Current State of Pain Management Services in Primary Care in the UK


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This lecture was given by Dr Martin Johnson, a General Practitioner from Barnsley, Yorkshire, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. This lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".

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  • Thank you for asking me to talk about the State of Pain Management Services in the UK
  • Current State of Pain Management Services in Primary Care in the UK

    1. 1. Current State of Pain Management Services in Primary Care in the UK NBPA: Edinburgh 18 th May 2007
    2. 4. Overview <ul><li>Pain Management in Primary Care </li></ul><ul><ul><li>The Big Picture </li></ul></ul><ul><ul><li>The “average” GP’s experience/views </li></ul></ul><ul><ul><li>Where does pain management fit in General Practice? </li></ul></ul><ul><ul><li>Why should pain be managed in the community? </li></ul></ul><ul><ul><li>What should a community pain service look like? </li></ul></ul><ul><ul><li>GPwSIs </li></ul></ul><ul><li>National Influences on Primary Care </li></ul>
    3. 5. 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
    4. 6. The Scale of the Problem <ul><li>An average practice of 10,000 patients can expect to include 1,000-2,000 people with chronic pain </li></ul><ul><li>These patients require 6,250 consultations for pain-related conditions a year </li></ul><ul><li>Practice based retrospective audit (2002) </li></ul><ul><ul><li>Looking at efficacy problems, side effect and intolerance, clinical condition, compliance etc., the figures for a year: </li></ul></ul><ul><ul><li>4,602,000 consultations with 793 GP’s per year </li></ul></ul><ul><ul><li>Cost = £69,030,000 </li></ul></ul>
    5. 7. NOP
    6. 8. My Practice (’03 to ’04) <ul><li>Profile </li></ul><ul><ul><li>9,500 patients </li></ul></ul><ul><ul><li>Urban, ex-mining area </li></ul></ul><ul><li>Analgesics on Repeat or more than 2 acute Rx </li></ul><ul><li>Non-Opioid Analgesics; 2210 patients (22%) </li></ul><ul><li>Opioid Analgesics; 342 patients (4%) </li></ul><ul><li>NSAID’s; 2058 patients (22%) </li></ul>
    7. 9. Dr Foster Report - 2004 <ul><li>(1)    Nearly two-thirds of PCOs fail to allocate any resources specifically for pain management services in primary care </li></ul><ul><li>(2)    Average 0.7% of the average PCO annual budget is allocated for chronic pain management services in primary care </li></ul><ul><li>(3)    Most (80%) of PCOs fail to provide any kind of structured or formal pain service in primary care  </li></ul>
    8. 10. Dr Foster Report - 2004 <ul><li>(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 </li></ul><ul><li>(5)    Most (70%) of PCOs do not provide guidelines or recommendations for the management of chronic pain </li></ul><ul><li>(6)    A small number (8%) of PCOs allocate any resource specifically for GP training in chronic pain management </li></ul>
    9. 11. Problems in General Practice <ul><li>We are trained badly in assessment of pain </li></ul><ul><li>We dislike dealing with pain </li></ul><ul><li>Prefer conditions where symptoms can be measured </li></ul><ul><li>Guidelines are sent but are not educated and in the case of most aspects of pain not available </li></ul><ul><li>We are frustrated because of the lack of treatment options available. </li></ul><ul><li>The lack of immediate treatments invariably links in with chronic sickness behaviour & certification. </li></ul>
    10. 12. 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
    11. 13. Pain management – where does it fit into General Practice? <ul><li>Chronic disease management is defined by the new GMS contract as an essential service </li></ul><ul><li>OA and RA are chronic diseases that require quality management as an essential service </li></ul><ul><li>Not a Quality Indicator </li></ul><ul><li>Not an NSF </li></ul><ul><li>Not covered by NICE/SIGN </li></ul><ul><li>Poor Guidelines </li></ul>
    12. 14. What are the Developments?
    13. 15. Pain – Where to Treat ? <ul><li>Primary care </li></ul><ul><li>Secondary care </li></ul>© Mark Adams/SuperStock © Stockbyte
    14. 16. They say the NHS is short of cash? Well, let’s see if we can save a bit.
    15. 17. Well, the ambulance service could save on petrol
    16. 18. And if paying petrol costs for the ambulance cars becomes too much …
    17. 19. The district nurses can still use their bikes in most weather As long as they take reasonable security precautions
    18. 20. Ensure vital equipment is safely secured
    19. 21. England <ul><li>White Paper Our health, our care, our say: a new direction for community services </li></ul><ul><li>Key themes </li></ul><ul><ul><li>Choice </li></ul></ul><ul><ul><li>Plurality of providers </li></ul></ul><ul><ul><li>Increase in community-based services </li></ul></ul><ul><ul><li>Prevention </li></ul></ul>Our health, our care, our say: a new direction for community services. Department of Health, January 2006.
