Chronic pain service delivery - draft framework: consultation

Case Studies

Case Study 1: The Pain Navigator Tool

Describing the experience and impact of their condition can be challenging for people with chronic pain. This can mean they experience difficulties in explaining their concerns to family and healthcare professionals alike, which can be a barrier to accessing support at the right time in a way that matters to them. In order to improve the quality of care planning conversations, the Scottish Government funded the development of the Pain Navigator Tool. Through a series of questions that can be considered in advance of an appointment, the Tool aims to support people with chronic pain to identify and describe their wishes for their treatment, their feelings, what they would like to achieve from their care as well as what questions they would like to ask their healthcare professional during the consultation.

Case study 2: Digital access to mental health support for people with chronic pain

Cognitive behavioural therapy (CBT) is a programme of support that is most commonly used to treat anxiety and depression often as part of wider strategies to support people with other mental and physical health conditions. In Scotland, people can be referred to a computerised CBT (cCBT) course which can help to address the psychological impact of a number of long-term conditions, including chronic pain.

Case study 3: Local multidisciplinary pain management services in East Lothian.

The East Lothian Pain Management Service (ELPMS) accepts referrals from local GP practices for people requiring specialist pain management support. It works collaboratively with pain management consultants, community mental health teams, exercise specialists and GPs to support mental and physical health needs of people with chronic pain with the aim of improving quality of life.

Services are provided via a range of methods including telephone, NHS NearMe, digital group work, face-to-face and online resources in accordance to individual access and choice. They also collaborate with other pain management services in the region via the Lothian Physiotherapy Pain Network which supports shared learning and service development to improve patient care.

It is intended that in future it will also embed psychological therapies, occupational therapy and pharmacy support within the service, further enhancing the multidisciplinary care available for people with chronic pain in the area.

Case study 4: New models of support for people with chronic pain.

Physiotherapists providing a first point of contact service means that patients presenting with a musculoskeletal problem for a GP appointment can be offered an appointment with a first contact physiotherapist instead. First contact physiotherapists (FCPs) working in general practice have expertise and autonomy to support and advise people experiencing pain, including investigation and referral. These roles aim to ensure that the patient sees the most appropriately skilled healthcare professional, in a primary care setting, as their first point of contact. This ensures timely access to diagnosis, early management and onward referral if necessary along with saving both time and resources within primary care teams. Data at the national level demonstrates that less than 2% of people assessed by FCPs require onward referral to a GP, and there has been a 30% reduction in orthopaedic referral and for imaging with an increase in appropriate referrals for both services. This data also reveals that 60 – 70% of people do not require further intervention and are empowered and more confident to engage with self-management. There has also been a 60% reduction of referral to physiotherapy clinical services, which means more capacity is available to manage cases where more specialist support is required.

Case study 5: Local opportunities to become physically active.

There is evidence that becoming or remaining physically active can support people with long-term conditions, including chronic pain, manage their condition in addition to the benefits of overall fitness and mental health associated with exercise. A number of resources such as Moving Medicine have been developed to support medical professionals to explain and highlight the benefits of physical activity as part of management strategies for long-term conditions, including pain.

While exercise and activity can be self-directed, many people with chronic pain benefit from additional support to overcome barriers to being active, for example concerns that exercise could exacerbate painful symptoms. The Scottish Health Walk Network, overseen by Paths for All, comprises over 250 walking group projects across Scotland which offer free supported group Health Walks in local areas. Improved signposting and access to activities like these can increase the confidence of people with chronic pain to manage the direct and indirect impact of their condition and quality of life.

Case Study 6: The Scottish approach to pharmacological management of chronic pain.

In 2017, NICE set out its intention to develop a guideline for persistent pain with the intention of supporting improvements in care for adults. It was not intended to cover management of pain covered by existing NICE guidance for example endometriosis, headaches or low back pain. The Scottish Government identified the importance of setting out differences in approach to the management of chronic pain between the draft NICE guideline and SIGN Guideline 136, chiefly related to response to the consultation, with many of the points echoed by other leading UK clinical, research and patient rights groups in their individual responses.

NICE published the final guideline in April 2021, and responded positively to certain aspects of the issues raised by the Scottish Government and other stakeholders. SIGN guidelines are regularly reviewed in order to ensure they continue to reflect best practice and available evidence, however there are no plans at present to alter the existing guidance on pharmacological management of chronic pain in Scotland in response to the NICE recommendations.

