Pain management - service delivery framework: consultation analysis

Implementing and delivering the Framework

The consultation paper sets out plans for implementation of the Framework, including an intention that implementation and improvement actions will be undertaken in collaboration with service users and providers. This would build on relationships and systems that enable organisations to co-design care and support through the inclusion of people with lived experience of chronic pain.

Question 24- Please share your views on the barriers to implementing the Framework.

A total of 97 respondents made a comment at Question 24.

Current problems

Some respondents, including several Individual respondents with lived experience of chronic pain, saw elements of the present system, including in relation to the make-up and functioning of the National Advisory Committee for Chronic Pain (NACCP), as presenting barriers to implementing the Framework. Views included that the NACCP is unwilling to publish lived patient experience and that it needs to operate with a much greater degree of transparency. The importance of patient input and of evaluating individual experience to identify problem areas was highlighted as was a view that, to date, pain management has not been prioritised and that service provision currently does not meet demand.

Poor public understanding of chronic pain, or the conflicting understanding of patients and clinicians was also referenced.

Lack of detail and clarity

Comments with respect to the draft Framework included that it is not sufficiently specific, lacks clarity on timing and priorities for implementation, or lacks a strategy to provide the structure under which the framework hangs. It was suggested a strategy for pain management being developed by the Faculty of Pain Medicine along with other stakeholders will provide this.

It was also argued that the Framework should be more precise, measurable and relevant or should distil down to specific outcomes and stakeholders. It was suggested that it is unclear to what extent the Framework will feed into the National Care Service and whether this will change the landscape of the Framework.

A specific suggestion was that the Framework would benefit from clarity on 'effective treatments', as there are few effective treatments but many approaches to supporting people to live alongside persistent pain.

Financial constraints

Many respondents saw funding as a potential barrier to implementation of the Framework. Some respondents referenced historical underfunding of services and plans to reduce pain management services, which were described as the poor relation in healthcare. It was also argued that underfunding of services can create incentives to deflect referrals or to discharge patients in order to manage waiting lists. Specific concerns were raised with respect to funding for the NHS Centre for Integrative Care.

It was observed that the draft Framework does not identify how funding will be addressed and a Representative Body respondent noted that they would welcome additional funding to enable local authorities to invest and improve outcomes in chronic pain management. Competing priorities in both health and social care were also acknowledged.

Specific suggestions as to how resources might be allocated included:

• Primary care.
• Online resources to help clinicians offer a better quality of care.
• Sustained funding for third sector organisations.

However, the effectiveness of some past resource allocation was also questioned. One suggestion was that NHS Scotland should stop relying on voluntary sector organisations, instead establishing their own version of successful service models.

Staff and training shortages

Low staffing levels and lack of time were frequently identified as barriers to implementation of the Framework. While it was acknowledged the draft Framework offers support to implement a workforce plan, it was argued the solutions need to be more robust to ensure effective person-centred care can be delivered. Significant difficulties in recruitment of allied health professionals in chronic pain were also reported.

Potential for community pharmacy and practice-based pharmacy teams to support good quality pain management was suggested, although it was reported that the resource is limited and the workload already high. It was also noted that the ability of community pharmacists to undertake chronic pain reviews is likely to be limited by a requirement to refer to a prescriber with recommendations for the patient's management plan.

In terms of staff training, it was suggested that, as well as a lack of training in specialist skills, there is poor understanding of the effects chronic pain has across all healthcare professions and that appropriate training should be provided. Development of formal pain medicine training programmes was proposed. There was also a specific concern with respect to anaesthetists' training in chronic pain.

It was also argued that the Framework focuses on knowledge but makes no reference to communication skills needed to facilitate this. A specific suggestion from an Individual respondent was that clinicians require specific training in assisting patients through a process of acceptance and adaptation, moving away from a 'medical model' to an 'acceptance orientated model'.

However, limitations in training opportunities were also identified in terms of:

• Staff who want to train in pain management.
• Chronic workforce shortages that make teaching and training a challenge.
• Access to training and time for training.

Effects of COVID

Some respondents commented on the potential impact of COVID on implementation of the Framework, including in relation to the effects of the pandemic on staff – their redeployment, fatigue, low morale and lack of training opportunities.

