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Transcript – Programme 50: Pain Services in the Community

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.]

‘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 ‘de-med­icalise’ 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.

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!’


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.


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 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.



  • 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.


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