Integrated Pain Management HIT To provide a fully integrated, multidisciplinary, life span clinical service for chronic pain that brings together senior clinicians, researchers and local and national health commissioners with service users across Bristol and Bath

The Problem  Over 5 million people/year in the UK develop chronic pain and only two-thirds recover. 11% of adults and 8% of children report chronic pain: ~8m people in the UK  Common causes include musculoskeletal and neuropathic (diabetes mellitus, cancer and HIV) both of which are increasing in prevalence  Chronic pain is hugely detrimental to an individual’s quality of life and places an enormous emotional and financial burden on patients, carers and society  Over 25% of people with chronic pain lose their jobs within 5 years of diagnosis  Chronic pain costs >£15 billion/year in the UK of which £4 billion is attributable to childhood pain  Current drug treatments are largely inadequate and there is a huge unmet clinical need. Existing treatments need to be optimally used  More effective long-term therapies are urgently required

Aims of the HIT  Focus on improvements in performance, productivity and efficiency  Simplified and integrated pathways for the major causes of chronic pain  Service users will be given evidence based and cost-effective interventions at the correct time, in the right setting and by practitioners with appropriate expertise  Ensure that our multidisciplinary research programmes and international expertise in the management of chronic pain are fully integrated into the clinical services  A reduction in health and social costs  Generation of novel evidence based interventions that will inform future changes in clinical practice  Setup an interdisciplinary rotational training and education programme across all of our centres  Improve the uniformity of clinical services  Train the next generation of clinicians who will deliver our pain services  All work will be informed by existing and new public and patient involvement initiatives

Current Challenges  Generate an integrated regional chronic pain pathway that optimally delivers cost-effective clinical care  Stop patients “bouncing” around the system  Fewer patients will be inappropriately seen in secondary or tertiary care  A system-wide reconfiguration is complex and there are significant difficulties in addressing issues relating to demand, capacity and tariff  Pilot “one-stop shop” for chronic pain assessment  Integrated assessment by a physiotherapist, pain consultant and psychologist  Sited in a primary or secondary care setting  Generate a clear management/treatment plan for patient and GP  Only a minority of patients then need to be seen in a specialist secondary care settings  Evaluate patient satisfaction and cost-effectiveness (decreased utilisation of healthcare resources) compared to treatment as usual (TAU) in a similar population e.g. MATS

 The CCGs were supportive of the pilot but had concerns:  How the required data for evaluation on healthcare usage would be obtained (and by whom) for the control group  Given the very long waiting lists, patients in the control group may not be seen by each relevant service within the timeframe of the pilot  How would a one-stop assessment clinic be rolled out as a commissioned service, given the very long waiting lists at NBT and UHBristol with no capacity in the system  The closure of the spinal pathway has exacerbated issues of demand and capacity  The CCGs are currently considering how to reduce:  New referrals to secondary care  Use a standard proforma which would allow triage of some referrals. Reluctance to give this to GPs for completion due to consultation time pressures  Follow-ups in secondary care  Decreased usage of pain management interventions that are less well evidenced (e.g. acupuncture and facet joint injections) Problems