Commissioning pain Commissioning pain management services: management services: what do care pathways what do care pathways

for people with long term for people with long term pain and clinicians need?pain and clinicians need?

Dr Frances Cole Clinical Lead, NHS Kirklees

GP + Pain Rehabilitation Specialist, Bradford Teaching Hospitals

June 2012frcole@btinternet.com

Undertake daily activities Not feel bodily painJoin in social activities Feel peaceful and happyDo physical tasks Feel full of life

WHO 1984, Ware 1993

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

Self coverage Health services programmes not flexible to meet needs

Housing structure / location unsuitable adaptations need to reduce disability

Difficult to use public transportUnable to drive due to drugs

Multidimensional impact of chronic pain on health

Long term low income +/- benefit issues

Perceived lack of control over their pain and their life

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

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

Carers needs; little appropriate support

Reduce goals, planning, pacing of daily life activities,

Fitness activity levels reduced

Loss of work (paid/unpaid)

Poor sleep patterns;

DepressionFear, Anger,

Shame, Fatigue

Poor understanding of pain condition/s and self manage confidentlyDyslexia, literacy, language

Women > Men >65 more than<65

Vitamin D insuff

The NHS Commissioning CycleThe NHS Commissioning Cycle

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 Kirklees Joint Strategic Needs Assessment (JSNA) 2009Assessment (JSNA) 2009

Pain worst impact on health - physical function20% = 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 years 46% pain in past year: women >

men Poor sleep 1 in 3 Depressed 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 CycleThe NHS Commissioning Cycle

What do patients need to manage What do patients need to manage pain?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 + servicesConfidence in GP + their skillsSeeing right clinician at right timeContinuity of care: more seamlessConsistency of experience at all steps of pathwayFaster access: assessments + investigationsFaster access: Physiotherapy, Occup.Therapy, Pain

Specialist

What do primary care clinicians What do primary care clinicians need?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 Kirklees Council Scrutiny Panel for Health Inequalitiesfor Health Inequalities

20102010Main recommendations:Consistent pain services - person

centred approaches to pain management

Services closer to homeTraining & professional development

about self management options Reduce referral times – physiotherapyPilot person centred chronic pain

service across Kirklees

Pathway Objectives Pathway Objectives forfor NHS NHS KirkleesKirklees

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 OutcomesPatient 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 +

depressedReduce unhealthy behaviours: weight loss, stop smoking,

more physically activeReduce in health care use: GP, specialist referrals

Patient Reported Outcomes Measure Scores

PathwayPathway

Commissioning services: Commissioning services: so people self care better in Kirkleesso 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 Self management resources neededneeded

Tier 1

Tier 2

Tier 3

www.npowered.co.uk

www.paintoolkit.org/

www.overcoming.co.uk/

Resources in clinics, libraries etc

Oral + written information =

important as drugs, test, scan or surgery

Information needs change over time

Clinicians need more medicines Clinicians need more medicines management guidancemanagement guidance

Neuropathic Pain algorithmOpioid algorithm

Boost confidence so prescribe safely, effectively + ££Provide range of patient tools: self assess + self manageProvide 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 Commission pain specialist procedures 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 yearsOutcomes so far – 4 yearsTier 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 Management GP survey - use + helpful, costs

flattening + savings GP implement incentive scheme - drugs + self care referralSelf care services Greater use + more proactive care

pharmacy schemes, leaflets, other ways etc

Key messagesKey messagesPeople 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

• 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

• 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

• 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

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

Patient & Health Care Professional – Shared decision makingand discussion of self care options to support motivation to change and manage social, emotional and physical impact of LTC

Referring patients to self care Referring patients to self care servicesservices

Kirklees approachKirklees approachChronic Pain as a Long Term

Condition (LTC)LTC organisational structureChronic Pain programmeChronic Pain - Health

Improvement Team (HIT)

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

• 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?

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

Mind the gapEveryone needs skills + resources

TimescalesTimescalesPhase 1(June 09)- experience of

chronic pain, current service provision and needs for future.

Over 70 participants attendedPhase 2 (Sept 09) – presenting draft

care pathway & whether it meets service user needs.

Over 25 participants attended

Phase 1 - key issuesPhase 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 Chronic condition management as applied to the NHSNHS

3. 5% case management

2. 15-25% Condition

management

1. 70-80% self-management

LTC framework

NHS Kirklees LTC Programme Delivery

Group

Kirklees LTC Partnership Board

LTC HITS (Health Improvement Teams)

Cardiology PainStroke NeurologyRespiratory Self CareDiabetes & Renal Dermatology

LTC programme delivery group

WORKSTREAM Workforce

capability and capacity

LTC Project Boards

TelehealthPredictive risk

NHS KirkleesStrategic Development

Commitee

WORKSTREAM Rehabilitation and

self care

WORKSTREAM Information and

performance

WORKSTREAM Personalised care

planning

LTC Programme Dependencies

End of Life Older PeopleIntermediate care Urgent Care Medicines Mental healthManagement Planned careCHIK Programmes

LTC frameworkLTC framework

NHS Kirklees LTC Programme Delivery

Group

Kirklees LTC Partnership Board

LTC HITS (Health Improvement Teams)

Cardiology PainStroke NeurologyRespiratory Self CareDiabetes & Renal Dermatology

LTC programme delivery group

WORKSTREAM Workforce

capability and capacity

LTC Project Boards

TelehealthPredictive risk

NHS KirkleesStrategic Development

Commitee

WORKSTREAM Rehabilitation and

self care

WORKSTREAM Information and

performance

WORKSTREAM Personalised care

planning

LTC Programme Dependencies

End of Life Older PeopleIntermediate care Urgent Care Medicines Mental healthManagement Planned careCHIK Programmes

Reviewing pain servicesReviewing pain servicesInvolve 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 usersEngagement of service usersRecruitment – Public & Patient

Involvement (PPI) database, via pain services, Expert Patient Programme (EPP) support groups

Discussion groups across KirkleesSessions facilitated by PPI team and

Public HealthReport back to service users for

comments

Proposed care pathwayProposed care pathwayOverall support for the proposals:Liked patient centred approach- HNA’s

and health trainer inputImprove access to GP /primary care -

referral to specialist servicesWant all GP’s to refer all patients to

self care servicesBetter condition managementImproved emphasis on control via self

care

And information + resources…..And information + resources…..what patients need to copewhat 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 surgerySource: Patient-focused intervention A review of the evidence Angela Coulter, Jo Ellins Picker Institute 2006

Key drivers nowKey drivers nowNational 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 painCondition Order of impact on health

Pain Worst Impact

Heart Disease

Backache

Depression

Stroke

High Blood Pressure

Diabetes

Asthma Least Impact

Coping: the efforts to deal with stressful situations that tax orexceeds 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.

Living with pain… and Living with pain… and LTHC’sLTHC’s

Health needs assessment toolHealth needs assessment tool patients guide us…. patients guide us…..their agenda.their agenda

1000 + Patients using a specific HNA tool in 1000 + Patients using a specific HNA tool in clinical settingsclinical 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