Chronic Pain Specialty Group · Care Institute. The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish

01

Chronic Pain Specialty Group

Design Workshop ReportApril 2019

0302

The Cabinet Secretary for Health and Sport launched the Scottish Access Collaborative in November of 2017. This will be closely aligned with the Regional Planning, Realistic Medicine, Elective Centres Programme and extant Performance Management and Clinical Priorities, Delivery Activities and Programmes. In the complex landscape of healthcare planning and delivery the Access Collaborative will focus on developing collaborations which build on existing work streams and networks to sustainably balance demand and capacity.

The Collaborative is led by Professor Derek Bell, Chair of the Academy of Medical Royal Colleges, and Paul Hawkins, Chief Executive of NHS Fife and is made up of a range of professional bodies including the Scottish Academy of Medical Royal Colleges, patient representatives and service leaders. The Collaborative has developed six fundamental principles which will shape and prioritise the way services are provided in the future. These principles are described in this report in the context of the findings.

The Digital Health and Care Institute (DHI) was commissioned to design workshops aimed at producing high level mapping of each clinical area and identifying clinically led and patient centred sustainable improvements. The findings from these workshops will form the basis of a speciality-led Access Collaborative programme delivering solutions to help scheduled care services to sustainably meet the challenges of the future.

For more information on the workshops and instances of best practice please see the Collaborative’s blog: http://bit.ly/accesscollaborative

Scottish Access Collaborative Approach

The aim of the Scottish Access Collaborative is to sustainably improve waiting times for patients waiting for non-emergency procedures.

A key strand of the Collaborative’s work is the delivery of the Specialty Group programme, in which a range of experts in clinical specialties undertake a cycle of design-led workshops with the support of the Digital Health and Care Institute.

The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish Funding Council’s Innovation Centre Programme. It is part funded by Scottish Government. DHI support innovation between academia, the public and third sectors and businesses in the area of health and care.

0504

Further scoping of these ideas is currently underway.

1. Prepara�on 2. Map the Landscape

3. Ask the Right Ques�ons

4. Sketch Solu�ons 5. Priori�se

Members of the Speciality Group came from more than 20 different clinical and community roles and 10 different NHS Board areas, giving the Group both a broad geographic and functional reach. The first step for the workshops was to identify a number of focus areas in Chronic Pain outpatient pathway, noting the reason to prioritise them. Challenges were mapped for each theme and corresponding opportunities for improvement were recorded.

Further discussion around these improvement areas led to ideas for sustainable improvement. These ranged from staff training, funding for supported self-management for people living with Chronic Pain and the provision of information. The Chronic Pain Speciality Group workshops generated clear consensus on the area’s most likely to make a difference to people presenting with Chronic Pain. These included:

04 05

Executive Summary

1. Preparation 2. Map the Landscape

3. Ask the Right Questions

4. Sketch Solutions 5. Prioritise

HOW MIGHT WE: allocate available resource to educate, train, supply, and retain healthcare professionals with the right skillsets in the right places?

HOW MIGHT WE: make people aware of what self-management is and what options are available?

HOW MIGHT WE: ensure sustainable funding for Chronic Pain?

HOW MIGHT WE: make information about Chronic Pain self-management widely accessible as well as widely used?

HOW MIGHT WE: develop strong links between primary and secondary care, as well as acute and chronic services, in order to create a clear model of care?

HOW MIGHT WE: use measurement of current and future staffing to drive improvement?

HOW MIGHT WE: agree and communicate a common language in order to support and promote Realistic Medicine, de-pharmaceuticalisation, and effective prescribing?

0706

Contributors to Chronic Pain Workshop

NHS Greater Glasgow and Clyde

NHS Tayside

NHS Lothian

NHS Forth Valley

NHS Grampian

NHS Dumfries and Galloway

NHS Highland

NHS Ayrshire and Arran

NHS Lanarkshire

NHS Fife

Elizabeth Brooks

Dr Paul Smith

Ute Schauberger

Line Blank

Alex Porteous

Health Boards Involved

Acknowledgements

DHI Team

Thanks to Chris Bridgeford from Affa Sair and Dr John

Macleod who met with us and wrote a blog

for the Scottish Access Collaborative site.