For patients, it was noted that long waiting times have been made worse by the pandemic and there was a suggestion that increased infection risks associated with society opening up post-COVID could mean that specialist services cannot resume. It was also noted that pain is amongst symptoms reported following COVID-19 infection.

Equity of access to services

Variation in opinions and approaches across or between Health Boards was also highlighted as a barrier to implementation, with respondents referencing difficulties in providing consistent care, standardised care, or a choice of effective treatments. Lack of consensus between healthcare professionals and lack of priority in Local Delivery Plans were both suggested as potential issues.

On the latter point it was suggested that there should be consequences for Health Boards and HSCPs that do not apply the Framework in their areas, although also that this might be unfair to Boards with smaller populations and hence less funding.

Respondents also commented on existing inequalities in terms of the services available to patients, including that this can amount to a postcode lottery. The need to ensure fair access for those living in remote rural areas and in deprived communities was argued.

Practical issues identified as limiting a patient's ability to access available services included:

• Location.
• Patient mobility.
• Affordability of travel.
• Access to both the internet and telephone.

Primary care

Specific points were also made about primary care and the role of GPs including a view that not all GPs are willing to refer patients to specialist pain management services, or that GPs may decide to prescribe medication to treat pain without investigating the underlying cause.

With respect to GP appointments it was argued that a typical 10-minute consultation is not long enough to help someone with chronic pain and an NHS respondent reported findings that longer consultations and/or a series of shorter appointments, together with a wider multi-disciplinary team approach in primary care are effective.

Connecting and co-ordinating services

Given the wide variety of contexts where the Framework will apply, it was argued that planned implementation and governance processes will be important to ensure sharing of best practice and service innovations. It was also observed that in the existing health model, chronic pain works in series with other services but should operate in parallel such that, in some cases, advice and input can be given without transfer of care.

Other challenges identified included:

• Reducing duplication, fragmentation, and waste.
• Removing artificial boundaries between primary care and secondary care.
• Effective multidisciplinary working and joining up services. In particular, existing gaps between chronic pain management and mental health and addiction services were highlighted. With respect to mental health, it was argued that improved collaboration will require investment in mental health services to enable additional pain working, rather than a loss or diversion of their existing resources.

Practical issues such as inability to access patient notes or a risk of data loss during restructuring were also highlighted, with one Representative Body respondent arguing that co-ordination across sectors of care requires a single patient record that all members of the multidisciplinary team can read and write into.

In terms of local co-ordination it was suggested that, in the absence of a local Managed Pain Network, getting key people together to communicate regarding current work/developments and priorities could be difficult on a practical level.

Exploring new ideas and managing change

Respondents also highlighted a number of situations where they thought reluctance to change existing practices or inability to achieve a consensus on treatment could act as a barrier to implementation of the Framework. With respect to healthcare professionals this included suggestions that:

• Clinicians who feel they offer the best service they can with the resources available may be reluctant to change as may those who have developed ways of practice that are not necessarily evidenced based, but have maintained levels of patient satisfaction with the status quo.

As well as varying clinical judgement, it was suggested that barriers to implementation could be created by:

• Healthcare professionals lacking awareness of the Framework and its implications for their own practices.
• A culture of working in isolation rather than in partnership.
• Lack of team working between primary and secondary care and a lack of understanding of the other's role in pain management.
• Lack of recognition that not all people with chronic pain need (or want) to be managed in secondary care.
• Failure to share best practice.

On the last point, it was also suggested national professional networks with a specialist interest in pain will need to ensure they interconnect and share best practice.

With respect to patients, it was argued both that expectations of pain management services may not always be realistic and that there will be no one-size-fits-all solution to chronic pain management. It was also suggested that:

• A public health campaign could highlight the need for change and champion new approaches.
• Some patients may be reluctant to engage, to accept new approaches or to accept a view that the solution to their pain may not always be a medical one. There was a concern that some individuals might disengagement if they feared they would come under pressure to agree to changes to existing drug treatments.
• Partnership working on better solutions should involve patients with chronic pain. Along with openness to new ideas, therapies and treatments there should be an open debate on providing relief of suffering, with legal prescribing of medical cannabis given as an example.
• Specifically with respect to withdrawing opioids, patients may not understand that opioids stop helping and they may feel targeted by people that have never lived with chronic pain, especially if they are not offered alternative support. An alternative perspective was that, if effective, opioids should continue to be available to individual patients.
• On a practical level, there may be difficulties contacting chronic pain sufferers who are not currently receiving support and who may have given up trying to get help.

