We aim to improve, and make more reliable, patient pathways and services as proposed in the Scottish Service Model for Chronic Pain.

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1 Fife Integrated Pain Management Service (FIPMS) Service Redesign Proposal Introduction: This proposal seeks Scottish Government Health and Social Care Directorate funding to support a 2 year programme of Chronic Pain Management Service Improvement Group activity. Pain Management services in Fife underwent significant service redesign in Funding was secured at that point to develop the Fife Integrated Pain Management Service (FIPMS). This resulted in the development of the first pain service in Scotland to have an integrated pathway involving central triage, multi-disciplinary pain management in both Primary and Secondary care, with a clear discharge pathway to voluntary organisations and the leisure sector. This is in line with the current Scottish Government service model for chronic pain services. In adherence to the guidelines for managing long term conditions, patients are given the skills to self-manage their chronic condition. The FIPMS model has been working well and would require minimal change in order for it to function as a Managed Clinical Network (MCN). This bid seeks to consolidate the work which has already been achieved. There is a need to establish effective audit/research of outcome data in order to demonstrate the efficacy of the model. In addition there is a need to improve and strengthen links with Primary Care so that better and more consistent pain management can be delivered to the majority of pain patients who are managed in general practice. It is envisaged that a portion of funding may be used as backfill so that the idea of GP and community physiotherapy Pain Champions can be developed. We aim to improve, and make more reliable, patient pathways and services as proposed in the Scottish Service Model for Chronic Pain. 1. Background Summary of Pressure or Opportunity In Scotland 18% of the population suffer from chronic pain, defined as pain lasting more than 3 months. 6% of the population have Chronic Pain that is severe and disabling.in Fife, this means more than 65,000 people will experience chronic pain and almost 22,000 people are likely to have chronic pain that is severe and highly disabling. These figures have personal, healthcare and social costs: 25% of people diagnosed with chronic pain will not be able to continue working as a result (GRIPS 2008). One in three households contain a family member with chronic pain. One in 5 chronic pain sufferers have concurrent depression. Chronic pain is associated with poor health and other long term conditions. The cost of back pain alone accounts for about 1 billion of the UK s health expenditure8 and between 5 10 billion total cost to the UK economy in People with chronic pain use health care services up to five times more than the general population (Smith 2001), and have reduced life expectancy. Current Service Model Funding was secured in 2009 for the development of FIPMS, Scotland s first integrated pain management service. There is full integration of chronic pain management services involving interventions delivered in both primary and secondary care. Secondary care acute pain services are also under the same funding umbrella. The multi-disciplinary team includes medical, nursing, physiotherapy, occupational therapy, psychology, pharmacy, admin staff, nursing assistants and technical assistants. Referrals to the service are centrally triaged

2 against our referral criteria, and if accepted a questionnaire is sent out to the patient for completion. Upon receipt of the completed questionnaire the patient referral is reviewed and triaged to the most appropriate pathway within the service. The pathway is illustrated below. Patients with more straightforward presentations are triaged to the primary care RIVERS programme which is a 5 week functional restoration program delivered in group format by physiotherapy and pharmacy. Complex presentations, particularly those with significant psychological needs are triaged to secondary care where multi-disciplinary care may be delivered by a variety of professionals in both 1:1 and group formats. Once this pathway is completed the patient is discharged to the care of voluntary organisations such as Pain Association Scotland (PAS) and also to the leisure sector.

3 Fife Integrated Pain Management Pathway Complex presentation Pain Management Central Triage Referral Letters vetted against referral criteria - Pre clinic questionnaire sent out with 2 week return date. Questionnaire scores determine complexity and patient triaged accordingly Non Complex presentation Secondary Care Pain Management Service Kingdom Pain Management Programme Living with Pain 11 Week Pain Management Programme Primary Care RIVERS Coping with Pain 5 Week Functional Restoration Programme Maintenance Classes Referral on to other Services Maintenance of Pain Management Skills Voluntary sector (in line with NHS/Leisure Trust redesign) PAS Discharge Arthritis Care

4 2. Drivers leading to the further development of FIPMS National In 2007 chronic pain was recognised, by the Scottish Government, as a long term condition in its own right. The Scottish Service Model (see Fig 1) was developed in response to the variation of service provision across the regions in Scotland which were exposed by the GRIPS report (2007) and subsequent updates. The recommendations of the Healthcare Improvement Scotland 2012 update are: Implementing the Scottish Service Model for Chronic Pain Working with patients and the voluntary sector Data collection and measurement Collaborating for success Local In 2010/11 more than 1000 patients were referred to FIPMS, representing around 3% of the Fife population. Given that 18% of the population have chronic pain, it is apparent that the majority of the chronic pain population are being managed in primary care, or referred into other condition-specific services such as Orthopaedics, Rheumatology, Neurology, Musculoskeletal or Cancer services. Historically there has been a problem with patients being referred to, and seen by, multiple specialties for the same problem, leading to increased cost to services, and to unnecessary distress and conflicting messages for the patient. Patients have highlighted a need for early recognition of chronic pain, so that more information and better self-management skills can be provided earlier in the patient journey. Despite integration between Primary and Secondary Care branches of FIPMS, there remains a lack of knowledge regarding what the service offers, and the pathways on offer amongst clinicians not directly involved with the service. There is a desire to consolidate and improve communication and patient flow between primary and secondary care, so that patients have reliable access to the best advice and treatment at all stages of the pathway. GPs want easier access to advice and support, and clearer signposting to sources of support. There is a need to support and continue to build on work already started in primary care under the whole system working programme. Secondary chronic pain services are centralised at Queen Margaret Hospital, Dunfermline, and offer many of the level 2 elements of the Scottish Service Model. In a relatively rural area patients want access to local services where possible and support with appropriate transport when they have to travel long distances. Multidisciplinary Pain Management Programmes are delivered in Dunfermline and Kirkcaldy. Primary care pain services and the RIVERS programme are provided in the three CHP s across Fife. At present there is some overlap with small numbers of patients attending pain services in NHS Tayside, Forth Valley and NHS Lothian.

