ESCAPE-pain programme for hip and knee pain

More than 8.5 million people in the UK suffer from chronic joint pain. In many cases, patients are diagnosed with osteoarthritis in early old age, when they are particularly vulnerable to rapid deterioration in health and loss of independence.

Without adequate support, many enter a vicious cycle of severe pain, leading to prolonged rest, which contributes to further muscle weakness, physical instability and fatigue. Inactivity increases the risk of co-morbidities such as diabetes and cardiovascular disease. Meanwhile, pain and disability can contribute to social isolation, feelings of helplessness and anxiety, and depression. In the worst cases, people are losing their independence and suffering dramatic deterioration in their quality of life decades earlier than necessary.

In the early 2000s, Mike Hurley, a professor and physiotherapist at King’s College London, and later at St George’s University of London, became increasingly concerned about the care of these patients. Many were managed in primary care, with high reliance on painkillers, typically non-steroidal anti-inflammatory drugs, despite their limited long-term effectiveness and the risk of side effects. Only a small proportion received short, one-to-one physiotherapy courses with the focus on exercises to improve muscle strength and endurance. However, even these patients received little practical support to help them learn to manage their conditions on their own. 

With a research grant and funding from Arthritis Research UK, Mike spent most of the 2000s developing an alternative approach. His aim was to develop a programme that challenged patients’ common belief that arthritis was an inevitable and untreatable consequence of ageing, convince them of the key role of exercise in improving their symptoms (despite the counterintuitive experience that exercise makes things worse, at least in the short term) and empower them to manage their conditions, while at the same time providing a tailored exercise regime. 

The result was the ESCAPE-pain programme, with ESCAPE standing for enabling self-management and coping with arthritic pain through exercise. The course is run by physiotherapists for eight to ten patients who meet twice a week for ten to twelve sessions. The programme includes a combination of education, self-management and coping advice with physical exercises. During the sessions, patients share experiences and take stock on changes in their conditions since the previous session; set and review goals and action plans; engage in themed discussions on topics such as managing pain, healthy eating, and pacing activity and rest; carry out supervised exercises, and agree exercises to do at home. Unlike traditional treatments, the programme focuses on developing people’s appraisal and coping skills as much as on their physical function. It does this through allowing them to experience and document improvements and helping them to connect with others as well as through formal education and instruction.  

In the mid-2000s, Mike piloted the programme at a small number of sites in South London and North Kent. A series of evaluations demonstrated that the programme is safe and delivers substantial improvements in patients’ physical health including their levels of pain and ability to complete physical tasks. Patients also reported greater confidence in their ability to manage their pain and other symptoms and lower levels of anxiety and depression. It also reduces other health care costs through reduced use of A&E services, referrals, diagnostic tests, analgesics and other medications.

These assessments do not, of course, capture the full benefits of the programme. One patient described suffering with constant pain, being reliant on painkillers and being hardly able to walk before the programme. After the course, she was happier and more self-confident. Simply knowing that she could take practical steps to improve her condition made it easier to cope. She was spending more time out with friends and was able to play with her grandchildren. 

By the late 2000s, Mike had demonstrated the impact of the programme through a series of clinical trials. An independent assessment showed that the programme delivered comparable outcomes to one-to-one physiotherapy at half the cost. Nevertheless, Mike hit a ‘brick wall’ when the funding for the initial pilots ended in 2008. Only one centre in North Kent decided to retain the service. He continued to raise awareness of the new model at conferences and in academic journals, but with little effect. By this point, he was seriously considering a change of career. In his own words, ‘What was the point in dedicating a decade to research if it was just going to sit on a shelf?’.

Mike is convinced that the programme would have folded if it hadn’t been for a call from the chief executive of the newly created Health Innovation Network, the AHSN for South London, in 2013. The Network had selected musculoskeletal care as one of its initial priorities and saw ESCAPE-pain as a potential ‘quick win’, a proven, low-cost innovation that could be adopted quickly at scale.

From 2013, Mike joined the AHSN as a part-time clinical director with a small team to support him in marketing and implementing the scheme. Mike and Andrea Carter, the Director of the Network’s musculoskeletal programme, focused on persuading senior clinicians to trial the scheme, relying largely on personal contacts. Meanwhile, the team synthesised the research evidence and developed materials to explain the programme to commissioners and managers.

Mike and the team established ESCAPE-pain on a permanent basis within King’s College Hospital and Lewisham Hospital, with these becoming early champions and showcase sites. Over the next four years, they persuaded 10 of the 12 CCGs in South London to adopt the programme, as well as establishing it in Kent, Mid Sussex and individual clinical centres across the UK. It is also being established through collaborations with the North West AHSN and the North East and North Cumbria AHSN, an example of how the ASHNs are working collaboratively to spread innovations. 

One of the main benefits of ESCAPE-pain is that it can be put in place quickly at low cost using existing staff and facilities. Organisations pay a small fee to send their staff on a half-day training course. The Network requires providers to adhere to a number of minimum standards on the content and duration of the programme (there were battles with commissioners who wanted to shorten the programme to reduce costs) and to collect and share data on outcomes.

Nevertheless, Mike explained that one of the greatest challenges was persuading commissioners and providers to make small upfront investments to secure longer term benefits. It was particularly difficult to persuade a fragmented commissioning system to contract for the new service, particularly where commissioners were disconnected with providers. It was easier to make progress in areas where providers were funded through block grants and had greater flexibility to adapt services, without the need for changes to funding arrangements or the details of contracts. 

Similarly, the team encountered difficulties in persuading commissioners and providers to invest in the service since benefits would be felt by other organisations, for example taking the pressure off primary care. Some providers operating under payment by activity were concerned that investments in prevention would reduce demand for remunerated services. According to Mike, ‘Sometimes they could hear the madness as they articulated these concerns’. 

The team’s current focus is on introducing ESCAPE-pain in new environments, so that people can access services more easily and patients are able to continue group-based activities after their NHS treatment ends. In particular, the team has developed a new training course, accredited by the Royal Society of Public Health, which allows exercise professionals to lead the programme in leisure and community centres. They have introduced the programme at leisure centres in Camberwell, Peckham and Brixton. The Health Innovation Network team has recently secured a large grant from Sport England to spread the programme in leisure and community settings.