Commissioning pain management services:
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Commissioning pain management services: what do care pathways for people with long term pain and clinicians need?. Dr Frances Cole Clinical Lead, NHS Kirklees GP + Pain Rehabilitation Specialist, Bradford Teaching Hospitals June 2012 frcole @ btinternet.com.

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Dr Frances Cole Clinical Lead, NHS Kirklees

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Dr frances cole clinical lead nhs kirklees

Commissioning pain management services: what do care pathways for people with long term pain and clinicians need?

Dr Frances Cole Clinical Lead, NHS Kirklees

GP + Pain Rehabilitation Specialist, Bradford Teaching HospitalsJune 2012

[email protected]


Dr frances cole clinical lead nhs kirklees

Health is a resource for living so we are able to:

  • Undertake daily activitiesNot feel bodily pain

  • Join in social activitiesFeel peaceful and happy

  • Do physical tasksFeel full of life

  • WHO 1984, Ware 1993


  • Dr frances cole clinical lead nhs kirklees

    Poor understanding of pain condition/s and self manage confidently

    Dyslexia, literacy, language

    Long term low income +/- benefit issues

    Loss of work (paid/unpaid)

    Less contact with family, friends, social networks, specific support

    Housing structure / location unsuitable adaptations need to reduce disability

    Self coverage

    Health services programmes not flexible to meet needs

    Difficult to use public transport

    Unable to drive due to drugs

    Poor sleep patterns; Depression

    Fear, Anger, Shame, Fatigue

    Reduce goals, planning, pacing of daily life activities,

    Fitness activity levels reduced

    Perceived lack of control over their pain and their life

    Health needs change due to changing illness, disability. Pain relief mixed, variable

    Women > Men

    >65 more than<65

    Vitamin D insuff

    Multidimensional impact of chronic pain on health

    Carers needs; little appropriate support


    The nhs commissioning cycle

    The NHS Commissioning Cycle


    Dr frances cole clinical lead nhs kirklees

    National policies – UKChief Medical Officer report 2009; Dept of Work & Pensions 2006

    Dept of Health Long Term Health Condition Programme

    NICE Guidelines; UK Pain Summit 2011 British Pain Society MoM pathways; Royal College General Practice


    Kirklees joint strategic needs assessment jsna 2009

    Kirklees Joint Strategic Needs Assessment (JSNA) 2009

    • Pain worst impact on health - physical function

      20% = no physical activity

    • Affects 1 in 3 people 104,817 adults in Kirklees

      89,679 affected = working age.

    • People < 65 years 31% pain in past year

    • People > 65 years46% pain in past year: women > men

    • Poor sleep 1 in 3Depressed 1 in 2 esp. back pain

    • More have heart disease, diabetes, stroke

    • 75% at least overweight

    • Linked to low income £££

    • Impact on carers – many have chronic pain

      www.kirklees.nhs.uk/


    The nhs commissioning cycle1

    The NHS Commissioning Cycle


    What do patients need to manage pain

    What do patients need to manage pain?

    2 Commissioners engaged patients

    NHS Kirklees; NHS Bradford + Airedale

    • Self care: key part of control on their lives + pain; want all GPs to refer all patients > self care services

    • Better self care information - range of media + sources

    • Better access to self care resources + services

    • Confidence in GP + their skills

    • Seeing right clinician at right time

    • Continuity of care: more seamless

    • Consistency of experience at all steps of pathway

    • Faster access: assessments + investigations

    • Faster access: Physiotherapy, Occup.Therapy, Pain Specialist


    What do primary care clinicians need

    What do primary care clinicians need?

    • Change of model + pathway: biospychosocial model for long term pain

    • More knowledge + skills: <10 hrs training for doctors

    • More time with patient in consultation

    • Improve medicines management + clinical skills

      • Pain symptoms, side effects, guidance + decision aid tools

      • Manage emotional distress, cope with setbacks

    • Referral - minimum data > single entry point in pathway

    • Referral guidance – decision aids; Map of Medicine

    • Stop referring for spinal surgery for pain

    • Know about self care resources; where / how to refer or use them

    • More awareness - financial costs; primary + (secondary care clinicians)


    Kirklees council scrutiny panel for health inequalities 2010

    Kirklees Council Scrutiny Panel for Health Inequalities2010

    Main recommendations:

    • Consistent pain services - person centred approaches to pain management

    • Services closer to home

    • Training & professional development about self management options

    • Reduce referral times – physiotherapy

    • Pilot person centred chronic pain service across Kirklees


    Pathway objectives for nhs kirklees

    Pathway Objectives forNHS Kirklees

    Improve health & resilience by reducing disability + distress

    experience of persistent pain sufferers

    by a comprehensive, accessible + quality programme that

    • Commissions services with sustainable, consistent delivery + measure performance management

    • Monitors quality of clinical practice + meet standards set in line with local / national guidance

    • Ensures ongoing professional development

    • Ensures cost effectiveness + efficiency


    Patient centred outcomes

    Patient Centred Outcomes

    • Improve health as a resource for life

    • Improve confidence + sense of control (self efficacy) so….

      improve self care with more ways to help themselves

    • Return to or stay in work

    • Reduce pain distress + intensity; total relief not expected

    • Improve mental health & wellbeing; less anxious + depressed

    • Reduce unhealthy behaviours: weight loss, stop smoking, more physically active

    • Reduce in health care use: GP, specialist referrals

      Patient Reported Outcomes Measure Scores


    Pathway

    Pathway


    Commissioning services so people self care better in kirklees

    Commissioning services: so people self care better in Kirklees

    • Expert Patients Programmes self management courses or support to develop self-care skills (for conditions e.g. diabetes, mental health, COPD + chronic pain

    • Health Trainers / Physical Activity Leisure Scheme- Help to change behaviour (e.g: lose weight, stop smoking, take up activity), 1:1 or group support, Specific for pain: REVIVE

    • Self Care Web Portal– Local information in one place. Access to Networks and opportunities to talk to people in same situation i.e. support groups, forum;

    • Libraries- bibliotherapy + range of self help books, pain toolkit ,CDs etc

    • Gateway to care offers advice, practical support for both patients + carers; network to relevant services

    • Better health at work– confidential support and advice for all work related issues

    • www.kirklees.nhs.uk/self care


    Self management resources needed

    Self management resources needed

    Tier 1

    www.paintoolkit.org/

    Tier 2

    Tier 3

    www.npowered.co.uk

    www.overcoming.co.uk/


    Dr frances cole clinical lead nhs kirklees

    Resources in clinics, libraries etc

    Oral + written information

    =

    important as drugs, test, scan or surgery

    Information needs change over time


    Clinicians need more medicines management guidance

    Clinicians need more medicines management guidance

    Neuropathic Pain algorithm

    Opioid algorithm

    • Boost confidence so prescribe safely, effectively + ££

    • Provide range of patient tools: self assess + self manage

    • Provide clinical tools to assess + review

    • Integrate

      • into GP computer System 1 + PCT website

      • with pain specialist clinicians

        www.kirklees.nhs.uk/yourhealth/long-term-pain


    Commission pain specialist procedures

    Commission pain specialist procedures

    • Agreement on range of treatments provided

    • Evidence focus + clinician dialogue with public health

    • Specific contracts; so stop some procedures + agree to limit repeats

    • Prior commissioning approval for complex treatments e.g. spinal cord stimulators


    Outcomes so far 4 years

    Outcomes so far – 4 years

    Tier 3 Pain specialist services:

    • Overspend agreed budget limits – moving to prior approval

    • Map of Medicine changes starting

      Tier 2 Pain service

    • 90% less referral to pain specialist

    • 50% less health care use – primary care

    • Patient confidence to self care increased by 50%

    • More GP’s confident to use drugs + support self care

    • Tier 2 specification + tender for 250,000 pop.

      Tier 1 Primary care

    • Medicines ManagementGP survey - use + helpful, costs flattening + savings

    • GP implement incentive scheme - drugs + self care referral

      Self care services Greater use + more proactive care pharmacy schemes, leaflets, other ways etc


    Key messages

    Key messages

    • People with pain must be taken seriously!!!!!

    • Many helpful key drivers – clear frameworks, JSNA, Health Inequalities, Map of Medicine, etc

    • Quality information about local impact + evidence for action

    • Person Centred thinking so real outcomes specified

    • Being in control / resilience crucial i.e. able to Self care

    • Pathways need to be seamless, integrated with better skilled clinicians delivering consistent messages

    • Deliver more effectively for less ££££

    • Collaboration between patients, clinicians, public health + politicians


    Reviewing pain services

    Reviewing pain services

    • Involve services users at each stage of developing chronic pain pathway.

