Pain Concern

Meddygfa’r meddyg teulu, mewn galwad ffôn neu glinig poen: ble ddylai rheolaeth poen gymryd lle?

Cefnogwyd y prosiect darlledu a chyfieithu hwn gan Ymddiriedolaeth Oakdale.

To listen to this programme, please click here.

‘Bydd gwasanaethau rheoli poen da, wedi eu lleoli yn y gymuned, yn gwneud gwahaniaeth enfawr i fywydau unigolion ac i’r GIG,’ meddai Sue Beckman, oedd yn siarad ar ran Uned Cefnogaeth a Dosbarthu GIG yng Nghyfarfod Gwyddonol Blynyddol Cymdeithas Poen Cymru. Ond beth fydd symud gwasanaethau poen i’r gymuned yn ei olygu?

Mae Beckman, ynghyd ag arbenigwyr poen Mark Ritchie, Mark Turtle a Rob Davies yn cynnal trafodaeth ynghylch y mater allweddol – ble ddylai rheolaeth poen gymryd lle.

Yn aml meddygon teulu ydy’r rhai sydd agosaf i’r ‘gymuned’ – maen nhw’n aml yn gweld cleifion dros gyfnod o flynyddoedd, ond mae hyfforddiant cyfyngedig mewn poen cronig a diffyg amser mewn apwyntiadau yn achosi problemau. Bydd y panelwyr hefyd yn trafod yr heriau o ddod â gwasanaethau’n nes i gymunedau cefn gwlad Cymru, tra’n sicrhau bod cymaint o bobl â phosibl yn gallu cael gafael ar wasanaethau poen trwy ddefnyddio trafnidiaeth gyhoeddus. Yn olaf, gallai symud gwasanaethau o’r clinig poen lwyddo i ‘ddad-feddyginiaethu’ poen cronig trwy achosi gweithwyr iechyd proffesiynol a’u cleifion i ‘feddwl tu allan i’r blwch’?

Paul Evans: Rydych chi’n gwrando ar Airing Pain (Sôn am Boen), y rhaglen sy’n dod atoch dan nawdd Pain Concern, elusen yn y DU sy’n gweithio i helpu, cefnogi a rhoi gwybodaeth i bobl sy’n byw gyda phoen ynghyd â gweithwyr iechyd proffesiynol. Paul Evans ydw i, ac arianwyd y cynhyrchiad hwn gan grant ‘Gwobrau i Bawb’ (Awards for All) o Gronfa’r Loteri Fawr yng Nghymru.

Mae Cymdeithas Poen Cymru yn cynnal ei gyfarfod gwyddonol blynyddol bob hydref, ac i wlad sydd – sut fedra’i ddweud hyn? – yn heriol yn ddaearyddol, mae’n gyfle amhrisiadwy i bobl sy’n gweithio ym maes poen yng Nghymru i ddod at ei gilydd, i drafod ymarfer gorau – ac, ie, gwleidyddiaeth poen – ac yn y pen draw i greu gwasanaeth gwell ar gyfer y claf. Y Cadeirydd ydy Dr Mark Turtle, anesthetydd ymgynghorol yn arbenigo mewn rheolaeth poen yn Sir Gaerfyrddin. Ac yng nghyfarfod eleni gofynnais iddo oedd mynychter poen cronig yng Nghymru yn wahanol i wledydd eraill y DU.

Dr Mark Turtle: Does dim byd fyddai’n awgrymu bod y mynychter yng Nghymru yn wahanol i unman arall – rhywle rhwng yr arddegau uchel a’r ugeiniau isel yn nhermau canran. Beth all fod yn wahanol, ac un o’r pethau rydyn ni wedi bod yn ei drafod y dyddiau diwethaf ‘ma, ydy’r effaith ar unigolion, sut mae gwahanol bobl yn ymdopi â phoen. Er enghraifft roedd llawer o siarad am bobl yn y cymoedd, pobl mewn ardaloedd penodol yn ne Sir Benfro, ble efallai eu bod yn dod ar draws anawsterau cymdeithasol sylweddol, tra bo pobl mewn ardaloedd eraill yng nghefn gwlad Cymru, er enghraifft, yn ymdopi mewn ffordd hollol wahanol. Felly, nid mynychter y broblem yw’r pwynt ond y ffordd mae pobl yn ymdopi a delio â’r hyn all fod…. Yn bendant mae’n fater sy’n rhaid ei ystyried.

Evans: O safbwynt y claf, ydy cleifion o amgylch Cymru, o wahanol ardaloedd yng Nghymru, yn cael mwy neu lai o anhawster na’u cyfatebwyr mewn ardaloedd eraill?

Dr Turtle: I gael gafael ar wasanaethau…

Evans: I gael gafael ar a gwybod am wasanaethau.

Dr Turtle: Ie, ie. Rydw i’n meddwl mai un o’r pethau sydd wedi dod drosodd yn eitha cryf yn y dyddiau diwethaf yw’r anghyfartaledd rhwng gwahanol ardaloedd. Yn nhermau’r gwasanaeth cyfan – mae un neu ddwy ardal ble mae pobl yn gorfod teithio ymhell iawn i gael unrhyw fath o wasanaeth – ac hefyd yr hyn sy’n gynwysiedig yn y gwasanaeth. Mae’n eitha diddorol. Er enghraifft, dangosodd rhywun archwiliad o’r gwasanaethau i ni, ac mae gan Powys, sy’n ardal â phoblogaeth wasgaredig iawn, wasanaethau da iawn mewn rhai agweddau, er nad ydyn nhw wedi eu canoli o amgylch prif Ysbyty Gyffredinol Dosbarth, er enghraifft. Mae ardaloedd fel Ceredigion er enghraifft, ble nad oes llawer o wasanaethau o gwbl. Mae gwahanol glinigau, sydd â disgyblaethau gwahanol felly mae’r cyfan yn wahanol.

Yna dydyn ni braidd â mynd trwy’r haen gyntaf i edrych ar y berthynas rhwng y gwasanaethau sydd ar gael a maint cywir y boblogaeth. Felly er enghraifft, does dim ystyriaeth wedi ei roi i’r ffaith bod y boblogaeth mewn ardal benodol yn fawr iawn ac felly dylai’r gwasanaethau fod yn llawer gwell. Nawr, mae hynny hyd yn oed cyn i ni ddechrau edrych ar sut mae pobl yn cael gafael arnyn nhw, sut maen nhw’n cael eu hysbysebu, i unigolyn sut maen nhw’n gwybod beth sydd ar gael ac yn bendant mae’n rhaid cael llawer mwy o waith ar hynny.

Evans: Dr Mark Turtle. Wel, pwynt ffocws y dydd oedd sesiwn wedi ei roi drosodd yn gyfangwbl i’r union bwnc ble roedd panel o dri o weithwyr iechyd proffesiynol blaenllaw ym maes poen yn archwilio materion ynghylch gwasanaethau poen yn y gymuned. Y panelwyr oedd Dr Rob Davies, arbenigwr mewn rheoli poen gyda Bwrdd Iechyd Cwm Taf, Dr Mark Ritchie, meddyg teulu yn Abertawe gyda diddordeb arbenigol mewn poen, a Sue Beckman o Uned Cyflenwi a Chymorth Llywodraeth Cymru.

Sefydlwyd hwnnw gan Lywodraeth Cynulliad Cymru, a gyfeiriwyd ato wedyn fel LlCC, i gynorthwyo’r GIG (Gwasanaeth Iechyd Gwladol) Cymru i gyflawni ei dargedau allweddol a lefel y gwasanaeth. Term arall neu acronym a sonnir amdano yma ydy FfACh, neu Fframwaith Ansawdd a Chanlyniadau (QOF – Quality and Outcomes Framework). Mae hwn yn gynllun ysgogol ar gyfer meddygon teulu yn y DU, yn eu gwobrwyo am pa mor dda maen nhw’n gofalu am eu cleifion, dros ystod o adrannau, drwy system bwyntiau. Yn syml, po uchaf y sgôr, yr uchaf fydd y wobr ariannol i’r feddygfa. Does dim QOF ar gyfer poen. Felly gyda’r jargon y tu ôl i ni, gadewch i ni ymuno â’r drafodaeth. Y cadeirydd ydy Dr Mark Turtle.

Dr Turtle: Rydyn ni wedi dewis tri unigolyn sy’n hyderus, ddim yn eistedd yn ôl, felly rwy’n gobeithio byddan nhw’n ymgymryd â’r drafodaeth hon yn egnïol. Sue.

Sue Beckman: Diolch Mark, a diolch yn fawr iawn, rydw i’n teimlo’n freintiedig iawn i fod yma i ddweud y gwir. Mae hyn yn eitha cyffrous, ac mae cael fy ystyried fel rhywun sy’n gwybod rhywbeth am boen yn braf iawn oherwydd pe baech wedi gofyn i mi ychydig o flynyddoedd yn ôl am bwysigrwydd gwasanaethau poen cymunedol fasai gen i ddim clem. Rydw i’n radiograffydd diagnostig o ran galwedigaeth – rydw i wedi rhoi pelydr-X i lawer o bobl yn fy amser sy’n dioddef o bob math o gyflyrau ac o boen ofnadwy. Ond wnes i ddim meddwl un waith – ac mae gen i gywilydd i gyfaddef hynny – dim un waith wnes i feddwl llawer am sut maen nhw’n cael gafael ar reoli’r poen yn eu bywydau.

A does dim ond dau beth sydd wedi gwneud i mi feddwl am hynny yn y blynyddoedd diweddar. Un oedd ffocws y gwaith roedden ni’n ei wneud yn yr Uned Cyflenwi, ac mae’n ddrwg gen i bod hyn yn ymwneud ag orthopedeg, ond hwnnw oedd yr unig fodd i ni wneud hyn. Un oedd poen yn y gwar a’r cefn, pan yn sydyn agorwyd fy llygaid i bwysigrwydd poen y bobl yn y sefyllfa hon, yn dioddef poen yn eu gwar a’u cefn, a beth mae poen yn ei wneud i bobl, a doeddwn i ddim wedi meddwl llawer am hyn o’r blaen oherwydd rydw i wedi bod yn ffodus nad ydw i’n dioddef llawer fy hunan. Yr ail beth ydy gwylio fy mam yn ddyddiol yn ymdrechu mewn poen a ddim yn gallu cael gafael ar y math o reolaeth poen y baswn i’n dymuno iddi ei gael.

Felly gwnaeth y ddau beth yna i mi feddwl. Nawr mi fasech chi wedi meddwl y byddai hynny’n amlwg felly gwneth hynny i mi feddwl, “Wel, os nad ydy e’n amlwg i ti Sue, i bwy arall ydy e ddim yn amlwg?” Ac mae’n rhaid i mi ddweud, gyda thristwch, nad yw hyn yn amlwg i lawer o bobl a dyna pam rydw i’n meddwl nad ydyn ni wedi cael cymaint o fuddsoddiad mewn gwasanaethau poen cymunedol y basech chi i gyd yma, rydw i’n siwr, yn ei ddymuno, ac i ddweud y gwir rydw i’n credu’n angerddol iawn y bydd gwasanaethau poen cymunedol da yn gwneud gwahaniaeth enfawr i fywydau unigolion a chael effaith gadarnhaol a chost-effeithiol ar y GIG yn gyfan.

Rydw i’n credu mai dau ddeg wyth miliwn o bunnoedd oedd y ffigwr wedi ei ddyfynnu i mi fel cost poen gwar a chefn mewn prescripsiwns yn unig yng Nghymru. Rydw i’n meddwl bod hynny’n rhywbeth i feddwl amdano o ddifrif ac heblaw am hynny, meddyliwch am y bobl fyddai’n gallu cael gafael yn gyflym ar rywbeth fyddai’n gwella ansawdd eu bywydau yn fwy nag ydy e nawr. Felly, ar sail hynny’n unig, rydw i’n cyflwyno fy achos eu bod yn rhywbeth pwysig iawn i’w gwthio i’r blaen.

Dr Turtle: Diolch Sue. Rob.

Rob Davies: Mae wyth deg y cant o holl gyswllt meddygol (gyda ‘m’ fach) mae cleifion yn ei gael gyda chlinigwyr, 80% o’r holl gyswllt ag elfen o boen ynddo. Nawr cymharwch hynny â’r 0.9% o amser mae myfyriwr israddedig yn ei dreulio ar hyfforddiant mewn poen. Felly rydw i’n credu bod cwestiwn mawr yma. Mae’r syniad o symud poen i mewn i’r gymuned, yn nhermau’r gwasanaethau rydyn ni’n eu cyflenwi, mae’n rhaid i ni ofyn nifer enfawr o gwestiynau. Beth ydyn ni’n feddwl wrth symud poen i mewn i’r gymuned? Beth ydy’r gymuned? Ac ydyn ni wir eisiau colli’r holl leoedd a’r bobl hynny sy’n darparu gwasanaeth eisoes? Felly hoffwn i chi feddwl am y ddau gwestiwn yna: Beth yw ystyr symud poen i mewn i’r gymuned? Gyda phwy ydyn ni’n delio? Ble ydyn ni’n delio ag e? A sut ydyn ni’n delio ag e?

Turtle: Diolch. Mark.

Mark Ritchie: Beth yw poen? I mi nid y diffiniadau hyfryd yn y llyfrau gosod ydy poen ond yr hyn mae’r claf yn ei ddweud wrtha i ydy e, yn y pen draw. Ac mae Rob wedi ei fynegi’n gryno iawn mai 0.9% o hyfforddiant sydd ar boen. Mae e’n iawn, mae hynny’n cynnwys poen aciwt, nid hynny ydy poen cronig. Pan edrychwch chi ar boen cronig yn hyfforddiant yr israddedigion meddygol yn y wlad hon, mae rhwng pedair a chwech awr yn cael eu treulio arno, yn dibynnu ar ba brifysgol rydych yn ddigon ffodus o fynd iddi. Ag ystyried hynny, rydw i’n meddwl bod ein meddygon teulu’n ymdrin â phoen yn eitha da, ag ystyried yr ychydig hyfforddiant rydyn ni wedi ffwdanu ei roi iddyn nhw.

Pe baem yn gallu lledaenu’r hyfforddiant yna ychydig mwy, yna gallai ddod yn fwy seiliedig ar y gymuned, ond ni ddylai hynny olygu ein bod yn gwneud i ffwrdd â’n cydweithwyr mewn gofal eilradd na gwaredu’r clinigau gofal eilradd hynny. Bydd eu hangen i ryw raddau ond mae’n dibynnu sut rydyn ni’n rhyngweithredu hynny gyda gwasanaeth da’n seiliedig ar y gymuned. Ac rydw i’n meddwl y dylai’r gwasanaeth fod yn un rhyngweithredol a chydgysylltiol, nid y gymuned yn erbyn gofal eilradd: rydw i’n meddwl y dylid ei gydgysylltu.

Turtle: Iawn, diolch yn fawr iawn. Dyna safbwyntiau cyntaf ein panelwyr. Nawr gadewch i ni weld a allwn ni herio’r safbwyntiau hynny neu eu cael i ehangu ychydig gyda chwestiynau. Fy nghwestiwn cyntaf i ydy: ‘Ar ei ben ei hun, onid y ffordd fwyaf effeithlon o drin poen cronig ydy mewn model amlddisgyblaethol, model amlfodel? Mynediad hawdd i’r claf, trafnidiaeth, hygyrchedd y clinigwr i ganlyniadau’r delweddau, cyfathrebu’r tîm pan mae’r tîm wedi ei wasgaru dros ardal poblogaeth – sut allwn ni oresgyn y problemau hyn?’ Rob.

Davies: Iawn. A chymryd yr ail bwynt yn gyntaf: mae dosraniad y boblogaeth rydyn ni’n delio ag e a’r gallu i gael staff at ei gilydd yn awgrymu y dylen ni gael lle penodol i weithio ynddo. Rydyn ni wedi cynnal clinigau mewn meddygfeydd, lle mae ymgynghorwyr wedi mynd allan i’r meddygfeydd – rydych chi’n teithio’n bell i weld tri chlaf yn unig efallai. Felly mae’n gwneud synnwyr i mi i gael lleoliad penodol a dod â’r claf i’r lleoliad hwnnw. Ac yna mae’r cwestiwn ynghylch, ‘Iawn, sut ydyn ni’n eu cael nhw i ddod yno?’ Mae problemau trafnidiaeth, perchnogaeth car a mynegrifau amddifadedd i gyd yn berthnasol.

Cleifion, pe bai ganddyn nhw ysbyty ar stepen eu drws, bydden nhw’n hoffi gallu defnyddio’r ysbyty i bopeth. A dyma’r hyn wnaethon ni ei ddarganfod wrth symud i mewn i un o’r ysbytai cymunedol oherwydd roedd ein ysbyty presennol ar lwybr bws cydnabyddedig, roedd yn agos at draffordd, roedd pobl yn gwybod ble oedd e, roedd pobl yn gallu cyrraedd yna. Am gyfnod gweddol hir wedyn ces gwynion gan gleifion yn dweud ‘Pam ydych chi’n ei wneud e fyny yma? Allwn ni ddim cyrraedd yma, does dim bysiau yn dod i fyny yma.’ Mae’n bwynt pwysig i’w ystyried – os ydych chi’n mynd i symud pethau i mewn i’r gymuned, mae hynny’n iawn ond ei fod yn lleol i’r claf arbennig hwnnw. Os oes gennych dalgylch eang mae’n rhaid meddwl yn strategol yn nhermau ble rydych chi’n mynd i leoli rhan o’r gwasanaeth.

Turtle: Mark.

Ritchie: Faswn i ddim yn pigo beiau yn y broblem bosibl yna o gwbl. Fodd bynnag, mae manteision cryf iawn mewn bod yn nes at ble mae’r cleifion. Rhai o’r manteision hynny ydy, gallwn gychwyn dad-feddyginiaethu’r broblem hon, ac fel rydyn ni’n ei weld pan awn ni i Gymdeithas Poen Prydain…. Roedd rhywbeth fel hanner y darlithoedd yng nghyfarfod diwethaf Cymdeithas Poen Prydain yr es i iddo ddim am gyffuriau mwyach. Roedden nhw ar seicoleg, ar dechnegau ffisiotherapi, ar dechnegau corfforol yn hytrach na thechnegau fferyllol.