Research

Points were also raised with respect to the absence of research on and lack of knowledge about chronic pain. Particular issues raised included:

• That chronic pain is not recognised as a chronic disease, not monitored or coded in primary care in the same way as other diseases, and there is less funding and research.
• The difficulty quantifying pain, with a suggestion that better understanding of the physical and psychological causes may be needed before definitive guidelines can be produced.
• The limited evidence base for some interventions.

It was also argued that some specialist procedures do in fact have a good evidence base, and that any national guidelines would need to take account of these.

Question 25- Please share your views on the opportunities for the implementing the Framework.

A total of 83 respondents made a comment at Question 25.

The opportunities referenced most frequently were to improve quality of life for patients and to engage with, listen to and involve patients and carers. There was also a suggestion that the views of patients are currently being disregarded. A Third sector respondent reported that engagement with people with lived-experience of chronic pain has helped to inform drafting of the Framework, highlighting the importance of ongoing, regular updates as part of the roll out.

Some respondents saw the Framework as an opportunity for a change in culture and practice, a chance to do things differently, or to change attitudes and beliefs in relation to chronic pain and its management.

Education and training

Respondents also saw opportunities for improved education and training for healthcare and social care staff, including opportunities for healthcare professionals in other specialities to develop their skills around pain management. For those with such training, job-plan flexibility with their service base to allow sessional working was suggested as a way to stabilise the chronic pain workforce. It was also argued that, as Pain Management is being accredited for General Medical Council credentials, the Framework provides an ideal opportunity to increase the specialist workforce by introducing credentialling in Scotland for pain professionals.

A general opportunity suggested was to make pain management a more attractive area in which to work.

Opportunities for better education for patients and carers around pain management were also thought important.

Collaboration

Opportunities for sharing ideas, learning, resources and good practice were all referenced, including a suggestion that social media such as Facebook could be used to connect the Clinical Community. There was also a view that engagement and networking across all levels of pain management can be bolstered if published documents on standards, guidance and pathways are utilised.

Opportunities for improved multidisciplinary team working were highlighted, with a suggestion that shared patient care models that exist for other health conditions could be extended. There were calls for improved connections between primary and secondary care, for better links between health and social care, and for improved links to mental health and addiction services. Potential linkages with Healthcare Improvement Scotland's Medicines and Pharmacy work in areas such as prison pharmacy, cancer medicines, and Area Drugs and Therapeutics Committees were also suggested.

Developing a method of sharing a patient's record across members of their care team was seen as essential.

Other suggested opportunities for collaboration included:

• Collaborative working between Health Boards.
• Wider collaboration with industry.
• Improved connections between networks.

It was noted that COVID has brought about new ways of working that mean remote meetings are now the norm.

Consistency and quality

Opportunities to provide greater consistency of care and standardise service delivery were suggested, including an opportunity to standardise and rationalise both pharmaceutical and non-pharmaceutical prescribing across NHS Scotland. Although an opportunity to create a national pathway for chronic pain was highlighted, allowing variation of approach between Health Boards was also seen as a missed opportunity to implement a single pathway. Some respondents suggested opportunities to adopt regional approaches or to find models that work locally.

It was also suggested that the Framework will provide Quality Improvement (QI) opportunities, such as including pain elements in QI care bundles. Potential linkages with Healthcare Improvement Scotland's Access QI programme were highlighted, working in partnership with NHS boards to use quality improvement to sustainably and affordably improve waiting times.

Raising awareness

Opportunities to raise awareness on chronic pain management were suggested with ideas including a public health campaign on chronic pain and promotion of the Framework in GP surgeries, pharmacies and community centres.

Working with the Third Sector

A number of respondents commented on potential for third sector working, including that there is an opportunity to recognise the value of the services the sector provides. Improved awareness of the options available to support patients locally, including green prescribing options was suggested.

Working with the pharmacy network

The potential of the community pharmacy network was highlighted, noting its strengths in delivery of person-centred advice and interventions, with teams who are both experts in medicines and trained to support people with their own holistic self-care goals. It was suggested that, if properly resourced to support pharmacy teams, the Medicines Care and Review service would provide a vehicle for delivery of evidence-based interventions.