07

• Service Support Manager & AHP Pain Team Lead

• Senior Policy Manager – Neurological Conditions, Chronic Pain and Long-term conditions

• Consultant in Pain Medicine

• Senior Information Analyst

• Consultant Clinical Psychologist, Lead: Pain Management and Clinical Health Psychology Services

• General Practitioner

• Director, Programme Manager and Improvement Advisor - Modern Outpatient Programme, Scottish Government

• Consultant Addictions Psychiatrist

• Nurse

• Consultant Psychologist

• Cross Party Chronic Pain Group representative

• Consultant General Anaesthetists Acute Pain Lead

• Service Manager, ISD

• GP/ Regions Associate Medical Director for Primary Care

• Our Voice Co-ordinator, The Alliance

• Pharmacist

• Executive Committee Chair (Pain Concern)

• Clinical Nurse Specialist - Glasgow Pain Management Programme

• Clinical Specialist

• Industry, Health & Care Engagement Manager

• Consultant – Lead

• Consultant

• Public Health and Wellbeing Coordinator

• Consultant in Pain Medicine

• Flow Programme Improvement Manager (Scottish Government)

• Head of Health & Social Care

• Unit Operational Manager

• Lead Consultant, Scottish Public Health Network

• Consultant Psychologist

• Occupational Therapist

• Clinical Lead

• Policy – Neurological Conditions, Chronic Pain and Long-term Conditions (SG)

• Senior Medical Officer (SG) & GP

• Lead Nurse for Chronic Pain services

• Director, Pain Association Scotland

• Patient Representative

• Consultant in Paediatric Anaesthesia and Paediatric Pain Management

Roles Involved

0908

Clinical ForewordChronic Pain is the leading cause of disability – globally and in Scotland. Despite its high prevalence and impact, however, the available services have been variable and stretched. Chronic Pain is complex and needs multi-disciplinary and multi-dimensional approaches to management. These include, but are not restricted to medical, psychological and physical therapies, as well as support for self-management. To address the mismatch between prevalence and access to NHS and other services, the Scottish Access Collaborative convened discussions between patients, professionals, policy-makers and the third sector involved in pain management, from a wide range of geographical and disciplinary backgrounds around the country. There was remarkable and constructive consensus, despite this wide range, on how to advance service provision. This Report presents a summary of this consensus, and notes in particular the need to enhance community-based and non-medical models of care, while also addressing the pressing issues around specialist and generalist workforce availability and training, and around relevant public education.

Blair H. Smith MD MEd FRCGP FFPMRCA FRCP Edin. National Lead Clinician for Chronic Pain (Scottish Government), Professor of Population Health Science (University of Dundee), and Honorary Consultant in Pain Medicine (NHS Tayside).

Katie CuthbertsonDirector Modern OutpatientProgramme Scottish Government

Dr Gregor SmithChair of the National Advisory Committee for Chronic Pain, Deputy Chief Medical Officer (Scottish Government)

The aim of the Modern Outpatient Programme is to support the development of a Modern Outpatient service which, aligned with the principles of the SAC, will support effective and faster service change to ensure patients are able to access healthcare in a timely manner. This national Programme is well placed to action the outputs from the Chronic Pain workshops; supporting clinical teams to test innovative ways of working and how positive improvements proven to enable the provision of high quality care for patients, can be shared and implemented at scale across Scotland.

The National Advisory Committee for Chronic Pain advises the Scottish Government on chronic pain matters to inform effective national policy development, taking into account available data on outcomes. It comprises representation from healthcare professionals from primary and secondary care, Health and Social Care Partnerships, NHS Boards, the third sector, experts by experience, clinical research, the Scottish National Residential Pain Management Programme and the Scottish Public Health Network. It will therefore be able to provide guidance on the implementation of actions taken forward as part of the Scottish Access Collaborative and Modern Outpatient Programmes to improve Chronic Pain management at all levels of health and social care in Scotland.

