The Centre for Active Lifestyle The Centre for Active Lifestyle Management (CALM) Management (CALM)

Dr Stephanie JarrettDr Stephanie JarrettConsultant Clinical PsychologistConsultant Clinical PsychologistPain Management UnitPain Management UnitUniversity Hospital LewishamUniversity Hospital Lewisham

Setting the sceneSetting the scene Chronic pain - British Pain Society definition:

““continuous, long-term pain of more than 12 weeks or after the time that continuous, long-term pain of more than 12 weeks or after the time that healing would have been thought to have occurred after trauma or surgery”healing would have been thought to have occurred after trauma or surgery”

Diagnoses:Diagnoses: OsteoarthritisOsteoarthritis Degenerative changes/diseaseDegenerative changes/disease SpondylosisSpondylosis ‘‘Wear and Tear’Wear and Tear’ Complex Regional Pain SyndromeComplex Regional Pain Syndrome FibromyalgiaFibromyalgia Chronic widespread painChronic widespread pain

Setting the sceneSetting the scenePeople living with chronic pain: 7.8 millionPeople living with chronic pain: 7.8 million

Prescriptions for pain: £584 millionPrescriptions for pain: £584 million

The cost to the NHS of chronic (long-term) The cost to the NHS of chronic (long-term) backback pain alone is pain alone is estimated to be £12.3bn per year estimated to be £12.3bn per year

The management of chronic pain in primary care accounts for 4.6 The management of chronic pain in primary care accounts for 4.6 million GP appointments, costing around £69 million per yearmillion GP appointments, costing around £69 million per year

Patients with chronic pain experiencing depression: 49%Patients with chronic pain experiencing depression: 49%

Setting the sceneSetting the sceneComprehensive, multi-disciplinary group programme is the most efficacious and cost-effective treatment for patients with chronic pain (Gatchel & Okufuji, 2006; Guzmán et al 2001)

Multidisciplinary group pain management programmes (PMPs) are recommended for patients with chronic non-malignant pain by

The British Pain SocietyEuropean GuidelinesThe International Association for the Study of Pain

Report by Dr Foster (2003) identified the patchy provision of PMPs in the UK.

Hillingdon Ealing

Kingston

Wolfson

COPE

Chelsea

National

INPUT

Northwick Park

Epsom

Lack of PMPs in South-East London

Lack of PMPs in South-East London

15k Diameter

Hillingdon Ealing

Kingston

Wolfson

COPE

Chelsea

National

INPUTHillingdon Ealing

Kingston

Wolfson

COPE

Chelsea

National

INPUT

Northwick Park

Epsom

Past: 2001 – Recruitment of Clinical Psychologist to Chronic Pain Service, University 2001 – Recruitment of Clinical Psychologist to Chronic Pain Service, University

Hospital LewishamHospital Lewisham

2002 – Pilot Programme2002 – Pilot Programme

2004 – 12004 – 1stst Business plan put forward Business plan put forward

2009 – Obtained 12 month funding2009 – Obtained 12 month funding

2010 – 6 month extension2010 – 6 month extension

2011 – 12 month extension until March 20122011 – 12 month extension until March 2012

2012 – Mainstream funding2012 – Mainstream funding

Present: The CALM team – The CALM team –

Consultant Clinical PsychologistConsultant Clinical Psychologist Clinical Physiotherapist SpecialistClinical Physiotherapist Specialist Pain Nurse SpecialistPain Nurse Specialist Psychology AssistantPsychology Assistant AdministratorAdministrator

All 0.4 wteAll 0.4 wte

The CALM Programme

The CALM programme aims to help The CALM programme aims to help patients:patients: Develop strategies to reduce the distress & Develop strategies to reduce the distress &

disability caused by paindisability caused by pain

Decrease reliance on medical professionalsDecrease reliance on medical professionals

Improve quality of life Improve quality of life

Referral Referral Referrers - secondary care pain related services Referrers - secondary care pain related services

Chronic Pain serviceChronic Pain service RheumatologyRheumatology OrthopaedicsOrthopaedics Musculoskeletal assessment and triage (MSK) service Musculoskeletal assessment and triage (MSK) service PhysiotherapyPhysiotherapy

Referral processReferral process Check patient is registered with Lewisham GPCheck patient is registered with Lewisham GP Check patient eligible for CALM programme: Check patient eligible for CALM programme:

No ongoing litigationNo ongoing litigation No ongoing medical intervention (other than medication)No ongoing medical intervention (other than medication) No ongoing investigationsNo ongoing investigations No active psychosisNo active psychosis

Discuss referral with patientDiscuss referral with patient If patient in agreement – send referral letter to CALM teamIf patient in agreement – send referral letter to CALM team Discharge patient to care of CALM teamDischarge patient to care of CALM team

Referral letter received

Patient sent letter inviting them to phone and arrange a date to attend a group information meeting about the CALM programme

