Pain management - service delivery framework: implementation plan

Aim C – Safe, effective support to live well with chronic pain

We will improve the choice and outcomes from pain management support available to people with chronic pain by evaluating and promoting sustainable delivery of effective and evidence-based care.

You told us

Respondents to the consultation highlighted the challenges that are presented by people's expectations of the support and care they will receive from healthcare services. Specifically, there was a view that 'treatment' for chronic pain is rarely curative, and that services aim to support people to 'manage' their condition in order to improve their quality of life and wellbeing. It was also indicated that greater clarity is required on the range of options that should be considered as part of care planning, including non-pharmacological interventions.

There was also a call for better access to up-to-date information on best practice approaches and options for treatment and management of chronic pain, to help empower patients in care planning discussions with healthcare professionals. It was noted that this information should also reflect what support and services are available locally, which is challenged by the existing differences in how Health Boards approach service planning and delivery.

Linked to this, there was also considerable feedback on the challenges of achieving consensus on what constitutes 'effective' management of chronic pain. A range of opportunities to address this issue were identified, ranging from research and data-based approaches to the criteria that should be used to assess and endorse different care and treatment options, whilst taking account of the differing needs and treatment responses of individual patients and specific groups with chronic pain.

Respondents also provided views on how to improve consistency in clinical practice, including a focus on updated clinical guidance, improved education and greater skill-sharing across professional groups. Examples of work already carried out to improve the quality and consistency of pain management services were also shared, alongside potential standards of practice for healthcare professionals to improve their engagement and quality of care for people with chronic pain.

What we will do

Better quality, more consistent care for chronic pain

Action 11: Update clinical guidelines for management of chronic pain to deliver evidence-based care and support.

Scotland was the first country in the world to introduce national clinical guidelines to support non-specialist healthcare professionals deliver high-quality, evidence-led care for people with chronic pain (SIGN 136 – Management of chronic pain). The guidelines are based on systematic review of the scientific literature and aimed at aiding the translation of new knowledge into action. This includes assessment of the evidence on information resources, medication, mental health advice, physical and complementary therapies, supported self-management, and diet and work-related support programmes. The guidelines are intended to help health and social care professionals and patients understand medical evidence and use it to make decisions about healthcare; reduce unwarranted variations in practice and make sure patients get the best care available, no matter where they live; and improve healthcare across Scotland by focusing on patient-important outcomes. Since the SIGN 136 guideline was published in 2013 it has been reviewed once, to update content related to opioid prescribing for pain management.

We have carried out initial work with the developing Pain Clinical Networks and the NHS Research Scotland Pain Steering Group to assess the requirement for a further update of the guideline. This has identified areas where there has been growth in the evidence for pain management approaches or treatment across a range of clinical fields, including physiotherapy, pharmacy and psychology. This preliminary evidence and feedback will be used to form a request for advice from Healthcare Improvement Scotland (HIS).

This will contribute to the continued improvement of standards of care for people with chronic pain and we will consider how to support successful dissemination and implementation of any output. In 2018 the Scottish Government Published its Quality Prescribing Strategy for Chronic Pain which will be revised in 2022. We also recognise the challenges presented by an absence of evidence, and the need to identify opportunities for ongoing collection and analysis of data, which has informed our approach to Aim D.

Action 12: Promote safer, more effective prescribing for people with chronic pain.

While there is evidence that rates are now decreasing, prescribing for chronic pain in Scotland increased by 66% over the ten years from 2006. Many of the commonly prescribed medications included classes of medicines for which there is less evidence for their prolonged use for non-cancer chronic pain, such as opioids and gabapentinioids. There are also other risks associated with their use, including dependence.

The Scottish Government has already taken action to improve the use of medication for chronic pain through the Quality Prescribing for Chronic Pain Guide for Improvement 2018 – 2021. Additional resources have already been developed to support the implementation and use of this advice, including patient information leaflets, prescribing checklists and tools to aid healthcare professional decision making. In order to ensure we continue to promote safe and appropriate prescribing of medication as an element of pain management strategies we will update the Guide to reflect new evidence and emerging practice. This will help to ensure more appropriate consideration, prescribing and monitoring of pain medication.

