Adult Chronic Pain Management Services in Primary Care

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CHRONIC PAIN AND PRIMARY CARE Wednesday 10
November 1230pm 200pm Jubilee Room,
Westminster Hall Houses of Parliament
APHG WOULD LIKE TO THANK OUR ASSOCIATE MEMBERS
NAPP PHARMACEUTICALS FOR THEIR KIND SUPPORT OF
THIS SEMINAR, THROUGH AN UNCONDITIONAL
EDUCATIONAL GRANT
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CHRONIC PAIN AND PRIMARY CARE    
AGENDA   1230pm 1245pm
BUFFET LUNCH SERVED  1245pm WELCOME AND
INTRODUCTION Barry Sheerman MP 1250pm 105pm
ADULT CHRONIC PAIN MANAGEMENT SERVICES IN PRIMARY
CARE FINDINGS OF DR FOSTER SURVEY, COMMISSIONED
BY NAPP PHARMACEUTICALS, PATIENTS ASSOCIATION AND
LONG-TERM MEDICAL CONDITIONS ALLIANCE Dr Martin
Johnson, General Practitioner with a special
interest in pain management   105pm
115pm PATHWAYS TO WORK HELPING PEOPLE INTO
EMPLOYMENT Dr Ceri Phillips, Reader, Health
Economics, University of Wales  
115pm 125pm CHRONIC DISEASE - PAIN MANAGEMENT
AND PRIMARY CARE POLICY Dr Clare Gerada,
Director, National Clinical Governance Support
Team, GP Advisor to the Department of
Health 125pm 135pm PAIN IN LONG-TERM
CONDITIONS THE PATIENT PERSPECTIVE
David Pink, Chief Executive, Long-term Medical
Conditions Alliance 135pm 200pm QUESTIONS
AND ANSWERS AND OPEN DISCUSSION SESSION  
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Chronic Pain in Primary Care
Dr Martin Johnson General Practitioner,
Barnsley Chair of RCGP Committee on Pain
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What is pain?

• An unpleasant sensory and emotional experience
  associated with actual or potential tissue damage
  and expressed in terms of such damage
  IASP 2001
• Pain is inherently subjectivea patients
  self-report is the gold standard for assessment
  Portenoy 1999

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Influences on the pain experience
Age
Gender
Fears
Pain
Culture
Education and understanding
Previous pain experience (self/family)
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The impact.

• One in seven people in the UK suffer chronic pain
• Two out of three suffering chronic pain report
  that their medication is inadequate at times and
  pain scales are vastly underused
• One in five suffering chronic pain have stopped
  taking prescribed pain medication
• Long term unremitting pain has a long term impact
  on quality of life-
• - patients can become increasingly isolated and
  helpless
• family breakdown can occur
• one in four have been diagnosed with depression
  as a result of their pain
• One in five chronic pain sufferers feel their
  pain is sometimes so bad they want to die
• Pain is the second most common reason patients
  claim incapacity benefits, with few ever
  returning to work
• Often GPs feel unable to manage their patients
  pain in a satisfactory way
• 2nd Commonest cause of days off work through
  sickness (206m working days 99/00)
• 
  
  
  
  Refs Pain in Europe 2003, CSAG
  2000, www.dwp.gov.uk

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Cost of problem in the UK

119 million days certified incapacity




119 million days certified incapacity
900,000hospital bed days
12 millionGP consultations
Back pain 12 billion annually
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My Practice (03 to 04)

• Profile
• 9,500 patients
• Urban, ex-mining area
• Analgesics on repeat or more than 2 acute Rx
• Non-Opioid Analgesics 2210 patients (22)
• Opioid Analgesics 342 patients (4)
• NSAIDs 2058 patients (22)

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Facts Figures

• Most Published Surveys/Documents relate to
  Secondary Care
• Services for Patients with Pain (Clinical
  Standards Advisory Group) March 2000
• Pain Management Services Good Practice
  (RC Anaesthetists Pain Society) May 2003
• Dr Foster Adult Chronic Pain Management Services
  in the UK (Pain Society/Napp) 2003

GPs Community Staff manage the majority of
patients with chronic pain
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Secondary care research 2003

