Commissioning pain
management services:
what do care pathways
for people with long term pain
and clinicians need?
Dr Frances Cole
Clinical Lead, NHS Kirklees
GP + Pain Rehabilitation Specialist, Bradford Teaching Hospitals
June 2012
frcole@btinternet.com
Health is a resource for living so we are able to:
Undertake daily activities
Join in social activities
Do physical tasks
Not feel bodily pain
Feel peaceful and happy
Feel full of life
WHO 1984, Ware 1993
Less contact with
family, friends,
social networks,
specific support
Poor understanding of pain
condition/s and self manage
confidently
Dyslexia, literacy, language
Loss of work
(paid/unpaid)
Long term low income
+/- benefit issues
Self coverage
Health services
programmes not
flexible to meet
needs
Difficult to use
public transport
Unable to drive
due to drugs
Poor sleep
patterns;
Depression
Fear, Anger,
Shame,
Fatigue
Reduce goals,
planning, pacing of
daily life activities,
Fitness activity levels
reduced
Perceived lack of
control over their
pain and their life
Health needs change due to
changing illness, disability.
Pain relief mixed, variable
Carers needs; little
appropriate support
Housing structure /
location unsuitable
adaptations need to
reduce disability
Multidimensional impact of
chronic pain on health
Women > Men
>65 more than<65
Vitamin D insuff
The NHS Commissioning Cycle
National policies – UK
Chief Medical Officer report 2009; Dept of Work & Pensions 2006
Dept of Health Long Term Health Condition Programme
NICE Guidelines; UK Pain Summit 2011
British Pain Society MoM pathways; Royal College General Practice
Kirklees JSNA
Self Care for LTHC
Public Health
Kirklees Scrutiny Panel
Public Health and
Local Authority
NHS Kirklees
Commissioners incl. contracting, local authority,
public health, patients, providers
shape care pathway
Public and Patient
engagement
Public Health
GP / primary care
Public Health
Kirklees Joint Strategic Needs Assessment
(JSNA) 2009
Pain
worst impact on health - physical function
20% = no physical activity
Affects 1 in 3 people
104,817 adults in Kirklees
89,679 affected = working age.
People < 65 years
31% pain in past year
People > 65 years
46% pain in past year: women > men
Poor sleep 1 in 3
Depressed 1 in 2 esp. back pain
More have heart disease, diabetes, stroke
75% at least overweight
Linked to low income £££
Impact on carers – many have chronic pain
www.kirklees.nhs.uk/
The NHS Commissioning Cycle
What do patients need to manage pain?
2 Commissioners engaged patients
NHS Kirklees; NHS Bradford + Airedale
Self care: key part of control on their lives + pain; want all
GPs to refer all patients > self care services
Better self care information - range of media + sources
Better access to self care resources + services
Confidence in GP + their skills
Seeing right clinician at right time
Continuity of care: more seamless
Consistency of experience at all steps of pathway
Faster access: assessments + investigations
Faster access: Physiotherapy, Occup.Therapy, Pain Specialist
What do primary care clinicians need?
Change of model + pathway: biospychosocial model for long term pain
More knowledge + skills: <10 hrs training for doctors
More time with patient in consultation
Improve medicines management + clinical skills
◦ Pain symptoms, side effects, guidance + decision aid tools
◦ Manage emotional distress, cope with setbacks
Referral - minimum data > single entry point in pathway
Referral guidance – decision aids; Map of Medicine
Stop referring for spinal surgery for pain
Know about self care resources; where / how to refer or use them
More awareness - financial costs; primary + (secondary care clinicians)
Kirklees Council Scrutiny Panel
for Health Inequalities
2010
Main recommendations:
Consistent pain services - person centred
approaches to pain management
Services closer to home
Training & professional development about self
management options
Reduce referral times – physiotherapy
Pilot person centred chronic pain service across
Kirklees
Pathway Objectives for NHS Kirklees
Improve health & resilience by reducing disability + distress
experience of persistent pain sufferers
by a comprehensive, accessible + quality programme that
Commissions services with sustainable, consistent delivery +
measure performance management
Monitors quality of clinical practice + meet standards set in
line with local / national guidance
Ensures ongoing professional development
Ensures cost effectiveness + efficiency
Patient Centred Outcomes
Improve health as a resource for life
Improve confidence + sense of control (self efficacy) so….
improve self care with more ways to help themselves
Return to or stay in work
Reduce pain distress + intensity; total relief not expected
Improve mental health & wellbeing; less anxious + depressed
Reduce unhealthy behaviours: weight loss, stop smoking, more
physically active
Reduce in health care use: GP, specialist referrals
Patient Reported Outcomes Measure Scores
Pathway
Commissioning services:
so people self care better in Kirklees
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Expert Patients Programmes self management courses or
support to develop self-care skills (for conditions e.g.
diabetes, mental health, COPD + chronic pain
Health Trainers / Physical Activity Leisure Scheme - Help to
change behaviour (e.g: lose weight, stop smoking, take up
activity), 1:1 or group support, Specific for pain: REVIVE
Self Care Web Portal – Local information in one place.