Mae llawer o’r cleifion hyn, pan maen nhw’n dod i’r ysbyty, yn credu eu bod wedi dod am bigiad arall neu feddyginiaeth arall. Dydw i ddim yn mynd i ddibrisio’r triniaethau hynny o gwbl; pan fo nhw’n briodol dylid eu defnyddio. Ond yr hyn rydw i’n mynd i ddweud ydy os fyddwn ni’n symud hyn allan o amgylchedd yr ysbyty, bydd pobl yn dechrau meddwl tu allan i’r blwch yna, a byddan nhw’n meddwl am ddull ehangach a gwahanol i ddelio â’u problem, ac, yn bendant, rydyn ni wedi gweld canlyniadau da iawn.

Turtle: Sue.

Beckman: Y gair ‘cymuned’ – gallaf ddweud fel ffaith fod hyn yn hollol gywir, mae deuoliaeth nawr ynghylch y ffordd rydyn ni’n siarad ac rydw i mor euog ag unrhywun arall. Rydw i’n dweud, ‘Ydyn ni’n siarad am ofal yn y gymuned neu ofal eilradd?’ I ddweud y gwir, rydw i’n mynd i orffen gwneud hynny ac rydw i’n mynd i gychwyn dweud mai gofal eilradd a gofal sylfaenol blaenorol yw nawr y gymuned o driniaeth sydd gennym. Ac rydw i’n meddwl mai’r hyn y dylen ni wneud ynghylch y cwestiwn hwn yw dweud, ‘Wel, sut mae ein poblogaeth yn edrych? Pa ffordd sydd gennym ni yn y cyffiniau? A beth ydy’r ffordd orau i ddarparu’r gwasanaethau hynny?’ Felly nid yw un maint yn gweddu i bawb. Nid y sefyllfa hen ffasiwn o gleifion allanol / meddyg teulu ydy e. Dyma’r hyn ydy e: ‘Dyna ein demograffeg, dyna ein gwledigrwydd – sut ydyn ni’n mynd i reoli hynny?’ Nawr, bydd hynny’n golygu cynllunio eitha clyfar ac rydw i’n hollol siwr, pan fyddwn i’n gwneud hynny, byddwn ni’n gwneud camgymeriadau mawr – ond mi gyrhaeddwn ni.

Turtle: I gymryd y pwynt yma chydig ymhellach, ac yna Mark gewch chi ddod i mewn, alla i ofyn cwestiwn arall sy’n gysylltiedig yn agos iawn â’r hyn rydyn ni’n ei drafod yma. Mae’n ymddangos bod trafodaeth barhaus ynghylch beth yw ystyr cymuned. Beth mae’r panel yn meddwl yw ystyr cymuned? Cartrefi’r cleifion? Meddygfeydd? Canolfannau meddygol? Ysbytai ymylol? Ysbytai cyffredinol dosbarth? Ac ati. … Nes y gallwn ni ddatrys hyn, mae’r ffordd ymlaen yn parhau i fod yn eithaf anodd.

Ritchie: Y lleoedd uchod i gyd.

Davies: Rydw i’n meddwl mai’r lleoedd uchod i gyd ydy cymuned hefyd, ond yr hyn sy’n ddiddorol ydy gwasanaeth o fewn pum niwrnod. Does dim ffordd fyddwch chi’n cael hynny mewn unrhyw driniaeth wedi ei drefnu mewn ysbyty, os nad ydy e’n driniaeth argyfwng ar gyfer symtomau mesuradwy. Ond wedi dweud hynny, o ble mae’r driniaeth yn mynd i ddod? Mae’n mynd i ddod o feddygfa ac mae hynny’n ychwanegu at yr hyn roeddwn i’n ei ddweud yn gynharach; mae’n rhaid i ni addysgu ein hymarferwyr ar lefel israddedig fel eu bod oll, i ryw raddau, yn gallu delio â’r problemau hyn, er mwyn i ni beidio â chael problem enfawr yn cyrraedd clinigau bondichrybwyll, p’un ai yn y gymuned neu mewn ysbyty.

Rydw i’n meddwl, beth yw cymuned yn yr achos hwn? Maen nhw’r holl bethau rydych chi wedi sôn amdanyn nhw. Sut rydyn ni’n cofleidio’r gymuned honno ydy sut rydyn ni’n tynnu’r pethau gwahanol hynny at ei gilydd. Ac ie, efallai ein bod ni’n mynd i orfod tynnu gwahanol dechnolegau i mewn, p’un ai ydy’r rheiny yn Skype, y rhyngrwyd, cynadledda teledu, beth bynnag – maen nhw i gyd yn bosibiliadau. Wrth gwrs, dim ond gydag arian y dôn nhw’n bosibiliadau. Felly bydd yn golygu mantoli’r gyllideb a phenderfynu sut allwn ni roi i’n cymuned – y gymuned gyfan nawr – y gwasanaeth gorau gyda’r arian sydd gennym ar gael. Bydd hynny, wrth gwrs, yn rhywbeth i’r gwleidyddion a’n tâl-feistri i ddatrys.

Ritchie: Alla i ddod i mewn gyda phwynt ynghylch meddyginiaeth teledu a’r mater o wledigrwydd? Rydw i’n meddwl bod yn rhaid i ni gydnabod yng Nghymru bod, os hoffwch chi, ardaloedd o Gymru ble bydd yr atebion yn wahanol. Hefyd mae’n rhaid i ni edrych ar y ffaith fod gan amddifadedd effaith; dydych chi ddim yn mynd i ddefnyddio meddyginiaeth teledu ble mae gennych chi bobl sydd ag oedran chwech oed wrth ddarllen a bod eu gallu i ddeall darn o wybodaeth meddygol mewn cwestiwn ar y gorau. Felly rydych chi’n mynd i fod yn delio â disgrifiad ac esboniadau wyneb yn wyneb ar gyfer pobl fel yna – byddan nhw ddim yn cyfathrebu gyda chi ar Skype.

Turtle: Alla i gyfeirio at gwestiwn arall nawr? ‘Nid yw’n ymddangos yn gyfredol bod diddordeb mawr mewn rheoli poen tu allan i fodel meddygol mewn gofal sylfaenol. Ydy hyn yn rhesymol? Ac nos nad ydy e, sut ydyn ni’n newid ymgysylltiad ein cydweithwyr iechyd proffesiynol sy’n gweithio tu allan i ysbytai?’

Davies: Rydw i’n mynd i sefyll i fyny a bod yn ddadleuol. Rydw i’n ei chael yn anodd i ymgysylltu â llawer o’m cydweithwyr mewn gofal sylfaenol. Mae ganddyn nhw system apwyntiadau 10 munud, wedi ei bennu gan y llywodraeth, sy’n dweud bod yn rhaid i chi weld 6 claf bob awr, ac os byddan nhw’n lleihau’r nifer o gleifion fyddan nhw’n eu gweld, byddan nhw’n dweud wrthyn nhw nad ydyn nhw’n gweld digon o gleifion. Felly, i gychwyn, mae gennym ni’r model yma sydd wedi ei bennu gan y wladwriaeth yn dweud bod yn rhaid i chi weld hyn a hyn o gleifion bob awr – dyna’r broblem gyntaf. Yr ail broblem ydy – sy’n ateb mewn llawer ardal– ydy QOF a QUIP fel mae’n nhw’n ei alw nawr hefyd, ble rydyn ni’n ceisio codi safonau, ond does dim QOF ar gyfer poen. Felly’r hyn sy’n digwydd ydy bod y rhan fwyaf o feddygfeydd yn mynd i ardaloedd ble mae QOFs.

Dydw i ddim wedi fy synnu nad oes QOF ar gyfer poen oherwydd mae’n faes mor fawr ac eang y byddai’n rhaid rhoi swm enfawr o arian ynddo. Felly dyna pam mae wedi cael ei osgoi. Ond y broblem ydy eu bod yn canolbwyntio eu sylw ar y meysydd maen nhw wedi cael dweud wrthyn nhw am ganolbwyntio eu sylw arnyn nhw, ac hefyd ble mae’r arian yn mynd. Mae’n anhygoel cystal mae clefyd siwgwr wedi gwneud ers i QOF ddod i mewn. Mae clefyd siwgwr wedi gwneud yn ardderchog ac rydyn ni’n cael canlyniadau da iawn mewn clefyd siwgwr oherwydd bod arian wedi ei roi yn y cyfeiriad hwnnw ac mae’r canlyniadau wedi dilyn hynny.

Dydw i ddim yn credu bod digon o arian wedi ei fuddsoddi mewn poen. Rydw i yn deall bod cyfyngiadau ar gyllid, dydw i ddim yn dwpsyn sy’n credu bod cronfa dibendraw a diddiwedd, ond yr hyn rydw i yn ei feddwl y bydd yn rhaid i ni wneud ydy bod yn wahanol ynghylch sut rydyn ni’n mynd i ddelio ag e. Un ffordd o gael mynediad i feddygfeydd ydy pan rydyn ni’n cymysgu poen â rhywbeth arall. Felly er enghraifft, os edrychwn ar rywbeth sydd wedi cael ei werthu’n dda i feddygon teulu, fel clefyd siwgwr, os fyddwch chi’n rhoi darlith, neu rhoddir darlith sy’n cael ei noddi gan ddiwydiant neu beth bynnag, ar wahanol ffyrdd o reoli clefyd siwgwr, gallwch chi sôn am boen niwropathig yn y ddarlith honno, ac efallai trafferthion ymgodol; trwy ddod â’r tri pheth hynny i’r amlwg, sydd i gyd yn berthnasol i glefyd siwgwr, yn sydyn rydych chi wedi cael diddordeb y gynulleidfa.

Turtle: Alla i fynd ar ôl y busnes QOF yma. Mae llawer o bobl yn sôn am y QOFs ac wrth gwrs dydy pobl sy’n gweithio mewn gofal eilradd ddim yn deall hynny’n llawn. Mae’n ymddangos ei fod yn cael ei fynegi gan nifer fawr o bobl sy’n gwybod bod QOF ar gyfer poen yn broblem. Ydych chi’n cytuno gyda hynny? Ac ydy e’n rhywbeth sy’n debygol o newid?

Davies: P’un ai dylai fod QOF am boen, hynny yw yn y pen draw bydd y llywodraeth yn trafod hyn am amser i ddod eto. Beth mae QOF yn ei wneud gydag unrhyw faes heintus o fewn meddygfa? Yr hyn mae QOF yn ei wneud, y peth cyntaf ydy, mae’n rhaid i chi greu cofrestr o’r holl gleifion sydd â’r broblem yna. Felly gyda clefyd siwgwr, roedd yn rhaid i chi greu cofrestr clefyd siwgwr, fel bod hynny’n dweud ar unwaith wrthych chi faint o gleifion yn eich meddygfa chi sydd â chlefyd siwgwr.

Ar hyn o bryd does dim y fath gofrestr o boen. Felly does gan y meddygon teulu ddim modd ar y foment o ddweud, ‘Dyma faint o bobl sydd â phoen aciwt a dyma faint o bobl sydd â phoen cronig’. Felly pe bai ond hyn, pe bai hynny oedd yr unig ran o QOF a ddeuai i mewn, pe baen nhw’n dweud dau bwynt y flwyddyn am greu cofrestr yn dangos faint o bobl sydd â phoen sydd wedi parhau yn hwy na chyfnod gwella arferol, heibio’r 12 wythnos. Hyd yn oed pe baen nhw ond yn gwneud hynny, byddai’n bwynt cychwyn enfawr oherwydd byddai’n rhoi syniad i ni o faint y broblem ar gyfer cyllido yn y dyfodol a darpariaeth clinigau.

Turtle: Rydw i am gael barn Sue ar hyn fel rhywun sydd ddim yn feddyg ac i geisio gwneud hynny rydw i’n mynd i ddyfynnu’r cwestiwn hwn: ‘Ar ôl bod ar secondiad ar wasanaeth talu gofal eilradd i sefydlu gwasanaeth cymunedol, rydw i wedi gweithio gyda meddygon teulu ac wedi gweld eu systemau. Mae’n ymddangos i mi bod rhaniad dwfn rhwng gwasanaethau gofal sylfaenol ac eilradd. Sut allwn ni gael y ddwy garfan hon at ei gilydd?’

Beckman: Diolch Mark. Wel, yn gwrando â diddordeb mawr ar hynny. Mae’n hyfryd clywed grŵp o bobl brwdfrydig iawn sydd am weld pethau’n newid ac rydw i’n mynd i ofyn cwestiwn i chi: oes unrhywun yn gwybod a ydy’r Cyfarwyddebau Datblygu a Chomisiynu ar gyfer Poen Anfalaen Cronig (CNNPR) a ddyfeisiwyd yn 2009 wedi eu diddymu o gwbl?

Turtle: Dydyn nhw ddim wedi eu diddymu.

Beckman: Na. Gwych, dydyn nhw ddim wedi eu diddymu. Ga i gymryd eiliad i’ch atgoffa chi o’r hyn mae rhai ohonyn nhw’n ei ddweud? Mae’n nhw’n dweud, erbyn Mawrth 2009 y bydd cynllunwyr a chomisiynwyr yn sicrhau bod cynlluniau i ad-drefnu gwasanaethau arbenigol poen mewn gofal eilradd, yn seiliedig ar asesiad o anghenion lleol y claf, yn cael eu sefydlu i sicrhau bod cleifion â CNNPR yn cael eu brysbennu ac yn cael eu cyfeirio at lwybrau gofal priodol sy’n defnyddio tystiolaeth. Nawr mae tri neu bedwar o’r rheiny yn mynd ymlaen i esbonio beth yw amcan yr holl waith yna. Nawr, rhaid i ni beidio â cholli’r gwaith yna ac rydw i’n meddwl ein bod rywsut ar hyd y ffordd wedi colli hynny rhywfaint.

Nawr, os nad ydw i wedi camgymryd – a dyma un o’r troeon olaf fydda i’n defnyddio hwn Rob – mae gofal sylfaenol ac eilradd nawr o fewn byrddau iechyd lleol. Felly dylen ni ddefnyddio’r cyfarwyddebau hyn i annog byrddau iechyd lleol i ddechrau sefydlu gwasanaethau o’r math hynny. Dyna beth ddylen ni fod yn ei wneud. Rydw i’n dod o ddull mwy strategol na’m cydweithwyr, sy’n glinigwyr. Mark, peidiwch ag edrych arna i pan rydych chi’n sôn am gyllid, mae’n fy nychryn i! Oherwydd dyma pam rydw i’n dweud wrth bobl, ‘Peidiwch, plîs, dydw i ddim o’r Llywodraeth, rydw i o GIG. Iawn. Nid fy nghyfrifoldeb i ydy gosod y gyllideb!’

[Chwerthin]

Davies: Mae’n ddrwg gen i.

Beckman: Mae’n iawn, mae’n digwydd o hyd a dyna pam ro’n i’n awyddus i sôn amdano. Felly rydyn ni’n pontio hynny i chi, ac rydw i wedi bod yn chwilio am ffordd i mewn ers sbel oherwydd bod rhai pethau wedi digwydd, does dim rhaid i mi siarad amdanyn nhw yn y Llywodraeth, ynghylch sut mae’r amodau cronig yn gweithio, ac mae oedi wedi digwydd. Ac rydw i’n mynd i fynd yn ôl, a dod o hyd i ffordd i mewn eto. Rydw i wedi trio sawl ffordd i mewn oherwydd, mae’n amlwg, fel y dywedoch chi, poen cefn….enfawr. Poen cefn a gwar yw’r parth i mi ganolbwyntio arno ac rydw i’n ddifrifol ynghylch sut y gallwn ni ei gael yn iawn, wedi ei drefnu gyda dull cymunedol cywir. Felly peidiwch ag anghofio am y bobl hyn. Dylech chi fod yn gofyn i’ch byrddau iechyd, ‘Beth ydyn ni’n ei wneud ynghylch y cyfarwyddebau hyn ddaeth allan? Beth ydy fy rôl i ynddyn nhw? Sut ydyn ni’n mynd i gymryd hyn ymlaen, oherwydd maen nhw bedair blynedd ar ei hôl hi.’

Turtle: Ie, roedd hwnna’n bwynt ro’n i ar fin dweud.

[Chwerthin]

Turtle: Hynny yw, rydw i’n meddwl mai dyma’r broblem bod y geiriau hynny wedi ymddangos a bod llawer ohonom wedi cyfrannu at y geiriau hynny. Ond defnyddioch chi y gair ‘oedi’.

Beckman: Oedi, ie.

Turtle: A dyna’r broblem mewn gwirionedd ynte? Mae’r broses wedi oedi.

Davies: Dylen ni ddim fod wedi’n synnu am hynny oherwydd ro’n i’n chwilio am y dyddiad y cafodd ei lofnodi. Chi’n gwybod, cynhyrchwyd y ddogfen ei hun ym Mehefin 2008. Mae trobwll ariannol wedi taro’r gwasanaeth iechyd felly does dim syndod ein bod wedi oedi ar hyn. Mae llawer o bethau a ystyriwyd yn fwy gwerth chweil, oherwydd efallai nad ydyn ni wedi gweiddi’n ddigon uchel, ond mae pethau wedi dod i stop yn ariannol. Does dim arian wedi bod ar gael ar gyfer llawer o bethau. Rydyn ni wedi gorfod gwneud pethau ar fawr ddim o arian a’r rheswm mai fi ydy’r unig gynrychiolydd o fy mwrdd iechyd ydy bod y gweddill ohonyn nhw’n gorfod sicrhau eu bod yn y gwaith oherwydd mae arian y dyfodol yn ddibynnol ar ofynion a gorchmynion penodol mae gwleidyddion wedi mynnu eu rhoi arnom i gyflawni’r ddogfen hon.