Implementation Support

1110

I.Patients should not be asked to travel unless there is a clear clinical benefit, and that any changes should not increase the workload for primary, secondary or social care in an unplanned/unresourced way

II.All referrals should either be vetted by a consultant/senior decision maker or processed via a system wide agreed pathway – value vetting

III. Referral pathways (including self-management) should be clear and published for all to see

IV. Each hospital and referral system should have a joint and clear understanding of demand and capacity

V. Each local system should have a clear understanding of access to diagnostics as part of pathway management

VI. Improved and published metrics including how we record and measure virtual/ telehealth/ tech-enabled care

Scottish Access Collaborative Principles

Contents

Design Approach 12

Key Challenges 16

Ideas 28

Other Ideas 45

Additional Resources and Next Steps 46

1312

idea canvas AN IDEA BY:

HOW MIGHT WE...

CURRENT STATE

IMPACTCHANGE

WHO?

WHERE?

WHO BENEFITSAND HOW?

WHAT ARE KNOCK-ON EFFECTS?

WHAT IS THE VALUE?

HOW WOULDYOU MEASURE

SUCCESS?

ARE THERE POTENTIALNEGATIVE IMPACTS?

WHEN?

WHAT?

IDEA NAME:

Record the “How Might We” you are responding to here

What is happening now, what are the issues with this, why change it?

Describe what you would change, adding as much detail as possible.

Give your idea a name

Describe what impact this might have, what you would need to know to measure this impact,

and what success might look like.

&


HOW MIGHT WE...

CURRENT STATE

IMPACTCHANGE

WHO?

WHERE?



WHAT IS THE VALUE?


SUCCESS?


WHEN?

WHAT?

IDEA NAME:







&


HOW MIGHT WE...

CURRENT STATE

IMPACTCHANGE

WHO?

WHERE?



WHAT IS THE VALUE?


SUCCESS?


WHEN?

WHAT?

IDEA NAME:







&


HOW MIGHT WE...

CURRENT STATE

IMPACTCHANGE

WHO?

WHERE?



WHAT IS THE VALUE?


SUCCESS?


WHEN?

WHAT?

IDEA NAME:







&

CO

NSULTATIO

N

HOSPITAL

D

IAGNOSTICS

HOSPITAL

SLEEPSTUDY

SLEEPCLINIC

12 WEEKS

1/3 - 1/4 OF REFERRALSSENT BACK

1/3 OF PATIENTS:TREATMENT

1/3 OF PATIENTS:DISCHARGE

1/3 OF PATIENTS:UNSURE - BACK TO

CONSULTATION,GP, OR OTHER

CLINICAL AREAS

OTHERCLINICAL AREAS

SUCH ASNEUROLOGY

CO

NSULTATIO

N

GP PRACTICE

ISSUEMAP

1

INCONSISTENT VETTING & PRIMARY CARE EDUCATIONEXAMPLE FROM SOMNOLENCE (ALSO MENTIONED IN CHEST PAIN, AND FREQUENT CHEST INFECTION)

Lack of education in primary care about who to refer (for example there are clear indicators of risk for some symptoms such as sleep apnea that could be used), and what it is that secondary care respiratory can actually offer. Lack of clear referral criteria leads to inconsistent / variable vetting and means people are being referred inappropriately.

SCI GATEWAYREFERRAL V

ETTIN

G

TREATMEN

T

HOSPITAL

There are clear pathways for a variety of non-respiratory symptoms related to sleep, but most end up at sleep clinics and should be filtered out.

ISSUE:

WHAT INFLUENCESTHIS ISSUECURRENTLY?

how might we

how might we

how might we

how might we

LegHeadaches

TremorSeizure

PainLeftRight

Epilepsy

Weakness Numbness

ParaesthesiaNeuropathy

Request

Persistent

EpisodesLegs

Migraines

Sensation

Sided

Peripheral

New

Loss

Worsening

Migraine

PossibleArm

ClinicHand

Symptoms

WHY FOCUSON THIS?

WHY FOCUSON THIS?

WHY FOCUSON THIS?

ISSUE

ISSUE

ISSUE

DISCOVER & DEFINE

WORKSHOP 1 WORKSHOP 2

EXPLORE & DEVELOP

We identify key issues, recordwhy these are important to

focus on, and define areas for innovation and improvement

in current services.

From these discussions, the DHI team pulls together a

set of maps which illustratecurrent issues and highlightthe areas the group would

like to focus on.

From these discussions, the DHI team distills the

key issues and insights into a set ofopportunities.

We explore the issues bytaking into account patient

feedback, by looking at differentperspectives and using the diverserange of expertise and experience

in the group. We map factors influencing and being influenced by each issue.

