Written evidence submitted by The Faculty of Pain Medicine of the Royal College of Anaesthetists (CBP0046)

 

 

The Faculty of Pain Medicine of the Royal College of Anaesthetists (FPM) is the professional body responsible for training, assessment, practice and continuing professional development of specialist medical practitioners in Pain Medicine in the UK.

 

The FPM is submitting evidence to this inquiry as services across the four nations have been significantly impacted upon, with reports of severe backlogs within services. 98% of Pain Medicine doctors are from an anaesthetic background, a specialty which has played a critical role in the pandemic. During various times in the pandemic, there has been significant redeployment of pain medicine doctors to anaesthesia and critical care units, thereby impacting upon the delivery of Pain Medicine services across the UK. The evidence submitted consists of insights and findings from wide ranging work through our professional standards and training committees as well as reports from our Fellows.

 

Executive summary

Our submission below details the issues caused by the backlog due to the pandemic

 

 

What is the anticipated size of the backlog and pent-up demand from patients who require referral or treatment at specialist community, secondary and tertiary pain services?

The COVID-19 pandemic has had a significant impact on the delivery of holistic pain management and the delivery of specialist training. The Faculty of Pain Medicine of the Royal College of Anaesthetists (FPM) is aware that since the start of the pandemic, pain services across the country have faced new challenges, including redeployment of multidisciplinary members of pain teams, lack of access to outpatient and imaging facilities and increased risks of pain intervention procedures. In addition, for some time GP referrals reduced significantly due to patients’ reluctance and/or difficulty in seeking medical advice as well as challenges faced by doctors in general practice in seeing patients in a timely fashion.

During 2020 and 2021, the FPM has produced extensive guidance on managing various aspects of clinical care and the necessary changes to adapt to working with COVID-191. Moreover, significant input has been put into place to continue to support the training of doctors and other allied health professionals in Pain Medicine in spite of the disruption of services.

There has been a historical discrepancy between the demand and capacity of pain services across the four nations with numerous reports2 highlighting variations in pain clinic provision between services, particularly in the provision of multidisciplinary services and length of waiting times.

In May 2020 the FPM undertook an initial situational survey examining the changes of delivery in chronic pain management during the early phases of lock down.  That survey showed a profound impact of COVID on pain practice.  25% of clinicians reported that their services had been fully suspended. There was a significant shift towards telephone and video consultations and around 90% of units had stopped all procedure lists. There was significant redeployment of pain staff to contribute to the health requirements of the COVID pandemic. 

A second COVID survey3 was subsequently undertaken for a three-week period from the 6th August 2020 until the 31st August 2020.  The central aims of this second survey were to consider the state of re-opening, the clinical changes made in pain management in the NHS and to collate the experiences of Fellows of the FPM.  This second survey was designed to capture the varying experiences of Fellows during the evolution of care and the adaptions and initiatives undertaken since the outbreak of COVID across the United Kingdom.

Over the data collection period in August 2020, all Faculty Fellows were invited to participate in the survey.   The survey was undertaken electronically and contained demographic questions, specific questions related to COVID-19 and questions designed to investigate changes from usual, pre-covid practice.  This covered both outpatient pain services and in-patient services.  Information about the satisfaction and experience of remote consultation was collected. The survey investigated barriers to best practice and the viewpoints of Pain Doctors.  In addition, there were questions related to safety and the availability of PPE.  There was a total of 21 questions. 

Thematic analysis of the raw data was undertaken on answers from open questions.

Demographics

Responding clinicians were distributed widely from England, Scotland, Wales and Northern Ireland.  The collation of names of institutions indicated that responses were received from large teaching hospitals through to smaller district general hospitals.

 

General Issues

Only 20% of the respondents indicated that their pain services had returned to full activity.   Only half of respondents indicated that all pain team members were back at their normal roles.  Just under 10% of respondents reported that staff had taken leave through sickness because of burn out or stress.  A small minority of respondents indicated that they were not at work and this was either due to psychological consequences of COVID, sickness or a need to self-isolate.  In-patient services were heavily affected by the pandemic, with 50% of respondents reporting that after March 2020 in-patient services were providing only ‘minimal care’.  Only one in five respondents indicated their in-patient services were able to continue as normal.

