Pain management - service delivery framework: consultation analysis

Aim B: Timely access to care

The consultation paper notes the importance of timely access to high quality care and support wherever people live in Scotland. It acknowledges that there is variation in the way people currently access services for chronic pain across Scotland, especially in community and primary care settings, and suggests that action is needed to reduce the barriers people with chronic pain can face navigating the health system.

Aim B: Timely access to care

Support people to access the care they need, when they need it.

Question 6- Should this aim be a priority

A substantial majority – 97% of those answering the question – thought that Aim B should be a priority. All organisations thought it should be a priority, while one individual did not and two did not know.

Commitment 2

We will support people to access the right care, in the right place, at the right time by working with NHS Boards to improve how they plan and deliver care for people with chronic pain. This includes increased coordination across community-based, GP and hospital services.

Question 7- Should Commitment 2 be included in the Framework

A substantial majority – 95% of those answering the question – thought that Commitment 2 should be included in the Framework. Two individuals did not think so, and two individuals and one organisation did not know.

Commitment 3

We will improve the options people have in accessing chronic pain services, including digital technology where appropriate.

Question 8- Should Commitment 3 be included in the Framework?

A substantial majority – 91% of those answering the question – thought that Commitment 3 should be included in the Framework. All organisations thought it should be included but a number of individuals either thought it should not or did not know whether it should be included.

Question 9. Please explain your response to Questions 6,7 and 8.

A total of 98 respondents answered Question 9.

As at earlier questions, some respondents commented on the challenges that people encounter currently in accessing the care they need, when they need it. Points raised included that most patients have a long and tortuous journey to make before reaching chronic pain services. A 'Representative body' respondent making this point went on to suggest that by the time they have reached chronic pain services, some people would have received treatments that had not helped and would feel frustrated that they are not being heard and even believed. They were among the respondents highlighting that experiences such as these can have a significant impact on mental health and well-being, all of which leads to poor long-term prognosis.

The potential benefits of the right care, at the right time, were also highlighted. It was suggested that success would not only improve the quality of delivered care but also reduce the missed opportunities around disease progression and health promotion. At its simplest, it was suggested that early intervention can improve someone's quality of life.

Other comments referred to the extent of the challenge ahead. For example, it was reported that there are growing numbers of patients with chronic pain on waiting lists and that there are a lack of resources in primary care to deal with chronic pain. It was suggested that most GPs do not have the time or knowledge required to ensure that patients with chronic pain are managed effectively.

Questions about how this part of the Framework will be delivered were sometimes connected to the suggestion that it will depend on adequate resourcing. There was also a question as to how the aim and commitments will be achieved and what measures will be used to hold NHS boards accountable to deliver on these commitments. These themes are returned to at later questions.

Joined up, co-ordinated services

In terms of offering the right care, how services should work together was a central issue for a number of respondents. There was a concern that at present services are not joined up, and that as a consequence, people may be waiting for specialist services which they might not need if community based services could do more to support them.

A general point was that improving co-ordination will be key, including the Framework overall and not just Aim B and Commitments 2 and 3. Some comments were focused on the importance of improving communication and co-ordination between:

• Primary and secondary care.
• Acute and chronic pain treatment in both primary and secondary care.

In terms of how the necessary improvements could be achieved, there were references to the development of referral pathways. A connected point was that shared pathways between primary and secondary care could help ensure that the right professionals are placed at the right places. Other issues raised included that information sharing will need to be fully addressed to allow integration of services and the provision of safe care.

Other comments focused on how services could or should be developed or redesigned. From a systemic perspective, it was seen as important for primary care clinicians to be able to access support from specialist colleagues.

A number of respondents highlighted the importance of adopting a multidisciplinary team (MDT) approach in primary care. In terms of the range of professions or services, there was particular reference to pharmacists.

The role that non-medical services can play was also referenced, with an associated suggestion that Commitment 2 could be strengthened by acknowledging this potential. There was reference to housing, transport, education, training and employment, social support and social security. The role of local government in delivering many of these services was also noted.

In terms of key aspects on an MDT approach, the following were identified:

• Increased education around the roles of different professionals in improving a patient's quality of life.
• Access to a single shared patient record. This was described as a key enabler to safer and more integrated care.

Although a number of the comments were focused primarily on co-ordination between different parts of the health service, there was also a call for closer collaboration with third sector organisations. It was suggested that there should be a duty placed on those responsible for commissioning chronic pain services to recognise the contribution of charities, including by entering into formal service level agreements with them.

Care and support options

There was a concern, with particular reference to Commitment 2, that it is not clear which mechanisms will be used to ensure that NHS Boards take steps to improve their planning and delivery of services.