Patient phones to arrange date for group information meeting

Attends group information meeting. Invited to contact CALM team to arrange date for individual assessment

Patient phones to arrange individual assessment

Seen individually by psychologist, physiotherapist & nurse for assessment

Programme suitable - offered place

No contact from patient within28 days

DNA group information meeting

No contact to arrange assessment appointment within 28 days

DNA assessment

Programme not suitable – referred to more appropriate service

Discharged – inform referrer and GP

Assessment – offered place on programme

Weekly group sessions for 10 weeks

6 weeks later – First follow-up group session

6 months later – Second follow-up group session

Open invitation to yearly ‘booster’ session

Outcome Data – Quality of LifeOutcome Data – Quality of Life DistressDistress

Depression (Beck Depression Inventory II)Depression (Beck Depression Inventory II) Catastrophising (Pain Catastrophising Scale)Catastrophising (Pain Catastrophising Scale) Fear of movement (Tampa Scale of Kinesiophobia)Fear of movement (Tampa Scale of Kinesiophobia)

DisabilityDisability Sit-to-stand (number per minute)Sit-to-stand (number per minute) Pain interference (British Pain Inventory)Pain interference (British Pain Inventory)

96 patients reached 6 months follow-up96 patients reached 6 months follow-up Complete data available for 90 patientsComplete data available for 90 patients

Bonferroni’s correction for multiple analyses Bonferroni’s correction for multiple analyses pp<0.008<0.008

N = 90 Patients who had completed programme and returned questionnaires

Statistically significant improvement by end of 10

week programme

Statistically significant improvement at 6 month follow-up

Distress: p ≤ .008 p ≤ .008

Depression (BDI II) Yes Yes

Catastrophising (PCS) Yes Yes

Fear of movement (TSK) Yes Yes

Disability:

Sit-to-stand (No. per minute) Yes Yes

Pain interference (BPI) Yes Yes

Outcome Data – Quality of LifeOutcome Data – Quality of Life

Outcome Data – Health Care UseOutcome Data – Health Care Use

Computerised appointment system Secondary care pain-related appointments Physiotherapy appointment s

Contacted GPs to get data on primary care pain-related appointments

Outcome Data – Health Care UseOutcome Data – Health Care Use

Total number of appts (N=55 patients who finished programme >1 year ago)

12 months pre-programme

12 months post-programme

% Reduction

Secondary Care Pain Appointments

142 13 91%

Physiotherapy Appointments

206 20 90%

NHS Lewisham Target 80%

Primary Care Pain-Related Appointments

(N=25)

156 66 58%

Outcome Data – Health Care CostsOutcome Data – Health Care Costs

Clinical coding department to get accurate costs for: Secondary care pain-related outpatient

appointments Physiotherapy appointments Interventions (e.g. Epidural, trigger point

injection etc.)

Outcome Data – Health Care CostsOutcome Data – Health Care Costs

Cost of appointments (N=55 patients who

completed the programme >1 year

ago)

12 months pre-programme

12 months post-programme

% Reduction

Secondary Care Pain appointments

£21,115.46 £2,328.20 89%

Physiotherapy appointments

£14,584.80 £1,122.60 92%

Secondary Care Pain Related Interventions

£12,178.39 £2,989.27 75%

Happily Ever After?Happily Ever After?

Pilot phase ended and taken into mainstream Pilot phase ended and taken into mainstream funding in April 2012funding in April 2012

But...But...

Trust Special Administrator’s draft report Trust Special Administrator’s draft report “Securing Sustainable NHS Services” - “Securing Sustainable NHS Services” - Consultation on the future of South London Consultation on the future of South London Healthcare NHS Trust and the NHS in South Healthcare NHS Trust and the NHS in South East London (November 2012)East London (November 2012)

Thank youThank you The CALM TeamThe CALM Team

Sarah MacNeil – Clinical Physiotherapy SpecialistSarah MacNeil – Clinical Physiotherapy Specialist Tamzin Bunton – Pain Nurse SpecialistTamzin Bunton – Pain Nurse Specialist Ajay Clare – Psychology AssistantAjay Clare – Psychology Assistant Reuben Richards – AdministratorReuben Richards – Administrator

Lewisham support:Lewisham support: Dr Tom Smith – Consultant in Pain ManagementDr Tom Smith – Consultant in Pain Management Ashley O’Shaughnessy – Head of PBC and Services Redesign, NHS LewishamAshley O’Shaughnessy – Head of PBC and Services Redesign, NHS Lewisham Lewisham Practice Based CommissionersLewisham Practice Based Commissioners

Hilary Rankin, Consultant Clinical Psychologist and her team at COPE, Sutton Hilary Rankin, Consultant Clinical Psychologist and her team at COPE, Sutton HospitalHospital

INPUTINPUT