Current State of Pain Management Services in Primary Care in the UK NBPA: Edinburgh 18 th May 2007

Overview Pain Management in Primary Care The Big Picture The “average” GP’s experience/views Where does pain management fit in General Practice? Why should pain be managed in the community? What should a community pain service look like? GPwSIs National Influences on Primary Care

Pain Management in Primary Care

The Big Picture

The “average” GP’s experience/views

Where does pain management fit in General Practice?

Why should pain be managed in the community?

What should a community pain service look like?

GPwSIs

National Influences on Primary Care

Cost of problem in the UK £ 119 million days certified incapacity 119 million days certified incapacity 900,000 hospital bed days 12 million GP consultations Back pain £ 12 billion annually

The Scale of the Problem An average practice of 10,000 patients can expect to include 1,000-2,000 people with chronic pain These patients require 6,250 consultations for pain-related conditions a year Practice based retrospective audit (2002) Looking at efficacy problems, side effect and intolerance, clinical condition, compliance etc., the figures for a year: 4,602,000 consultations with 793 GP’s per year Cost = £69,030,000

An average practice of 10,000 patients can expect to include 1,000-2,000 people with chronic pain

These patients require 6,250 consultations for pain-related conditions a year

Practice based retrospective audit (2002)

Looking at efficacy problems, side effect and intolerance, clinical condition, compliance etc., the figures for a year:

4,602,000 consultations with 793 GP’s per year

Cost = £69,030,000

NOP

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%) NSAID’s; 2058 patients (22%)

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%)

NSAID’s; 2058 patients (22%)

Dr Foster Report - 2004 (1) Nearly two-thirds of PCOs fail to allocate any resources specifically for pain management services in primary care (2) Average 0.7% of the average PCO annual budget is allocated for chronic pain management services in primary care (3) Most (80%) of PCOs fail to provide any kind of structured or formal pain service in primary care

(1) Nearly two-thirds of PCOs fail to allocate any resources specifically for pain management services in primary care

(2) Average 0.7% of the average PCO annual budget is allocated for chronic pain management services in primary care

(3) Most (80%) of PCOs fail to provide any kind of structured or formal pain service in primary care

Dr Foster Report - 2004 (4) Nearly all (96%) of PCOs do not have a population-based or GP practice-based register to monitor the need for pain management services (5) Most (70%) of PCOs do not provide guidelines or recommendations for the management of chronic pain (6) A small number (8%) of PCOs allocate any resource specifically for GP training in chronic pain management

(4) Nearly all (96%) of PCOs do not have a population-based or GP practice-based register to monitor the need for pain management services

(5) Most (70%) of PCOs do not provide guidelines or recommendations for the management of chronic pain

(6) A small number (8%) of PCOs allocate any resource specifically for GP training in chronic pain management

Problems in General Practice We are trained badly in assessment of pain We dislike dealing with pain Prefer conditions where symptoms can be measured Guidelines are sent but are not educated and in the case of most aspects of pain not available We are frustrated because of the lack of treatment options available. The lack of immediate treatments invariably links in with chronic sickness behaviour & certification.

We are trained badly in assessment of pain

We dislike dealing with pain

Prefer conditions where symptoms can be measured

Guidelines are sent but are not educated and in the case of most aspects of pain not available

We are frustrated because of the lack of treatment options available.

The lack of immediate treatments invariably links in with chronic sickness behaviour & certification.

The Golden 2.5 Minutes The New GP Contract is rewarding GP’s for Extending their Consultations from 7.5 to 10 minutes PRESS THE BUZZER & WE ARE OFF….. 0 100 200 300 400 500 600 700 Total Consultation Time Seconds Patient Leaves GMS Contract Bits Prescribe Explain Examine Discuss Tell Story Initial Chat Entry and Positioning Patient Walks To Doctors Room

Pain management – where does it fit into 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/SIGN Poor Guidelines

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/SIGN

Poor Guidelines

What are the Developments?

Pain – Where to Treat ? Primary care Secondary care © Mark Adams/SuperStock © Stockbyte

Primary care

Secondary care

They say the NHS is short of cash? Well, let’s see if we can save a bit.

Well, the ambulance service could save on petrol

And if paying petrol costs for the ambulance cars becomes too much …

The district nurses can still use their bikes in most weather As long as they take reasonable security precautions

Ensure vital equipment is safely secured

England White Paper Our health, our care, our say: a new direction for community services Key themes Choice Plurality of providers Increase in community-based services Prevention Our health, our care, our say: a new direction for community services. Department of Health, January 2006.

White Paper Our health, our care, our say: a new direction for community services

Key themes

Choice

Plurality of providers

Increase in community-based services

Prevention

The Primary Care Advantage Early and local access Cheap! Benefit of knowing patient’s medical, family and social history and their personality type Reinforce positive proactive behaviour Enforce concordance with management of Drug therapy and their side effects Positive impact on surrounding GPs & practices (referral/advice/education)

Early and local access

Cheap!

