The Provision of Specialist Residential Chronic Pain Services in Scotland: Analysis of Consultation Responses

Section 2: Views Of Options

2.1 This section outlines the three options set out in the consultation paper then presents respondents' views of these options, as well as other ideas.

The options

2.2 The Scottish Government identified three options for the provision of specialist residential chronic pain services in Scotland. These are summarised below.

Option 1 - A Centre of Excellence in a single location

2.3 This option would involve the development of a national treatment and residential service in a single location, with a range of staff specialising in chronic pain. Local residential accommodation would be offered to those patients who wish to stay. This type of residential service would be similar to those provided in: Bath Centre for Pain Services; Pain and Fatigue Management Centre at Bronllys, Wales; and the INPUT pain management unit at Guys and St Thomas's, London.

Option 2 - A service delivered by local chronic pain clinicians supported by other clinical advisors in another part of the country

2.4 This option would involve local skilled chronic pain teams providing the service, with remote support from other experienced staff from a central point or hub. A patient could have a consultation and assessment in their local area, but involve other clinical advisors using technology. The clinical advisor would work with and support the local team, who would provide the treatment on a day to day basis over a 2-4 week period. Local residential accommodation would be offered to patients who wish to stay. This would be similar to service models used for other chronic health conditions which need a very specialised service and access to additional advice.

Option 3 - A service delivered in different locations by a team of chronic pain specialists (an outreach or roving service)

2.5 This option would involve the service being provided by a specialist chronic pain team who would go to different parts of the country. The team would be organised and managed by one NHS Board and travel to other health board areas to carry out assessment clinics. They would then work with and support local teams to deliver the treatment daily over a 2-4 week period. Local residential accommodation would be offered to those patients who wish to stay. This model has not yet been tested in Scotland, as other services provided on an outreach basis tend to have only outpatient or day case appointments, and do not have residential accommodation.

Views of the options

2.6 Questions 2 and 3 sought respondents' views of the options presented. For reference, the questions are set out below:

Question 2: Please choose your preferred option

Option 1 - a Centre of Excellence in a single location

Option 2 - a service delivered by local chronic pain clinicians (supported by other clinical advisors in another part of the country)

Option 3 - a service delivered in different locations (by a team of chronic pain specialists - an outreach or roving service)

Please tell us why this is your preferred option in the comments box below.

Question 3: Are there any of the options you disagree with?

If yes, please tell us which one(s) in the comments box, and why?

2.7 The findings are considered together in determining the overall pattern of views.

Overall views

2.8 Almost all of the written respondents (89%) ticked a box at Question 2 to indicate their preferred option. A small number (11%) either:

• Completed the previous response form (which did not offer these choices).
• Did not tick a box but made comments (a few of whom stated that they did not have a preferred option or were unable to select one).
• Did not address this question directly.

2.9 Respondents' overall preferences were also explored in the stakeholder meetings.

2.10 Of those who ticked a box at Question 2, around 85% made additional comments. Relevant comments were also made in all of the stakeholder events and by a small number of other respondents who did not tick a box.

2.11 Table 2 (below) sets out the preferred options of those who ticked boxes:

Table 2. Preferred option

Option ticked	Number	%
1	154	75
2	28	14
3	12	6
1,2	4	2
1,2,3	4	2
1,3	1	<1
2,3	1	<1
Total	204

2.12 There was a clear preference overall for Option 1. Among those who answered Question 2 in the written consultation, three quarters (75%) ticked a preference for Option 1, while much smaller numbers^[6] expressed a preference for the other options. Only 14% ticked Option 2 and 6% Option 3. A small proportion (5%) ticked more than one option, suggesting a preference for a combination of options, or "either / or" between different options.

2.13 Over two thirds of respondents in each of the categories (see table above) expressed a preference for Option 1 suggesting broad support for this.

2.14 These overall preferences were also reflected in responses to Question 3 (relating to options respondents disagreed with). Just over half of written respondents (54%) addressed this question. Most identified an option (or, in some cases, options) they disagreed with. Most also made additional comments relating to their views.

2.15 Overall, around 65% of those who addressed this question identified that they disagreed with Option 3 (including both those identifying Option 3 alone and in conjunction with another option). Similarly, around half (51%) identified that they disagreed with Option 2. A smaller proportion (around 10%) identified that they disagreed with Option 1.