MAPSWORD CLOUD & KEY ISSUES HOW MIGHT WE

QUOTES & PERSPECTIVE

CARDSLAYER MAPS IDEA CANVAS

WORKSHOP 3 People form working groups

around the opportunities and start ideating and developing

ways to address them.

1514

ChronicLowerSciatica

Pains

Knee

SevereSyndrome

Clinic

Low

LegLeftRight

Fibromyalgia

Ongoing

Joint

Lumbar

BilateralLongstanding

Multip

le

Abdominal

Generalised

Hip

Widespread

NeckPain Back

ManagementAssessment

This word cloud reflects the relative frequency of the most commonly used words in a group of Chronic Pain referrals from NHS Fife. The data were collected from more than five thousand referrals and were taken from the 98 character field in SCI Gateway. The word cloud gives a snap shot of Chronic Pain referrals and provides some initial context.

1716

During 2018, there were 20,117 new referrals to secondary care Chronic Pain clinics in Scotland; current recording does not include waiting times for return patients.

The first workshop explored current Chronic Pain services including existing pathways and vetting procedures across the country. Regional variation was noted and instances of best practice shared. This led to key challenges being agreed and grouped under themes.

The DHI design team translated the themes into a series of maps, which were then considered by participants during the second workshop. The following five maps describe the key themes, with the rationale for their inclusion. Opportunities for improvements, discussed during the workshop have been noted below each map.

Key Challenges

Map key

I.

II.

III.

IV.

V.

VI.

Primary Care

Steps

Split / Referral Secondary Care

Focus Areas

Scottish Access Collaborative Principles

1918

CONSULTATI

ON

GP PRACTICE

?

?

?

Information, Guidance, and Self-Management

• While the Scottish Service Model for Chronic Pain illustrates that the majority of people with Chronic Pain access support and care for their symptoms via community pharmacies or through primary care, there is variation in practice across Scotland on the availability and effectiveness of information and guidance. There is also still a high demand for relatively small scale specialist services in secondary and tertiary care, and many people may not have accessed support, prior to referral, to fully explore how self-management can help them to manage their symptoms on a daily basis.

• There is a wide range of information from diverse sources available. However, there is no clear national coordination of what is both available and effective. Some local resources might be useful nationally but are neither accessible nor widely known about.

• Information available online is not always reliable and may be difficult to find and to understand. It was noted that there is no common language used to describe Chronic Pain or its self-management.

• There is a need for wider availability and adoption of self-management, and for additional guidance and information.

• There can be a lack of coordination and coherence in the current approach where self-management is offered from different sources and levels in the NHS and community.

• Resources such as leaflets, books and websites supporting self-management can be temporarily available or go out of date. Personal support may be based in the third sector and can be provided by voluntary and short-term groups, such as peer support groups. Both the difficulty in finding the resource and the often transient nature of that resource is an issue for people with this chronic condition.

• There are issues of access for some self-management services such as the Pain Association Scotland Group. These issues include adoption of the service by the Healthboard and visibility of the service for healthcare professionals.

• People may not be able to afford activities such as swimming or going to the gym, both of which would be recommended as part of a self-management regime.

2120

Lack of Consistent and Sustainable Funding

• Currently, funding of pain management support can be short-term, inconsistent, and available in geographic pockets. This makes effective planning difficult, especially for the third sector. This results in precarious and unsustainable services, impacting trust between patients and providers.

• Investment in the future of Chronic Pain services is needed in order to achieve sustainable gains. Current funding is often reactive rather than being planned for the long term, for example in the areas of planning for the retirement of staff or for service expansion.

• There is a perception that Chronic Pain has not been a priority at government level and government priorities do not always match those of the Health Boards. There is a need for more joined up thinking.

• There are huge pressures on the primary care workforce. This pressure often makes it difficult to provide coordinated continuity of care, which is an important part of successful pain management.

• It is difficult for both primary and secondary care to keep up with a continuously changing service offering and to know where patients can be referred to in the local area for support.

CONSULTATI

ON

GP PRACTICE

?

?

?

2322

Disjointed Model of Care and Disconnected Systems

• Pathways vary between geographic areas and there is not always coordination between primary and secondary care. There is also variation in access to Chronic Pain and addiction expertise.

