NHS: Pain Management Services

Earl Howe Excerpts

Wednesday 7th July 2010 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, this has been an excellent debate. I begin by expressing my gratitude to the noble Lord, Lord Luce, for calling it and congratulating him on the eloquent way in which he has introduced a topic which I know is close to his heart.

Chronic pain can be a devastating condition, as many of your Lordships have testified. It affects a large proportion of the population, especially those of advancing years. The noble Lord has already quoted a number of relevant statistics; let me just add another. Data from the Health Survey for England suggested that more than half of the total impact of disease on quality of life is due to pain.

There are examples of really effective, joined-up, multidisciplinary pain services providing support to patients as and when they need it. As the noble Baroness, Lady Pitkeathley, said, that is how it should be. But, all too often, patients do not get the support and the treatment that they need.

In his 2008 annual report, the then Chief Medical Officer, Sir Liam Donaldson, described how the system was failing to give sufficient priority to chronic pain. A key response from the previous Government was to agree funding for a national pain audit. We are maintaining support for this initiative, which is led by the British Pain Society in collaboration with Dr Foster. More than 200 pain clinics are already signed up to provide data. The work is being piloted and data collection will begin later this year. We are expecting a report in the early part of 2012. The audit will not only assess the organisation of local services—location, staffing and equipment—but also assess the quality of patient care across NHS providers by measuring activities and outcomes.

What can the Government do? Our vision for the NHS is for a transfer of power away from the centre down to the people who really understand what is needed: to patients, GPs and other front-line health professionals. It is only by doing that that we will fashion a health service that is truly patient-centred. This is why we intend to devolve budgets to GP commissioners, working in small local consortia. They are best placed to understand their patients’ needs and to prioritise and commission appropriate services, including multidisciplinary pain management services.

On average, someone with chronic pain will have direct contact with a health professional for only around three hours a year. The rest of the time they care for themselves. Patients therefore need to be informed. By our educating people about their condition and ensuring that they have access to support from others in a similar situation, people’s health can be significantly improved. This also helps to reduce the number of GP visits and prevent unnecessary hospital admissions as well as reducing the length of any hospital stays.

I recognise that some patients cannot take decisions for themselves or express themselves, among whom are children, as my noble friend Lord Alderdice rightly pointed out. The detection of children's pain can, however, be improved by strategies to facilitate their expression of pain in ways that are appropriate to their cognitive development and that can be understood by the adults caring for them. So there is work going on in this area.

Good management of chronic pain takes account of the whole person. People agree goals and actions to be taken in a personalised care plan. This allows people to make choices about the care that they receive. The issue of choice was rightly mentioned by a number of noble Lords. It puts people at the centre of any decisions about their care. As my right honourable friend the Secretary of State put it recently,

“no decision is made about me, without me”.

Information from care plans can also help commissioners consider how to use funds most efficiently to support people to self care and identify services that are successfully meeting patients’ needs and expectations. It also enables them to recognise gaps where there is unmet need. This is an important way for the patient voice to have direct influence over the design and commissioning of services in a particular locality.

Of course, devolving decision-making in this way does not mean that the Government are devoid of responsibility. There are a number of ways in which the Government and other organisations can support patients and front-line staff, ensuring that funding is spent on appropriate and effective services. First, we can ensure that clinicians and commissioners have up-to-date, evidence-based clinical guidance. The National Institute for Health and Clinical Excellence plays a key role here. As the noble Lord, Lord Luce, mentioned, NICE issued a clinical guideline last year on lower back pain and has more recently published a guideline on neuropathic pain. Over time, NICE will create a library of quality standards that support NHS organisations as they look for evidence on how to improve outcomes for patients.

Secondly, we can promote the development and diffusion of ideas on the service models that work best for patients. Patients with long-term conditions want services that are based in the community and which support and affirm their ability to manage their own conditions. They want to be referred to secondary and tertiary care only when really necessary. That requires excellent co-ordination between all levels of the system. One of the workstreams of the quality, innovation, productivity and prevention programme is focused on delivering this approach for people living with long-term conditions such as chronic pain.

Thirdly, we can promote the development of indicators of the quality and outcome of services. Outcome indicators will help patients to exercise choice and hold providers to account. They will help service providers to benchmark their performance against their peers and improve the services that they offer. They will help to ensure that any serious failure in quality is identified quickly and action taken to ensure the safety of patients.

An aim of the national pain audit will be to measure patient outcomes using the brief pain inventory scale—an accepted pain management assessment tool. This, combined with an assessment of patients’ outcomes using other patient-reported outcome measures, will make for a comprehensive review of the quality of care. The audit will help to identify indicators that could be suitable for routine use.

Finally, we can ensure that the right financial incentives are in place. The tariff system already ensures, in broad terms, that money follows the patient and that providers are rewarded for delivering best practice. We will build on that by increasing the proportion of provider income that is responsive to the quality, not just the quantity, of care provided. It is just worth adding that in due course, patients with long-term conditions may be able to influence their choice of treatment and provider even more directly through the use of personal health budgets, which are being piloted at the moment.

My noble friend Lady Morris spoke about acupuncture. Use of acupuncture in the NHS is quite limited. The National Institute for Health and Clinical Excellence provides guidelines to the NHS on the use of treatments and it currently recommends that acupuncture is considered as a treatment option for lower back pain. However, it is often used to treat musculoskeletal conditions and a wide variety of pain conditions. Unfortunately there is an absence of clinical evidence in this area. We simply do not have the evidence base to be sure that it works for many of the conditions for which it is often used. More scientific research is undoubtedly needed to establish whether acupuncture is effective against many conditions.

My noble friend also referred to the problem of gaining access to hospital appointments at weekends. There is an important case for services such as pain control to be provided outside working hours. We would encourage local commissioners to continue to develop services such as this to meet the needs of the working public. The noble Baroness, Lady Greengross, with her wide experience, pointed out that the elderly frequently suffer worse treatment than those in other age groups. Those who commission services locally clearly have a duty to ensure that the needs of the whole community are met, with particular attention given to vulnerable older people. The multidisciplinary nature of teams is pivotal in making pain relief available to all age groups in society.

The noble Lord, Lord Luce, asked whether we would consider a national strategy for chronic pain or indeed a tsar. I am not persuaded at the moment that a tsar or a national strategy for chronic pain over and above our current policies for improving the quality of services is necessary. We need to liberate front-line staff as a first priority to enable them to work with their patients to improve the quality of services that they provide or commission. We need to ensure, too, that they have access to the guidance that is available. As I mentioned, there is a wealth of available guidance, including a commissioning pathway published by the Department of Health, and guidance for secondary care and primary care has been published by the British Pain Society, as he will know.

The noble Lord and the noble Baroness, Lady Emerton, asked whether a pain score should become part of the vital signs that are monitored for patients in hospital. Current guidance from NICE recommends that all patients admitted to hospital should be assessed and a decision made on which clinical indicators should be monitored. A pain score is one of the indicators that should be considered.

The noble Baroness, Lady Emerton, referred to nurse prescribing and how that might be improved in this area. In prescribing medication it is essential that the right person gives the right medication at the right time and that stands to reason. Nurse prescribing is a welcome development that can benefit patients significantly. She would agree that services should continue to look at what professional mix can best deliver safe, timely and effective treatments for patients. She also referred to the need for risk assessment among nurses. I have every sympathy with that point. Back pain among nurses as a result of injury at work is a great concern, both for the nurses and their families. Local employers also have a duty of care to provide safe working environments and prevent unnecessary and avoidable harm.

The noble Lord, Lord Tunnicliffe, asked about investment in services at a local population level. We share a commitment to improve health and healthcare. This is our driving principle and our proposals for reconfiguration of the NHS will drive the improvement for all patients.

I conclude by reassuring noble Lords that I should be happy to meet the noble Lord, Lord Luce, and the Chronic Pain Policy Coalition to discuss these issues further.