2.16 Some respondents (while expressing a preference for a specific option) also suggested that elements of the other options would be beneficial. In addition, a small number of respondents who did not tick any box at Question 2 expressed a preference for a combination of options. Overall, over a fifth of respondents to the written consultation identified benefits of some combination of the options. Participants in each of the stakeholder meetings also favoured a mix of elements of the options, generally suggesting a combination of a Centre of Excellence at a single location, alongside local provision.

2.17 Questions 2 and 3 also explored respondents' reasons for their overall views, and most made additional comments. These issues were also addressed at the stakeholder meetings. Views given at Question 2 tended to focus largely (although not only) on the perceived benefits of the particular option the respondent supported. Conversely, views at Question 3 tended to focus largely on concerns about options they did not support.

2.18 There were, however, some areas of overlap in the issues arising at each of the questions, and these comments are considered together. Some perceived benefits and drawbacks of particular options were also highlighted in response to other questions, and these have also been incorporated below.

Views of Option 1

2.19 Where respondents made additional comments at Question 2, the most common (by almost three quarters of these respondents) were about benefits of Option 1.

2.20 A low proportion of respondents (around 10%) expressed disagreement with Option 1 at Question 3, and some concerns were highlighted by a similar proportion. The most common concerns related to location and access issues.

Option 1 - benefits

2.21 A frequent theme in terms of the benefits of Option 1 was the perceived high quality of the service with Option 1. Some respondents identified an overall need for this approach, or stressed its general benefits (e.g. in terms of being seen to provide the best service; being the most "sensible" or "practical" option; or presenting fewer challenges than the other options). It was also argued that the adoption of Option 1 would help provide priority for, and a focus upon the management of chronic pain.

2.22 Another frequent theme related to the overall nature of provision. Several respondents made comments on the opportunity for the development of excellence (e.g. a "world class" or "flagship" service), the opportunity for recognition and the development of leadership in chronic pain management in Scotland.

2.23 A number of comments focused on the perceived value of having a team of expert, well-trained trained staff located together in one setting, with concentrated expertise and a breadth of knowledge. Related to this, it was argued that there would be sufficient patients to develop and maintain this expertise and sufficient staff for a Centre to operate at all times. It was also suggested that Option 1 would enable all necessary facilities to be made available and provide a permanent base.

2.24 Staff issues were also a common theme. Many comments were made about the opportunity for staff development and learning. It was suggested, for example, that a Centre could offer training, learning and support to a range of staff (including the opportunity to learn from patients). It was also suggested that it could provide a learning "hub", and enable shared knowledge, information, experience and best practice. Benefits in terms of attracting and retaining staff were also identified. It was suggested that specialists with existing expertise would be attracted to a Centre of Excellence.

2.25 In terms of the theme of management and delivery issues, it was suggested that this option would be most likely to deliver the service required, as well as being easier to manage and implement, and more sustainable. Benefits were also highlighted in terms of Option 1 being easier to monitor, inspect, audit and report upon. Some noted that it could also help support the development of local services.

2.26 Benefits were identified in relation to multi-disciplinary working (e.g. to meet complex needs), the delivery of integrative care, and the provision of a joined-up, rather than a fragmented service. It was also suggested that Option 1 would facilitate good communication, good links and effective patient follow-up.

2.27 Comments on types of provision were also common. It was suggested that Option 1 could offer a range of support and treatment. Comments were made on opportunities for specific kinds of provision, particularly peer support (which, it was suggested, may not be possible in the other options) but also traditional and complementary approaches and opportunities to try mobility resources. It was also suggested that there would be opportunities for research, development and innovation.

2.28 An additional theme was the positive impact on service users. There was a general view that this option would be beneficial to patients and carers in terms of meeting their overall needs and providing support. It was seen to provide a "rounded" service in one centre focusing on chronic pain care, as well as working with patients for a period of time.

2.29 It was also suggested that this option would have a positive impact on:

• The availability of equitable provision.
• Continuity of care.
• Access to information.
• Patient confidence.
• Reduced waiting lists elsewhere.
• Support to carers.