• People may have multiple referrals to multiple services, for different aspects of investigating and managing Chronic Pain before a diagnosis of their condition has been confirmed.

• Some people may have higher expectations of the outcomes that might be achieved through attending the service than those that are realistic in their specific circumstances.

• There is a tendency to adopt a medical model, investigating to find a treatable cause, which either cannot be identified or cannot be cured. Short GP consultation times are a contributing factor here.

• A person’s medical history is vital for assessing and managing Chronic Pain. However not all care providers have access to all patient records.

ALTERNATIVEMODELS OF CARE

PATIENT RECORDAND HISTORY

TREATMENT

AT HOMECONSULTATI

ON

GP PRACTICE

MENT

TREATMENT

GP PRACTICE

OME

TREATMENT

HOSPITAL

SCI GATEWAYREFERRAL

OTHERCLINICAL

AREAS

CONSULTATI

ON

HOSPITAL

RACTICCEE

TMEENNTT

SPITAL

?

• Some Chronic Pain management services have rigid referral criteria. Despite the high prevalence and impact of Chronic Pain on the individual, specialist services facing growing demand are stretched and often only see the most complex cases.

• Chronic Pain is rarely “curable”. There is a lack of clarity about what is an acceptable level of Chronic Pain, that might be achievable with healthcare support. There is also a complex relationship between Chronic Pain and other life circumstances such as stress, depression, fatigue and social circumstances

• More holistic and less medical models of care for tackling Chronic Pain are difficult to achieve within the current services. There is a need for more multidisciplinary, open and shared working.

(see research on Inverse Care Law).

2524

Communication and Language for Chronic Pain

• The language currently used around Chronic Pain can form a barrier to how patients, healthcare professionals, and society perceive treatment options for effectively managing long-term pain.

• There is a need to move away from a purely medical model. This should be a formally recognised change in order not to undermine or de-legitimise the treatment people receive, and the impact the condition has on their lives.

• Chronic Pain strategy at the moment consists of a number of disparate policies and there is a need to bring these together into one coherent message.

• The practice of shared decision making varies considerably. Encouraging difficult conversations and joint decision making between patients and healthcare professionals is key in order to de-medicalise the situation.

• A referral to psychology or other non-medical services can be perceived as having less value by patients, or even carry stigma. However these services provide valuable support in managing Chronic Pain.

ALTERNATIVEMODELS OF CARE

OTHERCLINICAL

AREAS

HOSPITAL

LANGUAGEAROUND

CHRONIC PAIN

GP PRACTICE

OTHERPRIMARY

CARE SERVICES

2726

Workforce Planning and Education

?

?

?

CONSULTATI

ON

GP PRACTICE

GP

NURSE

• There is an increasing demand for Chronic Pain services, yet recruitment and retention of a skilled workforce trained in treating Chronic Pain is already experiencing difficulties. There is a recognised shortfall of anaesthetic trainees going on to subspecialise in Chronic Pain.

• There is a lack of data around who is providing specialist Chronic Pain services, especially within primary care and non-NHS services.

• Many healthcare professionals lack knowledge, confidence and time to manage Chronic Pain properly. There is, for example, insufficient Chronic Pain education for mental healthcare professionals and GPs.

• The group highlighted the value of the appropriate person taking time to build a relationship with patients, having a conversation about Chronic Pain, and making a realistic plan for that patient. This requires available trained staff with sufficient time to do this and the capacity to provide continuity of care throughout the patient journey.

• There are no clear career pathways for Chronic Pain in non-medical healthcare disciplines or community services. There is also no clear model for what is the correct number and distribution of Chronic Pain healthcare professionals across the country.

• More initiatives are needed such as the current Faculty of Pain Medicine: this is developing credentials in pain medicine for non-anaesthetists, in order to extend access to a career in pain medicine to those trained in specialities other than anaesthetics. Such initiatives should train multi-disciplinary teams who can work in different settings across primary and secondary care. Current changes in primary care mean such teams are becoming increasingly important.

2928

IdeasIn the third workshop, the opportunities for improvement were translated into short statements starting with ‘how might we’. These statements consolidated key areas and opportunities into a single focus for improvement. The exercise of developing these statements led to a number of areas which the Chronic Pain workshop participants could meaningfully address and suggest service changes for.