Access to Networks and opportunities to talk to people in
same situation i.e. support groups, forum;
Libraries - bibliotherapy + range of self help books, pain
toolkit ,CDs etc
Gateway to care offers advice, practical support for both
patients + carers; network to relevant services
Better health at work – confidential support and advice for
all work related issues
www.kirklees.nhs.uk/self care
Self management resources needed
Tier 1
www.paintoolkit.org/
Tier 2
Tier 3
www.npowered.co.uk
www.overcoming.co.uk/
Resources in clinics, libraries etc
Oral + written information
=
important as drugs, test, scan or
surgery
Information needs change over time
Clinicians need more medicines
management guidance
Neuropathic Pain algorithm
Opioid algorithm
Boost confidence so prescribe safely, effectively + ££
Provide range of patient tools: self assess + self manage
Provide clinical tools to assess + review
Integrate
◦ into GP computer System 1 + PCT website
◦ with pain specialist clinicians
www.kirklees.nhs.uk/yourhealth/long-term-pain
Commission pain specialist procedures
Agreement on range of treatments provided
Evidence focus + clinician dialogue with public
health
Specific contracts; so stop some procedures +
agree to limit repeats
Prior commissioning approval for complex
treatments e.g. spinal cord stimulators
Outcomes so far – 4 years
Tier 3 Pain specialist services:
Overspend agreed budget limits – moving to prior approval
Map of Medicine changes starting
Tier 2 Pain service
90% less referral to pain specialist
50% less health care use – primary care
Patient confidence to self care increased by 50%
More GP’s confident to use drugs + support self care
Tier 2 specification + tender for 250,000 pop.
Tier 1 Primary care
Medicines Management GP survey - use + helpful, costs flattening +
savings
GP implement incentive scheme - drugs + self care referral
Self care services
Greater use + more proactive care
pharmacy schemes, leaflets, other ways etc
Key messages
People with pain must be taken seriously!!!!!
Many helpful key drivers – clear frameworks, JSNA,
Health Inequalities, Map of Medicine, etc
Quality information about local impact + evidence for
action
Person Centred thinking so real outcomes specified
Being in control / resilience crucial i.e. able to Self care
Pathways need to be seamless, integrated with better
skilled clinicians delivering consistent messages
Deliver more effectively for less ££££
Collaboration between patients, clinicians, public health
+ politicians
Reviewing pain services
• Involve services users at each stage of
developing chronic pain pathway.
• Patient views – needs based care pathway.
• Feedback to service providers and PCT
commissioners – inform care pathway
Engagement of service users
• Recruitment – Public & Patient Involvement (PPI)
database, via pain services, Expert Patient
Programme (EPP) support groups
• Discussion groups across Kirklees
• Sessions facilitated by PPI team and Public Health
• Report back to service users for comments
Proposed care pathway
• Overall support for the proposals:
• Liked patient centred approach- HNA’s and health
trainer input
• Improve access to GP /primary care - referral to
specialist services
• Want all GP’s to refer all patients to self care services
• Better condition management
• Improved emphasis on control via self care
Referring patients to self care services
Patient & Health Care Professional – Shared decision
making
and discussion of self care options to support motivation
to change and manage social, emotional and physical
impact of LTC
Menu of options
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Self management courses
One to one support
On line support
Structured education courses
Support groups
Weight management
Behaviour change
Smoking cessation
Support for carers
Physical activity courses
One single point
of access
Self Care
Kirklees approach
Chronic Pain as a Long Term Condition
(LTC)
LTC organisational structure
Chronic Pain programme
Chronic Pain - Health Improvement Team
(HIT)
Joint Strategic Needs Assessment
• Affects 1 in 3 people,104,817 adults in Kirklees
• Pain - worst impact on health function, esp. physical function, 20% did
no physical activity
• People 65 > - 31% experienced pain over past year;
• People < 65 - 46% experienced pain esp. women.
• Poor sleep 1 in 3
• Depressed 1 in 2
• More likely to have heart disease, diabetes, stroke
• 75% overweight or obese,
• Linked to low income
• Impact on carers – many have chronic pain themselves.
What Happened Next
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Pain recognised as a significant issue across Kirklees
Service users involved in developing a new pathway
Pain specific self management services
Review of practice in Primary Care
Medicines management guidelines
Priority for our CCG – tendering for a community based
pain service
• Work with secondary care specialists to develop evidence
based policies for key procedures
What will this achieve?
The following patient centred outcomes:
– Reduced levels of distress and disability
– Improved symptom control, physical functioning
and well-being
– Improved confidence to self manage their pain,
medication and their health
Mind the gap
Everyone needs skills + resources
Timescales
Phase 1(June 09)- experience of chronic pain,
current service provision and needs for future.
Over 70 participants attended
Phase 2 (Sept 09) – presenting draft care
pathway & whether it meets service user needs.