5 Sustainable funding for service development is difficult to achieve. Savings in medication costs, unscheduled care and more appropriate use of medical resources could generate savings which will justify on-going development of pain services. A common experience for patients with chronic pain is to have multiple referrals to secondary care specialties, with ensuing investigations and treatments, which can increase medicalisation of their problems, and in some cases increases dependence on specialist services. In addition, the dependence on medication to control pain can lead to escalating doses of opiates and other medication, which raises safety and governance concerns as well as increasing costs and disability. The FIPMS aims to deliver a rehabilitative approach which encourages self management strategies for patients to utilise. We believe that any change must be made within current budgets, using techniques such as service redesign, providing tools and developing the knowledge and skills of patients and professionals to make best use of existing resources. Further development of current services is the only option to ensure development of an improved care pathway for chronic pain which will be sustainable for the future. 3. Initial Improvement Leaders Name and Contact Details Fran Proctor, Clinical Service Lead & Nurse Specialist for FIPMS Dr Jane Timperley, Consultant in Anaesthesia and Chronic pain management, Lead Clinician for FIPMS Dr Steve Gilbert, Consultant in Anaesthesia and Pain management. Fiona McAslan, Advanced Specialist Physiotherapist Practitioner in Pain Management Dr Jackie Fearn Lead Consultant Clinical Psychologist for NHS Fife Clinical Health Psychology Service and Kingdom Pain management programme 4. Improvement Plan The improvement plan will include the following elements: Consultation exercise The chronic pain patient pathway will be reviewed from diagnosis to discharge. The exercise will include primary and secondary care staff, service users, carers, voluntary agencies and other relevant stake holders. Opinions will be sought on how to improve understanding of Chronic Pain, the patient pathway and adherence to treatment guidelines through stakeholder events, focus groups, questionnaires etc. The scoping exercise will establish the resources and services available, review patient pathways, and identify key people. Using the Scottish Service Model as a guide, the scoping exercise will identify gaps in current service provisions and whether there are obstacles to patients receiving appropriate care. Development of Quality and Outcome measures will ensure that improvements of services are effective and patient centred. This work will also be essential to underpin future sustainability and development of pain management services. This is a key need for our service as we have yet to demonstrate concrete benefits for our service model. This will be established by our research fellow who will evaluate appropriate outcome measures for our service. Work-streams are already established for research, communications, education, logistics and treatment options, and prescribing amongst others. These work-streams will continue to have an active role in the development of the service. Provision of multidisciplinary training to cascade education organised through existing training schedules, with ongoing provision of tools and materials. Local champions will be identified to facilitate accessibility and delivery of training and ongoing support. We hope to be able to develop the idea of providing training to GPs from each CHP area and also to community physiotherapy. Backfill funding may be provided to facilitate this.