Benefit of knowing patient’s medical, family and social history and their personality type

Reinforce positive proactive behaviour

Enforce concordance with management of Drug therapy and their side effects

Positive impact on surrounding GPs & practices (referral/advice/education)

Individual Projects All around the UK Southampton Cardiff Belfast Harrogate, West Sussex Sheffield Etc etc etc

All around the UK

Southampton

Cardiff

Belfast

Harrogate,

West Sussex

Sheffield

Etc etc etc

Community Pain Service Will be sent up to address the needs of the local PCT No two models will be alike – the bespoke approach. Hospital based triage service GP, physio (ESP), nurse based initial assessment GPwSI (Clinical – assessment, Waiting lists, education) Locality based/Practice Based Commissioning APMS (Alternative Providers of Medical Services)

Will be sent up to address the needs of the local PCT

No two models will be alike – the bespoke approach.

Hospital based triage service

GP, physio (ESP), nurse based initial assessment

GPwSI (Clinical – assessment, Waiting lists, education)

Locality based/Practice Based Commissioning

APMS (Alternative Providers of Medical Services)

GPwSI Activities Clinical Assessment (Referral, Scoring tools, Waiting List Management) Treatment (pain management, injections, minor operations) Education & Liaison Providers GP’s

Clinical

Assessment (Referral, Scoring tools, Waiting List Management)

Treatment (pain management, injections, minor operations)

Education & Liaison

Providers

GP’s

Potential Problems There simply are not enough Drs! The training for the GPwSIs not well defined at present The attitude of some consultants – some find problems with the changing balance of power Suspicion of other GPs

There simply are not enough Drs!

The training for the GPwSIs not well defined at present

The attitude of some consultants – some find problems with the changing balance of power

Suspicion of other GPs

Issued to be Sorted Which patients are to be seen? Where? Accommodation? Prescribing Support staff Referral to Diagnostics etc Protocols Relationships with other GP’s & Consultants

Which patients are to be seen?

Where? Accommodation?

Prescribing

Support staff

Referral to Diagnostics etc

Protocols

Relationships with other GP’s & Consultants

Chronic Pain Policy Coalition The mission statement: To improve the lives of people who live with chronic pain by developing and sharing ideas for improved prevention, treatment and management of chronic pain in the UK.

The mission statement: To improve the lives of people who live with chronic pain by developing and sharing ideas for improved prevention, treatment and management of chronic pain in the UK.

Parliamentary Report Multidisciplinary approach to pain management Early intervention and assessment in appropriate care Pain as the 5th vital sign (measurement) Pain education and training for healthcare professionals Reform of the sick note

Multidisciplinary approach to pain management

Early intervention and assessment in appropriate care

Pain as the 5th vital sign (measurement)

Pain education and training for healthcare professionals

Reform of the sick note

5 th Vital Sign

Dept. Work & Pensions 2.7 million people (working pop.) on state incapacity benefit Sickness Benefit costs industry - ?£30 billion Top 2 causes: Mental Health (33%) and Musculoskeletal (21%) Green Paper “Pathways to Work: Helping People into Employment” Third of paper is about pain management Focuses on rehabilitation

2.7 million people (working pop.) on state incapacity benefit

Sickness Benefit costs industry - ?£30 billion

Top 2 causes: Mental Health (33%) and Musculoskeletal (21%)

Green Paper “Pathways to Work: Helping People into Employment”

Third of paper is about pain management

Focuses on rehabilitation

CPPC: Listening Panels To enable the CPPC to engage with various audiences to prevent, manage & treat pain Occupational Health, PCT & Royal Colleges OH: M&S, Royal Mail, BT Initial GP contact vital to return to work Encourage early intervention in pain Sick Note is a barrier between GPs & employers GP’s have little incentive to get people back to work

To enable the CPPC to engage with various audiences to prevent, manage & treat pain

Occupational Health, PCT & Royal Colleges

OH: M&S, Royal Mail, BT

Initial GP contact vital to return to work

Encourage early intervention in pain

Sick Note is a barrier between GPs & employers

GP’s have little incentive to get people back to work

RCGP Pain Management Committee

Competency Training PBC has made the subject more attractive There are now criteria from RCGP Needs to encompass those with a simple interest through to ‘super’ GPwSI Discussion if it should include MS elements ? Distance Learning

PBC has made the subject more attractive

There are now criteria from RCGP

Needs to encompass those with a simple interest through to ‘super’ GPwSI

Discussion if it should include MS elements

? Distance Learning

Neuropathic Pain Guidelines

Fact or Fiction? What do GP’s do with all their complex (neuropathic) pain patients: Tell the patient it is all their mind Look in MIMS but then give up on the second attempt Classify them all as heart sinks Hope they have another disease Refer them all to secondary care

What do GP’s do with all their complex (neuropathic) pain patients:

Tell the patient it is all their mind

Look in MIMS but then give up on the second attempt

Classify them all as heart sinks

Hope they have another disease

Refer them all to secondary care

Quality Outcomes Framework 2 submissions Low Back Pain Diabetic Neuropathy Only one submission will progress to next stage

2 submissions

Low Back Pain

Diabetic Neuropathy

Only one submission will progress to next stage

Diabetic Neuropathy 20-24% of diabetics experience PDN 1

20-24% of diabetics experience PDN 1

WHO IS THIS???

