Case study

Implementing stratified care for low back pain: STarT Back

A clinically and cost effective care approach for low back pain using a screening tool to match patients to the right treatment.



The STarT Back approach addresses the high burden of back pain for patients and the NHS by providing physiotherapists and GPs with a screening tool to match patients to the most suitable treatment. The tool calculates a risk score for the patient and subsequently recommends appropriate management pathways such as primary care and physiotherapy.


Back pain is a common health condition that causes distress for those who suffer from it, and is costly for the NHS. In the UK, it accounts for the highest number of years lived with disability. In 2013, 131 million working days were lost worldwide due to back pain sickness absences.

Despite the availability of effective treatments for back pain, management based on clinical intuition alone often fails to match patients to the most suitable treatment. Stratified care approaches aim to improve this problem by providing a more systematic approach to management decisions.

Through improving the primary care management of back pain, there is potential to reduce long-term consequences of the condition, including low quality of life, persistent disabling symptoms, and reduced capacity to work.

What was involved

Delivered by Keele University, STarT Back is a stratified care approach that addresses the high burden of back pain for patients and the NHS. It uses a screening tool to match patients to the right treatment. This reduces over-treatment by ensuring low risk patients are supported in primary care, and medium and high risk patients receive more effective physiotherapy treatment.

Despite high quality evidence that STarT Back is both clinically and cost effective, uptake of the approach in clinical practice was poor. Supported by the West Midlands Academic Health Science Network (AHSN), Keele University worked with the NHS to address the barriers and solutions to implementing this high quality and cost effective evidence.

It was found that:

  • training of physiotherapists, GPs and patients in the core messages was required
  • GPs wanted an integrated e-version of the STarT Back tool

Keele University supported over 200 physiotherapists across the West Midlands AHSN to access training to implement the STarT Back approach. They designed and tested an electronic solution, embedding the STarT Back tool within GP clinical systems.

When a back pain code is entered, the tool automatically prompts the GP to complete the STarT Back questionnaire, which calculates the risk score and recommends appropriate management pathways. The GP system can also access high quality patient information.

What works well

The toolkit is free to the NHS, and per patient has been shown to save £34 in health costs and £675 in societal costs. It does so through matching patients to treatment packages appropriate for them, which:

  • significantly decreases disability from back pain
  • reduces work absence (average time off work was halved)
  • saves money by making better use of health resources and reducing healthcare utilisation such as GP visits, referral rates, MRIs and medication

Next steps

With the recent publication of the NICE low back pain guidelines and focus on Sustainability Transformation Plans (STPs), there is now an opportunity for the STarT Back approach to be further adopted regionally and nationally.

NHS England’s Five Year Forward View sets out the need for new models of care and multi-specialty clinical providers. STarT Back is an appropriate approach for ensuring GP and physiotherapy services work optimally to deliver suitable treatments.

STPs bring commissioners and providers to work together to find solutions for their health economy. Supported by NHS England, Arthritis and Musculoskeletal Alliance (ARMA), West Midlands AHSN, the new musculoskeletal network will allow the STarT Back team to:

  • offer STarT Back as an integrated care pathway within STPs across the region
  • maximise the opportunity of the network to offer clinical solutions to problems
  • promote clinical champions as a mechanism for change
  • achieve system change

Further information

Contact Nicki Evans, Project Manager

Published 6 December 2017