Case study 7: The role of community pharmacies in supporting people with chronic pain.

A number of common medicines, both drugs and topical treatments for pain (e.g. capsaicin cream) are available 'over the counter' in Scotland from a variety of sources, including pharmacies and supermarkets. This increases access to treatments that may help people manage their condition, and provides an opportunity to raise awareness about the safe and appropriate use of different medications, It also offers the chance for a pharmacist to provide advice and identify when an individual may benefit from attending their GP or other health service.

NHS Pharmacy First Scotland is a service which is provided by pharmacists in local communities in order to provide advice, treatment or referral for a range of minor and acute conditions, including pain. Community pharmacies also provide the Medicines: Care and Review service which is intended for people with long-term conditions who are receiving repeat prescriptions, including people with chronic pain. These are part of the broader Scottish Government strategy to improve access and quality of care by recognising and enhancing the skills of pharmacists.

Case Study 8: The role of Allied Healthcare Professionals in managing chronic pain.

Allied Health Professional (AHP) is the term used for a diverse group of professionals supporting people of all ages to live healthy, active and independent lives across a range of settings.

AHPs commonly involved in supporting people with chronic pain include physiotherapists and occupational therapists, roles in which core training is focused around empowering individuals to manage their health to improve their independence and quality of life.

A number of Government strategies support the training and development of this workforce around key priority areas relevant to people with chronic pain including early intervention to support prevention and management of musculoskeletal conditions. Commitments include developing 225 more Advanced Musculoskeletal Practitioners in primary care alongside an increase in training places for the physiotherapy workforce. Work to review AHP education and training is planned and we will identify opportunities to enhance support for people with chronic pain through its recommendations.

Case Study 9: Promoting pain education for all trainees.

As most healthcare professionals will encounter a person with chronic pain at some stage in their career as part of their direct or indirect role, there is an opportunity to improve their awareness of the impact of the condition and its management as part of undergraduate and post-graduate training.

For example, the FPM supports the dissemination of the Essential Pain Management (EPM) course to medical students across the UK including Scotland. The third sector is also a valuable source of information and training for healthcare professionals involved in managing painful conditions. Versus Arthritis provides accredited education resources alongside a Professional Network and Clinical Updates in order to improve care for people with painful musculoskeletal conditions.

Case Study 10: The role of Public Health Scotland in data collection and reporting

Public Health Scotland report on the number of referrals and waiting times for first appointment at chronic pain and pain psychology clinics on a quarterly basis. Numbers referred to services in the past number of years remained consistent, prior to the COVID-19 pandemic. These reports are available by NHS Health Board area and also provide information on the number of weeks waited for a first appointment, rejected referrals, the number of patients seen and other useful service-level data. Public Health Scotland will continue to work with Scottish Government, NHS Health Boards and services in order to improve the quality and availability of data which will lead to better planning, performance and outcomes for people in Scotland, including those with chronic pain.

Case Study 11: Data on the quality of services for people with chronic pain.

The Health and Care Experience Survey (HACE) is carried out every two years in Scotland in order to understand people's experiences of GP and community services, which includes an opportunity for participants to report if they have chronic pain.

From analysis of the most recent survey (2019/20), when compared to those without chronic pain, people reporting chronic pain were:

• more likely to report having a physical disability (29% compared to 6%) or mental health condition (19% compared to 9%)
• less positive overall about the care provided by their GP practice (71% compared to 80%)
• less likely to say their treatment or care from their GP practice was well coordinated (68% compared to 76%)
• more likely to have had care, support or help with everyday living (25% compared to 8%) but less likely to report this help or support improved their quality of life (57% compared to 72%)

While more work is required in order to fully understand these results, it is clear that people who report chronic pain also report a worse experience of the services and support they are accessing. As this Framework is implemented, this and other data are vital in helping us, the NHS, local authorities and other providers of support identify and measure actions to improve the experience and outcomes for people with chronic pain.

It should be noted that survey questionnaires were sent out before the COVID-19 pandemic in October 2019 asking about people's experiences during the previous 12 months. Comparison between results from this and future surveys will help to provide insight into people's experience of care during the pandemic.