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".www.wspg.org.ukTRANSCRIPT
Dr Martin Johnson
Current State of Pain Current State of Pain Management Services in Management Services in Primary Care in the UKPrimary Care in the UK
Current State of Pain Current State of Pain Management Services in Management Services in Primary Care in the UKPrimary Care in the UK
NBPA: Edinburgh
18th May 2007
Dr Martin Johnson
Dr Martin Johnson
Dr Martin Johnson
OverviewOverviewOverviewOverview
Pain Management in Primary Care The Big Picture The “average” GP’s experience/views Where does pain management fit in General
Practice? Why should pain be managed in the community? What should a community pain service look like? GPwSIs
National Influences on Primary Care
Dr Martin Johnson
Cost of problem in the UKCost of problem in the UKCost of problem in the UKCost of problem in the UK
££
119 million days certified incapacity
119 million days certified
incapacity
900,000hospitalbed days
12 millionGP
consultations
Back pain £12
billion annually
Dr Martin Johnson
The Scale of the ProblemThe Scale of the Problem
• An average practice of 10,000 patients can expect to include 1,000-2,000 people with chronic pain
• These patients require 6,250 consultations for pain-related conditions a year
• Practice based retrospective audit (2002) Looking at efficacy problems, side effect and intolerance,
clinical condition, compliance etc., the figures for a year: 4,602,000 consultations with 793 GP’s per year Cost = £69,030,000
Dr Martin Johnson
NOPNOPNOPNOP
Dr Martin Johnson
My Practice (’03 to ’04)My Practice (’03 to ’04)My Practice (’03 to ’04)My Practice (’03 to ’04)
Profile 9,500 patients Urban, ex-mining area
Analgesics on Repeat or more than 2 acute Rx Non-Opioid Analgesics; 2210 patients (22%) Opioid Analgesics; 342 patients (4%) NSAID’s; 2058 patients (22%)
Dr Martin Johnson
Dr Foster Report - 2004Dr Foster Report - 2004Dr Foster Report - 2004Dr Foster Report - 2004
(1) Nearly two-thirds of PCOs fail to allocate any resources specifically for pain management services in primary care
(2) Average 0.7% of the average PCO annual budget is allocated for chronic pain management services in primary care
(3) Most (80%) of PCOs fail to provide any kind of structured or formal pain service in primary care
Dr Martin Johnson
Dr Foster Report - 2004Dr Foster Report - 2004Dr Foster Report - 2004Dr Foster Report - 2004
(4) Nearly all (96%) of PCOs do not have a population-based or GP practice-based register to monitor the need for pain management services
(5) Most (70%) of PCOs do not provide guidelines or recommendations for the management of chronic pain
(6) A small number (8%) of PCOs allocate any resource specifically for GP training in chronic pain management
Dr Martin Johnson
Problems in General PracticeProblems in General PracticeProblems in General PracticeProblems in General Practice
We are trained badly in assessment of pain We dislike dealing with pain Prefer conditions where symptoms can be measured Guidelines are sent but are not educated and in the
case of most aspects of pain not available We are frustrated because of the lack of treatment
options available. The lack of immediate treatments invariably links in
with chronic sickness behaviour & certification.
Dr Martin Johnson
The Golden 2.5 MinutesThe Golden 2.5 MinutesThe Golden 2.5 MinutesThe 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
Dr Martin Johnson
Pain management – where does it fit Pain management – where does it fit into General Practice?into General Practice?Pain management – where does it fit Pain management – where does it fit into General Practice?into General Practice?
• Chronic disease management is defined by the new GMS contract as an essential service
OA and RA are chronic diseases that require quality management as an essential service
Not a Quality Indicator Not an NSF Not covered by NICE/SIGN Poor Guidelines
Dr Martin Johnson
What are the Developments?What are the Developments?What are the Developments?What are the Developments?
Dr Martin Johnson
PainPain –– Where Where to Treat to Treat??PainPain –– Where Where to Treat to Treat??
Primary careSecondary care
© Mark Adams/SuperStock © Stockbyte
Dr Martin Johnson
They say They say the NHS is short of cash?the NHS is short of cash?
Well, let’s see if we can save a bit.Well, let’s see if we can save a bit.
They say They say the NHS is short of cash?the NHS is short of cash?
Well, let’s see if we can save a bit.Well, let’s see if we can save a bit.
Dr Martin Johnson
Well, the ambulance service could save on petrolWell, the ambulance service could save on petrol
Dr Martin Johnson
And if paying petrol costs for the ambulance cars becomes And if paying petrol costs for the ambulance cars becomes too much …too much …And if paying petrol costs for the ambulance cars becomes And if paying petrol costs for the ambulance cars becomes too much …too much …
Dr Martin Johnson
The district The district nurses can still nurses can still use their bikes use their bikes in most in most weatherweather
The district The district nurses can still nurses can still use their bikes use their bikes in most in most weatherweather
As long as they As long as they take take reasonable reasonable security security precautionsprecautions
Dr Martin Johnson
Ensure vital equipment is safely securedEnsure vital equipment is safely securedEnsure vital equipment is safely securedEnsure vital equipment is safely secured
Dr Martin Johnson
EnglandEnglandEnglandEngland
White Paper Our health, our care, our say: a new direction for community services
Key themes Choice Plurality of providers Increase in community-based services Prevention
Our health, our care, our say: a new direction for community services. Department of Health, January 2006.