2.30 At a more specific level, it was also argued that Option 1 could best meet the needs of specific groups (e.g. minority groups; people in rural areas; and paediatric patients).

2.31 Location and access issues were also identified frequently among the benefits of Option 1, particularly in terms of a Scottish service being closer to home and addressing some of the current travel and access barriers both for patients and visitors (discussed further in Section 3). It was also argued that a single trip would be preferable to frequent journeys for treatment.

2.32 The view that Option 1 builds on both experience and evidence was also common. Many commented that Option 1 has been "tried and tested" as a method for treating those with chronic pain and the related issues. It was suggested that it is supported by the current evidence base (e.g. from specialist pain services elsewhere in the UK, from other services addressing specific conditions and from some respondents' own experiences).

2.33 It was suggested that Option 1 would be cost-effective (e.g. by delivering economies of scale and removing duplication) and offer value for money. A view was expressed that a Centre was the most likely option to be fully funded, and that it would encourage external funding (e.g. for research). One respondent argued that it would be beneficial to put resources into a Scottish service.

Option 1 - issues and concerns

2.34 A low proportion of respondents expressed disagreement with Option 1 at Question 3, and / or raised issues and concerns. The most common concerns (although from a small number of respondents) were about location and access issues, particularly the need to travel (and related barriers such as distance, transport links, health, and weather issues). Concern was also expressed about the potential inaccessibility of a single location to some service users.

2.35 A few respondents expressed concerns about their perceptions of the likely overall quality of the service or expressed a preference for another option. A few also expressed concerns relating to specific aspects of the service, particularly the residential focus. It was suggested that: this would not be most patient-centred; it would be an artificial environment; it would be short term; and it would be contrary to other aspects of the overall policy direction.

2.36 One respondent suggested that there had been no attempt to assess the extent to which needs could be met by strengthening local services. A concern was also expressed by a further respondent about a potentially negative impact on local services.

2.37 Staffing concerns were also raised by a few respondents. These related to three main areas: recruitment (e.g. a potential shortage of highly trained clinicians and the potential to detract from current services); the impact on local clinicians who feel they cannot provide the treatment; and the impact on skills (e.g. with no "upskilling" of local staff and the potential for skills to be lost).

2.38 A very small number of respondents raised concerns relating to delivery and management issues, including: the practicality and sustainability of the option; and the implications for clinical responsibility and clinical governance.

2.39 A few concerns were raised about the implications of Option 1 for aspects of provision such as self-management, follow-up and maintenance. Similarly, some concerns were raised about the implications of this option for service users' experiences, such as patient-centred care. The potential for both a lack of equitable access for patients and for the development of waiting lists was also noted. It was also suggested that this option would not meet the needs of all patients with chronic pain.

2.40 A very small number of respondents raised concerns about experience and evidence (e.g. whether there would be sufficient referral numbers to justify a new service; and the view that the model has been superseded in other parts of the world due to a perception of inefficiency, and ability to address only small numbers).

2.41 A very small number also raised concerns relating to funding and costs (e.g. high set up costs; higher costs than sending patients to Bath; follow-up costs; and the implications for resources to local services).

Views of Option 2

2.42 A small proportion of respondents identified benefits of Option 2 (around 13% of those who made additional comments at Question 2). A large number raised concerns (around half of those who addressed Question 3).

Option 2 - benefits

2.43 The most common perceived benefits of Option 2 related to location and access. It was suggested that Option 2 offered a service close to home (which, it was argued, accords with the Scottish Chronic Pain Service Model). It was also suggested that it would reduce the need to travel (viewed as important given the travel barriers for people experiencing chronic pain). It was argued that such a service would be more accessible and would promote greater equity of access, and deliver a good quality local pain services in all areas. The ability to consult with experienced and specialist clinicians (particularly in the early stages) was also considered beneficial.

2.44 Some respondents identified staffing benefits with Option 2. It was argued, for example, that there would be an increase in local skills. It was also argued that there would be benefits in terms of promoting local employment and removing the need for additional recruitment. It was suggested that Option 2 would lead to better staff retention.

2.45 A small number of respondents identified benefits in terms of the potential overall quality of the service with Option 2. It was suggested that this would offer the opportunity to build on and improve existing pain services, with additional support from the "hub". One respondent argued that it would be the most effective, comprehensive and sustainable option and that it could bring about an intervention which could be a national standard. It was also suggested that developing local clinicians' skills would support the Scottish Government's pain agenda.