Some of the comments addressed the range of services that should be available. There was reference to:

• Specialist pain services.
• Pharmacists having a role to play in both community and specialist settings. Key strengths of the community pharmacy network were said to be the accessibility of its healthcare professionals and their expertise in getting the best out of medicines whilst minimising harm. It was also suggested that a pharmacist should be based in all specialist pain services.

In terms of options to support people in managing their chronic pain, there were calls for better access to supported self-management and non-pharmacological treatment options for people with pain.

There was specific reference to:

• Self-management interventions for complex patients.
• Pharmacist led services, including through pain clinics in GP practices. It was also reported that pharmacists can support self-management via the Medicines Care and Review service.
• Non-pharmacological management such as Cognitive Behavioural Therapy (CBT) and mindfulness. Specifically, Computerised CBT.

It was also noted that the Modernising Patient Pathways Programme is sponsoring small test of change projects to assess different models of care, including a Scottish Pain Service Model to improve access to specialist pain management expertise in primary care, and that the results are promising.

In addition to references to the right care, there were also references to ensuring that patients are able to access services from someone with the appropriate expertise as quickly as possible. A 'Representative body' respondent suggested that Commitment 2 should make reference to the correct person as that is as important as the correct care, place and time.

Right place

A small number of respondents addressed the location of services, with comments including that while access to services and support close to home is desirable; some specialist services may be more appropriately delivered regionally or nationally.

As in relation to the right care, the potential of community pharmacies was highlighted. They were described as ideally positioned to support patients close to their home. A similar point was that those working in community-based services, such as community nurses, pharmacists, first-contact musculoskeletal practitioners and other health and social care professionals, should have an understanding of the impact of chronic pain management so as to equip them to assess and provide early support in a timely manner.

In terms of variations across the country, it was reported that the Centre for Sustainable Delivery is facilitating a 'once for Scotland' approach to minimise harmful variation in access to services across Scotland.

Right time

As noted above, a number of respondents commented on the impact that waiting for care or support can have on people's health and wellbeing. Current waiting times for pain management services were described as varied, and it was also reported that waiting times have increased during the pandemic. A number of respondents with lived experience spoke of having to wait for care or support. There was also reference to the inequalities in health care that arise from some being able to self-fund private health care.

Moving forward, it was suggested that timely access should cover all stakeholders, such as community pharmacists and out-of-hours services. It was thought that improving access to information and support, alongside an increase in the use of supported self-management, could help reduce the pressure on specialist services and allow for more timely access for those needing these services.

Other comments were that the Framework should set out realistic time frames for referrals and reviews.

Digital technology

A number of respondents commented on the use and potential of digital technology. Amongst these were a few notes of caution, including that there is already a huge digital divide, and this should not be increased further. It was noted that not all patients have access to the internet but that these patients still need access to the right information and support. Looking to the future, it was noted that issues around digital exclusion will need to be considered.

In terms of the potential uses of digital technology, there was reference to delivery of education programmes, and to some of the online resources that are available.

A number of the comments focused on the potential in relation to appointments and consultations. One view was that the use of digital technology will allow for easier access to appointments, including by eliminating travel time and reducing the need to take time off work and/or make childcare arrangements. It was noted that some people cannot leave their homes to attend appointments. The potential to address barriers to access in remote and rural settings was also noted. Overall, it was hoped that easier access would help improve patient satisfaction and mental health.

However, although digital services - including consultations - were seen as bringing real benefits, a number of respondents also commented that patients should also have the option of face-to-face appointments. It was acknowledged that technical or personal issues will mean that the digital approach is not right for all and there was support for the reference to using digital technology 'where appropriate'.

In terms of the types of approaches that are already being used, or which are being developed, there was reference to:

• Pain Association Scotland's work on digital services during the pandemic.
• One-to-one support provided through Versus Arthritis' Working Well Project and their online Let's Move initiative.

It was also reported that NHS Highland is designing and piloting a national In-healthcare online chronic pain platform. It was reported that the platform is being designed with the potential to be replicated across all Health Board areas. It was hoped that the approach will make access to services and referral processes consistent across the country and will help ensure quality of care in Scotland.

Looking to the future, it was suggested that while the pandemic has paved the way to increased use of digital technology, developing a good evidence base and careful design will still be critical. There was a note of caution that while digital technologies may well have a place, they can be poorly designed, can lead to health inequalities for those without digital access and that any evaluation tends not to consider possible harm. It was suggested that the controls around digital interventions need to be as rigorous as those around face to face clinical care.