encourage graduates tocontinue getting involved in physical activity in their communities. What can be offered will depend onwhat your organisations are willing to offer to incentivise people to remain active and generate revenueif needed. We would encourage you to be as imaginative as possible. Clinical departments have very limited ability to put in place activities, classes and programmes to help people sustain their activity levels, hence the benefits of the ESCAPE-pain programme. Clinical departments might consider linking with local leisure and community organisations to signpost participants to local activities and programmes that they might engage with.
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 16 of 17 Risks, Issues and Dependencies Find below examples of events that can have an adverse impact if they occur. Find below examples of potential matters that need to be considered and addressed by the provider.These are risks that have already occurred and need to be addressed. Find below examples of other services or programmes that ESCAPE-pain depends on or are a beneficiaryof programme outcomes. Risks Likelihood Potential procurement of community physioservices complicates this service. Close working withphysio procurement Issues Mitigation Owner Reprocurement of community physio services. Impact on other relatedservices, potentialconfusion of pathwayand referral for GPs. Impact on project Dependencies Owner Total Programme does not improve patient health asmuch as expected, leading to lower savings. Poor engagement with GPs meaning low referrals.Mitigated by awarding an activity-based contract, e.g.,Courses will not run without a minimum of eightstarters and the provider plans to oversubscribe by X%for each course due to reported drop off rates. COVID-19 poses a risk to the delivery of ESCAPE-pain. Infrastructure is in place to deliver theprogramme as an online course. Experience and skills gap Contingency funding for training will therefore beconsidered to ensure more than two leisure staffare qualified to deliver the programme if there isabsence due to sickness. Impact TotalRisksLikelihood
Copyright © 2017 ESCAPE-pain and Health Innovation Network.All rights reserved. Page 17 of 17 escape-pain.org @escape_pain The ESCAPE-pain programme is an intervention forpeople with knee or hip osteoarthritis developed byProfessor Mike Hurley. ESCAPE-pain is delivered byOrthopaedic Research UK (ORUK) under licencefrom Guy’s and St Thomas’ NHS Foundation Trust. If you would like to find out more about how ourother providers have delivered ESCAPE-pain in thecommunity, you can read and watch our suite ofcase studies here.hello@escape-pain.org #LiveBetterDoMore