Type of appointments

Around 78% of respondents were providing one or both telephone and video consultations. More telephone consultations were undertaken than video consultations.  However, 17% of units reported not undertaking remote consultations. 

Triage and consultation type

A common approach to the allocation of consultations involved offering an initial remote consultation - around 40% of respondents. Around a third of respondents offered more than 50% of patient consultations remotely.  There was divided experience on whether arrangements for new and follow ups differed with just under half the units stating that they did differ.  

Duration and effectiveness of remote consultations

10% of respondents were very satisfied with video consultations and 32% less so [quite satisfied]; around 10% of respondents were dissatisfied.  There was divided experience about whether remote consultations for new patients took longer, shorter or the same.  Most thought they took around about the same time.  The majority - 54%- thought that remote consultations were less effective though more respondents stated that they were easier for patients than harder. Some stated video consultations were used due to a lack of better alternatives.   

70% were satisfied (very or quite satisfied) with telephone consultations while the greatest number (around 40%) viewed these to be similar in time required as for face-to-face consultations with a mixed distribution of respondents to “less time” [27%] and “more time” [17%].   

The majority thought that remote consultations were better for review appointments. The highest number of respondents felt that the remote consultation was about the same length (40%). There was an equal number reporting they took either longer or shorter.  The majority of other services relating to the multi-disciplinary team and the majority of other team members were similarly undertaking remote consultations.

Redeployed staff

Around a quarter of respondents indicated that multi-disciplinary pain management team members were entirely re-deployed and 62% said that they were partially deployed indicating that at the time of the survey there was still significant ongoing deployment of staff due to the COVID pandemic.

Injections

It seems that around 40% of units were (gradually) increasing the number of injection procedures but 30% were still offering only a small number of injections for the most urgent cases.  Around 30% indicated that their injection services had not resumed. 

Pain Management Programmes

Regarding pain management programmes only 8% of respondents indicated their units were offering these in a socially distanced environment with other respondents indicating a spectrum of other strategies employed including online courses, face to face appointments in a socially distanced environment, remote assessments and online resources.   Around a quarter of units stopped pain management programmes after lock down and had not reinstated activities.   Most respondents were satisfied with video MDT meetings.

Safety

Around 25% of respondents felt that a lack of safety equipment and PPE had impacted their ability to deliver care.

 

 

Themes of survey review

 

Theme

Survey 1

Survey 2

Number of respondents

193 respondents. Broad representation across regions.

128 respondents. Some differences in regional proportions

Consultations 

Nearly a quarter in the first survey had stopped consultations completely now nearly a quarter have returned to full activity. 

Clinician – patient interactions stopped 22 % first survey

23% returned to full activity

Mode of consultation

Appears to be gradual increase in number of face-to-face consultation and becoming increasing ‘norm’ but continued use and availability of remote consultations.
 

67.84% No face to face 

No Remote consultation 32/190

Vetting service for suitability for remote

23% returned to full activity

Others gradually increasing

F2F dependent upon urgency/ type of appointment/ patient preference

Only 32/128 not accessing patients remotely due to lack of resource or patient opt out. Appears the norm unless specific indication why or patient choice.

Satisfaction with Remote consultation

Appears to be a general increase in satisfaction and efficiency of consultations over time.

Specific question not asked

13/128 dissatisfied with video

Efficiency of remote consultations

43/129 longer than usual

69/129 remote less effective 
 

28/128 longer than usual (video)

23/128 longer than remote

14/128 ineffective 

18/128 telephone dissatisfied
 

Pain injections

85% stopped (164/193)

12% (17/128) remain folded 

 

The following is a summary of the key findings from the second survey:

 

 

Overall, the second survey showed there had been radical changes in pain practice across the United Kingdom following COVID.  There has been an increased reliance on video and telephone consultations. There was evidence of significant re-opening but most services have not returned to normal in many different ways. This included lack of recommencing of injections, problems with delivery of pain management programmes and greatly reduced use of face-to-face consultations.  There was a vast array of different experiences of individuals in a local context. The majority of people felt safe at work but this was not always the case and the supply of PPE did occasionally impact on working.   Clearly there are limitations with a snapshot survey of this type.  There was no way of establishing the degree to which respondents in one survey were the same as in the first survey inhibiting the test re-test analysis, though the data clearly provides impressions of what is happening nationally and the weight to give to some highly vocal responses.