Beckman: Alla i wneud sylw ar y pwynt yna? Rydw i’n meddwl bod y pwynt yna a godoch chi’n un da iawn, Rob. Rydw i’n meddwl bod yna un peth nad ydyn ni’n rhy glyfar yn ei wneud – pob un ohonom, ac rydw i’n cynnwys fy hun yn hyn, er fy mod i wedi ceisio ar brydiau, roedd yn anodd iawn – ydy pwysleisio’n gadarn elfen economaidd hyn oll. Dydyn ni ddim yn hoffi siarad am arian, ydyn ni, oherwydd, chi’n gwybod, nid dyna’n galwad cyntaf. Ond ambell waith mae’n rhaid i ni, oherwydd os mai dyna beth sy’n ein gyrru ar y funud, yna mae’n rhaid i ni brofi pam fod agenda poen mor effeithiol yn ariannol. A dydyn ni ddim, yn anffodus, ar y funud, yn rhy glyfar yn gwneud hynny. Felly os ydy rhywun yn glyfar, plîs helpwch fi oherwydd baswn i’n hoffi gwneud hynny.

Turtle: Iawn, rydw i am roi sbaner yn y drafodaeth. Wrth gwrs y broblem ydy difuddsoddi ac rydyn ni i gyd yn gwybod bod bwcedi o arian yn cael ei daflu at bethau sydd ddim o gymorth, dadgysylltu swydd. Nes y gallwn ni feistroli difuddsoddi, allwn ni ddim symud ymlaen.

Beckman: Mae’n achos rydyn ni wedi ceisio ei ddadlau o berspectif yr uned gyflenwi nifer o weithiau. Os allwn ni osgoi peth o faich poen ar brescripsiwn, i Gymru mae hynny’n fordd o ailgyfeirio’r arian rydych chi’n ei arbed, oherwydd bod prescripsiwns am ddim gennym. Pe baech yn dadlau hyn yn Lloegr byddai’n ddadl wahanol, ond yma mae’n arbediad uniongyrchol oherwydd bod gyda ni brescripsiwns am ddim.

Nawr, yn amlwg, dydych chi ddim yn mynd i arbed £28 miliwn ond efallai y byddech chi’n arbed chwarter ohono, fyddai’n swm anferthol o arian. Felly po fwyaf o help y gallwn ei gael i geisio esbonio hyn a gweithio allan yr elfen ariannol yma, basen ni’n ddiolchgar iawn. Cofiwch, dim ond ffigyrau am y gwar a’r cefn rydw i wedi eu dyfynnu, dim ond y gwar a’r cefn. Yng Ngogledd Cymru, mae cost y prescripsiwns – dyna’r oll rydyn ni’n siarad amdano yma – wedi ei ddyfynu yn £6.4 milliwn.

Turtle: Iawn, Mark, ydych chi am ymateb i hynny?

Ritchie: Doeddwn i ddim yn awgrymu nad oedd ffyrdd y gallen ni ddod o hyd i restr o’r cleifion hyn. Yr hyn roeddwn i’n anelu ato oedd y byddai’n ddefnyddiol cael cofrestr QOF, byddai’n amlygu ar gyfer pob meddyg teulu yn unigol oherwydd mae’n rhaid iddyn nhw…. gyda’r QOF arall mae’n rhaid i chi drefnu rhywun i fod yn arweinydd clefyd siwgwr ac acti. Cyn gynted ag ydych chi wedi creu QOF mewn poen, bydd yn rhaid i rywun yn y feddygfa fod yn arweinydd poen ac felly byddai’n rhaid i rywun gael chydig o addysg o fewn y feddygfa ar boen ac felly byddai gwybodaeth yn cael ei hymestyn yn y ffordd yna. Felly, doeddwn i ddim yn golygu na allen ni ddod o hyd i’r data, ac rydw i’n siwr pe baem ni’n chwilio y gallem ddod o hyd iddo. Ond wrth esgus eich bod yn costio arbedion o brescripsiwns – maen nhw’n enfawr.

Ychydig flynyddoedd yn ôl cyn i ni ddod yn ymddiriedolaeth ar y cyd, gwnaeth Abertawe ymdrech fawr i arbed arian, ac rydw i’n cofio, pan oeddwn i’n arweinydd prescripsiwns yn fy meddygfa am saith mlynedd, a phan es i i’r feddygfa gyntaf roedden ni’n rhoi 44% o brescripsiwns generig. Erbyn i mi adael, pan oedden ni ymysg y tri prif rai yn rhoi prescripsiwns generig yn Abertawe, ac yn y flwyddyn olaf pan oeddwn i’n rhedeg y gyllideb i’r feddygfa, arbedais £330,000 o’r gyllideb ond nid aeth un geiniog i boen cronig, a dyna’r broblem.

Gallwn ymrwymo pobl mewn arbed arian ond os na fyddan nhw’n gweld…. Os ydyn nhw’n gweld y swm mawr o arian yna yn diflannu i rywbeth mawr o’r enw ymddiriedolaeth a diflannu i lawfeddygaeth orthopedig neu rywbeth, yna ni fydd yn cyflawni dim. Os edrycha i ar ein hymddiriedolaeth ni ar y funud, rydw i’n gwybod am un claf sy’n costio £4,000 y mis a rydw i’n gwybod bod tua hanner cant o’r rhain ar draws yr ymddiriedolaeth, a phoen yng ngwaelod ei gefn sydd gan y claf hwn ac mae’n defnyddio deunaw lolipop fentanyl 800 meicrogram y dydd. Gweithiwch hynny allan yn gyflym mewn arian ac fe welwch ei fod yn dod i tua £4,000.

Ar y funud pe bawn i’n llwyddo i’w newid e, ni fyddai un geiniog yn dod i mewn i gyllideb poen cronig, ond i ddweud y gwir dyna’r hyn faswn i’n ei hoffi oherwydd baswn i’n hoffi sefydlu clinig ar wahân unwaith yr wythnos dim ond i weld y cleifion hynny. Cymryd y dasg o roi’r prescripsiwns oddi wrth y meddyg teulu truan sydd wedi cael ei orfodi i wneud hyn. Cymryd hynny oddi wrthyn nhw a rhoi’r claf hwnnw ar feddyginiaeth briodol fydd ddim yn dinistrio’i ddannedd a mwy na thebyg fydd yn helpu gyda’i gefn, ac ar yr un pryd yn arbed tua hanner miliwn y flwyddyn, oherwydd dyna’r potensial, dim ond gyda’r grŵp bychan yna o gleifion yn ein hymddiriedolaeth ni. Felly, rydw i’n siwr bod cleifion tebyg gyda chi, os nad ni ydy’r ymddiriedolaeth waethaf o gwmpas.

Turtle: Nawr mae amser yn mynd ymlaen. Mae gen i un cwestiwn arall ac rydw i’n mynd i roi cyfle i bob un o’r panelwyr i ddweud brawddeg neu ddwy ac yna, mae’n ddrwg gen i bydd yn rhaid i ni orffen.

Evans: Rydw i’n torri ar draws cyn i ni ddod at y cwestiwn olaf oherwydd mae amser i mi ddweud diolch i bawb a gymerodd ran yn y drafodaeth yna yng Nghyfarfod Blynyddol Gwyddonol Cymdeithas Poen Cymru – y Doctoriaid Mark Turtle, Rob Davies, Mark Ritchie a Sue Beckman, a byddaf yn dilyn eu thema yng nghyfrol nesaf Airing Pain pan fydda i’n ymuno â rhaglen rheolaeth poen cymunedol yn y sir fwyaf, ond lleiaf poblog yng Nghymru.

Rdyw i am eich atgoffa o’r rhybudd arferol i fod yn ofalus; tra’n bod ni’n credu bod y wybodaeth a’r farn ar Airing Pain yn gywir ac yn gadarn yn seiliedig ar y farn orau sydd ar gael, dylech bob amser gysylltu â’ch gweithiwr iechyd proffesiynol ar unrhyw fater yn ymwneud â’ch iechyd a’ch lles. Ef neu hi yw’r unig un sy’n eich adnabod chi a’ch amgylchiadau ac felly’n gallu gweithredu’n briodol ar eich rhan.

Mae holl raglenni Airing Pain ar gael i’w lawrlwytho o wefan Pain Concern a gellir cael gafael ar gopïau ar CD yn uniongyrchol o Pain Concern. Mae’r holl fanylion cyswllt, pe baech am wneud sylw am y rhaglenni hyn trwy ein blog, bwrdd negeseuon, ebost, Facebook, Twitter neu ar bapur, ar ein gwefan, sef painconcern.org.uk. Felly, ar ôl dweud hynny, dyma’r cwestiwn olaf.

Turtle: Sut allwn ni ymgysylltu â gofal sylfaenol i alluogi symud ymlaen tuag at wasanaeth cymunedol? Dim ond rhan o’r mater ydy symud gwasanaethau fodal eilradd cyfredol i’r gymuned, ond er mwyn i ofal eilradd ganolbwytnio ar y rhai mwyaf anghenus mae angen gofal cynharach ar gyfer cleifion sydd mewn poen. Sut mae’r panelwyr yn meddwl y gallai hyn ddelio â phroblemau poen yn gynnar?

Davies: Mae’n rhaid i ni hyfforddi staff sy’n gweithio ar yr adeg yna yn siwrnai’r claf. Mae’n rhaid i ni roi’r teclynau academaidd angenrheidiol iddyn nhw i ddelio â hyn. Mae’n rhaid i ni roi’r sgiliau a’r hyder hanfodol iddyn nhw i ddelio â hyn. Mae’n fater o hyfforddiant.

Ritchie: Rydw i’n cytuno â Rob ei fod yn fater o hyfforddiant, ond rydw i’n meddwl ei fod yn rhywbeth mwy na hyfforddiant yn unig i feddygon. Rydw i’n meddwl y dylai’r hyfforddiant gychwyn gyda’n poblogaeth. Mae’n rhaid i ni siarad gyda’n cleifion ac annog hunan-reolaeth i raddau helaeth. Yr unig ffordd wnawn ni hyn ydy trwy addysgu’r claf yn ogystal ag addysgu’r meddyg. Yn y pen draw, rydw i’n cytuno mai addysg ydy’r ateb er mwyn i ganran uwch gael eu trin ar lefel is ac yna symud i fyny i’r rhai sydd wir angen bod mewn gofal eilradd.

Turtle: Ocê, Sue.

Beckman: Rydw i’n credu bod y ddadl addysg yn ffantastig a gwych, ond hoffwn i gyfuno addysg gyda synnwyr newydd o gymuned fel bod yr addysg yn bresennol ble mae ei angen arno. Does gennym ni ddim y ffiniau artiffisial hynny mwyach, ond beth am gael y bobl iawn yn y lle iawn, ble bynnag mae hynny.

Turtle: Diolch yn fawr iawn Sue, Rob a Mark a diolch yn fawr iawn i chi’r gynulleidfa. Mae’n ddrwg gen i na fedrwn ni fynd ymlaen yn hwy.

[Cymeradwyaeth]

Cyfrannwyr:

Mark Ritchie, Meddyg Teulu yn arbenigo mewn rheolaeth poen
Mark Turtle, Anesthetydd Ymgynghorol, Ysbyty Gyffredinol Gorllewin Cymru
Rob Davies, Anesthetydd Ymgynghorol, Ymddiriedolaeth GIG Pontypridd a Rhondda
Sue Beckman, Uned Cyflenwi a Chymorth Llywodraeth Cymru.

People on painkillers for chronic pain should have at least an annual review of their medication to ensure they are being given the best drugs to treat their condition, according to new advice to be issued to GPs and other healthcare professionals.

The recommendations – issued by the Scottish Intercollegiate Guidelines Network (SIGN), which is part of Healthcare Improvement Scotland – also calls for patients to be encouraged to take regular exercise and to attend pain management programmes to help manage their conditions.

Pain Concern played an important role in representing the views of people in pain at the consultation stage and our chair Heather Wallace reviewed the booklet for patients and carers. Heather said: ‘I hope people living with pain will use this booklet to become more aware of the treatment they are entitled to receive and to empower them in their appointments with healthcare professionals.’

The guideline’s key recommendations include:

• Ensuring all patients with chronic pain undergo a comprehensive assessment to help inform the best treatment options
• Directing patients to the best self-help advice and information resources that they can access either from home or at community health centres
• Conducting at least an annual review of patient medication to determine the success of a particular drug – more frequently if drug treatments change or pain continues
• Regularly reviewing the use of strong opioid medications – such as morphine – to treat patients with chronic low back pain or osteoarthritis; and securing specialist advice if there are concerns about patients having no pain relief despite increased medication doses.
• Referring patients with chronic pain to undertake a pain management programme
• Encouraging patients to be active and to try out all forms of exercise and exercise therapies

Dr Lesley Colvin, who chaired the Guideline Development Group, said the recommendations should play a major part in helping patients whose lives are blighted by ongoing pain.

She said: “The recommendations recognise that the best person to both understand chronic pain and to work to find ways to manage it, is the patient.

“Everyone is different – while one particular treatment may work very effectively in one individual, it may not work at all in another. As well as the physical sensations of pain, patients also often experience changes in their mood and what they are able to do, impacting on their work, family and friends.

“That is why it is important GPs and healthcare professionals use these guidelines to find the best treatments specific to patient and to address their overall condition, rather than just treating the pain itself.”

Each of Scotland’s NHS Boards will now be encouraged to fully share and implement the recommendations from the Guideline working through dedicated Service Improvement Groups in their local communities.

To read the patient booklet and for the full guideline, go to www.sign.ac.uk

GPs surgery, telephone or pain clinic: where should pain management take place?

[For a Welsh language transcript please click here.]

This edition has been funded by the Big Lottery Fund’s Awards for All Programme in Wales.

‘Good pain services, based in the community will make a huge difference to the lives of individuals and the NHS’, says Sue Beckman, speaking on behalf of the NHS’s Delivery and Support Unit at the Welsh Pain Society Annual Scientific Meeting. But what does moving pain services into the community mean?

Beckman, together with pain specialists Mark Ritchie, Mark Turtle and Rob Davies debate the key issue of where pain management should take place.

General Practitioners (GPs) are often those closest to ‘the community’ – they often see patients over the course of years, but limited training in chronic pain and lack of time in appointments pose problems. The panellists also discuss the challenges of bringing services closer to the isolated communities of rural Wales while ensuring that as many people as possible can access pain services by public transport. Finally, could moving services away from the pain clinic ‘demedicalise’ chronic pain by causing healthcare professionals and their patients ‘to think outside the box’?

Issues covered in this programme include: Community healthcare, GP, telephone consultation, remote/rural communities, small communities, primary care, secondary care, patient and staff travel, policy, multidisciplinary approach, funding and economic impact.

Contributors:

Mark Ritchie, GP specialising in pain management
Mark Turtle, Consultant Anaesthetist, West Wales General Hospital
Rob Davies, Consultant Anaesthetist, Pontypridd & Rhondda NHS Trust
Sue Beckman, Welsh Government Delivery and Support Unit.

GP’s surgery, telephone call or pain clinic: where should pain management take place?

To listen to this programme, please click here.

[For a Welsh language version of this transcript please click here.]

Prefer a PDF?Download

Beckman, together with pain specialists Mark Ritchie, Mark Turtle and Rob Davies debate the key issue of where pain management should take place.

General practitioners (GPs) are often those closest to ‘the community’ – they often see patients over the course of years, but limited training in chronic pain and lack of time in appointments pose problems. The panellists also discuss the challenges of bringing services closer to the isolated communities of rural Wales, while ensuring that as many people as possible can access pain services by public transport. Finally, could moving services away from the pain clinic ‘de-medicalise’ chronic pain by causing healthcare professionals and their patients ‘to think outside the box’?

Paul Evans: You’re listening to Airing Pain, brought to you by Pain Concern, a UK based charity working to help, support and inform people living with pain and healthcare professionals. I’m Paul Evans, and this edition has been funded by an ‘Awards for All’ grant from the Big Lottery Fund in Wales.

The Welsh Pain Society (Cymdeithas Poen Cymru) holds its annual scientific meeting each autumn, and for a country that’s – how can I put it? – geographically challenging, it’s an invaluable opportunity for people working in the field of pain in Wales to get together, discuss best practice – and yes, pain politics – and ultimately create a better service for the patient. Its Chair is Dr Mark Turtle, consultant anaesthetist specialising in pain management in Carmarthenshire. And at this year’s event I asked him whether the prevalence of chronic pain in Wales is any different to other countries in the UK.

Dr Mark Turtle: There is nothing which would suggest that the prevalence in Wales is any different from anywhere else – somewhere between upper teens and lower twenties in terms of per cent. What might be different, and one of the things we have been discussing in the last day or so, is the impact on individuals, how different people cope with pain. For example, we had a lot of talk about people in the valleys, people in certain areas in south Pembrokeshire, where perhaps they’re encountering considerable social difficulties, whereas people in other areas of rural Wales, for example, cope in a totally different way. So it’s not so much the prevalence of the problem, but the way that people cope and deal with it which might be…certainly it is an issue that has to be taken into account.

Evans: From the patients’ point of view, do patients around Wales, from different areas of Wales, have more or less difficulty than their counterparts elsewhere?

Dr Turtle: In accessing services…

Evans: In accessing and knowing about services.

Dr Turtle: Yes, yes. I think that one of the things that actually has come across quite strongly in the last day or so is the disparity between different areas. Both in terms of overall service – so there are one or two areas where people will have to travel a heck of a long way to get any sort of services – and there is also what that service is made up of. It is quite interesting. For example, somebody showed us an audit of the services, and Powys, which is a very sparsely populated area, it has got very good services in some respects, even though they are not centred round a major District General Hospital, for example. There are areas such as Ceredigion for example, where there are hardly any services at all. There are different clinics, which have different spreads of different disciplines so the make-up is different.

Then we’ve also hardly scratched the surface to look at the relationship between the services available and the actual population size. So for example, nothing seems to have taken to account that in a particular area the population may be very large and therefore the services ought to be a lot better. Now, that is even before we start looking at how people access them, how they are publicised, for an individual how they know what there is to access and that’s certainly something which needs more work.