2.46 A small number also identified benefits in terms of both delivery and management. It was suggested that Option 2 would:

• Be quick to set up.
• Be more practical than a "roving" service.
• Enable a collaborative and flexible approach.
• Enable the development of local services.
• Support links to other local services and initiatives.

2.47 A small number identified opportunities for particular types of provision, including the use of telehealth, and the provision of follow-up and maintenance of support.

2.48 Benefits in terms of the impact on service users were identified by small numbers including:

• Providing a tailored approach to meeting patients' needs (e.g. by drawing on the skill set of several health boards and meeting the needs of people in rural communities).
• Being more responsive to demand.
• Increasing confidence.
• Enabling support from friends and family.
• Providing consistency.
• Minimising waiting times.

2.49 A very small number of other benefits of Option 2 were identified. These included that it would be cost-effective through using existing expertise, and offer investment opportunities through demonstrating the lack of equity.

2.50 It was also suggested that there was a lack of evidence of the level of need for Option 1.

Option 2 - issues and concerns

2.51 Common areas of concern related to delivery and management issues, particularly the practicality, feasibility and sustainability of this option. Views were expressed that it: would not work; could lead to duplication of arrangements already in place for supervision; or would take an unacceptable length of time to set up. It was also suggested that the option would require inter-regional working (which would need dedicated resources).

2.52 A further common area of concern related to types of provision. Issues were raised about the lack of opportunity for face to face provision by specialist staff, with some offering the view that chronic pain consultations need to be undertaken in person. Some specific concerns were expressed about telehealth (with phone or video links) as a means of support. These included not only the lack of face to face contact, but other issues such as:

• Lack of clinician time.
• Lack of access to appropriate technology in some areas and for some patients.
• Lack of peer support to make this successful.

2.53 Several respondents raised concerns about the perceived overall quality of the service. Comments included views that Option 2 could dilute the benefits of a Centre of Excellence and that it would replicate current provision (or at least not add value). It was also suggested that it would compromise the ability to deliver continuity and quality of treatment.

2.54 Several also raised concerns about the impact of Option 2 on service users' experiences. It was suggested that treatment would be fragmented, disjointed and "piecemeal". It was also suggested that there could be lengthy waiting times relating to the level of demand and the need to accumulate sufficient patients. It was also suggested that provision to patients in different areas could be inequitable and that some patients may not be referred to the service.

2.55 A small number of concerns were also raised with location and access (e.g. inequality of access; multiple journeys). It was also argued that patients may feel isolated, and that attendance at different clinics may cause travel difficulties or impact on employment.

2.56 A small number of comments focused on concerns about funding and costs. These included concerns about the overall cost, or cost-effectiveness of Option 2, and the need for additional funding. The cost of training was mentioned specifically in this context. It was also suggested that funding for this option may be vulnerable and at risk of being limited, reduced or withdrawn.

2.57 Small numbers of additional concerns were expressed about the overall nature of the service in Option 2. These included a suggestion that it may not be possible to develop and provide the necessary expertise and specialist skills through this option. It was also suggested that the option would not provide the time period needed to work with patients and that it may dilute or undermine the residential element of the service.

2.58 It was suggested that the service would not be staffed by specialists or that suitable accommodation and facilities may not be available. At a practical level, it was also noted that it would be difficult for a remote expert to assess difficulties during a programme and give reliable guidance to a local team.

2.59 A very small number of staffing concerns were raised relating to difficulties in recruitment, and the availability of staff with the specialisms required. Potential variation in local expertise was also noted. A few respondents also raised concerns relating to experiences of similar types of provision (e.g. personal negative experiences of local assessment).

2.60 The lack of evidence for the effectiveness of this option was also suggested.

Views of Option 3

2.61 A small number of respondents identified benefits of Option 3 (around 6% of those who made additional comments at Question 2). Option 3 attracted the highest number of comments on issues and concerns (around 60% of those who addressed Question 3).

Option 3 - benefits

2.62 As with Option 2, the most common benefit identified (albeit by only a small number) related to location and access issues, particularly the local nature of provision and the lack of need to travel.

