Pain management - service delivery framework: consultation analysis

Aim C: Safe, effective treatments

The consultation paper sets out the aim of improving timely and equitable access to a range of evidence-based treatments through a person-centred approach. It notes that there are a range of interventions that can support people with chronic pain to manage their condition and its wider impact on their quality of life.

It also explains that, in developing this Framework, people with chronic pain have highlighted a number of treatment-related issues, including inconsistencies in the availability of certain interventions, delays or changes in how or when treatment is provided, and in some cases a lack of clear explanation about alterations to treatment plans with a lack of communication or involvement.

Aim C: Safe, effective treatments

Ensure people have a choice of effective treatments.

Question 10- Should this aim be a priority?

A substantial majority – 93% of those answering the question – thought that Aim C should be a priority. A small number of individuals did not think so.

Commitment 4

We will support people with chronic pain and healthcare professionals to better understand and agree effective treatment options to manage pain.

Question 11- Should Commitment 4 be included in the Framework?

A substantial majority – 94% of those answering the question – thought that Commitment 4 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.

Commitment 5

We will ensure people have more consistent access to effective treatment options wherever they live in Scotland.

Question 12- Should Commitment 5 be included in the Framework?

A substantial majority – 95% of those answering the question – thought that Commitment 5 should be included in the Framework. One individual did not think so, and one individual and a small number of organisations did not know.

Question 13. Please explain your responses to Questions 10,11 and 12.

A total of 100 respondents made a comment at Question 13.

General observations relating to Aim C, and the associated commitments, included that the importance of care being safe and effective is self-evident, but also that Commitments 4 and 5 should be reassuring for patients and clinicians alike.

Another general point was that the references to 'treatment' are not helpful, and that referring to 'pain management' or 'care' would be preferable.

There was also a view that the description of 'effective' should be agreed and set out in the Framework, along with an understanding of the range of treatments being referred to – for example, including whether the Framework covers non-pharmaceutical treatments.

Assessing effective treatments

A number of the respondents addressed what is meant by 'effective'. It was seen as important that treatment provision is based, as far as possible, on best available evidence of effectiveness. However, it was also suggested that, at present we do not have sufficient evidence to demonstrate the efficacy of many treatments. Further views about the current evidence base included that:

• There is very little clinical research that is relevant to real life, clinical settings.
• Where there is evidence, it often related to a small, specific population but results are generalised beyond the findings.
• Much of the research – including into medications, surgical and anaesthetic interventions, rehabilitation approaches and therapy – overstates the benefits and under reports the harms.

Issues relating to research and evidence are covered greater detail under the analysis for Aim D, but points made here included that the following are needed:

• More evidence on the effectiveness of injections and other interventions for chronic pain. With specific reference to injections, it was suggested there is a need for a 'national conversation' about what is a worthwhile intervention.
• Research into possible future drugs and treatments for conditions where pain levels cannot currently be adequately relieved.
• A better understanding of the range of conditions that exist among diverse communities, with investment into how these are treated and managed.
• Longitudinal action research into the effectiveness of current practice, including not only that of the NHS, but also work done by voluntary organisations, fitness clubs, pain management groups etc.

Where the existing evidence does not wholly support treatment effectiveness, it was suggested that the reasons for this should be explored and understood as well as possible. If sufficient research has been conducted, with a treatment found to be ineffective or harmful, it was thought that the Scottish Government should discourage use of that treatment in the NHS. However, it was also reported that the absence of evidence does not necessarily imply absence of benefit. It was suggested that clinicians should apply standards on evidence consistently in order to identify the most appropriate care whether that is surgical, medical or other.

In terms of other aspects that should be considered when assessing effectiveness, there was reference to the cost effectiveness of treatments, including of social prescribing and non-pharmacological treatments. There was also reference to availability.

It was seen as important to balance evidence-based effectiveness with other considerations, including individual patient choice and the balancing of the risks of harm against chances of benefit. An associated point was that it will be vital that prescribing of pain medicine involves an open and honest discussion with the patient about the risks and benefits of medication options. However, and also connected to issues around patient choice, there was a concern that references to 'safe and effective treatment' will be used as a means to limit the treatments patients can access.

Information about effective treatments

A common theme was that it will be important to share information about which treatment options are effective, and in particular to share messages that self-management is an effective treatment.