    20. 22. The Primary Care Advantage <ul><li>Early and local access </li></ul><ul><li>Cheap! </li></ul><ul><li>Benefit of knowing patient’s medical, family and social history and their personality type </li></ul><ul><li>Reinforce positive proactive behaviour </li></ul><ul><li>Enforce concordance with management of Drug therapy and their side effects </li></ul><ul><li>Positive impact on surrounding GPs & practices (referral/advice/education) </li></ul>
    21. 23. Individual Projects <ul><li>All around the UK </li></ul><ul><ul><li>Southampton </li></ul></ul><ul><ul><li>Cardiff </li></ul></ul><ul><ul><li>Belfast </li></ul></ul><ul><ul><li>Harrogate, </li></ul></ul><ul><ul><li>West Sussex </li></ul></ul><ul><ul><li>Sheffield </li></ul></ul><ul><ul><li>Etc etc etc </li></ul></ul>
    22. 24. Community Pain Service <ul><li>Will be sent up to address the needs of the local PCT </li></ul><ul><li>No two models will be alike – the bespoke approach. </li></ul><ul><ul><li>Hospital based triage service </li></ul></ul><ul><ul><li>GP, physio (ESP), nurse based initial assessment </li></ul></ul><ul><ul><li>GPwSI (Clinical – assessment, Waiting lists, education) </li></ul></ul><ul><ul><li>Locality based/Practice Based Commissioning </li></ul></ul><ul><ul><li>APMS (Alternative Providers of Medical Services) </li></ul></ul>
    23. 25. GPwSI Activities <ul><li>Clinical </li></ul><ul><ul><li>Assessment (Referral, Scoring tools, Waiting List Management) </li></ul></ul><ul><ul><li>Treatment (pain management, injections, minor operations) </li></ul></ul><ul><li>Education & Liaison </li></ul><ul><ul><li>Providers </li></ul></ul><ul><ul><li>GP’s </li></ul></ul>
    24. 26. Potential Problems <ul><li>There simply are not enough Drs! </li></ul><ul><li>The training for the GPwSIs not well defined at present </li></ul><ul><li>The attitude of some consultants – some find problems with the changing balance of power </li></ul><ul><li>Suspicion of other GPs </li></ul>
    25. 27. Issued to be Sorted <ul><li>Which patients are to be seen? </li></ul><ul><li>Where? Accommodation? </li></ul><ul><li>Prescribing </li></ul><ul><li>Support staff </li></ul><ul><li>Referral to Diagnostics etc </li></ul><ul><li>Protocols </li></ul><ul><li>Relationships with other GP’s & Consultants </li></ul>
    26. 28. Chronic Pain Policy Coalition <ul><li>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. </li></ul>
    27. 29. Parliamentary Report <ul><li>Multidisciplinary approach to pain management </li></ul><ul><li>Early intervention and assessment in appropriate care </li></ul><ul><li>Pain as the 5th vital sign (measurement) </li></ul><ul><li>Pain education and training for healthcare professionals </li></ul><ul><li>Reform of the sick note </li></ul>
    28. 30. 5 th Vital Sign
    29. 31. Dept. Work & Pensions <ul><li>2.7 million people (working pop.) on state incapacity benefit </li></ul><ul><li>Sickness Benefit costs industry - ?£30 billion </li></ul><ul><li>Top 2 causes: Mental Health (33%) and Musculoskeletal (21%) </li></ul><ul><li>Green Paper “Pathways to Work: Helping People into Employment” </li></ul><ul><li>Third of paper is about pain management </li></ul><ul><li>Focuses on rehabilitation </li></ul>
    30. 32. CPPC: Listening Panels <ul><li>To enable the CPPC to engage with various audiences to prevent, manage & treat pain </li></ul><ul><li>Occupational Health, PCT & Royal Colleges </li></ul><ul><li>OH: M&S, Royal Mail, BT </li></ul><ul><ul><li>Initial GP contact vital to return to work </li></ul></ul><ul><ul><li>Encourage early intervention in pain </li></ul></ul><ul><ul><li>Sick Note is a barrier between GPs & employers </li></ul></ul><ul><ul><li>GP’s have little incentive to get people back to work </li></ul></ul>
    31. 33. RCGP Pain Management Committee
    32. 34. Competency Training <ul><li>PBC has made the subject more attractive </li></ul><ul><li>There are now criteria from RCGP </li></ul><ul><li>Needs to encompass those with a simple interest through to ‘super’ GPwSI </li></ul><ul><li>Discussion if it should include MS elements </li></ul><ul><li>? Distance Learning </li></ul>
    33. 35. Neuropathic Pain Guidelines
    34. 36. Fact or Fiction? <ul><li>What do GP’s do with all their complex (neuropathic) pain patients: </li></ul><ul><ul><li>Tell the patient it is all their mind </li></ul></ul><ul><ul><li>Look in MIMS but then give up on the second attempt </li></ul></ul><ul><ul><li>Classify them all as heart sinks </li></ul></ul><ul><ul><li>Hope they have another disease </li></ul></ul><ul><ul><li>Refer them all to secondary care </li></ul></ul>
    35. 37. Quality Outcomes Framework <ul><li>2 submissions </li></ul><ul><ul><li>Low Back Pain </li></ul></ul><ul><ul><li>Diabetic Neuropathy </li></ul></ul><ul><li>Only one submission will progress to next stage </li></ul>
    36. 38. Diabetic Neuropathy <ul><ul><li>20-24% of diabetics experience PDN 1 </li></ul></ul>
    37. 39.                                                                                       
    38. 40. WHO IS THIS???
