Wednesday 10 November 12:30pm – 2:00pm Jubilee Room, Westminster Hall Houses of Parliament



Dr Martin Johnson, General Practitioner with a special interest in pain management 1:05pm – 1:15pm PATHWAYS TO WORK – HELPING PEOPLE INTO EMPLOYMENT Dr Ceri Phillips, Reader, Health Economics, University of Wales 1:15pm – 1:25pm CHRONIC DISEASE - PAIN MANAGEMENT AND PRIMARY CARE POLICY Dr Clare Gerada, Director, National Clinical Governance Support Team, GP Advisor to the Department of Health 1:25pm – 1:35pm PAIN IN LONG-TERM CONDITIONS – THE PATIENT PERSPECTIVE David Pink, Chief Executive, Long-term Medical Conditions Alliance 1:35pm – 2:00pm QUESTIONS AND ANSWERS AND OPEN DISCUSSION SESSION

Chronic Pain in Primary Care
Dr Martin Johnson
General Practitioner, Barnsley Chair of RCGP Committee on Pain

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 subjective……a patient’s self-report is the gold standard for assessment’ Portenoy 1999

Influences on the pain experience
Age Fears Gender

Education and understanding Previous pain experience (self/family) Culture

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,

Cost of problem in the UK

900,000 hospital bed days 12 million GP consultations Back pain £12 billion annually 119 million 119 million days certified days certified incapacity incapacity

My Practice (‟03 to ‟04)
– 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%)

Facts & Figures
Most Published Surveys/Documents relate to Secondary Care
– Services for Patients with Pain
(Clinical Standards Advisory Group) – March 2000

“GPs & Community Staff manage the majority of patients with chronic pain”

– 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

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

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

Scope of the Project

To build a coherent picture of chronic pain management services in primary care

Developed in consultation with the Patients Association and Longterm 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

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

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

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

Inequalities in care
Percentage of PCOs Providing Funding for Chronic Pain Services in Primary Care Across the UK
80 70









Ea st W er es n tM id la nd s

W al es

Tr en t

la nd N Sc ot


es t

as t

es t



So u

So u

an d

or th


or th er n

48% of all PCOs did not answer this question

or th er n


Ire la nd


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Comparison of pain management funding between primary and secondary care
Percentage of PCOs Providing Funding for Chronic Pain Management in Primary and Secondary Care
100 90 80 70

60 50 40 30 20 10 0
Ea st er n Lo nd on So ut h W es t So N ut or h th Ea er st n an d Y or ks N or th W es t W es tM id s Sc ot la nd Ire la nd Tr en t W al es

Primary Care Secondary Care

48% of all PCOs did not answer the primary care question 50% of all PCOs did not answer the secondary care question


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 noncancer pain

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

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

Formal or structured service for chronic pain management in primary care
Percentages of PCOs Operating a Formal or Structured Service for Chronic Pain Management in Primary Care
45 40 35

30 25 20 15 10 5 0
Tr en t Ea st er n W al es Lo nd on So ut h W es t So ut N h or Ea th er st n an d Y or ks N or th W es t M id la nd s Sc ot la nd N Ire la nd

48% of all PCOs did not answer this question

W es t

or th er n

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

He al th


100 90

30 20

60 50 40

80 70

10 0

51% of all PCOs did not answer this question
Chronic Pain Services Delivered in Primary Care
Ed uc ca at re io pr n of fo es rp sio at ie na nt l le s d cl in In ics di vid ua lO G T ro In up di vid O T ua lp hy G ro sio up ph Ps ys yc io h su pp Re o rt la xa Ac tio up n un Hy c pn tu re ot he ra Re py fle x Ho olo g m eo y p Ar om ath y at he ra py

Chronic pain services delivered in primary care

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

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

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

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

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

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

Obtaining funding to provide an adequate service Reducing waiting times

Development of clear standards and protocols
Training and education

Holistic approach

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

Chronic pain
The economic consequences and government response
APHG, November 2004

Sick leave Avoidance Depression

Helplessness Failed treatment
Anger &blame Catastrophising

Uncertainty & fear


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

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

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

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]

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)

The Burden of Chronic Pain affecting Capacity for Work
Nos Musculoskeletal Disorders 200,000 Pain % 100

Mental Health Problems
Neurological Diseases Cardiovascular Diseases Others

40,000 44,000 222,000

14 22 10

-------------------------------------------------Chronic Pain 277,000 28

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

Work >>>>>Disability over time

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/illhealth 10% reduction in major injury/incidents at work

Meeting the Challenge
Health and Safety Executive:

strategy & programmes


to Work  Framework for Vocational Rehabilitation

 Pathways

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

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

Change? - Return to work a positive
& realistic option
 Virtually all flowing onto IB want to get back to work at


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

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

Work Loss and Return to Work
 Dependent on other influences as well as sickness,

pain and disability:
type and satisfaction  the workplace  labour market  national and local economies  income, compensation  benefits and social security systems  closeness to retirement age  culture
 Job

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

Pathways to Work Pilots: Aims
 Particular focus on customers with:
  

Musculoskeletal disorders Moderate cardio-respiratory conditions Mild to moderate mental health conditions Helping patients to understand and manage their condition

 NOT to replace NHS Treatment but aimed at:


Using CBT and other validated interventions

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

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  Customer’s GP (with consent) kept informed

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

 address lack of NHS provision for treatment or

 DWP/CMG Website - Training and Advice for GPs

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

The Focus of Rehabilitation
 Rehabilitation is not a separate secondary stage after

 Good Clinical Management should relieve symptoms and

restore function
 Fundamental shift in healthcare culture  A multi-modal nature addressing:
- biological
- social components

- psychological
- and obstacles to recovery

Thank you for your attention

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