Evans: Dr Mark Turtle. Well, the focal point of the day was a session devoted to that very topic in which a panel of three prominent health professionals in the field of pain explored issues around community pain services. The panellists were Dr Rob Davis, a specialist in pain management in Cwm Taf Health Board, Dr Mark Ritchie, a Swansea GP with a special interest in pain, and Sue Beckman of the Welsh Government Delivery and Support Unit.

That was established by the Welsh Assembly Government, referred to later as WAG, to assist NHS (National Health Service) Wales in delivering its key targets and level of service. Another term or acronym here mentioned is QOF, or Quality and Outcomes Framework. This is an incentive scheme for GP (General Practitioner) practices in the UK, rewarding them for how well they care for patients across a range of areas through a points system. Put simply, the higher the score, the higher the financial reward for the practice. There is no QOF for pain. So with all that jargon behind us, let’s join the debate. It’s chaired by Dr Mark Turtle.

Dr Turtle: We have picked three people who are confident, not couch potatoes, so I hope that they will chew this debate with vigour. Sue.

Sue Beckman: Thank you Mark, and thank you very much, I feel quite privileged being here, actually, to be honest. It is quite exciting this is, and to be considered that I might be somebody who would know about pain I also find quite flattering, because if you’d asked me a few years ago about the importance of community services for pain I wouldn’t have had a clue. I’m a diagnostic radiographer by trade – I’ve X-rayed many people in my time who are suffering from all kinds of conditions and terrible pain. But not once I think – and I’m ashamed to admit it – not once I think had I given much thought to how they access control of that pain in their lives.

And there are only really two things that have made me think about it in recent years. One was the focus on work that we did from the delivery unit and I am sorry that it is couched round orthopaedics, but that became our only vehicle to do this. One was the neck and back pain, when suddenly my eyes were opened to the importance of pain for people in this scenario, suffering with neck and back pain, and what pain actually does to people, which I hadn’t given much thought to before because I have been fortunate in that I do not suffer much myself. The second is watching my mother on a daily basis struggle with her pain and not be able to access the kind of pain control that I would love that she should have.

So those two things made me really think. Now you would have thought that would’ve been obvious so that made me think, ‘Well, if it is not obvious to you Sue, who else is it not obvious to?’ And I have to say that sadly it is not obvious to a lot of people, which is why I think probably we have not had as much investment in pain services in the community that I am sure all of you folk here would like, and actually I believe very passionately that good pain services based in the community will make a huge difference to the lives of individuals and will have a very positive and cost-effective effect on the NHS as a whole.

Twenty-eight million pounds I believe was quoted to me as the cost in neck and back pain in prescriptions alone for Wales. I think that is well worth thinking about and aside from that, think of all the people who very quickly could access something that makes their quality of life so much better than it currently is. So, on that basis alone, I rest my case that they’re a really important thing to push forward.

Dr Turtle: Thank you Sue. Rob.

Rob Davis: Eighty per cent of all medical (with a small ‘m’) contact that patients have with clinicians across the board, 80% of all contact has pain as an element in it. Now put that against 0.9% of the time spent as an undergraduate is pain training. So I think there is a big ask here. The whole idea of actually moving pain into the community, in terms of the service that we deliver, we have got to ask a huge number of questions. What we mean by moving pain into the community? What is the community? And do we really want to lose all those places and people that already provide a service? So I would just like you to think about those two questions: What is moving pain into a community all about? Who do we deal with? Where do we deal with it? And how do we deal with it?

Turtle: Thank you. Mark.

Mark Ritchie: What is pain? To me pain is not the lovely textbook definitions we get, but it is what the patient tells me it is at the end of the day. And Rob very succinctly put that 0.9% of training is in pain. He is right, that’s including acute pain, that’s not chronic pain. When you look at chronic pain in undergraduate training in this country in medical professionals, it’s between 4 and 6 hours depending on which university you are lucky enough to attend. Considering that, I think our general practitioners probably handle pain pretty well, considering the little training we have bothered to give them.

If we could spread that training a bit more, then it could become more community based, but that should by no means mean that we throw away our secondary care colleagues or throw away those secondary care clinics. They are still going to be needed to some extent but it is how we interact that with a good community based service. And I think it should be an interactive and interlinked service, not community verses a secondary care: I think it needs to be interlinked.

Turtle: Ok, thank you very much. Those are the opening stalls of our panellists. Now let’s see if we can perhaps challenge those views or get them to expand a little bit with some questions. The first question I have got here is: ‘On its own is not the most efficient way to treat chronic pain in a multidisciplinary, a multimodel service model? Patient access, transportation, clinician access to imaging results, team communication when spread out over a population area – how can we overcome these problems?’ Rob.

Davis: OK. Taking the second point first: the distribution of the population that we are dealing with and the ability to actually get staff together suggests that we need a base to work from. We have done clinics in GP practices where consultants have gone out to the practices – you end up travelling a long way, maybe seeing three patients. So it makes the case for me to have a base and bringing the patient to that base. And then there is the question about, ‘OK, how do we get them there?’ The issues of transportation, the issues of car ownership, and deprivation indices all come into that.

Patients, if they have a hospital on their doorstep, they would like to be able to use that hospital for everything. And this is what we found moving into one of the community hospitals because our existing hospital was on a recognised bus route, it was close to the motorway, people knew where it was, people could get there. For quite a while I had complaints from patients turning up saying, ‘What are you doing it up here for? We can’t get up here, there are no buses to get up here.’ It is an important point to think about – if you are going to move things into the community that is fine as long as it is local for that particular patient. If you have a big catchment area you have got to think strategically in terms of where you are going to base part of the service.

Turtle: Mark.

Ritchie: I would not want to denigrate that potential issue at all. However, there are very strong advantages of being closer to where the patients are. Some of those advantages are, we can start de-medicalising this problem, and as we see when we go to the British Pain Society… the last British Pain Society meeting I went to, something like half of all the lectures were no longer about drugs. They were on psychology, they were on physiotherapy techniques, they were on physical techniques rather than pharmaceutical techniques.

A lot of these patients when they come into a hospital setting believe they have come for another injection or another medication. I am not going to ‘poo poo’ those treatments at all; where they are appropriate they should be used. But what I am going to say is that if we move this out of a hospital setting, people start to think out of that box, and they start to think about a wider and more diverse approach to their problem, and we have certainly seen some pretty good results.

Turtle: Sue.

Beckman: The word ‘community’ – I can say for a fact that this is absolutely right, there is now a dichotomy of the way we talk and I am as guilty as anybody else. I say, ‘Are we talking about community care or secondary care?’ Actually I’m going to stop doing that and I’m going to start saying secondary care and previous primary care is now the community of treatment that we have. And I think what we need to do about this question is we need to say, ‘Well, what does our population look like? What way have we got in the vicinity? And what is the best way to provide those services?’ So it isn’t one size fits all. It isn’t the old-fashioned outpatients/GP scenario. It is, ‘There’s our demographics, that’s our rurality – how are we going to manage that?’ Now, that will take some quite clever planning and I am jolly sure, when we do it, make huge mistakes – but we’ll get there.

Turtle: Just to take this on a little bit further, and then Mark I will let you in, can I just point out another question which actually really links in very closely to what we are talking about here. There seems to be an ongoing debate as to what community actually means. What does the panel regard community to mean? Patients’ homes? GP practices? Medical centres? Peripheral hospitals? District general hospitals? etc., etc., etc. … Until we resolve this, the way forward remains somewhat difficult.

Ritchie: All of the above.

Davis: I think it is all of the above, but what is interesting is service within five days. There is no way you are going to get that in any hospital arranged treatment, unless it is an emergency treatment for quantified symptoms. But, having said that, so where is that treatment going to come from? It is going to come from a general practice and that merely pushes forward what I was saying earlier; we need to educate our practitioners at undergraduate level so that they all to some extent can deal with these problems, so that we do not have the massive problem arriving in so-called clinics, whether they are community based or in a hospital.

I think, what is community in this case? It is all of things you have mentioned. How we embrace that community is how we pull those different things together. And yes, maybe we are going to need to pull in different technologies, whether that is Skype, the internet, telly conferencing, whatever – all of those things become possibilities. They will only become possibilities of course with money. So it is going to be a case of balancing the accounts and deciding how we can give our community – total community now – the best service with the amount of money we have available. That of course is going to be something for the politicians and for our pay masters to sort out.

Ritchie: Can I come in with a point about telly medicine and the rurality issue? I think that what we have to recognise in Wales is that there are, if you like, areas of Wales where the solutions will be different. We also have to look at that fact that deprivation has an effect; you are not going to effectively use telly medicine where you have got people whose reading age is six and their ability to assimilate a piece of medical information is questionable at best. So you are going to be dealing with face-to-face description and explanation for people like that – they won’t get to you over Skype.

Turtle: Can I refer to another question at this point here? ‘It does not appear currently that there is overwhelming interest in managing pain outside a medical model in primary care. Is this reasonable? And if not, how do we change the engagement of fellow health professionals who work outside hospital practice?’

Davis: I’m going to stand up and be controversial. I find it difficult to engage with many of my colleagues in primary care. They have a 10 minute appointment system, dictated to by the government, which says you have to see 6 patients every hour, and if they reduce the number of patients that they are seeing, they then tell them they are not seeing enough patients. So for a start we have got this model which is dictated to by the state saying you have got to see so many patients every hour – that is the first problem. The second problem is – which is a solution in many areas – is QOF and QUIP as they now call it as well, where we are trying to raise standards, but there is not a QOF for pain. So what happens is the concentration of general practice goes into where there are QOFs.

I am not surprised there is not a QOF on pain because it is such a large and vast area, that the money that would have had to be put into it would’ve been considerable. So that is probably why it has been avoided up state. But the problem is that they are focusing their attention on the areas they have been told to focus their attention on, and also where the money goes. It is amazing how well diabetes has done since QOF came in. Diabetes has done magnificently and we are getting really good results in diabetes because the money has been put into that direction and the results have followed.

I don’t believe enough money has been put into pain. I do understand there are limitations of a budget, I am not an idiot who believes that there is a limitless or bottomless pit, but what I do think we are going to have to do is we are going to have to be a little bit more diverse in how we approach it. One way we can get into general practices is when we mix pain in with something else. So for instance, if we look at something that has been sold well to the general practitioners like diabetes, if you give a lecture, or a lecture is given which can be sponsored by industry or whatever, on various different forms of diabetic control, and you bring into that same lecture neuropathic pain, and maybe erectile dysfunction; by bringing those three things which are all relevant to diabetes, you suddenly capture the audience’s interest.

Turtle: Can I just pursue a little bit with the QOF business. A lot of people talk about the QOFs and of course people working in secondary care don’t fully understand all that. It seems to be expressed by a large number of people that know QOF for pain is a problem. Do you agree with that? And is it something that stands any chance of changing?

Davis: Whether there should be a QOF for pain, I mean ultimately government will debate that for a while yet to come. What does QOF do with any diseased area within a practice? What QOF does, is the first thing is, you have to draw up a register of all the patients who have that problem. So in diabetes, you had to create a diabetic register, so it immediately tells you how many patients in your practice have diabetes.

At the moment there is no such register in pain. So the general practitioners have no actual way at the moment of coming out and saying, ‘This is how many people we have with acute pain and this is how many people we have with chronic pain’. So if nothing else, if that was the only bit of QOF that came in, if they just said two points a year for creating a register showing how many people have pain that has been ongoing past the time of normal repair, past the 12 week mark. Even if they just did that, it would be a massive starting point because it would at least give us an idea of the size of the problem for budgeting for the future and for the provision of clinics.

Turtle: I want to get Sue’s opinion on this as a non-doctor, and to tease that out I am going to just quote this question here: ‘Having been on secondment for my secondary care paying service to set up a community service, I have worked with GPs and I have been exposed to their systems. It seems to me that it is still a huge divide between primary and secondary care services. How do we see that we can get these two camps coming together?’

Beckman: Thank you Mark. Well, just listening with great interest to that. It is lovely to hear a group of really enthusiastic people who want to see things change, and I am going to ask you a question: Does anybody know whether the commissioning directives for chronic non-malignant pain that were devised in 2009 have ever been rescinded?

Turtle: They have not been rescinded.

Beckman: No. Excellent, they have not been rescinded. Can I take just a moment to remind you of what some of them say? They actually say that by March 2009 planners and commissioners will ensure that plans to reconfigure existing secondary care pain specialist services, based on assessment of local patient needs, are established, to ensure patients with complex CNNPR triaged are referred to appropriately using evidence-based care pathways. Now there are actually three or four of those that go on to explain what the aim of all of that work was. Now, we must not lose that work, and I think somewhere along the way we have kind of lost that a little bit.

Now, if I am not mistaken – and this is one of the last times I am going to use this Rob – primary care and secondary care are now embraced in local health boards. So we should be using these directives to encourage local health boards to start to put in place those kinds of services. That is what we should be doing. I am coming from a more strategic approach than my colleagues, who are actual clinicians, are coming from. Mark, do not look at me when you mention budget, it frightens me! Because this is why I say to people, ‘Don’t please, I’m not from WAG, I am from the NHS. OK. Not my responsibility to set the budget!’

[Laughs]

Davis: Sorry.

Beckman: It’s OK, it happens all the time and that is why I was keen to mention it. So we straddle that for you and I have been looking for a way in now for a while, because certain things happened, which I do not need to talk about in WAG, about how the chronic conditions work, and it has come to a stalling point. And I am going to go back and find a way in again. I have tried several ways in because clearly, as you said, back pain… massive. Back and neck pain is my zone on focus on and I am desperate to see how we can get that right, sorted out with a proper community approach to it. So do not forget about these guys. You need to be asking your health boards, ‘What are we doing about these directives that came out? Where is my role in them? How are we going to take this forward, because they are four years behind.’

Turtle: Yeah, that was a point I was about to say.

[Laughs]

Turtle: I mean, I think this is the problem that those words have appeared and many of us have contributed to those words. But you used the word ‘stalled’.

Beckman: Stalled, yeah.

Turtle: And that actually is the problem, isn’t it? The process has stalled.

Davis: We should not be surprised about that because I was just looking for the actual date that this was signed off. You know, the actual document was generated in June 2008. We have had a financial maelstrom hit the health service so it is hardly surprised that we have stalled on this. There have been a lot of things that have been deemed to be more worthy, maybe that is because we have not shouted loud enough, but things have stalled financially. There has been no money to pump prime a lot of things. We have had to do things on a shoe string and the reason that I am the only representative from my health board, is that the rest of them are having to make sure that they are in work because future funding is predicated on certain requests and demands that have been placed on us by politicians to actually fulfil this document.

Beckman: Can I just pick up on that point? I think that is a very good point that you raised Rob. I think one thing that we are not very clever at doing – all of us, and I include myself in this, though I have tried on occasions, it was very hard – is actually really emphasising the economic element of it. We do not like talking about finances, do we, because, you know, it is not our first port of call. But sometimes we have to, because if that is what is driving us at the moment then we have to prove why the pain agenda is so effective financially. And we are not, unfortunately, at the moment, too clever at doing that. So if anybody is, please help me because I would love to do it.

Turtle: Right, I am just going to throw a spanner into the works. Of course actually the problem is disinvestment and we all know that buckets of money are thrown at things which are worse than unhelpful, a post to dismantle. Until we master the disinvestment thing, we are not going to move forward.

Beckman: It’s a case we have tried to argue from the delivery unit’s perspective a number of times. If we can avoid some of the burden of pain on the prescription, for Wales that is a direct either redirection of money you are saving, because we have free prescriptions. If you were arguing this in England it would be a different debate, but here that is a direct saving of money because we have free prescriptions.

Now you are clearly not going to save £28 million but you may well save a quarter of it, which would be a massive amount of money. So the more help we can get on trying to explain this and get this financial element worked out would be gratefully received. Remember, it is only neck and back pain the figures I have quoted, only neck and back. For North Wales, the prescription cost – that is all we’re talking about here – is quoted at £6.4 million.

Turtle: OK Mark, did you want to reply to that?

Ritchie: I wasn’t suggesting there were not ways we could find a list of these patients. What I was aiming with saying would be useful having a QOF register, is it would highlight it for each GP individually because they have to… with the other QOF you have got to put somebody as lead for diabetes, etc. As soon as you have created a QOF in pain, somebody in the practice would have to be a lead for pain, and therefore somebody would need a bit of education within the practice for pain and so it would spread the word that way. So, I was not meaning we could not find the data, and I am sure if we searched we could find it. As regards to pretend you cost savings from prescriptions, they are astronomical.

A few years ago before we became a joined trust, Swansea made a very considered effort to save money, and I remember when I was prescribing leader in my practice for seven years, and when I first took up my practice we were prescribing 44% generic. By the time I left, when we were in the top three generic prescribers for Swansea, and in the last year that I ran the budget for my practice on prescribing I saved £330 000 from my budget of which not one penny went into chronic pain, and that is the problem.

We can get people involved in saving money but if they are not going to see…If they are going to see that money disappearing into a mass called the trust and vanish into orthopaedic surgery or something, then it is going to achieve nothing. If I look at our own trust at the moment, I know of one patient who is costing £4000 a month and I know that there are about 50 of these across the trust, and the patient in question has lower back pain and uses 18 800 microgram fentanyl lollies a day. Work that out quickly money wise, and you will find that it is about £4000.

At the moment if I managed to change him, not a penny of that would come into the chronic pain budget, but quite frankly that is what I would like because I would like to set up a separate clinic once a week to see just those patients. Take their prescribing away from that poor GP who has been landed with that horrible prescription. Take it away from them and let’s convert that patient onto appropriate medication that won’t destroy his teeth and may well help him with his back, and at the same time save about half a million a year, because that is the potential, just on that small group of patients within our trust. So, and I am sure that there are similar patients out in yours, unless we are the worst trust around.

Turtle: Now, time is pressing. I have just got one more question and I am just going to give each panellist the opportunity to give two or three sentences, and then I am afraid we are going to have to call it to a halt.

Evans: I am just cutting across before we get to that final question because there is just time for me to say thank you to all those who took part in that debate at the Welsh Pain Society: Annual Scientific Meeting. That’s Drs Mark Turtle, Rob Davis, Mark Ritchie and Sue Beckman, and I will be following up on their theme in the next edition of Airing Pain when I will be joining a community pain management programme in the largest, yet most sparsely populated, county in Wales.