How Might We...

Better support for people living with Chronic Pain so that they can inform themselves, take ownership, and self-manage?

Improve IT systems and communication compatibility, to provide good quality and consistent patient data to all healthcare professionals involved in care?

Agree and communicate common messages and language for Chronic Pain, including what not to say, and include this within postgraduate education across disciplines?

Support self-efficiency without creating dependence in an affirming non-judgemental way?

Make Chronic Pain self-help information widely accessible and motivate people to use this information?

Screen and identify people who may be at risk of addiction early in the journey and mitigate the risk?

Better support people while they are waiting to be seen by specialist pain services?

Consider existing pathways and service models in order to determine the workforce needs and how these could be met sustainably?

Focus on the future of changing Chronic Pain services to forecast staffing, service provision, and consequent outcomes?

Share best practice on an ongoing basis?

The next step was to consolidate and prioritise the statements before small groups of workshop participants selected what to focus their efforts on.

Improvements which would respond to the question asked in the ‘how might we’ statement were discussed and noted. The outcome of this was a series of suggestions that the group put forward as recommendations for further work which would improve the Chronic Pain service.

What follows are the seven prioritised ‘how might we’ challenges for Chronic Pain and a summary of the recommendations put forward by the group. Where possible a summary of the possible impact of the proposed improvement is included. Two additional ideas have also been included in this report. Both of these ideas were raised outside of the main discussion on the targeted issues and opportunities.

Ensure general practitioners have appropriate time for assessment?

Create sustainably-funded services which allow for long-term career pathways for healthcare professionals involved in treating Chronic Pain?

Identify role specific training needs within each service, and support healthcare professionals through further education and training?

Demonstrate the benefits and resource savings of having enough time to communicate well and to develop a shared understanding with patients?

Find ways to ensure people understand and remember what has been discussed in a consultation?

Have better conversations with people with Chronic Pain?

Communicate the strategy of de-medicalisation more effectively?

Raise the profile and perception of Chronic Pain at Health Board level?

Bring Chronic Pain services into patient pathways earlier to improve transitions from acute to chronic services?

Ensure Chronic Pain services are appropriately and sustainably resourced and have access to the right skillsets for treating?

Develop and instigate quality performance indicators and identify areas needing investment?

Better measure the impact of non-medical models of care?

3130

How Might We Allocate Available Resource to Educate, Train, Supply, and Retain Healthcare Professionals with the Right Skillsets in the Right Places?

Suggestions

Potential Impact

Developing credentials for non-anaesthetists and expanding this to non-medical healthcare professionals at all levels.

Shifting the current care model from a traditional medical model to one including increased community service provision and non-medical options.

Developing a national plan. A proposal could be made, describing the optimal number of Chronic Pain health professionals taking into account regional variation.

Tailoring service delivery to local circumstances such as geographic variation. An example would be to create a hub or community service for remote delivery to make efficient use of scarce resources.

Establishing a standardised framework for training in Chronic Pain starting earlier in undergraduate education and continuing through postgraduate education across all healthcare disciplines and specialties. Establishing a shared educational resource.

Making a career in Chronic Pain attractive through improved training, practice, funding, career progression support, realistic expectations of clinical outcomes, infrastructure and contracts.

Developing an enlarged sustainable workforce that can flexibly deliver services to support people to manage Chronic Pain.

Adopting a person-centred approach to Chronic Pain management and developing a standardised minimum quality of care available to all people.

Future proofing the Chronic Pain service and using this scarce resource efficiently by providing clarity on what is needed.

3332

How Might We Develop Strong Links between Primary and Secondary Care, as well as Acute and Chronic Services in order to Create a Clear Model of Care?

Suggestions

Clarifying Chronic Pain pathways across all services using a multidisciplinary approach.

Creating a toolkit to help identify people at risk of Chronic Pain earlier in the pain pathway, or of complications such as depression or addiction.

Raising awareness that the GP does not have to be the first port of call and there are benefits in receiving support and care from other healthcare professionals. There could be benefit from the development of local, multidisciplinary community Chronic Pain teams, implemented at the geographic level of GP clusters which would be accessible to a wider range of people.