• Conducted by Dr Foster in consultation with The
  Pain Society
• Researched Adult Chronic Pain Management Services
  in the UK
• Pain management in the UK is under- resourced and
  under-treated
• There is evidence of closure of waiting lists and
  waiting times of up to 2 years
• Only half of reported Pain Clinics offer Pain
  Management Programmes
• A tenfold difference was reported in service
  funding from one hospital to another

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Adult Chronic Pain Management Services in Primary
Care

• Findings of research by Dr Foster
• Endorsed by the Patients Association and
• Long-term Medical Conditions Alliance
• 10 November 2004

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Scope of the Project

• Aim
• To build a coherent picture of chronic pain
  management services in primary care
• Questionnaire
• Developed in consultation with the Patients
  Association and Long-term Medical Conditions
  Alliance
• Sent to PCO Chief Executives throughout UK
• 55 response rate
• Non-responders have been included in the analysis
  for comparison with those PCOs who were able to
  complete the questionnaire

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Questionnaire

• Resource allocation specifically for chronic pain
  management services
• Availability of guidelines and protocols
• Practice-based registers/auditing processes
• Specific chronic pain management for over 65s
  and those living in residential homes
• Budget allocation for training
• Initiatives and priorities

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Key findings

• The provision and organisation of primary care
  chronic pain management services across the UK is
  unequal, inconsistent and suffers from-
• A lack of adequate funding
• Patchy and inconsistent prescribing or management
  guidelines
• A lack of register or auditing processes
• Variable provision of healthcare professional
  training

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Inequalities in care

• 64 of PCOs fail to allocate any funding
  specifically for pain management services in
  primary care
• Of those that do, the allocation ranges from
  0 - 4.7, with an average of 0.7 of the PCO
  total budget
• There is a six-fold variation amongst the regions
  in terms of percentage of PCOs providing funding
  for pain management services in primary care

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Inequalities in care
48 of all PCOs did not answer this question
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Comparison of pain management funding between
primary and secondary care
48 of all PCOs did not answer the primary care
question 50 of all PCOs did not answer the
secondary care question
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Overview of guidelines and protocols

• Over half of respondents reported a lack of
  guidelines for the prescribing of medication for
  non-malignant chronic pain
• Over two-thirds report a lack of guidelines for
  the management of non-cancer pain

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Chronic pain services

• Auditing processes
• 96 of questionnaire respondents do not have a
  register of those patients requiring chronic pain
  management care, in spite of patients suffering
  on average for more than 6 years

20
Provision of formal or structured service

• 80 of respondents reported that no form of
  structured service was in operation, in spite of
  pain being the second most common reason why
  people visit their GP in the UK

21
Formal or structured service for chronic pain
management in primary care
48 of all PCOs did not answer this question
22
Although not offered specifically for pain
management

• 66 have services which are available to chronic
  pain sufferers if they are referred for treatment
• These treatments are provided by primary care as
  a matter of course

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Chronic pain services delivered in primary care
51 of all PCOs did not answer this question
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Services for Older People

• NSF for Older People (2001) aims to ensure a
  well co-ordinated, coherent and cohesive
  approach and to specifically address those
  conditions that are particularly significant for
  older people
• 86 of respondents reported that they do not
  provide specific chronic pain management for
  people over 65 years and 90 do not provide any
  services for those living in residential homes

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Expert Patients Programme

• The EPP is one of the new policies and
  initiatives to modernise the NHS to emphasise
  the importance of the patient in the design and
  delivery of services
• Two-thirds of respondents recommend patients with
  chronic pain join the EPP and provide
  information on how to join

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Links with secondary care and waiting times

• There are good links to the secondary care pain
  clinic, podiatry, rheumatology, orthopaedics and
  palliative care
• However, over half of responding PCOs do not have
  a defined protocol for referral from primary care
  to these services
• Out of those that did, waiting time to access
  this service can be up to 78 weeks

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Education and Training

• Continuing professional development is at the
  heart of improvement of standards
• 92 of respondents have no budget allocated
  specifically for training their GPs in chronic
  pain management

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Innovative Pain Initiatives

• Over half of PCOs surveyed do not have any
  innovative pain management programmes
• Of those that do, developing primary care pain
  management services , education, assessment and
  advice initiatives and a number of pilot studies
  to assess the effectiveness of primary care
  interventions are reported

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Pain management where does it fit in to
General Practice?