The Faculty of Pain medicine will continue to monitor the situation.  A year later, anecdotally from shared experiences of clinicians sitting on the Board of the FPM and its two major committees, the Professional Standards Committee and the Training and Assessment Committee, pain services in the country continue to report severe back logs in all aspects of delivery including new patient waiting times, access to multidisciplinary services, group sessions including pain management programmes. Moreover, return to providing pre-COVID style pain management services are being hindered by the need to socially distance patients in waiting areas, pain intervention facilities and group sessions.

It is heartening to note however that various Fellows across the country have been embracing innovative ways of delivering Pain Servicesin particular remote delivery of pain management programmes and other group delivered sessions – time will tell what impact these innovations will have on current waiting times and limitations in delivery.

NHS Digital Data

A review of NHS Digital Statistical Data yields no specific data regarding waiting times for Pain Management Code 191.

A review of Nuffield Trust “Elective Planned treatment time quality watch indicator4” last updated April 2021 produces data for several specialities.  Pain Medicine is not listed and we are assuming that it is included in the “Other Specialties” in Figure 2 below. Figure 1 shows general waiting times for all referrals from GPs including Pain medicine, most of which referrals will fall under the “Routine Section”. 

Figure 1

Figure 2

The Faculty of Pain medicine is also actively monitor training.  All medical trainees undergoing Higher and Advanced Pain training were given the opportunity of a one-to-one meeting with the Chair of the Training Committee and/or senior members of this committee. This was to ensure that despite the disruption in services as well as the redeployment of trainees to critical care units during the peak of the pandemic, training programmes were modified to ensure that each trainee underwent a comprehensive bespoke training period and achieved the required competencies.  An FPM-Learning digital website was also launched to support with remote learning in the absence of formal academic teaching which was significantly disrupted.

The Faculty of Pain Medicine in conjunction with our parent college, the Royal College of Anaesthetists, has and continues to provide signposting towards resources5 to support the wellbeing of its Fellows and doctors in training, in recognition of the considerable challenges faced during this pandemic.

 

 

What capacity is available within the NHS to deal with the current backlog? To what extent are the required resources in place, including the right number of staff with the right skills mix, to address the backlog?

The Faculty of Pain medicine undertakes a census every five years. The last census was in 2017, and work is already in progress to repeat another census in 2022. The number of Pain Medicine consultants and Staff and Associate Specialist doctors is estimated to be circa 615, with circa 30 doctors annually training in Pain Medicine.  As many consultants undertake only Acute/Inpatient Pain sessions, the number of consultants may be closer to 500 still active in chronic pain

Pain Medicine is historically under resourced.  The population of the UK is 66.85m (2019), meaning there is one Pain Medicine consultant per 109k of the population.  This compares to one Pain Medicine consultant per 77k of the population across Australia and New Zealand

There is national variation, with an average of 1 doctor per 100k of the population in Scotland, but over the border in the North of England, there is 0.4 doctors per 100k of the population. See Figure 3

98% of Pain Medicine doctors are from an Anaesthetic background.

The average (mean) number of pain Direct Clinical Care Programmed Activities (DCC-PAs) worked was 4.24 per week across an average of 8 total DCC-PAs.  This means the workforce works on average half of their time in Pain Medicine and half in another specialty.

61% of the workforce are aged over 46 years of age (up from 56% in 2015), indicating an aging workforce.

A clinical National Audit done using the standards of the Faculty of Pain medicine, over 4 years2 held prior to the pandemic showed that per annum, 0.4% of the total national population was estimated to attend a specialist pain service. A significant improvement in multidisciplinary staffing was found (35–56%, p<0.001) over the 4-year audit programme, although this still required improvement. Very few clinics achieved recommended evidence-based waiting times, although only 2.5% fell outside government targets. Safety standards were generally met. At that point it was noted that waiting times and staffing require improvement if patients were to get effective and timely care.

