Why is the topic important?
Pain is a complex bio-psychosocial experience and chronic pain requires a multi-disciplinary management approach to address these complex interactions. Although effective pain management interventions and programmes exist, provision of these services is inconsistent, and chronic pain is not given the priority it requires in view of the extent of its burden on individuals and society1. The costs of back pain alone account for 20% of the UK’s total health expenditure.2
The prevalence of chronic pain is estimated at 8-60% of the population, depending on the definition3. Severe pain is estimated at 11% for adults and 8% for children. Older age, female sex, poor housing and type of employment (for example heavy manual work) are significant predictors of chronic pain in the community. The average annual incidence is 8.3% and average annual recovery rate 5.4%4. Severe chronic pain is known to have adverse effects on employment status, daily activities, relationships, mood, sleep and all aspects of general health. Daily back pain is known to be associated with greater coronary events. Pain is not consistently managed across the whole health/social care system at present. Specialist services in secondary and tertiary care are tasked with managing complex pain, often too late and with few resources. In recent years more services have been set up in primary care, with or without specialist input. However, little is known of the population served, the services offered and outcomes. It is hoped that by improving the management of pain in its early stages that the consequences of chronic pain will be ameliorated, with obvious benefits both to the patient and to society. Patients should also be afforded better knowledge of the services that are provided and how they compare with others.
The Welsh Assembly has recently published a report entitled “Service development and Commissioning Directives for chronic non malignant pain, 2008”5. This highlighted the patchy provision of services in Wales and the need to provide services closer to home for the vast majority of patients.
Similarly The Department of Health’s Clinical Services Advisory Group (CSAG) found a large variation in quality of care offered by providers6. Half the patients attending a pain management clinic had been referred by their GP and half by their hospital consultant. The majority of patients (sixty-five per cent) had no prior knowledge of the existence of pain management clinics. A quarter of patients had waited more than twenty-two weeks for an outpatient appointment in the pain management clinic. The longest wait was ninety weeks. Shortages of specialist psychologists, physiotherapists, occupational therapists and pharmacists hindered a multi-disciplinary approach. There was little attempt to assess provision of pain services in relation to what local people actually needed. Most of the pain management services felt that pain relief was not adequately recognised. Eighty-one per cent had recently tried to obtain additional funding but sixty-three per cent had been unsuccessful. Many patients were positive about their experiences from attending the pain management clinic. They said their pain had improved. They felt supported and relieved to discover that expert advice is available. Many felt that they should have been seen at a pain clinic earlier. However, services discharged far fewer patients than they took on each year. This is unsustainable in the long term. Little appears to have changed since then.
Audit outcomes and processes
The audit will measure both outcomes and processes. The continuing data quality improvement programme would use similar methodology to that researched to improve process and measure flow (Hall 2008). Outcomes such as pain, disability, distress would be measured through a continuing quality improvement programme.
Impact upon patient care
There is significant variation in the quality of pain services and the access to these services across England. This variation was highlighted in the CSAG report on services for NHS patients with acute and chronic pain in 20007.
A recent Scottish benchmarking audit for chronic pain8 demonstrated signification variation in patient care and led to the Scottish government recognising chronic pain as a long-term condition in its own right. This has also lead to a direct intervention from the Health Secretary and has already had a positive impact on patient care.
In terms of outcomes the audit utilises Patient Reported Outcome Measures: the Brief Pain Inventory is its primary measurement tool. This provides pre and post treatment data using pain scores, disability scores and measurements of psychological distress.
High quality patient care in the complex chronic pain setting is usually delivered by multidisciplinary teams using multimodal strategies. We need to establish the efficacy of this approach through audit.
Within the UK, reviews of specialist pain services by the Audit Commission and Clinical Standards Advisory Group recommended both changes in practice and the monitoring of performance.
Pain Management Services have been supported through the Department of Health’s 18 week chronic pain cross-specialty pathway to shift care out of hospitals. This supports transformation of orthopaedic, cardiology and gynaecological pathways. Understanding what works where for whom would have a major impact on this policy.
NICE through its Health Technology Assessment programme and guidelines panel, has reviewed several areas of Pain management. It recommends registries for epidural steroids and spinal cord stimulation, changes in practice to the management of chronic low back pain and greater input of vocational rehabilitation workers. At present there is no way to assess the impact of these wide ranging changes.
Patients through completion of the questionnaires are involved in collection of data.
Relevant professional groups support The Quality Improvement Programme Relating to Pain Audit has high acceptability amongst clinicians who are members of the British Pain Society and Faculty of Pain Medicine at the Royal College of Anaesthetists. Clinicians have high degree of ownership in its design and development9. The Society feels that the technical aspect of the audit is best run externally, with the provider selected through a tendering process. The relevant professional groups and societies must be consulted in the development of the tender response.
Patient organisations support
The Patient Liaison Group of the British Pain Society has long advocated better information on UK pain services. This standing committee of the British Pain Society represents the patient perspective to the Council of the BPS and has links with many patient organisations such as Action on Pain and Pain Concern. The BPS belongs to the Long Term Conditions Alliance (National Voices). The relevant patient groups and societies will be consulted in the development of the audit process.