Leadership

Recruitment of clinical leads in each region was seen as an important opportunity to drive implementation of the Framework in collaboration with national leads. Creation of a stakeholder group to challenge, critically appraise and guide workstream development was also thought to be essential, with a requirement for such a group to have a degree of independence and a broad membership.

There was also a view that the Framework must ensure chronic pain is a priority for every Health Board and that services must be properly staffed and funded. It was suggested that the Framework should lead to discussion and planning at Health Board level, with changes to existing structure as needed to support optimisation of chronic pain services. An opportunity to drive cost effectiveness, both for people requesting care and staff delivering care without compromising the quality of care was also identified.

Respondents suggested opportunities that could be provided going forward, including the ability to switch plans and adjust to the changing needs of the population, as well as providing tailored management plans to suit the individual. It was also suggested there should be a route map which goes beyond the initial priorities and sets out medium- and long-term milestones, giving confidence that the Framework's vision is a dynamic one.

Other opportunities

A range of other potential opportunities were suggested including:

• Digital approaches including online pain management clinics.
• More research, co-ordinating research or better use of research on chronic pain, and embedding data and research in improving care.
• Use of apps and wearables for real-time monitoring.
• A national website of resources for both staff and patients.
• Investment in local business and creating community health hubs
• Addressing various health inequalities.

Question 26- Are there any groups who will be directly or indirectly impacted by the Vision, Aims and Commitments that have not been identified by the Equality Impact Assessment and/or Fairer Scotland Duty exercises in Annex A.

A total of 47 respondents made a comment at Question 26.

The most frequent comment was that there are no groups, or that the respondent had not identified any groups, that will be impacted and that have not already been identified in the documents presented in Annex A. Several others did not know or were unsure.

General comments included that the Framework should adopt a cohesive approach to tackling health inequalities, in line with the recommendations of Audit Scotland's report NHS in Scotland 2021. It was suggested this should be reflected in development of a strategy to tackle inequalities, focusing on programmes related to women, ethnicity and social deprivation. A broad point raised was that there may be secondary impacts on other service users if the Framework is not resourced properly.

Equality Impact Assessment

The Equality Act 2010 covers the protected characteristics of: age, disability, gender reassignment, gender including pregnancy and maternity, race, religion and belief, and sexual orientation. With respect to these protected characteristics, respondents highlighted potential issues relating to:

• Older people.
• People with life limiting conditions.
• Women, including because many chronic pain conditions affect women more than men and that women suffering from chronic pain are more likely to be ignored. The Scottish Government's Women's Health Plan was seen as an opportunity to connect with a broader framework tackling inequalities and it was argued the Framework should commit to engaging with the national Women's Health Champion and Health Board leads. Mesh survivors were noted as a particular group of women impacted by chronic pain.
• Women with childcare or other caring responsibilities who may need better support to enable them to attend appointments.
• Women who may experience cultural barriers that prevent them coming forward with concerns about chronic pain.
• Families, since better pain management can improve interactions within the family unit.
• The traveller community.
• People who require translation services.
• Ethnic minority communities, since there is limited research into conditions such as sickle cell anaemia that primarily affect these communities.

It was also argued that the Framework should contain more examples of people who are not white heterosexuals. Suggestions included both that examples relating to the LGBTQ+ community, and people of colour, need to be included, and that health care professionals involved in pain management should not make assumptions about an individual's gender based on their presentation.

Fairer Scotland Duty

The Fairer Scotland Duty places a legal responsibility on particular public bodies to consider how they can reduce inequalities of outcome caused by socio-economic disadvantage, when making strategic decisions. In this respect respondents identified groups that might be impacted as:

• Deprived communities where it was suggested there may be a lack of local health services, or where people may not be able to afford to travel to health appointments.
• Homeless and disengaged people.
• People experiencing digital exclusion or other communication barriers.
• People with drug or alcohol issues including those who may abuse prescribed drugs. People who may have turned to alternative substances were also referenced.
• Those in contact with criminal justice system who need pain management.

Other issues or groups identified

It was suggested that, at present, the Framework does not address those suffering acute pain, in hospital undergoing surgery, or in hospital with flare ups of chronic pain. Cancer patients and people with mental health issues were also highlighted as potentially impacted, as were healthcare professionals including GPs and staff in clinics.

Other suggestions included:

• Rural and island communities where access to services may be difficult.
• Third sector organisations.