An ageing population brings with it increased incidence of musculoskeletal and spinal pain, cancer pain, diabetes and associated painful morbidities, postsurgical pain from complex surgical procedures, visceral pain and ischaemic heart disease.  Unfortunately, a siloed approach to commissioning has led to decommissioning of some important specialist services.  We fear, without our intervention, that there would have been even more essential services lost.  Decommissioning of pain services also has a further impact on reducing training facilities for the future workforce.

There is therefore clearly limited capacity to deal with the current back log and this will be further impacted upon if there is another wave which requires that some of its Fellows and doctors in training are redeployed once again to work in Critical Care Units.

Various units across the country are trying to cut down on waiting times by asking their teams to work additional sessions during the weekdays and weekends.  This, however, cannot be sustained indefinitely as the workforce is already under considerable strain and there is a significant risk of burnout and increase in doctors taking early retirement.

 

Figure 3

 

 

How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term?

Living with chronic pain poses a huge challenge to patients and has a significant impact on NHS resources. There is no doubt that early intervention plays a significant part in preventing long-term disability and chronicity.

Eight million people in the UK7 live with pain of at least moderate intensity of which 50% have severe pain preventing normal daily activities. The prevalence of chronic pain doubles over the age of 65yrs. This has a significant impact on society relating to quality-of-life changes, days off work, provision of social care (private or state provided), utilisation of health care and has a significant financial burden on society. The National Pain audit8 from 2012 clearly demonstrated a significant variation in terms of what pain services deliver across the country, demonstrating a clear gap in how pain is managed nationally. An FPM audit of Clinical Commissioning Groups done in 2018 showed that only 20% of CCGs believed sufficient money was being set aside to meet the needs of patients with chronic pain. Another audit done by the FPM of UK pain services, completed in 2019 prior to the pandemic showed that waiting time from pain onset until referral by GP to a pain clinic was 5.97 years (mean) and range 1 month to 35 years. Time to first appointment in a pain clinic was 23 weeks (mean) and range 1 week to 29 months.

This clearly makes a case for the need to train more doctors to be able to care for patients with complex pain needs. Bearing in mind the last workforce census data, this need is significant and urgent.

With this in mind the Faculty of Pain Medicine has developed a National Pain Strategy document which aims to provide an overarching framework to deliver improved pain management across the whole healthcare including supported self-management and the third sector.

It outlines a delivery system with national standards but incorporates regional and local implementation making best use of current facilities whilst ensuring equality of care for all wherever they may live.

The process is patient focused from point of first contact including: self-help signposting, personalised care and shared decision making.

It provides opportunity for service integration, new ways of working, best utilisation of funds with the patient at the centre of the process at both individual and population levels.

The Faculty of Pain Medicine is also currently in the advanced stages of developing a GMC approved Credential for the Pain medicine specialist.  It is one of five specialties chosen by the GMC to pilot the concept of Credentialing. The purpose of a Credential in Pain Medicine is to allow the identification of doctors who have the necessary specialist professional and clinical capabilities to manage patients with acute and chronic (long-term) pain disorders. It will open the route to other non-anaesthetic specialities to train in Pain Medicine. 

As far back as 2017 when the concept of Credentialing started to evolve, the FPM had various informal discussions with other Colleges and Training Bodies including the Royal College of Physicians and the Joint Royal College Training Board with representatives from the Palliative Care Physicians, Neurologists, Rheumatologists and Rehabilitation medicine.  

The significant majority of Pain services in the UK have very close working relationships with these four allied specialties and it is widely agreed that the ability to have common access to training in Pain Medicine for the latter four specialties is likely to lead to a more seamless integrated practice which will be of great benefit to patient care and moreover also remove the unnecessary duplication of input which will result in better use of precious NHS resources.

The concept of Credentialing in Pain Medicine also has support from Specialty Grade SAS doctor representatives as evidenced by the recent Task and Finish Group organized by the GMC wherein various of the members present were such representatives and all spoke very much in favour of both the need for this Credential as well as the fact that it will allow SAS doctors who are already trained to be recognised and is likely to appeal to other SAS doctors who may be considering training in Pain Medicine.