Establishing clear multidisciplinary pathways between primary and secondary care which are initiated within 12 weeks of referral. This would include education and supported self-management with a range of options. This would include introducing a flag on the healthcare record to highlight potential issues around prescribing such risk of addiction and need for medication review.

Identifying Chronic Pain management strategies early on in patient pathways. Currently, the investigative stage can take as much as three years or longer. Chronic Pain services are generally involved at the point when other options have been exhausted. There is an opportunity to have clear agreed clinical indicators for what constitutes Chronic Pain and offer supported management strategies to people earlier, for example within primary care and by applying a multidisciplinary approach including psychology, pharmacy and occupational therapy.

3534

How Might We Make People Aware of what Self-Management is and what Options are Available?

Suggestions

Providing more long-term and sustainable resources for self-management including social prescribing.

Raising awareness of available support using public health initiatives and informed health professionals in order to set appropriate expectations. For example, Chronic Pain services can support people in mitigating the impact this has on their life, but not necessarily reduce Chronic Pain.

Ensuring self-management options are offered as an early, positive, and reinforced step, balancing early signposting with the danger of labelling people as having Chronic Pain while still undergoing investigation.

Enabling peer support and mentoring for people living with Chronic Pain.

Linking strategies and suggestions across community, primary, and secondary care. Recognising management needs and shared responsibility.

Creating an incremental pathway for self-management. For example, signposting can be a first step followed by peer supported self-management.

Introducing self-management options earlier in the patient pathways. Currently, medication is thought of as a first step and self-management is often only considered when that fails.

Creating clear accepted guidance for people including what can be expected, what is needed and what is available at different stages in patient pathways. Ensuring there is access to these resources from an early stage.

3736

How Might We Use Measurement of Current and Future Staffing to Drive Improvement?

Suggestions

Capturing data measuring the need and current levels of resourcing to drive improvements in planning staff definition, recognition and support. This would lead to the development of an informed plan for the development of a multi-disciplinary service where the person needs it. This data could include but not be limited to the number of specialists by training, how those specialists spend their time and a quantification of community support of people with Chronic Pain.

In order to drive improvement there is a need to record meaningful patient data for Chronic Pain across all disciplines. There is currently little data on people who attend secondary care Chronic Pain services, including the nature and severity of their Chronic Pain and related health, or changes in these following treatment in the service. The only things that are routinely measured are the numbers of people who are referred to, who attend, and/or who default from attendance at outpatient clinics, together with the waiting time from referral to first appointment. This does not directly measure efficacy for the patient and has limited use in informing future staff planning. This data set could include the number of drugs prescribed without ignoring the importance of non-medical options.

Measurement of shared data sets among Chronic Pain services across all Health Boards will help to gain a realistic view of capacity and demand and will help the planning process nationally. Readily available and relevant clinical data will allow assessment of baseline and outcomes for individuals and services, evaluation of service improvement measures, and comparison between services and time periods.

3938

How Might We Ensure Sustainable Funding for Chronic Pain?

Suggestions

Creating more awareness of Chronic Pain at government and chief executive board level and enhancing the voice of all Chronic Pain professionals (including, but not restricted to anaesthetists), nationally and regionally.

Using short-term funding better, rather than simply targeting waiting list initiatives, as well as funding long-term changes by planning in three-year cycles or longer.

There is a need to measure the impact of medical and surgical procedures on the development of subsequent Chronic Pain.

Ring-fencing funding for Chronic Pain and utilising some of this to bridge gaps between secondary care, primary care, community, and third sector services, as well as across geographical boundaries to avoid people being unable to access services because they are based in a specific Health Board.

Potential ImpactFostering better awareness of the multidisciplinary nature of Chronic Pain service delivery. Better planning and coordinating of funding across specialties.

Measure the full economic costs of pain service provision, based on agreed standards, to create a realistic funding model that is accountable and evaluated against pre-determined outcome measures.

Establishing Chronic Pain as an important clinical service which is independent of Anaesthetics or any other clinical discipline, by increasing autonomy and accountability, increasing representation at Health Board level and matching actions to government priorities.

Sustainable funding, allocated appropriately, will allow services to be delivered where they are most useful and necessary, including secondary care, primary care and the community, as required. Providing a more stable workforce and utilising this workforce better, resulting in a more stable and efficient service and seamless patient pathways.