Over 25 participants attended
Phase 1 - key issues
More immediate action for relevant assessments / investigations.
Improved GP understanding of other support services e.g. self care
programmes
Being able to see the right person at the right time
Improve waiting times for referral to Physiotherapy, O.T, pain clinics
More continuity of care with each service having an understanding
about other services that can provide help
Similar service provision across PCT area.
Better patient information.
Self care as an key part of managing pain with regular access to self
care resources and services
Chronic condition management as applied to the NHS
3.
5%
case management
2.
15-25%
Condition management
1.
70-80%
self-management
LTC framework
LTC programme delivery group
Kirklees
LTC Partnership Board
NHS Kirklees
Strategic Development
Commitee
LTC HITS (Health Improvement Teams)
LTC Programme Dependencies
End of Life
Intermediate care
Medicines
Management
CHIK Programmes
Older People
Urgent Care
Mental health
Planned care
NHS Kirklees
LTC Programme Delivery Group
Cardiology
Stroke
Respiratory
Diabetes & Renal
Pain
Neurology
Self Care
Dermatology
LTC Project Boards
Telehealth
Predictive risk
WORKSTREAM
Workforce capability
and capacity
WORKSTREAM
Rehabilitation and self
care
WORKSTREAM
Information and
performance
WORKSTREAM
Personalised care
planning
LTC framework
LTC programme delivery group
Kirklees
LTC Partnership Board
NHS Kirklees
Strategic Development
Commitee
LTC HITS (Health Improvement Teams)
LTC Programme Dependencies
End of Life
Intermediate care
Medicines
Management
CHIK Programmes
Older People
Urgent Care
Mental health
Planned care
NHS Kirklees
LTC Programme Delivery Group
Cardiology
Stroke
Respiratory
Diabetes & Renal
Pain
Neurology
Self Care
Dermatology
LTC Project Boards
Telehealth
Predictive risk
WORKSTREAM
Workforce capability
and capacity
WORKSTREAM
Rehabilitation and self
care
WORKSTREAM
Information and
performance
WORKSTREAM
Personalised care
planning
Reviewing pain services
Involve services users at each stage of
developing chronic pain pathway.
Patient views – needs based care pathway.
Feedback to service providers and PCT
commissioners – inform care pathway
Engagement of service users
Recruitment – Public & Patient Involvement
(PPI) database, via pain services, Expert Patient
Programme (EPP) support groups
Discussion groups across Kirklees
Sessions facilitated by PPI team and Public
Health
Report back to service users for comments
Proposed care pathway
Overall support for the proposals:
Liked patient centred approach- HNA’s and
health trainer input
Improve access to GP /primary care - referral
to specialist services
Want all GP’s to refer all patients to self care
services
Better condition management
Improved emphasis on control via self care
And information + resources…..
what patients need to cope
More tailored information
What is wrong and prognosis
How to make most of consultations, assessment
Understand roles in self care + sources of help
Learn how to prevent further problems
Information needs change over time
Ensure patient can ask for more help again, again
Pathway: Oral + written inform
=
important as drugs, test, scan or surgery
Source: Patient-focused intervention A review of the evidence Angela Coulter, Jo Ellins Picker Institute 2006
Key drivers now
National policy – UK
◦ CMO report 2009
◦ Pain Summit 2011 www.painsummit.org.uk
◦ British Pain Society, RCGP
Local policy – Kirklees - Bradford
◦ Joint Strategic Needs Assessment – population
needs led approach
www.kirkless.nhs.uk
◦ Scrutiny Panel for Health Inequalities agenda
◦ Long Term Conditions + Self Care frameworks
Patient + Public Involvement
◦ Shaping services commissioned
Impact of pain
Condition
Pain
Order of impact on health
Worst Impact
Heart Disease
Backache
Depression
Stroke
High Blood Pressure
Diabetes
Asthma
Least Impact
Living with pain… and LTHC’s
Coping: the efforts to deal with stressful situations that tax or
exceeds one’s individual resources Lazman R Folkman S 1984.
Pain coping efforts: strategies to cope with or deal with, minimise
pain & pain related distress + disability
Keefe F J Pain 1983
Resilience - the ability to adapt in the face of adversity and continue
to function ‘normally’.
The sense of control people feel they have over their lives, their
sense of purpose, confidence and self esteem.
Health needs assessment tool
patients guide us…..their agenda
1000 + Patients using a specific HNA tool in clinical settings
Lack of fitness and energy
Walking or moving about, balance or falls
Pain relief or side effects or problems with current medication
Understanding why my pain condition has occurred
Unhelpful pattern of pacing activities
Disturbed sleep
Eating the right types of food
Managing mood changes
Relationship difficulties; with partner, family, work etc
Sex life
Remaining or returning to work and/or training
Financial difficulties, housing or accommodation problems
Concerns about carer/partner, their health or other problems
Other difficulties important to change e.g. hobbies, leisure, social events etc…
Circle 3
priorities for
you now