We have broad 4 nation support with regards to the concept of Credentialing Pain medicine and providing a seamless integrated service across primary, secondary and tertiary care. The Credential is part of the FPM ‘Pain Strategy’.

Pain is common; Services are poorly organised and this has a huge impact on patients and society. There has been a lot of work over recent years to provide significantly improved patient pathways, management strategies and opportunities to integrate management.

Over the last 12-18 months there has been an awareness, and interest centrally to address this. The focus has been mainly via MSK services, and by moving patients with medically unexplained pain into the IAPT services (some areas), this misses a significant number of patients with pain that is neither musculoskeletal nor medically unexplained.

In July 2020 the FPM had a meeting with the RCGP and RCoA regarding pain management overall. The outcome was to consider developing a national strategy. This is the first real output following some earlier versions that highlighted the policy’s, guidelines, gaps and positives elements of the current situation. This has allowed this broader structural strategy to emerge.

There is a significant focus on Integrated care systems, with Pain Management seen as moving into community settings. The Personalised Care Institute is also driving this agenda.

From the perspective of Pain Medicine, talking and listening to colleagues within the MSK COVID group (includes rheumatology, physiotherapy, patent organisations, surgery) it is clear there is an understanding that good Pain Management is important, and that although a lot could, and should, be managed in the community there is a need for Specialist Pain Services. It is also recognised that new ways of working are required that cross the traditional commissioning boundaries. Proper clinical integration between all sectors (community, primary care, secondary care and third sector) is required if patients are to gain optimal outcomes.

Crucial to this is recognition of Pain Medicine as a Credential and pain education as a whole, to help further establish the importance of Pain Medicine as a critical facet of good medical practice, alongside more established disciplines.

There is genuine support for this within the Royal College of General Practitioners, Royal College of Anaesthetists, British Pain Societies and various Patient Support Groups.

Moreover, a Clinical Reference Group (which includes FPM membership) has been established to decide a commissioning framework for specialised Pain Management Services, that is those specialised pain management services which need to be nationally commissioned. It has been estimated that there is a need for 6-10 national centres in England.

Pain Medicine has also had discussions with GIRFT (Getting it right first-time national project) and it anticipated that GIRFT will be reviewing Pain Medicine when funds are available.

As we have already alluded to earlier, historically Clinical Commissioning Groups have been very supportive of Pain Services and indeed in areas where secondary care pain services were decommissioned, alternative providers were tasked to provide such services.  However, this in some areas has resulted in a significant variation and postcode lottery in terms of access and standard of services provided.   This was also highlighted by the National Pain Audit.

There is undoubtedly a need for a significant increase in the number of doctors trained in Pain Medicine and both the FPM and our Fellows look forward to working with the new Integrated Care Systems to achieve a greater integration of Pain Services, improving population access and reducing inequalities. Credentialing Pain medicine will undoubtedly allow the FPM to provide a sustainable work force to achieve this goal in the NHS Long Term Plan.

As part of the wider NHS Sustainability and Transformation projects and Integrated Care Systems, the FPM is currently in discussions with HEE regarding the setting up of a Credential for Advanced Health Care Practitioners in Pain Management, developing the workforce to deliver multidisciplinary community-based pain services, addressing patients’ needs at an earlier point in time, improving triage, access to management and ensuring appropriate communication, referral, and integration with pain management services at secondary level. This is likely to mean that patients will require a briefer intervention, with better outcomes and will be more cost effective for the NHS as well as the greater society at large. Support for the HEE Credential has been sought and obtained from the devolved nations.

Doctors awarded the GMC Credential in Specialist Pain Medicine will be the trainers, Leads and support the system for the HEE Credentialed Advanced Health Care Practitioners in Pain Management.

Developing this HEE Credential in Pain management together with this GMC Credential in Pain Medicine will provide the core workforce where pain management integrates across other services, be they, community, primary care, specialist services or pain specific services, including psychological, mental health, social services, secure environments, disability services and transition services.

Key components will include early access to pain services in the community with triage, patient education, patient empowerment including shared decision making, supported self-management, personalised care, medicine optimisation and early return to functional capacity with an emphasis on return/remain in work and/or education and a reduction on reliance on the welfare system if appropriate.