    39. 43. Practical aspects of prescribing 2: Who should prescribe? <ul><li>In most cases, day-to-day medical responsibility will lie with a general practitioner once the patient is taking a stable dose of opioid </li></ul><ul><li>Hospital based services should start opioid therapy only after discussion and agreement with primary care services </li></ul><ul><li>A single practitioner should take primary responsibility for prescribing opioids for individual patients </li></ul><ul><li>Fixed supplies of these drugs should be prescribed at fixed intervals </li></ul>
    40. 44. Opioids: New Regulations <ul><li>Computer generated </li></ul><ul><li>28 days validity </li></ul><ul><li>30 days supply (‘good practice’) </li></ul><ul><li>Patient Identifiers e.g. NHS Number </li></ul><ul><li>Minor Errors </li></ul><ul><li>Prescribing to family & friends </li></ul><ul><li>(Branded Prescribing) </li></ul>
    41. 45. British Pain Society <ul><li>Remains very supportive of Primary Care </li></ul><ul><li>Runs joint Educational Day with RCGP </li></ul><ul><li>Given advice on Neuropathic Pain Guidelines </li></ul><ul><li>Encouraging Primary Care SIG </li></ul><ul><li>Development of Cancer Pain Guidelines </li></ul><ul><li>Development of Primary Care Pain Guidelines </li></ul>
    42. 46. New or Recent Changes <ul><li>Changes to PCTs & SHAs </li></ul><ul><li>Increasing focus on 1 º & Community Care </li></ul><ul><li>Quality & Outcomes Framework </li></ul><ul><li>Choice & Book </li></ul><ul><li>National Tariffs/PbR </li></ul><ul><li>Private Providers </li></ul><ul><li>Practice Based Commissioning </li></ul>
    43. 47. 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
    44. 48. Pain Management: Other Issues <ul><li>COX2’s </li></ul><ul><li>Co-Proxamol </li></ul><ul><li>Branded Prescribing </li></ul>
    45. 49. Patient’s Association
    46. 51. Chronic pain in older people <ul><li>Major public health problem inflicting tremendous personal suffering </li></ul><ul><li>Most devastating impact amongst older people </li></ul><ul><li>10 million people aged over 65 years in the UK </li></ul><ul><li>Predicted to reach 11.9 million by 2011 1 </li></ul>1. Government’s Actuary Department, 2003
    47. 52. Challenges <ul><li>Under-diagnosis and under-treatment </li></ul><ul><ul><li>Lack of formalised and regular assessment of pain 1 </li></ul></ul><ul><ul><li>Lack of training for nursing home staff 2 </li></ul></ul><ul><ul><li>Poor medicines management 3 </li></ul></ul><ul><li><50% residents with predictably recurrent pain prescribed scheduled pain medication 4 </li></ul>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
    48. 53. How is chronic pain managed? <ul><li>Roles of health professionals and nursing home management </li></ul><ul><li>How pain is identified and assessed </li></ul><ul><li>GP visits to nursing homes </li></ul><ul><li>Prescribing process and management </li></ul>
    49. 54. Pain Management: Future <ul><li>Recognised as a Disease </li></ul><ul><li>Role of CPPC </li></ul><ul><li>Role of RCGP </li></ul><ul><li>Role of BPS </li></ul><ul><li>New Primary Care Society for Pain </li></ul><ul><li>Part of QOF </li></ul><ul><li>Increasing Focus on Primary Care Delivery </li></ul><ul><li>Need for Choice </li></ul><ul><li>GPSI etc Training Scheme </li></ul><ul><li>DWP </li></ul><ul><li>Further Academic Unit for Primary Care </li></ul>
    50. 55. A Wish List <ul><li>Raising awareness of Pain </li></ul><ul><li>Understanding when to stop the revolving diagnostic door </li></ul><ul><li>Develop the Training </li></ul><ul><li>Developing Pathways between Primary & Secondary Care </li></ul>
    51. 56. Have a good day!
    52. 58. Thank - You <ul><li>Any Questions? </li></ul>Original artwork courtesy of Thanks to Dr Peter Wright