Specific suggestions included:

• National public health messaging, or a campaign, to inform and educate the population on chronic pain, including around treatment options and realistic expectations of living with chronic pain. There was specific reference to clear and consistent public health messages about the role and limits of analgesics in the treatment of chronic pain.
• Ensuring that any information, including leaflets, produced provides consistent information on the potential harms of treatment and medication and how to understand if something is helping, not having an impact, or harming.
• The development of a national registry, which could support monitoring and learning about the efficacy and safety of procedures.
• Updating the SIGN guidelines.
• Ensuring healthcare providers have the appropriate education and support to make sure that patients receive the best and most appropriate care. This issue is covered in further detail in the analysis for Aim D.

Variation in access

As at other questions, some of the comments addressed current variations in the treatment people received. For example, it was suggested that as a patient, your treatment will depend on which Health Board are you live in, and that too often there is variability in access to treatment dependent on proximity to certain services and based on skills and availability of local personnel and funding streams.

It was also reported that the challenge of ensuring consistent access to treatment options has increased over the past few years, as gaps have opened up and backlogs worsened. There was reference to the SIGN guidelines on management of chronic pain having recognised the variation in the availability of safe and effective treatments and the impact of waiting times to access this care particularly during the recent COVID-19 pandemic.

While current variations were often acknowledged, there was also a view that any 'postcode lottery' needs to be avoided. It was considered essential that patients should have equitable access to effective treatment regardless of the Health Board area in which they live.

However, the importance of accounting for specific local differences and needs was also highlighted. The example given was around the importance of taking a localised approach to weight management services, within a nationally consistent framework, to improve both accessibility of, and engagement with, such services.

Achieving consistency

Other comments considered approaches or changes that could help improve consistency in provision.

One theme was around skill sets. There was a call for skills sharing, including in relation to injections, and for investment in training for local healthcare professionals. In the context of training there was particular reference to being able to identify those patients who should be referred on for expert opinion and management at an early stage. Training and skills development is covered in further detail in the analysis for Aim D.

Other comments addressed approaches – including national approaches – that could help promote consistency. They included that:

• Commitment 5 should also include access to effective assessment and treatment, as the latter cannot be properly discussed without the former.
• There needs to be robust national information, either through the SIGN guidelines or an equivalent mechanism, covering non-medical interventions, procedures and follow-up.

There were also comments about new approaches that are being developed or rolled out. They included that:

• The Centre for Sustainable Delivery (CfSD): NHS Golden Jubilee is facilitating a 'once for Scotland' approach, with a view to minimising harmful variation across Scotland.
• A new and expanded MDT has been recruited in the Highland area, which is now offering a new model of pain service. The plan is for a less centralised service, with localised MDT care across various areas of Highland. The approach allows for more collaborative working with primary care, third sector and specialist pain teams in more rural areas and expanded expertise in managing chronic pain consistently, supporting greater equity of care, regardless of postcode.

In terms of specific aspects of care and/or practice that could be looked at, comments included that:

• To empower them to make decisions and become involved in their treatment, all patients should have access to the same information on treatment options.
• MDT meetings with patients and healthcare professionals would be beneficial.
• Regular review of medications is important to preventing harm.
• New methods of providing support and monitoring should be implemented for patients prescribed medicines with a risk of dependence.
• Medication-specific interventions, which can target those on higher-risk therapies proactively, should be developed and resourced.
• There may be some treatments – such as radiofrequency procedures – that could be best provided through a national service.

Treatment options

With reference to effective treatment options, there was support for the Framework identifying the range of options and it was suggested that everyone should be offered a choice of effective treatments. It was highlighted that there is variation across Scotland in consistency and access to consultant level input. There was a view that different patients will respond better to different approaches and that, if a patient has a choice of treatments, and they are involved in decisions, they are more likely to comply with the treatment.

Complementary or alternative therapies: There were references to ensuring that people have a choice of allopathic and non-allopathic treatments, and to non-pharmacological treatment options being available. It was noted that not everyone can afford the alternative therapies that may help people deal with being in chronic pain.

In terms of the Framework, it was suggested that the complementary therapies section needs to be clearer, including possibly through more references to the SIGN guidelines.

Particular conditions or groups: It was suggested that the Framework needs to recognise the role of poor musculoskeletal health in chronic pain, and high-impact chronic pain in particular. A specific suggestion was that Commitment 4 should cover supporting people to improve their musculoskeletal health.