1.  INTRODUCTION

  1.1  The Chronic Pain Policy Coalition (CPPC) unites professionals, parliamentarians and patients who have joined together to make a positive contribution to improving the lives of people with pain and their families by working in collaboration with each other. The CPPC works to develop and coordinate a strategy for improving the prevention, treatment and management of chronic pain in the UK.

  1.2   The Executive Committee is formed of senior representatives from a range of stakeholders including;

Baroness Rennie Fritchie—CPPC President

Dr Beverly Collett—Consultant in Pain Management, University Hospitals of Leicester

Sylvia Denton—Past President, Royal College of Nursing

Jean Gaffin—Trustee, St Luke's Hospice Harrow

Dr Joan Hester—President, British Pain Society

Dr Martin Johnson—Chair, Pain Committee, Royal College of General Practitioners

Clive Jones—Director of UK Corporate Affairs, Napp Pharmaceuticals Ltd

Beatrix Maynard—Management Consultant

Professor David Rowbotham—Faculty of Pain Medicine, Royal College of Anaesthetists

Dr Gabriel Scally—Regional Director of Public Health, Government Office South West

Nia Taylor—Chair, Patient Liaison Committee British Pain Society and Chief Executive, BackCare

  1.3  The CPPC is supported by The Royal College of Anaesthetists, The Royal College of General Practitioners, The Royal College of Nursing, Royal College of Obstetricians and Gynaecologists, The Royal College of Physicians, The Faculty of Occupational Medicine, The British Pain Society, British Society for Rheumatology, The British Medical Acupuncture Society, Action for ME, Action on Pain, BackCare, Derbyshire Chronic Pain Support Group, emPower, Endometriosis SHE Trust, National Lichen Sclerosus Support Group, Pain Association Scotland, Pain Concern, Pain Relief Foundation, Pelvic Pain Support Network, Poole Endometriosis Support Group, RSD UK, Scleroderma Society, Shingles Support Society, Spinal Injuries Association, The British Polio Fellowship, The Migraine Trust, Vulval Pain Society, Grunenthal, Janssen-Cilag Ltd, NAPP Pharmaceuticals, Novartis, Pfizer and Sanofi Pasteur MSD.

2.  EXECUTIVE SUMMARY

  2.1  7.8 million people live with chronic pain in the UK. One-third of households have at least one adult who is in pain. This means 1 in 7 people in every single parliamentary constituency.

  2.2  Chronic pain can affect people at any age and at different stages of their life. In the UK, 75% are of working age between 18 and 65 years of age.

  2.3  The negative effect of chronic pain on quality of life can be considerable—with 24% of people being diagnosed with depression.

  2.4  There are severe economic consequences for the individual and their family as 25% of people with pain lose their job.

  2.5  There are significant economic consequences for the wider economy, for example the total cost of back pain being £12.3 billion in 2000.

  2.6  Pain Management Services are patchy and variable around the country. Current inequalities in access to adequate pain management services in the UK are unacceptable if the NHS is to be genuinely patient-centred.

  2.7  Management of chronic pain requires a biopsychosocial approach. General Practitioners cannot currently always manage chronic pain alone. There is a clear necessity for a different way of managing pain within the health community.

  2.8  Improved pain management could be achieved by implementation of the Chronic Pain Policy Coalition's Five Point Manifesto.

  2.9  Improved pain management could be achieved by service reconfiguration without significant extra resources. There is a clear imperative to work "smarter".

  2.10  There is necessity for a joined-up strategy between occupational health services, primary and secondary care in the management of patients with chronic pain.

Education So that pain is an integral part of all professional training	Parliamentarians Should Ensure that Government gives more priority to pain education as an important part of effective chronic pain management.
Empowerment To support people to make decisions about their condition	Liaise with the local health sector to improve services for people living with chronic pain.
Collaboration So that all stakeholders share in a joined up strategy	Support and encourage the development of local multidisciplinary pain management services and commit to reforming the "Med 3" sick note.
Early Access To prevent acute pain becoming chronic pain	Ensure that the Government supports Primary Care Trusts and employers in taking a long term view on tackling chronic pain.
Measurement Of pain as the 5th Vital Sign	Campaign for the adoption of Pain as the 5th Vital Sign by all health care professionals.

3.  BACKGROUND

  3.1  7.8 million people live the chronic pain in the UK. This is equivalent to about one in seven people in every single parliamentary constituency.

  3.2  Pain in a major humanitarian issue. The negative effect of chronic pain on the daily lives of individuals and their families is enormous. Twenty-five per cent of patients with chronic pain lose their jobs and 24% are diagnosed with depression (Breivik HB, Collett BJ et al. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain 2006;10:287-333)

  3.3  The consequences for the UK economy are of huge significance. Total cost of back pain alone was £12.3 billion in 2000 (Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000; 84: 95-103). Department of Work and Pensions data estimates the annual cost of incapacity benefit for claimants with musculoskeletal disorders to be £126 million in 2004-5 (Department of Work and Pensions 2007) and chronic pain is a major component of these disorders. It is estimated that 119 million working days are lost each year to back pain (www.backcare.org.uk,2007).

  3.4  Chronic pain is one of the commonest reasons for a patient to visit a GP, accounting for 4.6 million GP appointments each year at a cost of £69 million (Besley J. Primary care workload in the management of chronic pain: A retrospective cohort study using a GP database to identify resource implications for UK primary care. Journal of Medical Economics 2002;5:39-50). This represents a resource cost equivalent to around 800 full-time GPs per year.

  3.5  Persistent pain stimulates a vast number of prescriptions, investigations and referrals, causes frustration in its resistance to treatment and leaves patients and doctors with low expectations of successful outcome.

  3.6  Better management of acute pain may prevent chronic pain becoming entrenched. In addition, Pain Management Services in secondary care have traditionally been seen as a "Cinderella service" with long waiting lists and only to be tried when everything else has failed. A consequence of this is that there are often delays until a patient sees a health care professional interested in relieving them of their pain and returning them to functionality. Once off work with back pain for more than six months, there is less than a 50% chance of them ever returning to work.

  3.7  When pain is associated with a disease or condition (eg cancer, inflammatory conditions), the specialists dealing with the patient may be less interested in the pain than in the progression and management of the disease, and therefore spend little time in dealing with the pain. Yet for patients we know that adequate control of pain and discomfort is very important and affects their ability to deal with other aspects of their condition.

  3.8  In March 2000, the Department of Health published the Clinical Standards Advisory Group (CSAG) "Services for patients with pain". This report made certain recommendations, but was never implemented as the NHS was re-structuring service provision generally at that time. However, reference is still made to this document within the House when Parliamentary Questions are answered. These answers reflect a lack of understanding within the Department of recommendations made without any attempt to see they are implemented, (eg no targets for improving pain management and no NSF), and ignoring the fact that the CSAG Report was never sent to the newly emerged NHS bodies.

  3.6  In June 2007, the Chronic Pain Policy Coalition launched a Five Point Pain Manifesto to present some forward-looking and cost effective solutions to the problem of chronic pain. A copy of this manifesto is available.

  Our manifesto emphasised:

1.  Early access: to prevent acute pain becoming chronic

2.  Pain should be viewed as the 5th Vital Sign—ie health professionals should routinely ask patients if they are in pain and this pain should be measured so that the pain can be treated and subsequently re-assessed.

3.  Empowerment: to support people making decisions about their treatment in the way that patient information prescriptions currently being piloted

4.  Collaboration: so that all stakeholders share in a joined-up patient strategy

5.  Education: so that pain is an integral part of all professional training.

4.  SUGGESTIONS FOR TACKLING INEQUALITIES

  4.1  Patients need better access to Pain Management Services in primary care, and in secondary care for those who need it. The Chronic Pain Policy Coalition strongly supports the development of an 18 Week Commissioning Pathway for Chronic Pain. However, we need to ensure that patients struggling to manage their pain are identified early in primary care and appropriate management instituted.

  4.2  In addition, any improvement to pain management whether in primary or secondary care or both must encompass

—  demand management—making sure the right person gets seen in the right place at the right time

—  service design—structuring the service to permit a biopsychosocial approach

—  appropriate management of patient expectations

—  clear care pathways to take a person in and out of the service.

  4.3  We present below some examples of excellent innovative services currently being undertaken in primary and secondary care that emphasise how a different approach to acute and chronic pain management may improve patient care. However, we should like to emphasise that these examples are not the current common method of chronic pain management across the UK and disseminating these examples of good practice and encouraging their adoption would benefit millions of patients.

  4.4  We should like all patients to have the opportunity of such services.

5.  CASE STUDIES

    These are only resumes of the services and full details can be provided on request.

  5.1  Tower Hamlets Primary Care Trust.

  This project, which will be launched on 15th January 2008, offers a unique opportunity to improve the care of Tower Hamlets residents suffering from chronic musculo-skeletal pain. Using a bio-psychosocial model, patients will be helped to self-care and avoid long-term sickness and disability. This will be achieved by establishing a prompt patient triage and assessment service which, using an interdisciplinary team will provide a clear strategy of care leading ultimately to self-efficacy. The team will work closely with the physiotherapy department at Mile End hospital but there will also be links with external agencies such as providers of self care management.

  The project will be underpinned by an education programme provided by the team for other health care professionals. There will also be robust evaluation of the service including a formal assessment of lay-led patient programmes. This project follows the model that has been successfully pioneered in Southampton although it will be the first to effect these changes in an inner city multicultural environment.

  The new service will provide a new, improved pathway for patients with the key aims of the service being:

—  Early access to assessment by a specialist interdisciplinary team to help prevent people having long term health problems.

—  Use of an integrated specialist service of secondary care outreach consultants, PCT Allied Health Professionals, Clinical Psychologists and a Health and Advice worker. These will be supported by dedicated administrative staff.

—  Ongoing education and mentoring for other Health Care Professionals in the management of this complex group of patients.

—  Development of structured education programmes to enable patients effectively self manage. All people attending the service will be offered the opportunity to attend an appropriate self management course.

—  Providing appropriate information and advice about other important areas such as housing, ESOL and work related issues

—  Providing a full advocacy service for non-English speakers.

  5.2  The Southampton Pain Services Project "Managing Pain Management".

  A local services framework was agreed using a biopsychosocial approach at all levels of care as illustrated below:

  The emphasis is on viewing chronic non malignant pain as a long term health problem. The emphasis has been to ensure that primary care practitioners have the appropriate skills and resources to manage the vast majority of patients. Only a few (approximately 450 patients a year) are taken into specialist care for treatment but that treatment has clear end points. The principal changes to the service have been establishing treatment and referral guidelines for general practitioners, backed up by consultant visits to each practice, establishing a triage team, increasing the number and range of self management programmes in the community and setting up patient led support groups. The secondary care service was redesigned to increase emphasis on addressing complex psychosocial needs. All patients are required to opt in to differing arms of the service once choices have been thoroughly explained either through written information or during triage/assessment.

Outcomes

  An efficient, effective, sustainable service has now been established, involving a Care Pathway stretching across Primary and Secondary Care. Improved patient access has been achieved in largely through effective triage of referrals. GP's refer using an agreed and detailed proforma which is shared between all primary care based musculoskeletal services. Audit of outcomes at present shows that 30% of patient referrals can be either discharged after giving further advice or redirected based upon information given in the referral letter alone. 11% of patients do not opt into the service. DNA rates are very low. 36% of patients receive secondary care treatment. 5% opt to go directly to a self Management Programme with many of those seen in secondary care being referred at a later stage. The number of patients appropriate at assessment for a self management programme has increased from 30% to 60%.

  Redirection to the Expert Patient Programme and community rehabilitation teams are important and appropriate pathways.

  A patient satisfaction survey showed 75% were highly satisfied with the outcome of assessment. For many it was the first time they felt understood.

  There was a small initial cost to fund the Triage team and an increase in self management programmes for the more complex patients. There have been cost savings elsewhere with injection therapy, medical follow-ups and acupuncture being substantially reduced.

  5.3  Painmanagementsolutions

  Pain Management Solutions Ltd was formed with the vision to revolutionise the way in which pain management is delivered within the NHS. Pain Management Solutions believe that by introducing community based services, whilst at the same time developing and training primary care teams in the art and science of pain management, the financial cost and socio-economic burden (chronicity) of long-term benign pain can be critically reduced.

  Pain Management solution's services include:

—  Community Based Pain Management for Sheffield PCT

—  Choice & Book for Derbyshire County PCT

—  Extended Choice Network for Barnsley PCT (Delivered in the local community)

  Pain Management Solutions is establishing itself as a vehicle to bring the expertise of pain management into the community. In doing so patients are accessing services more rapidly, GPs and their clinical teams are being trained and developed, and the overall cost of this therapy area to the NHS is being reduced. Furthermore, commissioners and other users have access to information on clinical quality and contractual performance as well as cost effectiveness.

  They intend to develop their service further; and already have interest from commissioners & clinicians in several different areas of the North of England.

6.  RECOMMENDATIONS FOR ACTION6.1  The Chronic Pain Policy would humbly suggest that:

—  improved pain management is a significant public health issue

—  current inequalities in access to adequate pain management services in the UK are unacceptable.

—  improved pain management could be achieved by improved dialogue and joint working between primary and secondary care.

—  improved pain management services could be achieved with recognition of chronic pain as a condition is its own right and with a focus to manage this problem, with early intervention, with better primary care education and with resources re focused to deal with pain and functional impairment associated with pain

—  improved pain management could be achieved by implementation of the CPPC Five Point Manifesto

  6.2  The CPPC supports the implementation of the Musculoskeletal Services Framework, but has concerns that this will be patchy and variable around the country. In addition, it deals only with musculoskeletal pain problems.

  6.3  The CPPC welcomes the opportunity to present models of pain management services in primary care and models that incorporate productive cross boundary working across primary and secondary care as good practice which will improve the management of this condition, improve quality of life for many patients and improve functionality and the ability to participate fully in a working and social life.

January 2008