I will just remind you of Pain Concern’s usual words of caution, that whilst we believe the information and opinions on Airing Pain are accurate and sound based on the best judgments available, you should always consult your health professional on any matter relating to your health and wellbeing. He or she is the only person who knows you, and your circumstances and therefore the appropriate action to take on your behalf.

All editions of Airing Pain are available for download from Pain Concern’s website and CD copies can be obtained direct from Pain Concern. All the contact details, should you wish to make a comment about these programmes via blog, message board, email, Facebook, Twitter or pen and paper are on our website, which is painconcern.org.uk. So with all that said, here is the final question.

Turtle: How do we engage with primary care to enable progress towards community-based service? Moving current secondary care services to a community is only part of the issue, but in order for secondary care to concentrate on the most needy there is a need for earlier care of patients presenting with pain. How do the panellists think this could be addressing pain problems early?

Davis: We have to train the staff working at that stage in the patient’s journey. We need to give them the necessary academic tools to deal with it. We need to give them the necessary skills and confidence to deal with it. It is a training issue.

Ritchie: I agree with Rob in that it is a training issue, but I think it is more than just a training issue for medics. I think the training needs to start with our population. We need to be speaking to our patients out there and encouraging self-management to a large extent. The only way we are going to do that is by patient education as well as doctor education. Ultimately, though I agree education is going to be the answer so that a larger portion can be handled at a lower level and then move up to the ones that really do need to be in secondary care.

Turtle: OK, Sue.

Beckman: I think the education debate is fantastic and brilliant, but I would like to combine the education with that new sense of community so the education is where it is needed. We do not have those artificial boundaries anymore, but let’s have the right people in the right place, wherever that is.

Turtle: Thank you very much Sue, Rob and Mark and thank you very much audience. I am sorry we can’t go on any longer.

[Applause]

Contributors:

Mark Ritchie, GP specialising in pain management
Mark Turtle, Consultant Anaesthetist, West Wales General Hospital
Rob Davies, Consultant Anaesthetist, Pontypridd & Rhondda NHS Trust
Sue Beckman, Welsh Government Delivery and Support Unit.

This Wednesday, we are co-hosting a Twitter Q&A with The Painful Truth, answering your questions about chronic pain, especially regarding living with pain in the festive season.
The Painful Truth is a collaborative campaign to raise awareness of chronic pain and the need for innovation in chronic pain management – supported by Boston Scientific. 100cm sex doll

Tweet your questions on the hashtag #PainQA and we will answer them between 1pm and 5pm on Wednesday the 11th of December.

image from immrchris

Talking to representatives from a variety of pain organisations, including the Trigeminal Neuralgia Association, about the wide-reaching impact that pain has on society

To listen to this programme, please click here.

Prefer a PDF?Download

Christine Johnston heads to Brussels to investigate the impact that pain has on society as a whole at the Societal Impact of Pain lobby group’s fourth annual event. She talks to Neil Betteridge of Neil Betteridge Associates which promotes a holistic approach to pain management. Betteridge explains that early intervention is beneficial not only for the patient but also for employers, as it leads to faster, more effective treatment and less time spent outside of the workplace. Jamie O’Hara, who works with Adelphi Real World and the Haemophilia Society, discusses the results of a survey carried out about the effect pain has on society, which found that those living with chronic pain and their carers experience disproportionately high levels of unemployment.

Christine also speaks to Jacqui Lyttle, an Independent Commissioning Consultant, who criticises the current care given to those with chronic pain conditions, citing wrong diagnoses and the subsequent delays in accessing effective treatment as the main issues. She explains that pain management costs more when it’s not managed effectively than when it is, both in terms of money and in working days lost through illness.

Paul Evans then meets Jillie Abbott, the Projects Officer of Trigeminal Neuralgia Association, who describes the organisation’s attempts to raise awareness of the little-understood condition within the healthcare profession, citing the high frequency of misdiagnoses and ineffective treatment as the motivation for this educational focus. She also shares some coping mechanisms that can help those living with Trigeminal Neuralgia and emphasises the need for better communication between people living with the condition and healthcare professionals.

Issues covered in this programme include: Trigeminal neuralgia, orofacial pain, holistic approach, workplace, employment, misdiagnosis, communicating pain, raising awareness, stigma, patient experience, discrimination, social support, the biopsychosocial model, economic impact and carers.

Paul Evans: I’m Paul Evans and welcome to Airing Pain, a programme brought to you by Pain Concern, a UK-based charity working to help, support and inform people living with pain and healthcare professionals. This edition’s been funded by a grant from the Scottish Government.

Now, the Societal Impact of Pain (SIP) is an international platform with the aims of raising awareness of how pain impacts on our society’s health and economic systems. Their fourth annual event took place in Brussels back in May 2013 and the delegates focused on topics previously agreed in their roadmap of action, one of which was European best practices for the reintegration of chronic pain patients into the workforce. Pain Concern’s Christine Johnson attended the event to gain a UK perspective.

Neil Betteridge: My name’s Neil Betteridge, I’m at the SIP meeting representing my own company mainly, which is Neil Betteridge Associates, a patient consultancy. But I’m also, in the UK, the vice chair of the Chronic Pain Policy Coalition, which works with most organisations in the UK with an interest in pain, including Pain Concern.

I think there is a general lack of awareness amongst, I suppose, society generally and employers specifically really, and lack of awareness about issues like the importance of early intervention. I think too often there’s a kind of stigma associated with pain; people are often reluctant to mention it, of course its invisible, it doesn’t show often so sometimes it doesn’t get raised with them. And often by the time people have worked out that they really have to talk about this, or do something about it, sometimes the pain has developed so far that it’s harder to treat.

Whereas all the evidence shows that when there’s early intervention, when there’s a good employer or good trade union, or even just when the individual decides to sort of flag it early and take some action, then nearly always there’s a much better outcome. Of course a better outcome is a great thing for the patient, but at the same time it’s better for the employer, because it means they’re less likely to lose that person from the workforce and have to pay to replace them and train somebody else etc., so if we can get that right then it’s a win, win.

Christine Johnson: And what key changes are we talking about at the moment, what is being proposed as the best way to deal with this?

Betteridge: I think culturally all parties need to promote cultures within their workplace which promote prevention and good, honest, open dialogue about it, and I think government have a role to play there by providing support programmes, so that employers don’t have to carry the full burden, financially, if they want to offer support to an employee who has pain. And I think it’s also important that worker participation in programmes of that sort… is really important, so that management and workers can discuss together the best ways of offering support to people with pain, because after all it’s in their mutual interest to get it right.

Often the best outcomes are arrived at when there’s a sense of a kind of holistic assessment taken of the persons condition. Obviously it will vary, if we know what’s causing the condition, such as, you know, a form of cancer, or muscular skeletal problem, then often it’s just about getting that person to see the right specialist. If the pain is undiagnosed and it’s not clear what exactly is causing it, then after some sort of triage, and some sort of test to see whether we can get to the bottom of it, often it’s best if that person gets to see a specialist in pain services, rather than a particular medical specialty. But I think the thing running through all of this is acting early, ‘cause it’s early intervention which gets the best results in the long term.

Johnson: And if it’s too late for early intervention, when we’re talking about later rehabilitation programmes, what’s being proposed there?

Betteridge: Well I guess it’s never too late, there’s always something positive that can be done to help, so I think the message really is to patients is ‘don’t despair!’ There’s primary prevention, which can stop pain developing in the first place, and there’s secondary prevention, which can stop deterioration. So, whatever stage the patient is at, there’s always something positive that can be done.

I think, psychologically, knowing for the patient, or the employee, to know that they have a supportive employer is immensely important; it means they’re often more prepared to be open and honest about how their pain is affecting them. And whilst they’re getting the most appropriate medical support, their psychological, sort of bio-psycho-social model really, needs to really kick in, cos it’s all too easy to become depressed by your pain, that depression can be worse if you’re also pessimistic about your chances in the workplace for the longer term. So getting that kind of social support, and the psychological support, alongside the more medical and mechanical support, I think is the right package.

Johnson: And if we take this as a starting point, how soon do you think we could hope that these measures could be implemented, with the required support at each level?

Betteridge: Some places are doing it now, there are some really great examples of best practice. I think the challenge is to really capture that, and disseminate it and promote it so that those who aren’t delivering to that standard realise that a) that it can be done and b) if they do it, they’re not only going to be doing the right thing, but they’ll be saving money in the long term too.

Johnson: And while we’re discussing at European level, and that’s important, can we talk about the UK model, because obviously there’s differences between Scotland, between England, and so on?

Betteridge: I think the how, that these support measures can be delivered and developed will vary, quite rightly, between different nations across the UK, but the what, what it is that we are trying to do, I think is common, it’s a common challenge, it’s about providing support for people early on so that they don’t deteriorate, so that they’re better in the long term, and the employer is better off in the long term.

Jamie O’Hara: I’m Jamie O’Hara and I work with Adelphi Real World and the Haemophilia Society in the UK. We’ve conducted a survey across the five main EU countries, looking at four thousand different patients, from both the physician and the patient perspective, and we’ve been able to develop a holistic burden of illness study so we can gain a better idea into the overall effect that pain is having on society as a whole.

And we’ve found some quite interesting things: that the level of unemployment for those suffering from chronic pain, particularly within the neuropathic parts of it, are only employed up to 40%, so obviously that’s hugely different from the 7% average across the normal population. And not only that, we find that quite a large portion, around 20%, in fact, have full time care givers which is also again a huge societal perspective, a cost to society.

Johnson: So the consequences are felt by the individual, as well as by society as a whole, it’s quite far reaching?

O’Hara: Well yeah, obviously because the majority of the care givers are often partners, friends or volunteers, so obviously these are either not paid at all, or subsidised by the state in order to provide this care to the patient. So this represents an opportunity cost, and within our sample of around four thousand patients we found that there was over five thousand lost working days from the caregiver alone, that’s before we’ve even begun to quantify the total lost number of days from the patients themselves, which is even more substantial.

Johnson: We talk about preventing chronic pain, but how do you reintegrate people into the work place, what key changes are we talking about?

O’Hara: I think it’s about strategy, I think the way that we currently assess pain care, and medical pain care interventions, and healthcare interventions with regards to pain is quite narrow, because we look at disease areas individually, whereas pain is by and large a symptom of many different disease areas. So I think the SIP initiative is very good because it calls for an overall strategy across every disease area in order to push the standard of care to support these patients. So particularly the strategy, as well as the process indicators that have been developed could be very, very helpful in improving people’s lives, and not just the patients, that of the wider society as well.

Jacqui Lyttle: I’m Jacqui Lyttle, I’m an Independent Commissioning Consultant, working across the UK, working with CCGs (Clinical Commissioning Groups) and trust and health boards trying to improve patient care.

Johnson: Today we’ve been discussing the reintegration of chronic pain patients into the workplace, so what has the research indicated the main problems are for the patient if they’re at work or if they are trying to return to work after a period of being off?

Lyttle: One of the biggest things that we found was the care wasn’t seamless, and if patients got the diagnosis wrong at the beginning their journey was delayed, which meant that they were often away from work, or trying to get back to work and there were delays in the system, and actually a lot of people felt that their pain was not taken seriously.

We discovered that there was a real issue with initial diagnosis, and of appropriate diagnosis, and if patients got on the wrong pathway they could be referred to the wrong professional and they got stuck in the system, and actually as a consequence of that their condition often deteriorated, which meant they were either off work longer or it was more difficult to get back into work. There’s a lot of time loss, there’s a lot of delays, there’s a lot of waste in the system, where people go from their GP [general Practitioner] to an orthopaedic surgeon, for example, then it’s not an orthopaedic problem it’s a gastro problem so they can get referred onto multi professionals and they go back into the system, by which time the patient’s condition has deteriorated.

Johnson: And obviously there’s a massive impact on the individual, but what about the cost to society as a whole?

Lyttle: I think that’s more far reaching than people realise, the work that we did, we mapped not just the impact on patients but on… impact in primary care, so the number of times that a patient went back to their GP, the times that they accessed secondary care services, but also the time that they were away from work, people were then claiming benefits because they were obviously unable to go to work, so the impact is bigger than people understand, especially in the UK, especially in England with the changes in the NHS [National Health Service]. It costs more when pain is not managed that it does to actually manage it properly.

Johnson: You’re one of five people who is drafting, or has drafted, the proposal for action – can you tell me what this is based on and what key changes it puts forward?

Lyttle: We mapped in great detail a number of patients from their initial attendance at the GP practice, through to when they and their professionals felt that their pain was adequately controlled, and the things that we discovered, that patients circled the system a number of times, again depending on how the diagnosis happened, whether it was done timely, by the right person, whether actually they got the right treatment, the complications. And one of the things that we identified is that even though the burden of pain is greater than diabetes, asthma and COPD (Chronic Obstructive Pulmonary Disease) combined it doesn’t have the same priority as those long term conditions. So what we’re hoping for is that pain will be seen as a priority within the NHS in England.

Johnson: And is it significant to discuss this at European level, why is it important to do this?

Lyttle: I think it is actually, because I don’t know if the UK is unique, I don’t think it is, I think one of the things that we found that there was clinical variation across England, and I don’t think it will be any different in the devolved nations in the UK and I don’t think it’ll be different across Europe.

Johnson: What support is required from individual governments? What do they have to do to support this?

Lyttle: I think, I can only speak for England, I think we need to get it on the priorities within the operating framework for NHS England, and then across the wider UK and I would imagine similar processes would have to happen in the other EU countries.

Johnson: And what impact, if this is followed through properly, will this have on a chronic pain patient who’s in work or who’s finding trouble staying in work?

Lyttle: If we were able to make even some improvements to the way which patients get treated it would mean that they could live more independently, they’d have better pain control sooner, and it would also mean that we would have less burden on the NHS, we would then hopefully be able to, sort of reuse some of that money to treat more patients, because one of the problems is that patients wait a long time for treatment, so I think it would just be improving the whole circle of treatment really.

From the work that we did last year we are now working with the British Pain Society and the Royal College of GPs to… we’re in the process of writing a commissioning guide for pain and we’re now trying to raise the profile of pain in England at the moment with commissioners. But I think there’s a long way to go, and I really think it needs some more support and a higher profile nationally, from NHS England and the Department of Health down before we do see a sea change, ‘cause at the moment we’re competing with diabetes and asthma and other long term conditions, and I think pain should be seen as a long term condition in the same way.

Evans: That was Independent Commissioning Consultant Jacqui Lyttle, speaking with Pain Concern’s Christine Johnson.

The Societal Impact of Pain is held under the umbrella of the European Federation of the International Association for the Study of Pain Chapters, and they’ve designated 2013/14 as the Global Year Against Orofacial Pain. This is pain experienced in the face and/or oral cavity. One such condition is Trigeminal Neuralgia; it’s a condition often misunderstood by health professionals,

Back in the spring of 2012 Jillie Abbott, then Chairman of the Trigeminal Neuralgia Association UK, addressed the British Pain Society annual scientific meeting on that very point.

Jillie Abbott: Trigeminal Neuralgia is very severe face pain, neuralgia is a nerve pain and trigeminal refers to the trigeminal nerve, which has three branches either side of the face.

Evans: Let’s call it TN from now on [yes], we’ve talked about TN before on Airing Pain, but you’re here talking to health professionals on how to deal with it.

Abbott: Yes, it’s wonderful to have that opportunity, one of our main concerns is trying to raise awareness of TN amongst medical professionals and it’s come to our notice over the years certainly that people are not being treated properly. Diagnosis, I’m please to say, is quicker than it used to be, people are getting diagnosis much faster than in the past, but quite often they are not being treated effectively.

Evans: I suppose that’s one thing, to get the diagnosis done, but in what way aren’t they being treated?

Abbott: Quite often GPs don’t know very much about the condition. Sadly, some of them don’t seem prepared to research it and they’re sometimes not prescribing the right medication and, sometimes, if they are prescribing the right medication, they’re not telling the patients how to take the drugs.

For example, it’s normally treated with anticonvulsants and these must build up in the bloodstream, so they need to be increased very slowly and if the pain isn’t so severe they can be decreased slowly, but they mustn’t be taken like pain killers: you can’t just take it when the pain comes along. And patients are not told that, so, therefore, they’re taking the drugs and they’re not having any effective pain relief as a result.

They’re also not told about the side effects so, quite often, because carbamazepine is the main anticonvulsant drug used to treat TN, they’re not told that they do quite often have very severe side effects; that you’re going to feel dopey, spaced out, may have nausea… it does cause mental confusion in some cases, and because patients aren’t told this, or warned [about] it in advance they will stop the drugs and think, ‘I can’t take that, I can’t function, I’m too zombie like’, so they need to be warned that this is the effect or could be the effect. So, therefore, it would be far better if there was a bit more communication between the GP and the patient initially, so they knew what to expect.

Antidepressants are also used to treat TN, and patients aren’t told that they are being given antidepressants for pain relief, they say to us, ‘I’m not depressed, or if I am depressed it’s the condition that’s making me depressed. I don’t want to be given anti depressants’, then, it isn’t explained to them and that’s the message that we’re trying to get across.

Evans: You have trigeminal neuralgia?

Abbott: Yes.

Evans: Explain what it’s like.

Abbott: It’s an electric shock type pain. When it’s at its worst it is like being electrocuted; it’s like having a cattle prod in your face and it is so intense and so excruciating that while you’re having an attack of pain you’re completely incapacitated: you can’t do anything, you can’t speak, you can’t think, it just rivets you to the spot, sometimes it will even bring you to your knees.

And, unfortunately, it’s a progressive condition, so the pain attacks tend to become more frequent, they don’t necessarily increase in intensity – they can’t really – but they tend to become more frequent and it’s this absolute fear of having another attack of pain that worries people so much. And because they’re frightened they will take whatever action possible to avoid having another attack. It can be triggered by light touch, eating, drinking, talking, smiling, kissing, all these sort of things, so people become very isolated, they won’t go out in the wind – even air conditioning in a shop can set it off – so they don’t go out very much. They can’t socialise because they can’t eat and they find it embarrassing to try and eat in public, so they withdraw and they can become very isolated and that isolation in itself causes depression loneliness and more anxiety, so it can be a vicious circle.