6 Long term prescribing of medications for managing chronic pain represents a significant percentage of the NHS budget. In addition there is often significant polypharmacy and potential for patient harm. It is anticipated that, through improved integration with primary care, including the work of the pain champions, and improved use of community pharmacies, there may be reductions to prescribing costs and improvements in patient safety. In the wake of the GRIPS report and the recognition of chronic pain as a long term condition, FIPMS has already made considerable progress as Scotland s first integrated pain management service. The philosophy of our service is one of supporting and enabling patients to self-manage their own condition in the long term, thereby helping to restore physical and psychological function and improve quality of life. The improvement plan will continue to be patient focussed and there will be representation and involvement from both patient representatives and from voluntary sector organisations such as Pain Association(Scotland) and Pain Concern. It is anticipated that there will continue to be funding from NHS Fife for the maintenance support groups already provided by PAS. Further development of the local web based resources to provide information on local services, access to patient and professional information, assessment tools and referral criteria, treatment support and schedules. This should link into existing web based resources. Events to launch the resource and publicise training will be required. FIPMS has service interfaces and overlap with a number of other services including Acute pain, Pain and Addictions service, Neurology, Musculoskeletal, Neurosurgery, Rheumatology, Cancer care, Chronic fatigue/me and Dementia. Although we do not envisage being able to take on additional case load from these services we do aim to improve interfaces with them. Although the service provided by the present FIPMS is currently for adults, we aim to improve awareness of services available in the region for children, and to improve the transition from paediatric to adult care. Identify and clarify pathways to tertiary care. Change will be evaluated against the information collated during the initial scoping exercises. 5. Membership of the Service Improvement Group There is already a management structure established to facilitate the smooth running of FIPMS. This consists of the FIPMOG (operational group) and the FIPMEG (executive group). It is envisaged that these groups will function as the Service Improvement Group and will oversee the consultation period and establishment of the MCN. Key members are outlined below: Fran Proctor Clinical Service Lead and Nurse Specialist for Fife Integrated Pain Management Service (FIPMS) & Chair of the Executive Group (FIPMEG) Dr Jane Timperley Lead Clinician Dr Steve Gilbert National Lead Clinician for Chronic Pain and Consultant in Fife. Fiona McAslan Advanced Specialist Physiotherapist Practitioner Pain Management, Amanda Leech Lead Physiotherapist for Primary Care Pain Service & RIVERS Dr Jackie Fearn - Lead Consultant Clinical Psychologist for NHS Fife Clinical Health Psychology Service and Kingdom Pain management programme Paul Cameron Highly Specialist Physiotherapist, RIVERS & Chair Fife Research Network Melanie Hutchison Advanced Occupational Therapist & Chair of Operational Group (FIPMOG) Deborah Steven Lead Pharmacist for FIPMS

7 Neil Clark Highly Specialist Physiotherapist; link between FIPMS and musculoskeletal services (MSK) Susan Fraser, Directorate manager, Planned Care Division Bob Thomson, Directorate accountant, Planned Care Division. Representation from voluntary sector and patient forum. Other members may be co-opted as required, including GP representation from all 3 CHPs, and CHP managers. 6. Proposed Timeline Milestone Start End Submission of chronic pain service March 2013 June 2013 improvement bid Set up service improvement group - first and Established: Ongoing subsequent meetings FIPMOG/FIPMEG Apply to SMT to recruit administrative support November, dependent on funding Scoping - making contacts, holding events, pathway mapping. August/ September 2013 November 2013 Recruit IT support November 2013, dependent on funding First line training for key cascade trainers In progress ongoing Development of website and sustainable In Place Nov 2013 ongoing ongoing support MDT education launch package in progress ongoing Review patient pathway Spring 2014 Spring 2015 Evaluation November 2014 May Costs Year 1 Administrative support/ project co coordinator Band 3, 22 hours/week 0.6 WTE IT support Band 6, 22 hours/week 0.6 WTE for 6 months Printing/computers/educational resource and materials 3000 Research fellow/service evaluation coordinator/training for pain champions. Expenses (e.g. travel) 2000 Events 1000 Total Year 2 Administrative support/ project co coordinator Band 3, 22 hours/week 0.6 WTE IT support Band 6 11 hours/week (0.3 WTE) for 12 months Printing/educational resource and materials/evaluation software 3000

8 Service evaluation coordinator/research fellow and backfill for training pain champions. Expenses (e.g. travel) 2000 Events 1000 Total Monitoring, Reporting & Evaluation Expected Outcomes Clinicians, patients and their carers will have a better understanding of chronic pain as a long term condition Service users and their carers will have local access to self management tools and training earlier in their care Up to date and comprehensive information on local services will be readily available and accessible Staff who are involved in the care of patients with chronic pain will be more knowledgeable and confident in advising and supporting them Interfaces with services which overlap with pain management will have been identified and streamlined Resources will be used effectively. Patients will be referred into and will move through pathways appropriately Service users will have a holistic assessment of their needs at an early point in their care. Current sources of local self care education (e.g. Pain Association Scotland courses) are supported on an ongoing and sustainable basis. These form an important part of our discharge strategy and offer long term support for pain selfmanagement. There will be achievement of access targets at all stages of the pathway An effective audit/research database will have been established such that the efficacy of the service can be demonstrated. The web based information will have been optimised Timescales and interim goals will be developed and the steering group will be responsible for monitoring and reporting progress. Governance: Financial monitoring will be through NHS Fife finance department via the planned care directorate accountant. Progress regarding outcomes will be reported back in the first instance to the FIPMEG and FIPMOG. Following FIPMEG meetings a quarterly report will be submitted to the Health Board/SMT. Annual reports will be submitted to the steering group/his, with the first being due prior to the release of second year funding. Funding Support Exit Strategy The expectation is that the links developed within the service improvement group will continue after the formal programme finishes in 2015 to form the core of a formal managed care network. By this time it is envisaged that the service evaluation process will be operational and embedded, and that there will not be an ongoing requirement for the support of a research/audit assistant. In addition, the additional costs for equipment and IT support are not expected to be ongoing beyond the 2 year transition period. The creation of a core of GP and community physiotherapists with enhanced knowledge of chronic pain management will

9 facilitate an ongoing improvement in primary care pain management. It is not anticipated that there will be a residual funding gap.