Practical aspects of prescribing 2: Who should prescribe? In most cases, day-to-day medical responsibility will lie with a general practitioner once the patient is taking a stable dose of opioid Hospital based services should start opioid therapy only after discussion and agreement with primary care services A single practitioner should take primary responsibility for prescribing opioids for individual patients Fixed supplies of these drugs should be prescribed at fixed intervals

In most cases, day-to-day medical responsibility will lie with a general practitioner once the patient is taking a stable dose of opioid

Hospital based services should start opioid therapy only after discussion and agreement with primary care services

A single practitioner should take primary responsibility for prescribing opioids for individual patients

Fixed supplies of these drugs should be prescribed at fixed intervals

Opioids: New Regulations Computer generated 28 days validity 30 days supply (‘good practice’) Patient Identifiers e.g. NHS Number Minor Errors Prescribing to family & friends (Branded Prescribing)

Computer generated

28 days validity

30 days supply (‘good practice’)

Patient Identifiers e.g. NHS Number

Minor Errors

Prescribing to family & friends

(Branded Prescribing)

British Pain Society Remains very supportive of Primary Care Runs joint Educational Day with RCGP Given advice on Neuropathic Pain Guidelines Encouraging Primary Care SIG Development of Cancer Pain Guidelines Development of Primary Care Pain Guidelines

Remains very supportive of Primary Care

Runs joint Educational Day with RCGP

Given advice on Neuropathic Pain Guidelines

Encouraging Primary Care SIG

Development of Cancer Pain Guidelines

Development of Primary Care Pain Guidelines

New or Recent Changes Changes to PCTs & SHAs Increasing focus on 1 º & Community Care Quality & Outcomes Framework Choice & Book National Tariffs/PbR Private Providers Practice Based Commissioning

Changes to PCTs & SHAs

Increasing focus on 1 º & Community Care

Quality & Outcomes Framework

Choice & Book

National Tariffs/PbR

Private Providers

Practice Based Commissioning

Future Commissioning Model BARNSLEY PCT BOARD PEC PBC Steering Group PBC LIT Planning Procurement Performance Management Contract Compliance Practice Based COMMISSIONERS COMMISSIONING DIRECTORATE Provider e.g. Single GP Provider e.g. Independent Sector Provider e.g. Trust etc. Provider e.g. Group of GPs PROVIDERS

Pain Management: Other Issues COX2’s Co-Proxamol Branded Prescribing

COX2’s

Co-Proxamol

Branded Prescribing

Patient’s Association

Chronic pain in older people Major public health problem inflicting tremendous personal suffering Most devastating impact amongst older people 10 million people aged over 65 years in the UK Predicted to reach 11.9 million by 2011 1 1. Government’s Actuary Department, 2003

Major public health problem inflicting tremendous personal suffering

Most devastating impact amongst older people

10 million people aged over 65 years in the UK

Predicted to reach 11.9 million by 2011 1

Challenges Under-diagnosis and under-treatment Lack of formalised and regular assessment of pain 1 Lack of training for nursing home staff 2 Poor medicines management 3 <50% residents with predictably recurrent pain prescribed scheduled pain medication 4 1. Sengstaken & King, 1993; Allcock et al, 2002 2. Allcock et al, 2002; Mozley et al, 2004 3. CSCI, 2006 4. Hutt et al, 2006

Under-diagnosis and under-treatment

Lack of formalised and regular assessment of pain 1

Lack of training for nursing home staff 2

Poor medicines management 3

<50% residents with predictably recurrent pain prescribed scheduled pain medication 4

How is chronic pain managed? Roles of health professionals and nursing home management How pain is identified and assessed GP visits to nursing homes Prescribing process and management

Roles of health professionals and nursing home management

How pain is identified and assessed

GP visits to nursing homes

Prescribing process and management

Pain Management: Future Recognised as a Disease Role of CPPC Role of RCGP Role of BPS New Primary Care Society for Pain Part of QOF Increasing Focus on Primary Care Delivery Need for Choice GPSI etc Training Scheme DWP Further Academic Unit for Primary Care

Recognised as a Disease

Role of CPPC

Role of RCGP

Role of BPS

New Primary Care Society for Pain

Part of QOF

Increasing Focus on Primary Care Delivery

Need for Choice

GPSI etc Training Scheme

DWP

Further Academic Unit for Primary Care

A Wish List Raising awareness of Pain Understanding when to stop the revolving diagnostic door Develop the Training Developing Pathways between Primary & Secondary Care

Raising awareness of Pain

Understanding when to stop the revolving diagnostic door

Develop the Training

Developing Pathways between Primary & Secondary Care

Have a good day!

Thank - You Any Questions? Original artwork courtesy of Painexhibit.com Thanks to Dr Peter Wright

Any Questions?