If they have the right treatment and if they can talk to other people with the condition and get some help and advice and tips and coping mechanisms they will fare much better.

Evans: Tell me what that help involves and what the coping mechanisms are?

Abbott: Above all, what people say when they first contact us is how relieved they are to talk to somebody else who suffers from the condition, actually someone who really understands their pain and what they’re going through, that’s a huge relief to them. And being able to talk to somebody who is coping with their life is extremely beneficial; they can see that other people suffer from it. Alright, there may not be an effective long lasting cure, I mean there are various treatments, but there are ways of dealing with the pain, ways of coping with it, and that gives them hope and encouragement. So that’s hugely beneficial.

Evans: What ways?

Abbot: If people start off with the right medication and first of all get their pain under control, that takes away some of the fear. We can then explain how others of us cope with pain attacks: if you can’t drink you could drink through a straw; you can eat mushy food, or put your normal food in a food blender if you’re having difficulty eating. We always advise people to talk to their employers, explain the situation. Because it’s an invisible condition, employers can sometimes be very unsympathetic, but if they get brochures and information and leaflets from us and take those in to their employers, that helps for the employer to understand what they’re going through and become more sympathetic and try and make arrangements about their working life to accommodate the difficulties that they might face.

There are lots of other tips, for example it you’re suffering on a windy day or a cold day we say to people: ‘wear a balaclava – don’t be embarrassed about the fact that people may look at you rather oddly because it’s not midwinter’. Food to avoid: different things we’ve found can trigger it, sweet foods, spicy foods, nuts… anything crunchy will cause it, so we give people dietary advice and just various tips on how to get round the situation.

Evans: What sort of response do you get from the professions when you stand up in front of them and talk to them about the problems that their patients are facing?

Abbott: I think to a degree most of them now are more understanding about the actual problems. When I talked to them in the meeting yesterday they were quite surprised about the fact that there are complaints from patients about the way they’re treated; perhaps the people who came along to the meeting were the ones who are treating people properly.

But I think some of the horror stories that I was telling them were quite shocking to one or two of them, or to most of them in the room in fact. And I think they probably will be determined hereafter to treat their patients with a great deal more care and compassion and, in fact, all of the medical profession are going to have to do that because there’s a NICE [National Institute for Health and Care Excellence] guideline, which came out in February 2012, which covers what patients in time will grow to expect from all their medical staff: information, involvement, choices and shared decision making.

Evans: You might have noticed the shock on my face – why does a health professional need a guideline to tell them how to treat a patient with respect?

Abbott: Exactly, you wouldn’t have thought it would be necessary, but I’m afraid it is. We have collected quite a few stories from people which are actually quite heart rending. These are from records kept by our telephone helpline team:

Her mother had seen a neurologist – she couldn’t remember his name – who treated her, quote, with ‘indifference’ and said that she had migraine. The caller said that she thought the neurologist had no interest in her mother because of her age.
Her GP is not helpful and tells him to forget about it.
His dentist tells him that the patient is no longer his ‘pigeon’.
The GP has done a really good scaremongering job on all the procedures for TN, telling him that ‘they were all far too dangerous and not performed often enough.’
And, to end on a good one, her GP immediately recognised the symptoms and diagnosed TN.

Evans: Now that’s a mixture of responses to your TN helpline, predominantly bad experiences?

Abbott: Yes, I mean it is true that the people who come to us could be those who are not getting the right treatment… but I do think a lot of people do get very good treatment, but people do still come to us and there should not be as many of these stories as there are. It’s too often the case that people feel that they need to ask for further help with dealing with the medics – that shouldn’t be necessary.

Evans: So when you read these to the room of consultants and professionals yesterday was there an audible gasp?

Abbott: I think there was, yes. I think this was quite a shock to most of them in the room.

Evans: What sort of questions did they ask you?

Abbott: One chap actually said that he felt it was disgusting and this ought to be referred to the General Medical Council.

Evans: At a British Pain Society event you may be speaking to the converted?

Abbott: Yes.

Evans: It’s the unconverted you need to get hold of.

Abbott: I know, I know, and this is the difficulty we have. We would love to have the opportunity of running training courses for general practitioners and dentists. Our medical advisor is Professor Joanna Zakrzewska and she runs courses for trainee dentists on dental pain, facial pain… and she tells me that very few people turn up to these pain courses, but if there is a course being run on cosmetic dentistry the queue is down the road and round the corner.

So there is a difficulty there of getting the message across, we’d love to have more opportunity of training GPs and dentists. We have a joint patient and profession, healthcare professional, conference every two years and we try desperately to publicise this widely. We’d love the opportunity to do more of those and to get the message across… I mean I’ve no idea how many GPs there are in the country – probably something like 250,000 – but GPs don’t, obviously, have enough time. But what they need to do, if they suspect TN, is to first of all sort out the right pain relief and then to refer on, so that they’re referring then to a specialist who does have enough time to give to the proper history taking.

Evans: That’s Jillie Abbott, of the Trigeminal Neuralgia Association UK. And for more information, go to their website, which is TNA.org.uk.

I’ll just remind you of our usual words of caution, that whilst we believe the information and opinions on Airing Pain are accurate and sound, based on the best judgements available, you should always consult your health professional on any matter relating to your health and wellbeing; he or she is the only person who knows you and your circumstances and therefore the appropriate action to take on your behalf.

All editions of Airing Pain are available for download from Pain Concerns website and CD copies can be obtained direct from Pain Concern. All the contact details, should you wish to make a comment about these programmes via our blog, message board, email, Facebook, Twitter or pen and paper, are on our website which is painconcern.org.uk .

A final word of advice on trigeminal neuralgia, for doctors from the patient: Jillie Abbot…

Abbott: Yes, it’s very important I think for medics to provide time for the patient to be able to give their opening statement, to tell their story. Research has shown that not enough time is given to this, apparently, from a study recently in outpatients, of 335 patients the average time given to them was 92 seconds; 78% of patients finished in just two minutes.

And it’s in the first few minutes of telling their story that professionals can sometimes make judgements, and I think they need to listen more to the patients and it’s listening to the patients that will give them the diagnosis. There’s no diagnostic test for TN, it’s all down to the history taking, so this is what’s very, very important: getting the right diagnosis is crucial because, if they don’t get the right diagnosis and the medical treatments are not effective, patients sometimes go on to have surgery and that, if it’s not classic TN, will make the situation far, far worse and then it becomes an intractable condition.

Evans: But in many ways you can’t blame the health professionals for only having 92 seconds average with a patient, could the patient prepare for that 92 seconds?

Abbot: Yes, there are three different stages to this: while they’re waiting for their initial appointment, they need to learn to accept the condition; they need to learn, hopefully from us, some coping mechanisms and focusing on their pain will be unhelpful and self-destructive; and, very importantly, failing to eat properly will lower the body’s defence mechanism and its ability to heal.

At the consultation I think it’s important that they expect that they may well get given questionnaires; they may meet someone other than just one specialist. These days there are multidisciplinary teams that are conducting these patient sessions, so they might have with them a neurologist, a psychiatrist, a registered nurse, perhaps, a biofeedback therapist, possibly even a neurosurgeon.

And we say to them keep a pain diary – that’s really important – because that will give the medical professional an idea of when the pain is occurring, how often, what effect the drugs are having, what side effects they might be having… so that’s very important. And they need to take along notes about the drugs and also lower their expectations sometimes: don’t expect a complete cure, but expect a reduction in pain.

Contributors:

Neil Betteridge – Director of Neil Betteridge Associates and Vice-Chair of Chronic Pain Policy Coalition
Jamie O’Hara – Adelphi Real World and elected trustee of Haemophilia Society
Jacqui Lyttle – Independent Commissioning Consultant
Jillie Abbott – Projects Officer of Trigeminal Neuralgia Association.

Talking to representatives from a variety of pain organisations, including the Trigeminal Neuralgia Association, about the wide-reaching impact that pain has on society

This edition has been funded by a grant from the Scottish Government.

Contributors:

Christine Johnston, Pain Concern
Neil Betteridge, Owner of Neil Betteridge Associates and Vice-Chair of Chronic Pain Policy Coalition
Jamie O’Hara, Adelphi Real World and elected trustee of Haemophilia Society
Jacqui Lyttle, Independent Commissioning Consultant
Jillie Abbott, Projects Officer of Trigeminal Neuralgia Association.

The staff and volunteers at Pain Concern are taking part in the Edinburgh Christmas 5k Fun Run to raise money for the charity.

You can help us out by donating on our JustGiving page. You can donate as much as you like, and also apply Gift Aid to your donation.

Why support us?

To help us to continue to campaign effectively for improved pain management in the NHS and better education for all healthcare professionals.
To help us to continue to produce high-quality, reliable healthcare information on the topics that matter most to people with pain and support our efforts to make our information as widely available as possible.
To help us to continue producing our radio programme Airing Pain, which brings information and support into the homes of thousands of listeners.
To help us to keep our helpline volunteers providing information and support to callers.

People living with pain rely on our support, and we rely on your donations. Please consider donating to help people living with pain. For example: £15 lets us provide ten callers with information and support from our helpline volunteers.

£25 lets us distribute 100 copies of our booklet A Guide to Managing Pain which helps people in pain to build their confidence and self-management skills.

Sut gall nyrsus ddefnyddio therapi ymlacio, tylino, aciwbigo ac empathi i helpu pobl reoli eu poen

Cefnogwyd y prosiect darlledu a chyfieithu hwn gan Ymddiriedolaeth Oakdale.

To listen to this programme, please click here.

Prefer a PDF?Download

‘Dychmygwch sut mae’n teimlo os ydych chi mewn poen a phobl ddim yn eich helpu.’ Yn union fel gweithwyr proffesiynol eraill yn y byd iechyd, gall nyrsus ei chael yn anodd ar brydiau i ddeall agwedd pobl sy’n byw gyda phoen. Ar ddiwrnod hyfforddi i fyfyrwyr nyrsio ar boen cronig, roedd Gareth Parsons wedi pwysleisio pwysigrwydd credu’r claf ac fe ddywedodd rhai gwirioneddau anghyfforddus yn seiliedig ar ei ymchwil i’r rhywystredigaethau mae pobl mewn poen yn aml yn eu profi gyda gweithwyr iechyd proffesiynol: ‘chi yw’r broblem!’

Yn dilyn yr hyfforddiant hwn, gobeithir y bydd y grŵp hwn o nyrsus yn rhan o’r ateb i’r broblem. Y cam cyntaf yw deall bod poen cronig yn gyflwr ynddo’i hunan – yn y ffordd hon bydd y nyrsus yn ymwybodol o’r broblem o drin poen cronig yn union fel petai’n boen aciwt (er enghraifft, defnyddio opioidau yn ormodol) ac yn gallu helpu i ddelio â phryder ac ofn.

Pan fydd ganddynt well syniad am natur poen cronig, bydd nyrsus yn llai tebygol o ‘daflu cyffuriau’ at y broblem, meddai Owena Simpson. Mae hi’n tywys y myfyrwyr nyrsio trwy sesiwn therapi ymlacio, tra bo Maria Parry yn addysgu technegau tylino craidd i’r myfyrwyr ac yn dwyn i gof ei phrofiadau ei hun o sut y llwyddodd claf roedd hi’n gweithio ag ef oresgyn methu cysgu yn dilyn therapi tylino. Bydd Gareth Parsons yn gorffen y sesiwn gyda gwers ar aciwbigo gan esbonio pam fod y driniaeth hon yn gallu bod yn fwy effeithiol i rai cleifion yn hytrach nag i eraill.

Paul Evans: Helo a chroeso eto i Airing Pain (Sôn am Boen), y rhaglen sy’n dod atoch dan nawdd Pain Concern; elusen yn y DU sy’n gweithio i helpu, cefnogi a rhoi gwybodaeth i bobl sy’n byw gyda phoen, ynghyd â gweithwyr iechyd proffesiynol. Arianwyd y cynhyrchiad hwn gan grant ‘Gwobrau i Bawb’ (‘Awards For All’) o Gronfa’r Loteri Fawr yng Nghymru.

Owena Simpson: Fel nyrsus sy’n nyrsio oedolion rydym yn awyddus iawn, neu’n tueddu yn gyntaf, i fynd ar ôl meddyginiaeth yn hytrach na chwilio am ffyrdd amgen i reoli pobl sydd mewn poen a helpu pobl i ddod i wybod bod ffyrdd eraill o ddelio â phoen cronig yn hytrach na mynd yn syth am feddyginiaeth a’r holl sgîl effeithiau sydd ynghlwm â hynny.

Evans: Yn y cynhyrchiad hwn o Airing Pain (Sôn am Boen) rwyf wedi dod i Brifysgol De Cymru i weld sut mae grŵp o fyfyrwyr nyrsio yn cael mewnwelediad i sut y gallant helpu pobl gyda phoen cronig yn eu gyrfaoedd yn y dyfodol. Ac mae hwn yn amser da i ymuno â nhw oherwydd dyma’r ddarlith olaf un yn eu cwrs gradd tair blynedd mewn nyrsio oedolion. Y darlithydd yw Gareth Parsons, sydd, pan oedd yn nyrs glinigol arbenigol mewn rheoli poen, wedi datblygu clinigau poen cronig wedi eu harwain gan nyrsus, ar aciwbigo, ysgogi nerfau trawsgroenol (transcutaneous nerve stimulation (TNS)) a therapi ymlacio.

Gareth Parsons: Bydd heddiw ychydig yn wahanol: rydym am ddatgelu rhai o’r ymyrraethau y gall pobl â phoen cronig ddod ar eu traws a nyrsus fydd yn rhoi’r ymyrraethau hyn i gyd. Felly dyma dylino, fydd yn cael ei arddangos gan Maria Parry.

Maria Parry: Roedd gennym glaf oedd wedi torri ei gefn a byddai’n dod yn ôl ac ymlaen am ofal seibiant bob 6 wythnos ac roedd ganddo lawer o boen o’r gwingiadau yn ei goesau ac o gramp. Doedd e byth yn cael noson dda o gwsg, roedd yn symud yn barhaol ac roedd ei boen yn golygu nad oedd byth yn gallu bod yn gyfforddus.

Parsons: Bydd Owena yn gwenud y sesiynau ymlacio.

Simpson: Dyma amser aseiniadau ac mae un wedi ei gyflwyno’n barod a nawr mae’r traethodau hir ar y gorwel! Felly ydych chi i gyd yn teimlo dan straen? Neu efallai bod rhai ohonoch yn teimlo’n iawn. Ond mae arwyddion sylfaenol – crïo, cur pen ac anwydau o hyd neu’n teimlo’n nerfus yn gyffredinol.

Parsons: Os edrychwch chi ar y siart yma, fe welwch o amgylch ochr y pen bod llawer o bwyntiau aciwbigo. Mae nerfau’r craniwm â llawer o gyflenwadau bach i’r croen a’r cyhyrau o amgylch yr ardal hon – yn hawdd iawn i ysgogi pwysedd. Felly byddai rhwbio ochr eich pen yma – mae’n siwr eich bod yn gwneud hyn yn barod? Mae hyn i wneud i chi feddwl am ffyrdd eraill y gallwch helpu pobl mewn poen ac mae hefyd er mwyn gwneud i chi feddwl mewn ffordd wahanol i’r ffordd rydych chi’n meddwl am boen ar hyn o bryd. Felly gyda hynny mewn golwg, mae gen i gwestiwn i chi. Ydych chi’n teimlo bod unrhyw wahaniaeth rhwng poen aciwt, cronig a lliniarol? Beth ydych chi’n deimlo yw’r gwahaniaeth rhyngddyn nhw? Hyd amser? Math o boen? Iawn, felly gwahaniaethau mewn dwyster neu fynychder – chi’n gwybod, p’un ai ydy o yno bob amser. Dwyster? Felly rydych wedi deall rhai o’r pethau rydw i’n sôn amdanynt ac hefyd efallai wedi sôn am rai o’r mythau rydym am eu harchwilio.

Os edrychwch chi ar ddiffiniadau’r gwahanol fathau o boen yn y llyfrau gosod, dyma beth mae nhw’n ddweud: poen aciwt – poen diweddar, gall fod yn rhywbeth sy’n digwydd am eiliad fel pan fyddwch yn brifo’ch hun efo nodwydd neu’n cael pigiad. Neu gall barhau am ychydig o funudau neu rai oriau. Byddai’r rhan fwyaf o bobl yn dweud bod poen aciwt yn rhywbeth sy’n para llai na 3 mis. Rydym yn aml yn meddwl bod achos penodol i boen aciwt – mae’n digwydd ar unwaith. Mae’r ddanodd wedi ei achosi gan ofal deintyddol neu rydych wedi cael anaf neu gall fod gennych glefyd cudd sy’n achosi’r boen. Ac mae’n bosibl amcangyfrif pa mor hir fydd yn para; gallwn feddwl bod diwedd i’r boen. Ac rydych yn aml yn gweld pethau o’r enw tafl-lwybr poen, fel y gellir mapio’r hyn fyddai poen aciwt clasurol i rywun sydd wedi cael triniaeth hernia neu rywun sy’n esgor babi. Mae pobl wedi mapio hyn – beth yw nodweddion y boen, pa mor hir fydd yn para a gallwch weld y gwahaniaethau rhyngddyn nhw.

Os ystyriwch chi boen lliniarol, yna mae ei hyd yn amrywio. Mae’n rhaid i ni beidio â meddwl am ofal lliniarol fel gofal yn y cyfnodau terfynol. Os siaradwch chi gyda Maria am ofal lliniarol, byddai hi’n dweud ei fod yn ymwneud â newid o driniaeth gweithredol i ymestyn bywyd i driniaeth sy’n canolbwynito ar ansawdd bywyd. Mae’n dibynnu ar natur y clefyd, oherwydd mae’r rhan fwyaf o bobl yn meddwl am ofal lliniarol yng nghyd-destun canser ond gall hefyd fod yn berthnasol i glefydau cronig eraill. Ac fel arfer, ond nid bob tro, mae’n gwaethygu wrth iddo fynd ymlaen. Ond mae perthynas achosol oherwydd y clefyd neu oherwydd y triniaethau.