    • Patient views – needs based care pathway.

    • Feedback to service providers and PCT commissioners – inform care pathway


    Engagement of service users

    Engagement of service users

    • Recruitment – Public & Patient Involvement (PPI) database, via pain services, Expert Patient Programme (EPP) support groups

    • Discussion groups across Kirklees

    • Sessions facilitated by PPI team and Public Health

    • Report back to service users for comments


    Proposed care pathway

    Proposed care pathway

    • Overall support for the proposals:

    • Liked patient centred approach- HNA’s and health trainer input

    • Improve access to GP /primary care - referral to specialist services

    • Want all GP’s to refer all patients to self care services

    • Better condition management

    • Improved emphasis on control via self care


    Referring patients to self care services

    Referring patients to self care services

    Patient & Health Care Professional – Shared decision making

    and discussion of self care options to support motivation to change and manage social, emotional and physical impact of LTC

    One single point of access

    Self Care

    • Menu of options

    • Self management courses

    • One to one support

    • On line support

    • Structured education courses

    • Support groups

    • Weight management

    • Behaviour change

    • Smoking cessation

    • Support for carers

    • Physical activity courses


    Kirklees approach

    Kirklees approach

    • Chronic Pain as a Long Term Condition (LTC)

    • LTC organisational structure

    • Chronic Pain programme

    • Chronic Pain - Health Improvement Team (HIT)


    Joint strategic needs assessment

    Joint Strategic Needs Assessment

    • Affects 1 in 3 people,104,817 adults in Kirklees

    • Pain - worst impact on health function, esp. physical function, 20% did no physical activity

    • People 65 > - 31% experienced pain over past year;

    • People < 65 - 46% experienced pain esp. women.

    • Poor sleep 1 in 3

    • Depressed 1 in 2

    • More likely to have heart disease, diabetes, stroke

    • 75% overweight or obese,

    • Linked to low income

    • Impact on carers – many have chronic pain themselves.


    What happened next

    What Happened Next

    • Pain recognised as a significant issue across Kirklees

    • Service users involved in developing a new pathway

    • Pain specific self management services

    • Review of practice in Primary Care

    • Medicines management guidelines

    • Priority for our CCG – tendering for a community based pain service

    • Work with secondary care specialists to develop evidence based policies for key procedures


    What will this achieve

    What will this achieve?

    The following patient centred outcomes:

    • Reduced levels of distress and disability

    • Improved symptom control, physical functioning and well-being

    • Improved confidence to self manage their pain, medication and their health


    Dr frances cole clinical lead nhs kirklees

    Mind the gap

    Everyone needs skills + resources


    Timescales

    Timescales

    • Phase 1(June 09)- experience of chronic pain, current service provision and needs for future.

    • Over 70 participants attended

    • Phase 2 (Sept 09) – presenting draft care pathway & whether it meets service user needs.

    • Over 25 participants attended


    Phase 1 key issues

    Phase 1 - key issues

    • More immediate action for relevant assessments / investigations.

    • Improved GP understanding of other support services e.g. self care programmes

    • Being able to see the right person at the right time

    • Improve waiting times for referral to Physiotherapy, O.T, pain clinics

    • More continuity of care with each service having an understanding about other services that can provide help

    • Similar service provision across PCT area.

    • Better patient information.

    • Self care as an key part of managing pain with regular access to self care resources and services


    Chronic condition management as applied to the nhs

    Chronic condition management as applied to the NHS

    3.5%

    case management

    2. 15-25%

    Condition management

    1.70-80%

    self-management


    Ltc framework

    LTC programme delivery group

    Kirklees

    LTC Partnership Board

    NHS Kirklees

    Strategic Development

    Commitee

    LTC HITS (Health Improvement Teams)