The GMC Credential will provide a sufficient cohort of well-trained doctors working to FPM professional standards. Access from different specialities to the Credential will mean that these Credentialed doctors will all bring in their own specialism background but have a common goal in managing pain. They will be able to support and train the community services but offer a seamless step up to secondary and tertiary services for complex patients. A similar “step-down” facility can be provided for patients who can be discharged from secondary pain services but are not ready to manage without input.

The Faculty of Pain Medicine has developed standards and guidance that allows commissioners to make informed decisions on commissioning, better preserving effective pain services. The second edition of the Core Standards for Pain Management Services (CSPMS)9 have just been published. It is a collaborative multidisciplinary publication providing a robust reference source for the planning and delivery of Pain Management Services in the United Kingdom.  It is designed to provide a framework for standard setting in the provision of Pain Management Services for Healthcare professionals, commissioners, and other stakeholders to optimise the care of our patients.

The Faculty of Pain Medicine also provides commissioning guidelines in its document: Improving the Lives of People with Complex Chronic Pain and how to Commission Effective Pain Management Services in England10

 

What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic? How could this support the future work of the NHS and care services?

 

We are aware both from our surveys as well as anecdotal reports that our Fellows have risen to the challenge of working in the current pandemic, in particular embracing the need to use technology to provide remote consultations both to individual patients and in group settings.  Remote technology has also been embraced to provide formal teaching to our doctors in training11.

The Faculty of Pain Medicine has also issued multiple guidance documents through its Professional Standards Committee and Training and Assessment Committee, (see FPM website) produced in real time as the pandemic evolved to support both its Fellows and its doctors in training.  It has also written an addendum to the Improving the Lives of People with Complex Chronic Pain and how to Commission Effective Pain Management Services in England guidance to highlight some of the key challenges that exist with commissioning and provision of care for people with pain during the COVID-19 pandemic and signposting some of the themes that need to be considered12.

 

What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges?

Chronic pain is a very common disease and it seems likely, while yet unproven, that an additional load to chronic pain clinics will result from the Covid disease process itself – Long COVID (widespread muscular pain, postinterventional pain from intensive care, post-stroke pain and pain from deep venous thrombosis)12

Although most people adapt well to pain and manage it successfully, post-COVID-19 there are increased inhibitory factors upon people’s ability to cope and manage. These involve restriction on exercise and socialisation as well as the psychological impact of COVID-19 in families including bereavement, potential delays in care, absence from work, disturbance to routines, increased risk of unemployment and domestic abuse.  Many people with pain are likely to have reduced their levels of physical activity. The social threats of the COVID-19 pandemic are postulated to impact most severely on people with chronic pain.

Commissioning needs to reflect different ways of working during the various stages of the COVID-19 pandemic response, including support for remote consultations by telephone and video, safe and prudent planning and provision of pain interventions, as well as access to self-management strategies that, will for the most part, not be undertaken face-to-face. Treatment should be tailored to individual patient need as well as demographic factors and undertaken in a timely way if possible. In addition, obstacles to effective treatment through digital poverty need consideration including provision of on-line hardware to enable self-management.

Wellbeing services should offer enhanced support to isolated people, including consideration of social prescribing link workers and wellbeing services.

The impact of COVID-19 varies across different socioeconomic and ethnic groups needs to be recognised. Adverse outcomes from COVID-19 are also more likely to occur in individuals that have other associated medical conditions which is greater in the chronic pain group. It is likely that the overall outcomes from COVID-19 will be worse in people with chronic pain and commissioning should reflect these issues.

An integrated multidisciplinary approach must be provided for people with complex pain who are at greater risk of poor outcome. Given that early biopsychosocial intervention in the lower risk groups may be associated with better outcome, it is likely that COVID-19 will adversely affect access to treatment for people with chronic pain. Throughout the COVID-19 crisis, measures should be put in place to enable these people to continue to be identified and treated early as far as possible.

Reliable access to specialist secondary care support is required for the more severely affected patients. GPs require rapid access to advice on management and medications through e-referral advice. Referrers should make best use of community services to support patients before referral. This may include local innovation of community services.