Os ystyriwn ni boen cronig, rydych i gyd wedi deall bod poen cronig yn rhywbeth sy’n para am amser hir ac mae’r syniad o boen cronig wedi ei ddisgrifio mewn sawl ffordd. Byddai’r rhan fwyaf o ddiffiniadau’n cytuno ei fod yn rhywbeth sydd wedi para am fwy na 6 mis. Byddai rhai’n dweud mwy na 3 mis, a byddai eraill yn edrych ar feini prawf eraill. Golyga hyn bod y boen wedi para yn hwy na phrosesau gwellhâd arferol a gall olygu bod achos sydd heb ei adnabod i’r boen, ac mae parhad poen cronig heb gyfyngiad a does dim sicrwydd prwyd ddaw i ben. Pur anaml y gellir gwella poen cronig. Rydw i wedi edrych ar ôl pobl gafodd eu geni mewn poen ac wedi byw am 80 mlynedd mewn poen, yn ogystal â phobl sydd wedi cael poen oherwydd rhywbeth sydd wedi digwydd iddyn nhw yn eu bywydau. Allwch chi ddychmygu sut fyddai bod mewn poen am 80 mlynedd?

Felly rydw i am i chi feddwl yn ôl i llynedd pan soniwyd am ddau gategori eang o boen. Y cyntaf ydy poen nocidderbyngar (nociceptive). Mae hyn pan fo’ch system nerfol yn iach ac yn gyfan. Yr ail yw poen niwropathig (neuropathic). Mae’r system nerfol yn ymwneud â’r poen hwn mewn rhyw ffordd wrth gynhyrchu poen neu waethygu poen sydd yno’n barod. Felly mae rhywbeth wedi digwydd i’r system nerfol. Nawr mae’r rhain yn bethau digon eglur i edrych arnyn nhw pan rydych chi’n edrych ar boen aciwt. Ond pan fyddwch chi’n edrych ar boen cronig mae’r system nerfol yn newid, mae newidiadau ffisiolegol yn digwydd yn y system nerfol sydd yn gallu newid poen arferol, nocidderbyngar i gael rhai o nodweddion niwropathig oherwydd bod y system nerfol yn blastig, mae’n newid ac altro.

Felly oherwydd y cymhlethdod hyn, bu datganiad bod y poen cronig hwn yn broblem iechyd pwysig ynddo ei hun. Dyma Ddatganiad Penod Cymdeithas Ryngwladol Astudiaeth Poen Ffederasiwn Ewrop (International Association for Study of Pain Chapter Declaration) – bod poen yn broblem ynddo ei hun. Cefnogwyd hyn gan Senedd Ewrop a chafwyd dadl ar y pwnc yn San Steffan hefyd. Felly os wnawn ni feddwl pam fod poen cronig yn broblem ynddo ei hun – mae oherwydd nad yw achos y boen yn amlwg. Os geisiwch chi gysylltu poen cronig â chlefyd a does dim arwydd o glefyd – beth ydych chi’n ddweud wrth y person â phoen cronig? Nid yw eich poen yn bodoli? Ac un o’r problemau sydd gennym gyda phoen ydy ein bod yn edrych ar boen trwy lens model bio-seicogymdeithasol. Fodd bynnag, mewn gwirionedd rydym yn esgus ei gefnogi.

Y gwirionedd yw fod pobl mewn poen cronig yn canolbwyntio llawer ar y fioleg, mae rhai’n canolbwyntio ar y seicoleg ac ychydig iawn yn rhoi ffocws i gymdeithaseg. Dylem feddwl ynghylch beth sydd wedi achosi’r boen cronig neu beth yw’r etioleg. Yn fwy pwysig, hoffwn wybod hanes y claf am y boen cronig – beth yw eu stori nhw. Dylem wrando ar yr hyn maen nhw’n ei ddweud a chredu’r hyn maen nhw’n ei ddweud ac addasu ein meddyliau i fod yn unol â’r hyn maen nhw’n ei feddwl am eu poen. A’r hyn ddylem ni anelu ei wneud yw lleihau’r risg o ddatblygu poen cronig oherwydd unwaith mae rhywun yn dioddef poen cronig mae’n llawer mwy anodd ei reoli na phe bae wedi bod yn bosibl rhwystro rhywun rhag bod dan ormes poen cronig yn y lle cyntaf. Felly mae angen asesu priodol cynnar arnom.

Mae’n rhaid i ni gredu’r claf – cofiwch bod yr achos o bwys ond dim hwn yw’r unig ffactor. Nid y ffactor mwyaf pwysig ydy e chwaith. Yn fwy pwysig, mae’n rhaid i ni gyfathrebu’n eglur – mae’n rhaid i ni esbonio pethau’n rhesymegol ac mewn dull y bydd pobl yn gallu deall yn lle taflu ‘jargon’ atyn nhw. Mae’n rhaid i ni eglurhau camsyniadau sydd gan bobl oherwydd mae hynny’n ffordd i ddelio ag ymddygiadau poen niweidiol. Mae’n rhaid i ni ddelio ag ofnau a phryderon. Dylem ddefnyddio dull holistig, cytbwys sydd ddim yn canolbwyntio popeth ar fioleg. A dylem anelu at gael dulliau lliniaru poen da yn gynharach ac nid yw hynny o reidrwydd yn cynnwys cyffuriau. Gall cyffuriau i bobl mewn poen cronig ddod yn rhan o’r broblem yn lle’r ateb.

Gobeithio ‘mod i wedi cyflwyno rhywbeth i chi gnoi cil arno ac wedi herio, ychydig, y ffordd rydych chi’n meddwl am boen cronig. A gobeithio y gwnewch chi fwynhau’r profiad o ymlacio, o gael tylino’ch dwylo a finne’n cael y cyfle i dalu’n ôl trwy roi nodwyddau aciwbigo ynoch chi. Mi wn y bydda’i’n mwynhau hynny! Unrhyw gwestiynau?

Parry: Maria Parry ydw i, uwch ddarlithydd mewn gofal lliniarol. Rydw i’n therapydd tylino ac heddiw rydyn ni’n addysgu myfyrwyr y drydedd flwyddyn am ffyrdd amgen i ddelio â rheolaeth poen. Felly, eu cael i feddwl am ddefnyddio therapïau eraill mewn perthynas â rheolaeth poen cronig trwy brofi rhai o’r therapïau hynny eu hunain.

[I’r myfyrwyr] Iawn, ocê – pawb yn iawn? Pan rydyn ni’n meddwl am boen, rydyn ni’n meddwl am y bocs tabledi. Ro’n i’n lwcus rhai blynyddoedd yn ôl fel nyrs staff i gael y cyfle i hyfforddi fel therapydd tylino ac i weithio o fewn yr Ymddiriedolaeth. Cafodd 6 ohonom yr hyfforddiant a dechreuais i weld bod defnyddio tylino syml ar y cleifion yn cael elw anhygoel.

Felly rydyn ni’n mynd i edrych ar dylino dwylo sylfaenol. Rydw i’n bwriadu defnyddio technegau tylino a’u rhoi mewn tylino dwylo syml iawn a gallwch, yn elfennol, ddefnyddio rhai o’r pethau rydych chi’n eu dysgu heddiw gydag unrhyw glaf heb ei alw’n dylino – gallwch roi hufen ar law neu droed rhywun (mae hwn yr un mor effeithiol ar y traed a bydda’i’n siarad am hynny hefyd). Felly gallwch ddefnyddio rhai o’r technegau hyn petaech yn adnabod rhywun â phoen cronig – gallech eu cyfeirio ymlaen at rywun arall neu gallech feddwl, “Wel, mae gen i 5 munud i eistedd yma a defnyddio hufen a falle bydd hynny’n helpu.”

Sôn am ymlacio ydyn ni yma – dydyn ni ddim yn trin unrhywun ac os edrychwch chi ar y gwrtharwyddion i dylino maen nhw mor hir â’ch braich. Felly fyddech chi ddim yn tylino neb ac mae’n siwr bod llawer o bobl â phroblemau poen cronig â rhai o’r gwrtharwyddion hyn. Efallai bod arthritis arnyn nhw, neu groen gwael, creithiau efallai, neu enyniad (inflammation). Felly mae’n rhaid rhoi popeth mewn perspectif. Mae’n rhaid edrych ar y buddion yn erbyn y risg. Ond rydyn ni’n edrych ar rywbeth sy’n ymlaciol iawn; dydw i ddim yn bwriadu trin unrhywun gyda hyn.

Felly, yn sylfaenol, dewch mor agos ag y gallwch – dyna’r rheswm am y dillad cyfforddus. Dim sgertiau byr ar gyfer heddiw! Rydw i’n defnyddio olew had grawnwin sylfaenol – mae o’n un o’r cludwyr gorau ar gyfer tylino. Ambell waith pan fyddwch yn mynd i weld therapydd tylino bydd llawer ohonynt yn defnyddio mousse neu olew almwn sy’n hyfryd iawn ac yn ddrud iawn. Yn amlwg, dylech feddwl am alergedd. Mae’n rhaid i chi feddwl am y math o olew rydych chi’n ei ddefnyddio. Rydyn ni eisoes wedi amlygu rhai o’r ystyriaethau mewn ymarfer clinigol. Os ydych chi’n mynd i ddefnyddio olew i wneud hyn a’i ddefnyddio fel therapydd yna mae’n rhaid i chi ystyried cael caniatâd ac ati.

Iawn, ocê – chwiliwch am bartner yr un. Felly beth rydw i isio i chi ei wneud yw rholio’ch llewys i fyny, cael cadair gyferbyn, nôl eich clustog a’ch lliain.

Evans: Felly Becky, dyma’ch darlith olaf yn eich nyrsio tair blynedd. A dyma’r tro cyntaf i chi ddod ar draws poen cronig?

Becky: Llawer o flynyddoedd yn ôl bues i’n gweithio fel ysgrifenyddes meddygol i arbenigwr poen ac hefyd gweithiais gyda ffisiotherapydd, felly mae hyn oherwydd mod i wedi gweithio gyda ffisiotherapi ar yr un pryd. Falle dyma sut mae’r math yma o beth… dwi’n gweld y buddion oherwydd mod i wedi gweld y buddion fy hun yn y gorffennol. Dwi’n hoffi cael tyliniad Thai o bryd i’w gilydd felly dwi’n gweld y budd yn hwnnw fy hun.

Evans: Ifan, rwyt ti’n cael tyliniad gan Becky. Gest ti dy synnu gan unrhywbeth yn y ddarlith bore ‘ma am y gwahaniaeth rhwng poen cronig a phoen aciwt?

Ifan: I ddweud y gwir rydw i wedi bod ar leoliad yn Arberth, sy’n amgylchedd gofal lliniarol felly mae’n rhywbeth rydw i wedi arfer ag e.

Evans: Dwi’n torri ar draws y broses tylino – sut mae’n mynd?

Ifan: Mae’n hyfryd. Wir yn neis.

Parsons: Dyma rywun gyda syndrom poen rhanbarthol cymhleth math 1. Cymerwyd y llun yma ym Mehefin ac roedd hi’n ddiwrnod poeth iawn o Fehefin. Dyma sut gerddodd e i mewn i’r clinig poen. Beth ydych chi’n weld? Wnaethon ni ddim gofyn iddo gymryd ei grys i ffwrdd gyda llaw. Daeth i mewn heb grys. Pe baech chi’n gweld yr unigolyn yma’n cerdded lawr y stryd, oherwydd dyma’r ffordd mae e’n cerdded lawr y stryd – byddech chi’n meddwl ei fod yn glaf iechyd meddwl wrth edrych arno? Ie? Fe ddywedodd wrtha i, ‘Gareth, mae pobl yn meddwl ‘mod i’n wallgo. Ond dyma’r unig ffordd y galla i reoli fy mhoen heb ddefnyddio cyffuriau.’

Felly’r hyn rydyn ni’n ei weld ydy cyfres o wahanol fathau o ymddygiadau poen. Dyma lle cafodd ei anaf gwreiddiol – ei arddwrn. Syrthiodd a thorri ei arddwrn. Gwellodd yn fuan; roedd y llawfeddygon orthopedig yn hapus iawn gydag e a’i anfon i ffwrdd. O fewn wythnos iddo gael yr anaf roedd yn cwyno am boen llosg trwy gydol yr amser ond rodden nhw’n dweud y byddai’n setlo. Pum mlynedd yn ddiweddarach daeth atom ni i’r clinig poen yn y stâd hon. Mae lleoliad y poen gwreiddiol wedi ymledu. Mewn gwirionedd, mae ei fraich gyfan mewn poen ac mae’n ymwybodol o boen yn y rhan fwyaf o’i dorso. Y rheswm pam nad oedd e’n gwisgo crys oedd bod y teimlad o ddillad ar ei groen yn achosi poen. Mae e yn dioddef o ymdeimlad sydd wedi newid. Mae e hefyd yn dioddef o rywbeth o’r enw allodynia oer, felly mae oerfel yn achosi poen. Ar ei law, o amgylch lleoliad yr anaf gwreiddiol. Byddai awel yn mynd drosto mewn ystafell yn achosi poen.

Y cyflwr arall sydd arno yw allodynia mecanyddol. Pan ddaeth i mewn cymerodd ei sling i ffwrdd oherwydd roedd bob amser yn cadw ei fraich mewn sling. Mae hyn wedi achosi problem gyda’i ysgwydd; mae ganddo’r hyn rydyn ni’n ei alw, yn nhermau lleygwr, ysgwydd wedi rhewi, oherwydd ei fod yn gwisgo sling o hyd. Oherwydd bob tro mae e’n symud ei arddwrn mae’n achosi poen a dyna pam mae e’n gorffwys ei arddwrn ar ei goes.

Hefyd mae ganddo wrth-ysgogiad eithafol – mae e’n cymryd sigarét ac yn llosgi’r croen ar dop ei fraich oherwydd bod gwneud hyn yn lleddfu’r boen. Anfonwyd ef i weld seiciatrydd gan y llawfeddygon orthopedig fel rhywun sy’n niweidio’i hun. Daeth atom ni ar ôl cael ei drin gan y seiciatrydd fel rhywun sydd am ladd ei hun. Doedd e erioed wedi meddwl am ladd ei hun ond ddaru nhw roi cyffuriau gwrth-iselder iddo oherwydd ei fod wedi cael ei anfon atyn nhw oherwydd ei fod yn niweidio’i hun.

Hefyd roedd e’n gwisgo TubiGrip ond dydy hyn yn gwneud dim ond dweud wrth bobl eraill bod ganddo broblem gyda’i fraich. Felly os ydych chi’n cerdded o amgylch gyda sling a TubiGrip ar eich penelin mae pobl yn dangos cydymdeimlad – maen nhw’n ofalus o’ch cwmpas, dydyn nhw ddim yn taro i mewn i chi. Does ganddo ddim anaf ar ei fraich; mae ei anaf yn ei arddwrn. Ond mae’r Tubigrip yn fwy amlwg – felly mae’n ymddygiad sy’n arddangos poen.

Rydych chi newydd ddweud eich bod yn meddwl ei fod yn edrych fel rhywun o’i go. Felly beth mae e’n feddwl ohonoch chi? Mae hyn o fy ymchwil i ac mae’n edrych ar sut mae cleifion yn amgyffred gweithwyr proffesiynol iechyd, ac yn sylfaenol, i’r cleifion, chi ydy’r broblem. Mae aelodau’r cyhoedd yn broblem hefyd ond chi ydy’r broblem go iawn, oherwydd atoch chi maen nhw’n troi am gymorth a dydych chi ddim yn eu helpu. Rydych chi’n gwneud eu sefyllfa’n waeth. Ac rydych chi’n gwneud hyn trwy beidio â’u credu. Neu does gennych chi ddim diddordeb ynddyn nhw. Neu rydych chi’n eu trin fel eitem i’w brosesu. ‘Dewch i mewn, dewch i’n gweld, gwnewch hyn, cewch y driniaeth hon, ewch i ffwrdd.’ Ac maen nhw’n teimlo’u bod ond yn cael help os ydyn nhw’n mynnu sylw. Ond pan maen nhw’n mynnu sylw maen nhw’n cael eu labelu fel pobl ddig ac ymosodol ac mae hynny’n cael ei roi yn eu nodiadau. Ac yna’r tro nesaf maen nhw’n dod i mewn mae’n rhaid gwneud yn siwr bod apwyntiad yn cael ei wneud gyda rhywun arall yno i ddiogelu’r meddyg.

Ac mae eu poen cronig yn cael ei drin fel poen aciwt oherwydd y prif ffordd o drin hynny yw taflu cyffuriau ato. Ac rydych chi’n taflu cyffuriau ato sy’n gweithio ar system nerfol iach. Ac os nad ydych chi’n fy nghredu, mae hyn o fy ymchwil i: dyma’r prescripsiwns am boen cronig gan feddyg teulu Cymreig nodweddiadol. Nifer y cleifion yn y feddygfa ydy tua 12,000, sy’n arferol i feddyg teulu yn yr ardal hon. Yn fy ymchwil wnes i geisio recriwtio pobl oedd â phoen cronig ond doedd y meddyg teulu ddim yn cadw poen cronig fel label yn ei system gyfrifiadurol er mwyn eu hadnabod, felly roedd yn rhaid i mi ddod o hyd i ffyrdd amgen o wneud hyn. Meddyliais, ‘Faint o bobl yn y feddygfa hon sydd wedi cael prescripsiwn am boenladdwyr am o leiaf 6 mis?’ Dyna un ffordd o ddarganfod os oes gennych boen cronig. Os ydy poen cronig yn para mwy na 6 mis, gadewch i ni edrych ar nifer y poenladdwyr. Roedd pymtheg y cant yn y feddygfa hon yn cymryd opioidau weddol gryf neu gryf iawn.