    Cardiology Pain

    Stroke Neurology

    Respiratory Self Care

    Diabetes & Renal Dermatology

    NHS Kirklees

    LTC Programme Delivery Group

    LTC Project Boards

    Telehealth

    Predictive risk

    WORKSTREAM Workforce capability and capacity

    WORKSTREAM

    Rehabilitation and self care

    WORKSTREAM

    Information and performance

    WORKSTREAM

    Personalised care planning

    LTC framework

    LTC Programme Dependencies

    End of Life Older People

    Intermediate care Urgent Care Medicines Mental health

    Management Planned care

    CHIK Programmes


    Ltc framework1

    LTC programme delivery group

    Kirklees

    LTC Partnership Board

    NHS Kirklees

    Strategic Development

    Commitee

    LTC HITS (Health Improvement Teams)

    Cardiology Pain

    Stroke Neurology

    Respiratory Self Care

    Diabetes & Renal Dermatology

    NHS Kirklees

    LTC Programme Delivery Group

    LTC Project Boards

    Telehealth

    Predictive risk

    WORKSTREAM Workforce capability and capacity

    WORKSTREAM

    Rehabilitation and self care

    WORKSTREAM

    Information and performance

    WORKSTREAM

    Personalised care planning

    LTC framework

    LTC Programme Dependencies

    End of Life Older People

    Intermediate care Urgent Care Medicines Mental health

    Management Planned care

    CHIK Programmes


    Reviewing pain services1

    Reviewing pain services

    • Involve services users at each stage of developing chronic pain pathway.

    • Patient views – needs based care pathway.

    • Feedback to service providers and PCT commissioners – inform care pathway


    Engagement of service users1

    Engagement of service users

    • Recruitment – Public & Patient Involvement (PPI) database, via pain services, Expert Patient Programme (EPP) support groups

    • Discussion groups across Kirklees

    • Sessions facilitated by PPI team and Public Health

    • Report back to service users for comments


    Proposed care pathway1

    Proposed care pathway

    • Overall support for the proposals:

    • Liked patient centred approach- HNA’s and health trainer input

    • Improve access to GP /primary care - referral to specialist services

    • Want all GP’s to refer all patients to self care services

    • Better condition management

    • Improved emphasis on control via self care


    And information resources what patients need to cope

    And information + resources…..what patients need to cope

    More tailored information

    • What is wrong and prognosis

    • How to make most of consultations, assessment

    • Understand roles in self care + sources of help

    • Learn how to prevent further problems

      Information needs change over time

    • Ensure patient can ask for more help again, again

      Pathway: Oral + written inform

      =

      important as drugs, test, scan or surgery

      Source: Patient-focused intervention A review of the evidence Angela Coulter, Jo Ellins Picker Institute 2006


    Key drivers now

    Key drivers now

    • National policy – UK

      • CMO report 2009

      • Pain Summit 2011 www.painsummit.org.uk

      • British Pain Society, RCGP

    • Local policy – Kirklees - Bradford

      • Joint Strategic Needs Assessment – population needs led approach www.kirkless.nhs.uk

      • Scrutiny Panel for Health Inequalities agenda

      • Long Term Conditions + Self Care frameworks

    • Patient + Public Involvement

      • Shaping services commissioned


    Impact of pain

    Impact of pain


    Living with pain and lthc s

    Living with pain… and LTHC’s

    Coping: the efforts to deal with stressful situations that tax or

    exceeds one’s individual resources Lazman R Folkman S 1984.

    Pain coping efforts: strategies to cope with or deal with, minimise

    pain & pain related distress + disability Keefe F J Pain 1983

    Resilience - the ability to adapt in the face of adversity and continue

    to function ‘normally’.

    The sense of control people feel they have over their lives, their

    sense of purpose, confidence and self esteem.


    Dr frances cole clinical lead nhs kirklees

    Health needs assessment tool patients guide us…..their agenda1000 + Patients using a specific HNA tool in clinical settings

    Lack of fitness and energy

    Walking or moving about, balance or falls

    Pain relief or side effects or problems with current medication

    Understanding why my pain condition has occurred

    Unhelpful pattern of pacing activities

    Disturbed sleep

    Eating the right types of food

    Managing mood changes

    Relationship difficulties; with partner, family, work etc

    Sex life

    Remaining or returning to work and/or training

    Financial difficulties, housing or accommodation problems

    Concerns about carer/partner, their health or other problems

    Other difficulties important to change e.g. hobbies, leisure, social events etc…

    Circle 3 priorities for you now


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