• Chronic disease management is defined by the new
  GMS contract as an essential service
• OA and RA are chronic diseases that require
  quality management as an essential service
• Not a Quality Indicator
• Not an NSF
• Not covered by NICE
• Absence of defined standards

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Priorities

• Obtaining funding to provide an adequate service
• Reducing waiting times
• Development of clear standards and protocols
• Training and education
• Holistic approach

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Summary

• There are major inequalities in chronic pain
  management services across the UK
• PCOs allocate very little resource allocation to
  the provision of chronic pain management services
  in primary care
• Most do not offer their GPs guidelines or
  protocols in pain management
• Very few audit those suffering chronic pain
• A minority operate a formal or structured service
• There is a lack of training for GPs and other
  healthcare professionals
• Healthcare professionals working in primary care
  need help to alleviate the pain their patients
  are suffering

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Chronic pain



The economic consequences and government response
APHG, November 2004
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Invalidism
Sick leave
Avoidance
The Pain Ladder
Depression
Weiser, 1997-1999), Main 2000
Helplessness
Failed treatment
Anger blame
Catastrophising
Uncertainty fear
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Current context

• 1 million report sick each week 3000 remain off
  work at 6 months and 80 of these will not work
  again in next 5 years
• 2.7 million people of working age on a state
  incapacity benefit less than 1 million
  unemployed
• demographics not good ageing population IB load
  projected to rise further regional dimension

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Sickness absence

• Sickness absence costs industry 11 bn pa
• up to 16 of salary costs
• other direct and indirect costs
• absence management costs
• burden on other employees
• Occupational health services still only available
  to the minority of employees

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Pain its prevalence
In the first of two studies, 46.5 of the general
population reported chronic pain, with 26.9
reporting pain that was at least moderately
limiting and of high disability. The second
study showed that the prevalence of chronic pain
had increased from 46.5 at baseline to 53.8 at
the 4-year follow-up and that 79 of those with
chronic pain at baseline still had it at
follow-up. The two most commonly reported causes
of pain were back pain and arthritis accounting
for a third of all reported causes. Back pain was
the most common problem in men and in the younger
age groups, and arthritis was the most frequent
cause of pain in women and in the older age.
Elliott et al, 1999 2002
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Pain its costs

• 2.5 million people have back pain every day of
  the year BackCare, 2001 total cost of 12.3
  billion (22 of UK healthcare expenditure) with
  75 of costs attributable to work loss.
• It has been estimated that in the UK there are
  2,150 million chronic pain days per year, based
  on a prevalence of chronic pain of 10 McQuay
  and Moore, 1997
• One in eight unemployed people give back pain as
  the reason they are not working BackCare, 2001.
  
• Chronic pain patients account for 4.6 million
  appointments per year, equivalent to 793 whole
  time GPs Belsey, 2002

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Disability and Incapacity epidemiology

• 6.9 million people of working age (UK) report
  some long-term disability (OECD 2003)
• - one third report severe
• - 48 regard themselves as disabled (LFS 2002)
• - 49 (25 severe) are working
• - 51 receiving benefits (cf 7.5 of working
  age population)

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The Burden of Chronic Pain affecting Capacity for
Work
Nos Pain Musculoskeletal
Disorders 200,000 100 Mental Health
Problems 240,000 20 Neurological
Diseases 40,000 14 Cardiovascular
Diseases 44,000 22 Others 222,000 10 - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - Chronic
Pain 277,000 28
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The impact on Exchequer
Total Expenditure on Incapacity Benefit (2001/02)
- 6.7 billion Percentage of IB
claimants in ICD-10 Group (Musculoskeletal
conditions) - 22 Expenditure
on IB as a result of Musculoskeletal problems
1.46 billion
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Work gtgtgtgtgtDisability over time
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Government welfare strategy

• Work for those who can security for those who
  cannot
• To increase participation in work as a socially
  inclusive and economically supportive activity by
  working age people disadvantaged by ill health or
  disability
• Economic and social inclusion for disabled people
• Targets by 2006
• increase employment rate for disabled people
• 30 reduction in working days lost from
  work-related injury/ill-health
• 10 reduction in major injury/incidents at work