Nawr, edrychwch ar y rhai sydd yn cymryd y cyffuriau sy’n trin poen cronig, cyffuriau fel gabapentin neu pregabalin – yn cael eu rhoi y dyddiau hyn yn eithaf cyffredin i bobl â phoen cronig. Neu’n cael eu cyfeirio i glinig poen, neu i’r adran orthopedig neu rewmatoleg neu’n cael eu cyfeirio at ffisiotherapydd neu at ffisiotherapydd sy’n ymarferydd uwch. Dim ond 78 claf, dim ond 0.63 y cant. Felly dylai 15 y cant o’r cleifion fod yn cael help; os ydyn nhw’n cymryd y poenladdwyr cryf hyn maen nhw wedi bod mewn poen am fwy na 6 mis. Dylid edrych ar hyn. Yn y DU, ar gyfartaledd, mae’n cymryd pum mlynedd i gael apwyntiad mewn clinig poen. Erbyn hynny mae’r boen wedi ei sefydlu’n gryf ynoch chi. Mae’n broblem anweladwy. Amcangyfrifwyd bod hyd at 11 y cant o bobl yn y gymuned â phoen cronig – mae rhai arolygon wedi dweud bod y rhif yn uwch. A dim ond nifer fach sy’n cael eu hanfon at arbenigwyr i gael triniaeth am boen. Mae 7 Bwrdd Iechyd yng Nghymru, mae gan 6 allan o’r 7 glinig poen, mae gan 6 allan o’r 7 raglen rheolaeth poen. Does dim digon o wasanaethau, sy’n golygu gohirio mynediad a phroblemau cynyddol. A dychmygwch sut beth ydy bod mewn poen a neb yn mynd i’ch helpu ac rydych chi’n mynd at bobl i’ch helpu a dydyn nhw ddim yn gallu’ch helpu chi oherwydd dydyn nhw ddim yn gwybod sut i’ch helpu chi.

Simpson: Fy enw i ydy Owena Simpson a dwi’n un o’r uwch ddarlithwyr mewn nyrsio oedolion ac yn y sesiwn hon byddwn i’n gwneud therapi ymlacio, yn edrych ar reoli poen cronig. Ces gymhwyster 20 mlynedd yn ôl a nghefndir ydy cardioleg a llawfeddygaeth cardiac a chyn dod i’r brifysgol roeddwn i’n nyrs yn arbenigo mewn methiant y galon.

Evans: Fel Nyrs Cardioleg beth allwch chi ddysgu nyrsus am boen cronig?

Simpson: Fel nyrsus oedolion rydyn ni’n awyddus, neu rydyn ni’n tueddu, yn gyntaf oll, i fynd at feddyginiaeth yn hytrach na chwilio am ffyrdd amgen i reoli poen; mae’n ymwneud â helpu cleifion i gydnabod bod ffyrdd eraill o reoli poen cronig yn hytrach na mynd at feddyginiaeth ar unwaith a’r holl sgîl effeithiau’sy’n dod yn dilyn hynny.

Evans: Ac mae ymlacio yn bwysig?

Simpson: Mae ymlacio yn bwysig iawn ac mae’n rhywbeth y gallwn ni oll ei wneud gyda chydig o ymarfer ac yn rhywbeth y gall pobl ei wneud gartref. Does dim angen pobl arbenigol; gallan nhw brynu gwahanol CDau a phrynu gwahanol gyfarpar a dod o hyd i rywbeth sy’n gweddu iddyn nhw.

Evans: Ac rydw i’n gwneud ac mae’n gweithio.

Simpson: [Yn chwerthin] ‘Wel, dyna ni. [I’r myfyrwyr] Ar y funud mae’n debyg – falle mai dyma’r adeg iawn neu’r adeg anghywir – ei bod yn brif adeg asesiadau ac ati felly mae un aseiniad wedi ei gyflwyno ac mae’r traethawd hir ar y gorwel. Felly ydych chi’n teimlo’r straen? Neu falle bod rhai ohonoch yn teimlo’n iawn. Ond mae arwyddion cudd falle eich bod? Pa fath o bethau? Crïo, cur pen ac anwydau byth a hefyd a theimlo’n nerfus yn gyffredinol. Ddim yn bod yn neis efo pobl eraill – felly falle’ch bod yn bigog efo pobl? Cwsg? Felly dyna’ch arwydd chi o fod dan straen. Bydd pobl eraill yn mynd i gysgu, yn deffro’n gynnar tra bo eraill methu mynd i gysgu. Felly rydyn ni i gyd yn delio â phethau’n wahanol. Briwiau ar y gwefus ac ati? Dyna un o’m rhai i. Ac ydy e’n iachus i ni fod dan straen ‘te? Na? Ddim o gwbl, byth? Oes angen i ni fod dan chydig o straen i godi yn y bore ac i wneud pethe? Felly mae chydig o straen yn iawn ac yn iachus ond y broblem ydy pan mae’n para. Ocê, os wnewch chi ddod o hyd i le ar y llawr ac fe gawn ni ymarfer rhai dulliau ymlacio. Bydd rhai ohonoch chi’n mynd i gysgu a rhai ohonoch chi ddim. Ydyn ni’n barod?

Parsons: Rwy’n mynd i ddangos y nodwydd aciwbigo ‘ma i chi. Peidiwch â phanicio, iawn? Dyma un fyddai’n cael ei ddefnyddio ar berson mawr iawn ar y pen ôl. Maen nhw’n nodwyddau dur gloyw tafladwy. Eu defnyddio unwaith ac yna’u taflu – mae hynny’n bwysig gydag aciwbigo. Peidiwch ag ailddefnyddio nodwyddau. Profiad y rhan fwyaf o bobl o nodwyddau yw cael pigiad, ynte? Os edrychwch chi ar y nodwydd fawr sy’n dod o amgylch – dwn i ddim ydy hi wedi’ch cyrraedd chi eto, ond byddai dwy o’r nodwyddau hynny’n mynd i mewn i’r lumen, twll y nodwydd pigiad werdd. Maen nhw wedi eu dylunio i lithro drwy’r meinwe ac nid i dorri meinwe. Beth all fod yn rhyfedd ydy dod o hyd i’r synnwyr o gael aciwbigo.

Wnes i ddysgu hyn oll yn y ‘90au ac ers y ‘90au mae sganiau fMRI (functional magnetic resonance imaging) wedi datblygu a gyda sganiau fMRI gallwn ddangos bod rhywbeth yn digwydd pan roddir nodwydd aciwbigo yng nghorff rhywun. Pan fo ymenydd rhywun yn cael ei ddeffro gan boen, mae ysgogiad aciwbigo yn cynhyrchu modd i ddiffodd y boen yna. Y dybiaeth ydy fod llwybrau opioid endogenig eich corff eich hun yn cael eu deffro – dyma’r cyffuriau yn eich corff sy’n debyg i morphine. Pan fyddwn ni’n rhoi morphine i bobl mae’r un peth yn digwydd, ond yn ddiddorol pan fyddwchc hi’n rhoi moddion ffug (placebo) mae’r un peth yn digwydd. Rydyn ni’n gwybod bod moddion ffug yn cael effaith enfawr ar boen cronig. Defnyddir y rhain mewn milfeddygaeth ar gyfer moch a cheffylau a gwartheg. Nawr mae hyn yn ddiddorol oherwydd mae’n ymddangos ei fod yn gweithio – felly ydy ceffylau a moch yn gallu elwa o effaith y moddion ffug fel rhywun dynol? Yn seiliedig ar y data archwilio sydd gen i rwy’n credu bod rhywbeth yn mynd ymlaen gyda phoen nocidderbyngar oherwydd, yn fy mhrofiad i, mae’r bobl hynny roddais i aciwbigo iddyn nhw oedd â phoen nodweddiadol nocidderbyngar – cur pen, poen yn y cymalau, poen penglin, poenau gwaelod y cefn, wedi cael effaith buddiol heb lawdriniaeth. Ond y bobl hynny oedd â rhyw fath o elfen niwropathig, fel niwralgia ôl-hepatig neu sglerosis ymledol (multiple sclerosis) – doeddwn i ddim yn gallu eu helpu nhw gyda’u poen. Felly, rwy’n meddwl ei fod yn rhywbeth sy’n ymwneud â’r llwybrau opiad. Felly oes rhywun am gael tro? Mae’n rhyw fath o loes ysgafn onid yw e? Mae’n od onid yw e?

Evans: Ai dyma’r nyrsus fydd yn rhoi nodwyddau ynof fi nesaf?

Parsons: Mae’n un peth i roi poen i rywun arall – ond i’w gael e eich hun.

Parry: Tra’ch bod yn newid lle fe ddyweda’i stori am un o’r buddion i glaf oedd gen i. Roeddwn i’n nyrs staff mewn ysbyty gymunedol ddim yn bell o ble roeddwn i’n byw, a gweithiais yno am tua pum mlynedd ac roedden ni arfer â chael llawer o gleifion gyda phroblemau poen cronig – roedd llawer o gleifion yn dod yn ôl ac ymlaen am ofal seibiant. Roedd un claf wedi torri ei gefn ac roedd e arfer a dod yn ôl ac ymalen bob chwech wythnos. Roedd ganddo boen difrifol oherwydd gwingiadau yn eu goesau a chramp. O’r herwydd roedd e’n canu’r gloch tua 30 gwaith y nos – doedd e byth yn gallu cael noson dda o gwsg. Roedd yn symud o hyd ac roedd ei boen yn golygu nad oedd e byth yn gallu bod yn gyfforddus. Felly pan wnes i’r cwrs hwn es yn ôl a dweud, “Sut hoffech chi drio rhywbeth newydd?” Felly pan ddaeth i mewn, dywedais, “Iawn, beth am eich sortio chi allan – wnawn ni dylino eich coesau a gweld beth ddigwyddith.” Felly erbyn i ni orffen – byddai’n gorwedd yn y gwely fel hyn ac roedd e’n eitha doniol oherwydd roedd e arfer â rhegi’n ofnadwy ac am ryw reswm arferai â ngalw i yn Mo. Ddim yn siwr pam, ond byddai’n dweud, “Mo – Symud fi!” Felly dywedais i, “Gadewch i ni weld os allwch chi lwyddo i gysgu”, a wyddoch chi beth? Fe gysgodd! Ar ôl pythefnos o fod i mewn roedd gwahaniaeth mawr yn ei batrwm cysgu.

Yn anffodus dim ond 5 diwrnnod yr wythnos oeddwn i’n gweithio ac roedd rhai o’r rheiny yn ystod y dydd. Felly pan oeddwn i’n gweithio yn y dydd roeddwn i arfer â mynd yn ôl am 9yh, oherwydd mai dim ond lawr y ffordd roeddwn i’n byw, nôl fy merch oedd yn un ar y pryd, ei rhoi hi yn ei sedd arbennig a’i gadael yn y swyddfa a mynd i weithio ar ei goesau. Ond roedd gen i broblem foesegol gyda hyn yn y diwedd oherwydd pan aeth gartref am chwech wythnos cawsom broblem ofnadwy i geisio dod o hyd i rywun fyddai’n gwneud hyn. Ond yn y diwedd fe ddaethon ni o hyd i rywun a allai wneud hyn o dro i dro oherwydd roedd y buddion yn amlwg. Ac ambell waith roeddech chi ond am ddweud wrth bobl nad oes llawer wedi ei ysgrifennu ac nad oes llawer o dystiolaeth ymchwil go iawn ond mae’r dystiolaeth yna ac os edrychwch chi ar y budd i’r cleifion mae’n anhygoel. Roedd e’n esiampl dda iawn o sut y gall tylino weithio.

Evans: Dyna Maria Parry, uwch ddarlithydd mewn gofal lliniarol ym Mhrifysgol De Cymru. Nawr, y rhybudd arferol i fod yn ofalus – tra’n bod ni’n credu bod y wybodaeth a’r farn ar Airing Pain yn gywir ac yn gadarn, yn seiliedig ar y farn orau sydd ar gael – dylech bob amser ymgynghori â’ch gweithiwr iechyd proffesiynol ar unrhyw fater yn ymwneud â’ch iechyd a’ch lles. Ef neu hi yw’r unig berson sy’n eich adnabod chi a’ch amgylchiadau ac felly’n gallu gweithredu’n briodol ar eich rhan. Gellir lawrlwytho’r holl raglenni o wefan Pain Concern a gellir cael copïau ar CD yn uniongyrchol o Pain Concern. Mae’r holl fanylion cyswllt – pe baech am wneud sylw am y rhaglenni trwy flog, bwrdd negeseuon, ebost, Facebook, Twitter neu hyd yn oed ar bapur – yn ein gwefan: painconcern.org.uk. Dyma Maria Parry a’r geiriau olaf.

Parry: O edrych ar yr ochr liniarol, mae wedi rhoi mwy o syniadau i mi am ddefnyddio therapïau di-gyffur oherwydd y cyswllt rhwng hosbis a therapïau. Maen nhw’n cael eu defnyddio’n eang mewn gofal hosbis ac wedi eu cymeradwyo mewn gofal hosbis fel rhywbeth defnyddiol ac ambell waith rwy’n meddwl ei bod ychydig yn drist nad ydyn ni’n cydnabod y pethau hyn. Gall y therapïau eraill hyn fod mor ddefnyddiol i gleifion. Yn amlwg, mewn llawer canolfan gofal lliniarol, maen nhw am ddim felly gellir cyfeirio cleifion lliniarol yn aml at therapydd fydd yn rhoi sesiwn tylino iddyn nhw unwaith yr wythnos. Does dim rhaid iddyn nhw dalu amdano unwaith yr wythnos oherwydd weithiau rwy’n meddwl eu bod yn meddwl bod pobl â phoen cronig yn gallu cael gafael ar yr holl wasanaethau hyn ac mae hynny hefyd yn rhywbeth y dylen ni ystyried. Byddai’n braf gweld mwy o bobl, a dyna pam mae heddiw mor bwysig – eu bod yn gadael yma ac yn cofio’r tylino hyfryd a “O, ie, roedd e’n berthnasol i boen”. Ac os mai’r cwbl wnawn nhw ydy rhoi’r ddau beth yna at ei gilydd yna rwy’n meddwl ein bod wedi gwneud rhywbeth sy’n ddefnyddiol mewn perthynas â chleifion mewn poen. Fel arall byddan nhw’n gadael a meddwl “Beth am roi morphine neu co-codamol iddyn nhw” neu beth bynnag ac ni fyddai hynny o reidrwydd o fudd i’r cleifion.

Cyfrannwyr:

Gareth Parsons, Uwch Ddarlithydd mewn Nyrsio Oedolion, Prifysgol Morgannwg
Maria Parry, Uwch Ddarlithydd mewn Gofal Lliniarol, Prifysgol Morgannwg
Owena Simpson, Uwch Ddarlithydd mewn Nyrsio Oedolion, Prifysgol Morgannwg.

December sees the launch of a new e-PAIN programme designed to improve early diagnosis and management of pain. The multi-disciplinary programme is aimed at all NHS healthcare professionals who do not specialise in pain medicine, but regularly encounter patients suffering from acute or chronic pain. Dr Douglas Justins, Clinical Lead for e-PAIN, says: ‘This exciting and important project will help improve the recognition, assessment and safe treatment of unrelieved pain resulting in the significant improvement of patient care.’

e-PAIN consists of engaging and highly interactive learning sessions and assessments that cover how to:

recognise unrelieved acute and chronic pain
assess pain
manage pain
recognise and manage patient safety issues in relation to pain relieving techniques.

Also included within the programme are training modules on: basic pain management, basic pain science, pharmacological and non-pharmacological treatment, acute pain, neuropathic/nerve pain and cancer pain. All training is recorded in the learning management system and can be used as evidence of continuing professional development.

E-pain was developed by the Faculty of Pain Medicine, in partnership with the British Pain Society and e-Learning for Healthcare, and the official launch will be held on Tuesday 3rd December at the Royal College of Anaesthetists. This launch will include demonstrations of the programme’s benefits to patients and health professionals, plus an opportunity for hands-on experience.

For more information please see the e-PAIN website.

Cookie	Duration	Description
__cfduid	1 month	The cookie is used by cdn services like CloudFare to identify individual clients behind a shared IP address and apply security settings on a per-client basis. It does not correspond to any user ID in the web application and does not store any personally identifiable information.
_GRECAPTCHA	5 months 27 days	This cookie is set by Google. In addition to certain standard Google cookies, reCAPTCHA sets a necessary cookie (_GRECAPTCHA) when executed for the purpose of providing its risk analysis.
cookielawinfo-checbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-advertisement	1 year	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Advertisement".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Cookie	Duration	Description
_ga	2 years	This cookie is installed by Google Analytics. The cookie is used to calculate visitor, session, campaign data and keep track of site usage for the site's analytics report. The cookies store information anonymously and assign a randomly generated number to identify unique visitors.
_gid	1 day	This cookie is installed by Google Analytics. The cookie is used to store information of how visitors use a website and helps in creating an analytics report of how the website is doing. The data collected including the number visitors, the source where they have come from, and the pages visted in an anonymous form.
vuid	2 years	This domain of this cookie is owned by Vimeo. This cookie is used by vimeo to collect tracking information. It sets a unique ID to embed videos to the website.

Cookie	Duration	Description
IDE	1 year 24 days	Used by Google DoubleClick and stores information about how the user uses the website and any other advertisement before visiting the website. This is used to present users with ads that are relevant to them according to the user profile.
NID	6 months	This cookie is used to a profile based on user's interest and display personalized ads to the users.
test_cookie	15 minutes	This cookie is set by doubleclick.net. The purpose of the cookie is to determine if the user's browser supports cookies.
VISITOR_INFO1_LIVE	5 months 27 days	This cookie is set by Youtube. Used to track the information of the embedded YouTube videos on a website.

Cookie	Duration	Description
_gat_gtag_UA_32255482_2	1 minute	No description
CONSENT	16 years 8 months 9 days 15 hours 12 minutes	No description
huBv		No description

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern

Peer Support. Join the community

Subscribe to Pain Matters

In pain? Don’t understand what’s happening?

Fundraise for Pain Concern