Chapter 3: Scottish Government Response - Setting out what next
Scottish National Chronic Pain Management Programme
National Specialist and Screening Services Directorate (NSD) has a role on behalf of all NHS Boards in Scotland and the people of Scotland, to commission specialist services. A specialist service will be commissioned where this has been agreed by Scottish Government based on the recommendation of National Specialist Services Committee (NSSC) and the NHS Board Chief Executives group.
In line with the Cabinet Secretary's commitment that a specialist service would be provided in Scotland a short life expert group, with full involvement of patients and service users, was formed by NSSC to develop a specification for a national specialist residential chronic pain management programme.
This group considered the findings of the responses to the public consultation published on 23 January 2014. Following the meeting of the expert group on 29 January 2014, the service specification was agreed and signed off, which includes reference to the referral pathway, the elements of the specialist programme to be offered, the accommodation needed to deliver the programme, and the support that will be required by individuals as follow up to their participation in the programme.
The service specification was approved by NSSC at its meeting on 5 March 2014. NSD has subsequently written to all NHS Boards in Scotland inviting proposals from them to deliver the residential Chronic Pain Management Programme for Scotland. NSSC has identified a small group to work with NSD to assess the proposals and to make recommendation as to which NHS Board will be invited to host the programme. NHS Boards are invited to submit proposals by 30 April 2014.
NSD will then work with the identified clinical team, local service management and the NHS Board to agree a Service Agreement which will ensure that the Scottish National Chronic Pain Management Programme will be provided in a safe, effective and person centred way.
NSSC will to report to the Scottish Government in May 2014.
An announcement on the location of the service will be made following approval and notification of the decision on the preferred provider. We anticipate that an announcement will be made by the end of May 2014.
Every effort is being made to ensure that the development of the service is taken forward swiftly. Following the decision on the approved provider a number of actions will need to be taken before the service will be launched. These will include:
- Undertaking any appropriate Equality Impact Assessments/Business Regulatory Assessments.
- Recruitment of staff and undertaking of any required training.
- Carrying out any necessary capital works.
- Development of treatment programme.
Scottish National Chronic Pain Management Programme - Service Specification
The Scottish programme will deliver an evidence based biopsychosocial approach, that will aim to replicate the current service provided by Bath. This means an approach which takes account of the complex interplay of biological, psychological, and social factors in the understanding of health and illness. The range of service elements which have been incorporated in the service specification of the new Scottish National Chronic Pain Management Programme are detailed below.
The programme will offer residential accommodation for those who wish to stay, however, it is not intended to offer an inpatient level of care, nor is it designed to offer specialist pain alleviating interventions (implantable devices, surgical resections, injections etc,) if these are required these will be arranged and/or delivered by through existing specialist or regional chronic pain management services.
The Scottish National Chronic Pain Management Programme will be available to all residents of Scotland who are assessed by the local chronic pain management service as likely to benefit from participation in the intensive residential programme of assessment and intervention which will be carried out over a 2-4 week period. It is expected that the patient's carer will also be directly involved at appropriate times. The programme is delivered through a mix of one to one and group activities with an emphasis on helping the individual with chronic pain to manage their condition more effectively.
Numbers of referrals have initially been estimated as 100 per year. However, the programme will be able to run on a monthly basis with up to 10 participants per programme.
Objectives of the programme are to:
- Offer a detailed biopsychosocial assessment which will include review of the referred diagnosis of chronic pain
- Promote the highest possible quality of life for patients with chronic pain
- Provide psychological and behavioural interventions that support patients (and their carers) to better manage their pain, enabling them to lead more normal lives with reduced disability
- Support clinicians and local care providers in managing their patients care
- Reduce recurrent inappropriate admissions and attendances to other health care services by promoting self-management
- Increase social and physical functioning, promoting return to work and maintaining productivity through employment
- Promote independence and wellbeing for patients through the provision of structured self-management support.
The programme will be delivered by a core multidisciplinary group of key professionals (clinical and academic) who have a remit to lead and deliver the highest standard of patient care, research, audit output, teaching and training in the area of complex pain and pain-associated disability, within a dedicated environment. The multidisciplinary team will be skilled in and have specialist interest and experience of working with patients with chronic pain. The team will consist of (as a minimum):
- Clinical Psychology.
- Specialist nursing - pain management.
- Occupational therapy.
- Medical specialist in chronic pain management.
Referrals to the Scottish National Chronic Pain Management Programme will be made through an existing local or regional specialist chronic pain service. In the majority of cases, as with the current service provision, referral to the programme will follow the patients participation in a local programme of chronic pain management but will be available to individuals who are unable to access local out-patient / day care because of issues of remote geography / difficult travel.