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Meeting the Challenge

• Health and Safety Executive
• strategy programmes
• DWP
• Pathways to Work
• Framework for Vocational Rehabilitation

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(No Transcript)
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Obstacles to work - culture

• inappropriate early interventions/ management
• assumptions of unemployability/health beliefs
• stigma and discrimination by employers and public
• interagency problems
• loss of motivation and self confidence
• income related issues
• steps to activation are undermined

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Benefits Culture Under Fire May 19th 2003

• No-work culture
• One firm advertised 150 posts only 3 vacancies
  filled
• Restructure the benefits system, reduce benefits
  dependency and "tease people" back to work

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Change? - Return to work a positive realistic
option

• Virtually all flowing onto IB want to get back to
  work at outset
• 90 expect to get back few months into their
  claim
• Most have more manageable health conditions where
  outlook should be good
• 35 mental disorders (mostly depression)
• 28 chronic pain
• 22 musculoskeletal problems (mostly back pain)
• 11 - circulatory problems (mostly complications
  of angina etc.)
• Return to full activity (including work) will
  improve health

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Obstacles to Work - Retention and
Rehabilitation

• Stakeholders Views
• Occupational health too reactive
• Failure to adopt (seek) best practice
• e.g. - in sickness absence/attendance
  management - in clinical management of back
  pain, mental health problems, etc
• Poor rehabilitation service provision (especially
  NHS)
• Inter-agency co-operation poor
• Employers engagement

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Work Loss and Return to Work

• Dependent on other influences as well as
  sickness, pain and disability
• Job type and satisfaction
• the workplace
• labour market
• national and local economies
• income, compensation
• benefits and social security systems
• closeness to retirement age
• culture

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New Rehabilitation Support to Help People Manage
Their Conditions

• Evident Gap in provision of employment-focused
  rehabilitation programmes
• Provision of additional specialist support with
  NHS
• Multidisciplinary programmes adapting holistic
  approach to help the patient to
• ? manage their pain
• ? improve their health, fitness, outlook, and
  mood
• ? cope with uncertainty and fear about their
  illness

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Pathways to Work Pilots Aims

• Particular focus on customers with
• Musculoskeletal disorders
• Moderate cardio-respiratory conditions
• Mild to moderate mental health conditions
• NOT to replace NHS Treatment but aimed at
• Helping patients to understand and manage their
  condition
• Using CBT and other validated interventions

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Pathways to Work Pilots Essential Elements

• Work Focused Interviews for all NEW IB claimants
• Earlier Intervention with Dedicated Personal
  Advisers
• Screening/Exemption
• Financial incentives
• Return to Work Credit
• Discretion Funds
• Job Grants
• Permitted Working
• Immediate Access to Job Centre Plus New Deals

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New Condition Management Programmes The
Objectives

• 6-13 weeks duration (individual or group-based)
• holistic approach to
• managing and coping with pain
• coping with, and understanding, uncertainty and
  fear
• improving mood, outlook, health and fitness
• addressing physical de-conditioning
• Voluntary will not affect benefit entitlement
• Delivered by local Primary Care Trusts and Health
  Boards
• Customers GP (with consent) kept informed

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Support for GPs as key influencers, which
recognises

• insufficient knowledge on basic fitness for work
  issues
• lack of emphasis on work retention and
  rehabilitation
• acknowledge that relationships with patients
  cause difficulties
• address lack of NHS provision for treatment or
  rehabilitation
• DWP/CMG Website - Training and Advice for GPs

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Review of Employers Liability Compulsory
Insurance Second Stage Report (November 2003)

• Government leadership and help to establish a new
  approach to rehabilitation
• Commitment to A Framework for Vocational
  Rehabilitation (Summer 2004)
• establish definition, focus and range of work
• a framework for effective intervention and
  management
• towards a flexible and diverse range of provision
• delivery as a shared effort (business, insurers
  and unions)
• To lasting cultural change and better outcomes

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The Focus of Rehabilitation

• Rehabilitation is not a separate secondary stage
  after healthcare
• Good Clinical Management should relieve symptoms
  and restore function
• Fundamental shift in healthcare culture
• A multi-modal nature addressing
• - biological - psychological
• - social components - and obstacles to recovery

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Thank you for your attention