2.63 A very small number of positive comments were made about the overall perceived quality of the service, or respondents' general preference for the development of local services. A few respondents also highlighted delivery and management benefits, such as the development of a team approach and provision by local staff.

2.64 A few mentioned opportunities for particular types or means of provision (e.g. tailored provision and sustained peer support). A few also identified a positive impact on service users' experiences (e.g. through providing access to specialist provision for particular groups; and avoiding financial and emotional costs).

Option 3 - issues and concerns

2.65 Delivery and management issues were a common area of concern with Option 3, particularly suggestions that this would not be practical, workable, viable or sustainable. As with Option 2, it was suggested that this option would require inter-regional working (which would need dedicated resources, and may be difficult for members of different teams being brought together on an ad hoc basis). It was also argued that the option would take an unacceptable length of time to set up and that co-ordination and management would be challenging.

2.66 Staffing concerns were also common in relation to Option 3, particularly the perceived difficulties of recruiting and retaining staff. It was argued that the requirements of the staff role would create difficulties, including the level of specialism required. It was also noted that there is a current shortage of qualified and experienced chronic pain professionals in parts of Scotland.

2.67 At a practical level, it was suggested that the geography of Scotland and the nature of the service would require clinicians to be away from home for long periods, which would be unattractive to them. A concern was also expressed about the impact on local services of the involvement of "mobile" staff.

2.68 Amongst the concerns about the impact of this option on service users' experiences were that it could lead to variation, inconsistency and fragmentation of provision. It was also suggested that it would lack a stable clinical base and could lead to isolation for patients and have disadvantages for patient-centred care. It was further argued that there could be lengthy waiting times. A number of reasons were offered for this concern, including small numbers and the need to accumulate a viable number of patients in an area, or as a result of the delivery team working elsewhere in Scotland. It was also suggested that fewer patients may benefit from such a service.

2.69 Several respondents raised concerns about experience and evidence, particularly what they saw as the untried and untested nature of the service. One respondent suggested that this option would need to be piloted before any future investment was made.

2.70 Other concerns identified by several respondents related to the overall perceived quality of the service. It was suggested, for example, that:

• The benefits of a Centre of Excellence would be lost or diluted.
• Provision could be "hit or miss".
• The logistics of delivery might detract from the quality.
• There would be a lack of added value.
• The level and standard of provision would not be sufficiently high.

2.71 Concerns about funding and costs were also raised by several respondents. It was suggested that this option could be expensive as a result of specialists travelling to different locations. One respondent suggested there could be a need for incentives. It was also argued that this option could lead to a lack of investment in local pain services. There were also concerns about funding vulnerability.

2.72 Concerns were also raised about location and access issues including:

• Geographical variations in the provision of services.
• Access difficulties for staff attending specific areas (e.g. rural areas).
• The need for some patients still to have to travel and require accommodation.
• The travel time and distances involved in some areas.

2.73 Concerns about the overall nature of the service were also raised. It was suggested that Option 3 would not enable the necessary expertise to be developed. It was suggested that some areas would not have sufficient facilities. It was also suggested that there could be variation in the availability of appropriate accommodation.

2.74 As with Option 2, it was suggested that the residential concept could be diluted or undermined, and that the accommodation may not be staffed or supported by chronic pain specialists.

2.75 In terms of particular types or means of provision, it was suggested that there could be difficulties in providing group work and peer support with this option, as well as follow-up. It was also suggested that the option would not provide a sufficient time period for effective work.

Other options

2.76 Question 4 asked respondents to identify other ideas they may have. For reference, the question is set out below:

Question 4: If you have other ideas that have not been covered, please tell us about these in the comments box below. You may want to include the advantages and disadvantages of each.

2.77 Over a third of respondents addressed this question (39%), and suggestions were also made in the stakeholder meetings. Among respondents to the written consultation, however, the most common theme was not the identification of alternative options, but the identification of particular aspects of service provision, or the means of taking this forward. These are discussed in Sections 4 and 5.

2.78 A small number of respondents did, however, suggest other options at Question 4, although the most common suggestion was some form of combination of Options 1 to 3 (as set out in Question 2). As noted earlier, a small number of respondents had also identified their support for a combination of options by ticking more than one box at Question 2. Some respondents in all of the stakeholder meetings also expressed support for a mix of elements of the options presented.