Dr Martin Johnson
The Primary Care AdvantageThe Primary Care AdvantageThe Primary Care AdvantageThe Primary Care Advantage
Early and local access Cheap! Benefit of knowing patient’s medical, family and
social history and their personality type Reinforce positive proactive behaviour Enforce concordance with management of Drug
therapy and their side effects Positive impact on surrounding GPs & practices
(referral/advice/education)
Dr Martin Johnson
Individual ProjectsIndividual ProjectsIndividual ProjectsIndividual Projects
All around the UK Southampton Cardiff Belfast Harrogate, West Sussex Sheffield Etc etc etc
Dr Martin Johnson
Community Pain ServiceCommunity Pain ServiceCommunity Pain ServiceCommunity Pain Service
Will be sent up to address the needs of the local PCT
No two models will be alike – the bespoke approach. Hospital based triage service GP, physio (ESP), nurse based initial assessment GPwSI (Clinical – assessment, Waiting lists,
education) Locality based/Practice Based Commissioning APMS (Alternative Providers of Medical Services)
Dr Martin Johnson
GPwSI ActivitiesGPwSI ActivitiesGPwSI ActivitiesGPwSI Activities
Clinical Assessment (Referral, Scoring tools, Waiting List
Management) Treatment (pain management, injections, minor
operations)
Education & Liaison Providers GP’s
Dr Martin Johnson
Potential ProblemsPotential ProblemsPotential ProblemsPotential Problems
There simply are not enough Drs! The training for the GPwSIs not well defined
at present The attitude of some consultants – some find
problems with the changing balance of power Suspicion of other GPs
Dr Martin Johnson
Issued to be SortedIssued to be SortedIssued to be SortedIssued to be Sorted
Which patients are to be seen? Where? Accommodation? Prescribing Support staff Referral to Diagnostics etc Protocols Relationships with other GP’s & Consultants
Dr Martin Johnson
Chronic Pain Policy CoalitionChronic Pain Policy CoalitionChronic Pain Policy CoalitionChronic Pain Policy Coalition
The mission statement:
To improve the lives of people who live with chronic pain by developing and sharing ideas for improved prevention, treatment and management of chronic pain in the UK.
Dr Martin Johnson
Parliamentary ReportParliamentary ReportParliamentary ReportParliamentary Report
Multidisciplinary approach to pain management
Early intervention and assessment in appropriate care
Pain as the 5th vital sign (measurement) Pain education and training for healthcare
professionals Reform of the sick note
Dr Martin Johnson
55thth Vital Sign Vital Sign55thth Vital Sign Vital Sign
Dr Martin Johnson
Dept. Work & PensionsDept. Work & PensionsDept. Work & PensionsDept. Work & Pensions
2.7 million people (working pop.) on state incapacity benefit
Sickness Benefit costs industry - ?£30 billion Top 2 causes: Mental Health (33%) and
Musculoskeletal (21%) Green Paper “Pathways to Work: Helping
People into Employment” Third of paper is about pain management Focuses on rehabilitation
Dr Martin Johnson
CPPC: Listening PanelsCPPC: Listening PanelsCPPC: Listening PanelsCPPC: Listening Panels
To enable the CPPC to engage with various audiences to prevent, manage & treat pain
Occupational Health, PCT & Royal Colleges OH: M&S, Royal Mail, BT
Initial GP contact vital to return to work Encourage early intervention in pain Sick Note is a barrier between GPs & employers GP’s have little incentive to get people back to
work
Dr Martin Johnson
RCGP Pain Management CommitteeRCGP Pain Management CommitteeRCGP Pain Management CommitteeRCGP Pain Management Committee
Dr Martin Johnson
Competency TrainingCompetency TrainingCompetency TrainingCompetency Training
PBC has made the subject more attractive There are now criteria from RCGP Needs to encompass those with a simple
interest through to ‘super’ GPwSI Discussion if it should include MS elements ? Distance Learning
Dr Martin Johnson
Neuropathic Pain GuidelinesNeuropathic Pain GuidelinesNeuropathic Pain GuidelinesNeuropathic Pain Guidelines
Dr Martin Johnson
Fact or Fiction?Fact or Fiction?Fact or Fiction?Fact or Fiction?