4140

How Might We Agree and Communicate a Common Language in order to Support and Promote Realistic Medicine, De-Pharmaceuticalisation, and Effective Prescribing?

Suggestions

Potential Impact

Establishing the message that medication is just one part of a wider therapeutic approach to managing Chronic Pain, forming is a biopsychosocial approach. Supporting conversations and making sure healthcare professionals themselves are not reinforcing the pharmaceutical bias.

Emphasising the long-term nature of Chronic Pain management, while promoting person-centred approaches, shared decision making, and continuity of contact with the same professional where possible in both secondary and primary care.

Implementing alternative, non-pharmaceutical supports, and ensuring widespread access to these, by patients and professionals. Before communicating and implementing de-medicalisation, there is a need to ensure other support is available to people.

People coming to a consultation with a healthcare professional would already be aware of the support available and they would also be open to non-medical options, leading to better conversations about the full range of treatment options.

Clear and consistent messages about treatment options would inform local and national initiatives and encourage their uptake.

Lifelong improvements in health and function, achieved through methods that suit the person and that are as safe and effective as possible.

Note: Supporting the implementation of Health Literacy https://www.alliance-scotland.org.uk/wp-content/uploads/2017/11/Making-It-Easier-A-Health-Literacy-Plan-for-

Scotland.pdf

4342

How Might We Make Information about Chronic Pain Self-Management Widely Accessible as well as Widely Used?

Suggestions

Making information accessible and available at the right time, to people and professionals.

Clarifying that self-management may mean accessing support through link workers, local groups, internet or other professional sources, rather than doing it by oneself.

Supporting and guiding people to make choices by using consistent language and approaches across community, primary and secondary care.

Reinforcing the message that self-management should be the mainstay of Chronic Pain management in most cases, perhaps supplemented by appropriate medication. One example put forward by a workshop participant was the use of a personalised laminated sheet with information for young people in appropriate language.

Providing information on websites, such as NHS inform, which is easy to access, consistent, up to date and validated. Moving beyond traditional public health campaigns, Chronic Pain education and an awareness of long-term conditions could be delivered in schools.

Creating a navigational tool for primary care, to support people and professionals in communicating about the multi-factorial impact of Chronic Pain and the relevant management options available, irrespective of locality.

4544

Other Ideas

Currently some people are required to travel long distances to access Chronic Pain services, and/or have to wait a long time because of staffing shortages in their local area.

Consider the employment of a visiting Chronic Pain specialist for

areas such as the Western Isles where people are currently required to

travel a long distance.

Explore increased use of telephone,

IT tools and telehealth supporting technology.

4746

Next StepsThe Chronic Pain Speciality Group workshops generated clear consensus on the areas most likely to make a difference to people presenting with Chronic Pain. These included:

47

HOW MIGHT WE: allocate available resource to educate, train, supply, and retain healthcare professionals with the right skillsets in the right places?

HOW MIGHT WE: make people aware of what self-management is and what options are available?

HOW MIGHT WE: ensure sustainable funding for Chronic Pain?

HOW MIGHT WE: make information about Chronic Pain self-management widely accessible as well as widely used?

HOW MIGHT WE: develop strong links between primary and secondary care, as well as acute and chronic services, in order to create a clear model of care?

HOW MIGHT WE: use measurement of current and future staffing to drive improvement?

HOW MIGHT WE: agree and communicate a common language in order to support and promote Realistic Medicine, de-pharmaceuticalisation, and effective prescribing?

Additional Resources

The Scottish Access Collaborative site includes blogs and documents on the following subjects:

• Core Data and Performance Measurement for Chronic Pain

• NHS Grampian Chronic Pain Service

• Affa Sair: self help for Chronic Pain sufferers

• Blog post by Dr John Macleod, Consultant in Pain Management NHS Highland

• The Landscape of Pain in Scotland

• The Importance of Psychological Approaches in Pain Management Programmes in Primary Care

• ALISS is A Local Information System for Scotland

• Chronic Pain Project North West Angus

• Scottish Public Health Network Report

• Five Year Financial Strategy

• Survey of Lothian GPs’ Experience of Community Management of Chronic Pain and Attitudes to Further Training

48

DHI is a collaboration between:

Documents

Chronic Pain Specialty Group · Care Institute. The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish