Pain-talk.co.uk The online community & discussion forum for UK Pain Management

Alf Collins, Consultant in Pain Medicine, Musgrove Park Hospital, Taunton.

W(h)ither chronic pain management?

We know that what we do is important and worthwhile. It is important for our patients and it is important for the NHS. The problem is, what exactly do we do and why is it so important?

A couple of years ago, John Loeser wrote a largely unnoticed IASP newsletter bemoaning the fact that pain services throughout the world don't operate to a cohesive philosophy of care. Just think what your clinic offers patients with back pain and compare that to what the clinic down the road offers. Almost certainly, patients in the two places are getting a very different deal. And that difference is probably as much to do with your clinic's attitudes and beliefs as it is to do with hard resources. Indeed, your clinic's philosophy of care will have driven your plans for resource allocation.

The IASP mantra that 'pain is a disorder in it's own right' is true, but the message doesn't wash with the people that matter; politicians and policy makers, both locally and nationally. What they want is something a bit more solid, something that clearly defines what we do and that also help them to define where pain clinics should be going.

What do we do?

Pain clinics offer assessment and management of people with pain according to the principles of biopsychosocial care. Assessment may involve seeking a medical diagnosis, but could just as easily involve a formulation, whereby structural and psychological factors that might contribute to the pain experience are assessed and managed. One vital aspect of biopsychosocial care is patient involvement in the decision making process and this of course, is very much in line with what the government (with good reason) believes to be best practice.

So, we should sell ourselves as patient-centred, multidisciplinary teams, providing biopsychosocial assessment and management of patients with pain problems.

That's all very laudable (as well as being a bit of a mouthful), but what particular patients might benefit from this approach? Of course, the answer is the vast majority of the 5-10 million people in this country with chronic pain. And there's the problem. What healthcare commissioner at any level is going to take that on? With this background, we need to think very carefully before any of us try getting more money for pain clinics in their current form.

Where should we be going?

What we do complements the care provided by any other healthcare professionals who care for patients with pain from any source. What we do is also subtly (and often not so subtly) different from the care provided by most other professionals.

So, we need to meet with professionals from other disciplines and let them know what we can do. Evidence suggests that 20% of frequent attenders in any out-patient department have a medically undiagnosed disorder often manifest as pain. Patients with chronic pain are gumming up out-patient departments across the country. Get out there. Meet the urologists, the cardiologists and the gastroenterologists. Get them to put their complex patients into one clinic and do the clinic with them. Try to help them to manage their own complex patients rather than just referring them to you when they have run out of options (and when any intervention from you stands little chance of making a real difference).

But the professionals who have most need of our services are general practitioners. How many GPs on your patch really know what you do? Don't whinge about the lamentably small number who are aware of what your service can offer; it's not their fault- it's yours. Meet them. Offer to work with them in their health centres. A buzz phrase at the moment is 'demand management'; when you work with GPs, help them to manage pain problems within their practice. Help them to know when they perhaps should refer to a hospital-based service. Above all, promote the message of biopsychosocial care.

W(h)ither chronic pain management?

The NHS is cash-limited. That is an opportunity for us. What we do is cheap. What we do at the moment is also unrecognised.

The time is nigh for a radical restructuring of pain services in this country. We need to work much more closely with the people that refer to us. We need to let them know about how to assess and manage patients with pain according to biopsychosocial principles.

Above all, we need to shift our focus into the community. Where better to deliver biopsychosocial care than close to the patient's home alongside the patient's GP?

We need to work with general practitioners locally and at a national level. We need to prove ourselves. The Cinderella service should indeed have a slice of cake at the ball.

Alf Collins, Consultant in Pain Medicine, Musgrove Park Hospital, Taunton.