What do GP’s do with all their complex (neuropathic) pain patients: Tell the patient it is all their mind Look in MIMS but then give up on the second
attempt Classify them all as heart sinks Hope they have another disease Refer them all to secondary care
Dr Martin Johnson
Quality Outcomes FrameworkQuality Outcomes FrameworkQuality Outcomes FrameworkQuality Outcomes Framework
2 submissions Low Back Pain Diabetic Neuropathy
Only one submission will progress to next stage
Dr Martin Johnson
Diabetic NeuropathyDiabetic NeuropathyDiabetic NeuropathyDiabetic Neuropathy
– 20-24% of diabetics experience PDN1
Dr Martin Johnson
Dr Martin Johnson
WHO IS THIS???
Dr Martin Johnson
Dr Martin Johnson
Dr Martin Johnson
Practical aspects of prescribing Practical aspects of prescribing 2: Who should prescribe? 2: Who should prescribe?
Practical aspects of prescribing Practical aspects of prescribing 2: Who should prescribe? 2: Who should prescribe? In most cases, day-to-day medical responsibility
will lie with a general practitioner once the patient is taking a stable dose of opioid
Hospital based services should start opioid therapy only after discussion and agreement with primary care services
A single practitioner should take primary responsibility for prescribing opioids for individual patients
Fixed supplies of these drugs should be prescribed at fixed intervals
Dr Martin Johnson
Opioids: New RegulationsOpioids: New RegulationsOpioids: New RegulationsOpioids: New Regulations
Computer generated 28 days validity 30 days supply (‘good practice’) Patient Identifiers e.g. NHS Number Minor Errors Prescribing to family & friends
(Branded Prescribing)
Dr Martin Johnson
British Pain SocietyBritish Pain SocietyBritish Pain SocietyBritish Pain Society
Remains very supportive of Primary Care Runs joint Educational Day with RCGP Given advice on Neuropathic Pain Guidelines Encouraging Primary Care SIG Development of Cancer Pain Guidelines Development of Primary Care Pain
Guidelines
Dr Martin Johnson
New or Recent ChangesNew or Recent ChangesNew or Recent ChangesNew or Recent Changes
Changes to PCTs & SHAs Increasing focus on 1º & Community Care Quality & Outcomes Framework Choice & Book National Tariffs/PbR Private Providers Practice Based Commissioning
Dr Martin Johnson
Future Commissioning ModelFuture Commissioning ModelFuture Commissioning ModelFuture Commissioning Model
BARNSLEY PCT BOARDPEC
PBC Steering Group
PBC LIT
Planning
Procurement
Performance
Management
Contract Compliance
Providere.g. Single GP
Providere.g. Independent Sector
Providere.g. Trust etc.
Providere.g. Group of GPs
PROVIDERS
Practice Based COMMISSIONERS
COMMISSIONING DIRECTORATE
Dr Martin Johnson
Pain Management: Other IssuesPain Management: Other IssuesPain Management: Other IssuesPain Management: Other Issues
COX2’s Co-Proxamol Branded Prescribing
Dr Martin Johnson
Patient’s AssociationPatient’s AssociationPatient’s AssociationPatient’s Association
Dr Martin Johnson
Dr Martin Johnson
Chronic pain in older peopleChronic pain in older peopleChronic pain in older peopleChronic pain in older people
Major public health problem inflicting tremendous personal suffering
Most devastating impact amongst older people
10 million people aged over 65 years in the UK
Predicted to reach 11.9 million by 20111
1. Government’s Actuary Department, 2003
Dr Martin Johnson
ChallengesChallengesChallengesChallenges
Under-diagnosis and under-treatment Lack of formalised and regular assessment of pain1
Lack of training for nursing home staff2 Poor medicines management3
<50% residents with predictably recurrent pain prescribed scheduled pain medication4
1. Sengstaken & King, 1993; Allcock et al, 2002Sengstaken & King, 1993; Allcock et al, 20022. Allcock et al, 2002; Mozley et al, 20042. Allcock et al, 2002; Mozley et al, 2004 3. CSCI, 20064. Hutt et al, 2006Hutt et al, 2006
Dr Martin Johnson
How is chronic pain managed?How is chronic pain managed? How is chronic pain managed?How is chronic pain managed?
Roles of health professionals and nursing home management
How pain is identified and assessed GP visits to nursing homes Prescribing process and management
Dr Martin Johnson
Pain Management: FuturePain Management: FuturePain Management: FuturePain Management: Future
Recognised as a Disease Role of CPPC Role of RCGP Role of BPS New Primary Care Society for Pain Part of QOF Increasing Focus on Primary Care Delivery Need for Choice GPSI etc Training Scheme DWP Further Academic Unit for Primary Care
Dr Martin Johnson
A Wish ListA Wish ListA Wish ListA Wish List
Raising awareness of Pain Understanding when to stop the revolving
diagnostic door Develop the Training Developing Pathways between Primary &
Secondary Care
Dr Martin Johnson
Have a Have a good day!good day!Have a Have a good day!good day!
Dr Martin Johnson
Dr Martin Johnson
Thank - YouThank - YouThank - YouThank - You
Any Questions?
Original artwork courtesy of Painexhibit.com
Thanks to Dr Peter Wright