Action 13: Delivering a national approach to specialist interventions for chronic pain.

Healthcare professionals may consider specialist intervention, including injections, are required for some patients with chronic pain, depending on individual circumstances and the outcome of other approaches which may already have been explored. From our engagement with clinicians and people with chronic pain, it is clear there continues to be significant variation not only in provision of these treatments across Scotland. There is also debate on the factor contributing to this issue, and potential solutions, including workforce and staffing challenges, patient expectations and outcomes, and differences in clinical opinion on the efficacy of certain treatments.

This is a complex challenge and we are committed to working towards a more consistent, national approach to provision of specialist interventions for people with chronic pain. It is intended that this Action will build on previous and ongoing service improvement activity and expert guidance such as that from the Faculty of Pain Medicine. We will also seek to involve and consult the expertise of the new Pain Medic Network, other clinical areas and the views of people with chronic pain to drive progress on this issue. This will include assessing existing local provision and access pathways for specialist interventions, reviewing the evidence and requirement for guidance to inform and improve clinical practice and decision making and the potential for more standardised treatment outcome measures and assessment. This Action will also help to guide deliberation of opportunities for increased regional (e.g. mutual aid) and national pathways to improve the coordination and sustainability of services, as well as improving timely access to effective support for people with chronic pain.

Increasing the impact of our actions

Empowered and involved in decisions on care

It is expected that these Actions will contribute to embedding more consistent messages and information for patients and the wider public on potential options for effective management of chronic pain. This will increase recognition and establish expectations of what support is available. These Actions will also support the 'Pain Informed Care' approach and ensure different management options are discussed as part of care planning conversations. New guidance will be disseminated via the national Pain Clinical Networks and contribute to a more consistent and effective approach to clinical assessment, treatment planning and shared decision making for people with chronic pain.

Improved access and choice of pain management support

One of the key goals of the Framework is to ensure people with chronic pain have easier and more consistent access to the support they need, when they need it. It is expected that as the Aim B working group and the Pain Service Manager Network explore existing care pathways they will identify variances in the approach to planning of pain services across Scotland. This is likely to include how to improve decisions made by Health Boards and Local Authorities to provide different management options by utilising the clinical evidence base alongside other commissioning criteria.

Appropriate prescribing for chronic pain

Action to update prescribing guidance will be supported by both the ambition to update the SIGN chronic pain guideline, and work to deliver the recommendations of the Short Life Working Group on Prescription Medicine Dependence and Withdrawal. Shared outputs from these activities are expected to include more frequent publication and analysis of prescribing data at the national level, enhanced out-of-hours support for those experiencing dependence and withdrawal from medication and improved resources such as shared decision making tools for patients, including those with chronic pain.

More broadly, the impact of these Actions will be amplified by the Government's continued work to enhance the role and skills of pharmacists as part of the health and care workforce. This includes increased funding for pharmacy support for medication reviews in GP practices, and the Medicines: Care and Review service which is available in more than 1,200 community pharmacies and aims to support people with long term conditions to get the most effective outcomes from their repeat medicines. As part of our approach we have also established a national Pain Pharmacy Network which includes representation across community, primary and secondary-care based pharmacists.

Next steps

Work to initiate each of these Actions is already underway. The first meeting of the Prescription Medicine Dependence and Withdrawal Recommendation Implementation Group has already taken place, with work underway to identify and align shared outcomes with this Framework and relevant Actions. We will ensure coordination and input as required across relevant stakeholder groups including the national Pain Clinical Networks and relevant Framework working groups.

We are currently working with stakeholders to develop and submit an application to Healthcare Improvement Scotland (HIS) to request an update to the SIGN guideline for management of chronic pain in adults, with a decision expected in summer 2022, with a specific timeframe for development to follow. We will continue to support the National Clinical Networks to engage with the challenges surrounding the provision of specialist services for chronic pain. Work is already ongoing at the local level to explore new approaches and potential solutions to some of the key issues, and as this progresses we will coordinate relevant support and input at the national level.

Given the initial focus on enhancing the evidence base on management of chronic pain we do not propose establishing a working group for Aim C in the short-term. However it is expected that that going forward there will be a requirement for dedicated working groups to support implementation and further development of Actions for this Aim.