Guidance for prioritisation should be transparent with established care pathways with appropriate waiting times. It is clear that the significant impact of the pandemic on General Practice provision will inevitably have a knock-on effect on the care of people with pain as a whole e.g., through reduced identification of high-risk individuals, impaired early intervention, and late diagnosis.

 

Commissioning for pain management must aim at limiting this impact and reflect optimal ways of working. This may include systems changes such as rapid on-line advice, e-referrals for support and changes in medicine management.

A requirement for onward referral to secondary care pain services is that no underlying cause can be identified to treat a person with pain on a condition specific basis. The interference from COVID-19, leading to disrupted or delayed access to investigation and subsequent diagnosis will impede this process of forward referral to specialist pain services. Despite complex issues, referral to specialist pain services should continue. There is no evidence that suspension of referrals is beneficial. With the reprioritisation of pain specialists to other duties including intensive care, Trusts must have active mechanisms to preserve pain services as chronic pain may be at the lower end of reopening priorities compared with other more acute services. Grading and prioritisation of referrals is even more important and triage with cancer pain being most urgent.

The addendum to the initial commissioning document12 highlights some of the key challenges that exist with the commissioning and the provision of care for people with pain in the COVID-19 pandemic and signposts some of the themes that need to be considered in commissioning processes during the COVID-19 pandemic. This addendum should be considered alongside the primary commissioning document and other FPM pain documents on the COVID-19 pandemic. It is inevitable that many of the solutions to problems highlighted will inevitably involve effective local commissioning and successful implementation of frameworks of care, retaining individualised treatment and not a one size fits all prescription.

The Faculty of Pain Medicine requires support to implement its Pain Strategy.  Approval of both GMC and HEE Credential would ensure that there is a work force across the whole of the Health Service that is able to meet the demands and provide equitable services without postcode lotteries.

Key components will include early access to pain services in the community with triage, patient education, patient empowerment including shared decision making, supported self-management, personalised care, medicine optimisation and early return to functional capacity with an emphasis on return/remain in work and/or education and a reduction on reliance on the welfare system if appropriate. “Step-up” to secondary services for complex patients will be put into place and a similar “step-down” facility provided for patients who can be discharged from secondary pain services but are not ready to manage without input.

 

References:

  1. https://www.fpm.ac.uk/standards-guidelines/evolving-challenges-delivering-pain
  2. Cathy Price, Amanda C de C Williams, Blair H Smith The National Pain Audit for specialist pain services in England and Wales 2010–2014, British Journal of Pain - First Published December 7, 2018 https://doi.org/10.1177/2049463718814277

 

  1. https://www.fpm.ac.uk/documents/survey-resumption-chronic-pain-services-during-covid-19/introduction

 

  1. https://www.nuffieldtrust.org.uk/resource/treatment-waiting-times

 

  1. https://www.fpm.ac.uk/careers-workforce/wellbeing

 

  1. The second Workforce Census of the Faculty of Pain Medicine of the Royal College of Anaesthetists: https://www.fpm.ac.uk/careers-workforce/workforce-planning

 

  1. Murray CJ, Richards MA, Newton JN, Fenton KA, Anderson HR, Atkinson C, et al. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet. 2013;381(9871):997-1020. https://vizhub.healthdata.org/gbd-compare/ 
  2. The National Pain Audit, 2010 – 2013 https://data.england.nhs.uk/dataset/the-national-pain-audit/resource/3980731b-8bb3-4d4e-9ca5-a03cee96322d
  3. Core Standards for Pain Management Services (CSPMS) second edition

https://www.fpm.ac.uk/standards-guidelines/core-standards

  1. Improving the Lives of People with Complex Chronic Pain and how to Commission Effective Pain Management Services in England https://fpm.ac.uk/sites/fpm/files/documents/2020-06/Commissioning%20guidance%20draft%20design%20FINAL_0.pdf
  2. FPM- learning https://fpm.ac.uk/fpmlearning
  3. Evolving challenges in delivering a pain service during the COVID-19 pandemic https://fpm.ac.uk/sites/fpm/files/documents/2021-03/commissioning-and-covid-19.pdf

 

Sept 2021

 

 

 

 

 

 

 

 

 

 

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