2.79 Additionally, some respondents made reference elsewhere in their responses to the need for (or benefits of) the inclusion of aspects of other options as part of the development of provision in Scotland (whether or not they expressed support for a specific option).

2.80 Although it is impossible to provide a definitive number (given the nature of the data), the material suggests that over a fifth of all respondents made some comments suggesting the need for, or value of, the inclusion of elements of more than one of the options in the service provided in Scotland.

Combination of options

2.81 Where respondents suggested a particular combination of options, the most common was Options 1 and 2, or elements of all three. Some comments focused generally on the need for a combination of a specialist Centre of Excellence at one location, alongside, for example:

• Support for the improvement and development of high quality local pain services (and links to, or integration with such provision).
• The use of telehealth options (although, as noted, there were also some concerns with this).
• Outreach work (including, for example, domiciliary care and peripatetic work).

2.82 Some respondents suggested the potential to develop additional elements of provision at a later stage, including expanding to other areas and / or types of provision following the development of a Centre of Excellence.

2.83 It was also argued that it should be made clear that the establishment of a Centre of Excellence or specialist service should not be an alternative to, or at the expense of the continuing development of local pain services and that all regions should have appropriate provision in place.

2.84 Comments on the perceived benefits of a combination of options included overcoming perceived problems or gaps with a specific option in isolation, or providing a response to a perceived lack of evidence to support a specific option. The importance of good local services (and access to specialist input in some form at this level) was also identified as a benefit. Further benefits were seen to be the opportunity to provide the best service and choice for patients (given the variation in individual needs) and better health. It was also argued that this approach would align with wider Scottish Government objectives.

2.85 Suggestions were also made about the potential roles of a Centre of Excellence and local services. In relation to a Centre of Excellence, these included:

• Dealing with complex needs.
• Acting as a "hub" for service provision, learning and research.
• Providing specialist expertise and intensive treatment.
• Providing training and advice.

2.86 Suggestions about the role of local provision included that it could:

• Offer early intervention and assessment.
• Identify issues.
• Work locally with patients (including those with less complex needs).
• Provide regular local specialist clinics.
• Provide patient follow-up.

2.87 It was suggested that local services could meet the needs of those who did not, or could not attend a Centre of Excellence, and that they could generally complement the support provided at a Centre.

Alternative approaches

2.88 A small number of respondents suggested other alternatives, suggested that none of the options would be beneficial, or indicated that they did not support the need for a residential service.

2.89 Specific alternative suggestions included the development of satellite units in each health board area, offering beds and facilities for residential patients, and linked to a Centre of Excellence. It was suggested that this solution would demonstrate a commitment to helping individuals improve their lives closer to home. A further suggestion was the development of more than one Centre.

2.90 One respondent suggested a partnership with other regions or nations (e.g. Northern Ireland, Wales or Northern England), arguing that this could perhaps address perceived issues relating to the high costs and relatively small number of patients in the establishment of a facility in Scotland.

2.91 A few respondents suggested targeting resources elsewhere, such as:

• Improving the current inconsistency in funding of pain services.
• Investing at community / primary care level and providing multidisciplinary non-resident pain management in patients' local environments.

2.92 It was suggested that multidisciplinary non-resident local services could help tailor approaches to individual circumstances and daily life, as well as providing the option of regular follow-up, support and refreshment of pain management skills. It was also argued that this model was being used successfully elsewhere.

2.93 A few argued that the long term care of sufferers should be improved. Suggestions included stopping treating chronic pain as an acute illness, and improving integration with other organisations to support chronic pain patients for the longer term.

Other comments and suggestions

2.94 As well as providing respondents' overall views of the options presented, many respondents made additional comments or suggestions in their responses to Questions 2-4. Most of these focused upon aspects of a Scottish service they considered necessary (either in relation to a specific option or overall), or the means of taking the provision of specialist residential chronic pain services in Scotland forward.

2.95 Comments were also made on a small number of other issues, including: the nature of current provision; questions or issues for clarity; or comments on the consultation itself. All of these issues are discussed more fully in Sections 4 and 5.