The National Chronic Pain Steering Group will help to ensure that awareness of service and the referral criteria are widely shared, alongside their existing work to increase awareness of local service provision and development of care pathways.
Following referral the team will undertake a range of specialist interdisciplinary and multidisciplinary assessments leading to the development of an agreed care plan including:
- Review of need for further investigations/pain interventions (may involve referral being returned to local/regional specialist team for action)
- Review of current pharmacological interventions
- Detailed biopsychosocial assessment
- Planning of appropriate psychological and behavioural interventions
All patients will be offered an initial specialist assessment to understand the individual needs of the referred patient and to explain the programme in detail. It is expected that the patient's family and / or carers will be involved in aspects of the assessment and offered the opportunity to participate in the actual programme itself. Patients can then consider whether or not they feel the programme is right for them and that they are able commit to it.
Following assessment it is anticipated that the 2-4 week residential chronic pain management programme will invite patients to join a group of 8-10 participants who will be encouraged to offer peer support as well as benefitting from the expert inputs from the multidisciplinary team.
Needs of specific groups
The current programme in Bath is able to offer tailored courses to match a range of needs for specific groups, for example individuals with similar experiences, situations or conditions. The consultation has suggested mixed views on the need for specific tailored courses, however, previous users of the service report that this can aid the peer support element of the programme and be of benefit in maintaining informal networks following attendance on the programme. The Scottish programme will aim to encourage peer support and where possible provide similar tailored provision however this will be largely dependent on referrals received. The main aim of the service is managing the effects of chronic pain and the impact of this on daily life, it will be available to all those assessed as likely to benefit from and appropriate for the programme, regardless of any underlying condition.
While the service specification developed primarily relates to a programme to be offered to adults, particular attention will be given to a number of specialist groups including children and young people and through transition to adult services. It is recognised that tailored courses for children and young people may be difficult to provide within reasonable timescales as the cohort of patients in this group is likely to be small.
The programme will need to meet the particular requirements for the range of groups identified as with any other service, in compliance with current Disability and Equality legislation.
Follow up and discharge
Following the programme participants will in most cases be discharged home with an agreed self-care plan and offered appropriate support to develop their independence/independent living. This will include specific patient experience questionnaire to be completed at appropriate time periods following discharge.
The consultation highlighted the need for clear information and advice. This is important at all stages in the patient journey and is an integral part of the Scottish Service Model for Chronic Pain. The new Chronic Pain website provides a national resource of information. Many of the local Service Improvement Groups have identified this as a priority and the National Chronic Pain Steering Group are working with boards to encourage sharing of best practice in this area to ensure the provision of consistent quality assured information.
In further supporting this, the Scottish National Chronic Pain Management Programme team will be asked to develop clinical guidelines, in partnership with local/regional services. Clinical guidelines will help to deliver a consistent approach within and across all Pain Management Programme (PMP) teams in Scotland, whilst continuing to support individual needs. When developed, these guidelines will be available to participants as part of the continuing support following attendance in the programme.
The consultation outlined the requirements of both the clinical space required and the need for suitable residential accommodation. The service specification mirrors these requirements and adds the potential option for hydrotherapy where this may be available. The host board will need to identify residential accommodation near to but out with the clinical environment that will need to be available for patients and carer/partner/family who will be encouraged to accompany the participant.
Boards will outline in their proposals to host the service indicative costs for providing the service. The successful NHS Board will, working with NSD, develop a full application for submission to the NSSC, to enable the service to be established as soon as possible.
A decision will be taken in discussion with the approved provider, as part of the Service Agreement, whether the existing arrangements for meeting travel costs will continue or whether these will be included in the financial arrangements of the new Scottish National Chronic Pain Management Programme.
A key theme from the response to the consultation was that although a Centre of Excellence is the preferred option - elements of the other options also had merit and could be considered in the design of a service delivered from a single location. In particular the use of telehealth solutions.
This view is acknowledged and supported by the Scottish Government and the Cabinet Secretary expressed this in his foreword to the consultation, stating that none of the options were mutually exclusive.
In providing high quality patient centred services we need to explore and provide innovative approaches to the delivery of our healthcare services. Respondents have not only identified this need but have also suggested ways in which this can be achieved.
The initial focus will be to establish the core service programme, however, as the service develops we would encourage partnership working with patients and communities to explore and test options to further enhance provision. The service will continue to evolve over time to incorporate new and emerging innovative approaches to ensure that the service will provide the most up to date care and treatment.
Further elements of the service will be introduced as the service establishes, for example web site, clinical guidance etc. Details of progress will be communicated with stakeholders and through public communication channels as appropriate.
Email: Gill Gunn