From: "Paulo Quadros" To: "Heather Wallace" Subject: Cross Party Group on Chronic Pain Date: Tue, 26 Feb 2008 09:45:28 -0000 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_015E_01C8785C.51AA51A0"; type="multipart/alternative" X-Priority: 3 X-MSMail-Priority: Normal X-Mailer: Microsoft Outlook Express 6.00.2900.3138 Disposition-Notification-To: "Paulo Quadros" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3198 This is a multi-part message in MIME format. ------=_NextPart_000_015E_01C8785C.51AA51A0 Content-Type: multipart/alternative; boundary="----=_NextPart_001_015F_01C8785C.51AA51A0" ------=_NextPart_001_015F_01C8785C.51AA51A0 Content-Type: text/plain; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Dear Helen/Gillian Please pass on my apologies as I will not be able to attend tonight's = meeting - again, and thank you for forwarding me the minutes of the last = meeting and all the documents. With reference to the NHS QIS report (Getting to GRIPS), it is the most = complete report yet produced on the Chronic Pain services and I feel = that there is a need for positive action now rather than endlessly = debating the subject and going round in circles. The report really has = everything that's needed for action and provides a framework for = restructuring the delivery of services to chronic pain sufferers. On the other hand, trying to put myself on the government's position, = the task seems so enormous that I can understand why there's so much = difficulty in putting recommendations into place. I feel that, one way = we (the X-party group) could help the government to have a clearer view = of how to put appropriate mechanisms in place which would match the = recommendations of the many reports published so far, would be the = provision of one initial practical strategic plan showing HOW the = service could be delivered. This would include not only mechanisms for = referral, fairly detailed staffing needs and costs. Perhaps the appointment of an independent pain service = Regulator/Minister with powers and responsibilities, working with = his/her own advisory team, specialised on each of the points outlined in = the NHS QIS' action plan would help implement and maintain an effective, = standardised chronic pain service. There is much already in place in = terms of existing advice, from QIS' 'Getting to GRIPS' and 'Health = Technology Assessment Reports' to Managed Clinical Networks and the of = extended scope practitioners (ESPs). I feel that there are 'too many = cooks' (of the best calibre, I'd like to add) but no one putting it all = together. Difficulties in the provision of effective, standardised chronic pain = management service is not only a Scottish/British issue but seem to = apply the world over. Perhaps we could learn what other countries are = doing about their chronic pain services, take the best of what is = relevant to the British health service and use this together with what = we already have to formulate our own solutions. There are good examples = of organisations that could be looked at to help develop our own chronic = pain services such as the International Association for the Study of = Pain, the US' Department of Veteran Affairs (which, incidentally has a = very good tool kit called 'Pain as the 5th Vital Sign') and many others. One of the 'Health Technology Assessment Report 12' (HTAR 12) = (secondary) recommendations is that "Any evaluation of service redesign = should incorporate consideration of both clinical and cost effectiveness = and should use validated clinical outcome measures". Although the = report refers to acute back pain, this would also be valuable in the = chronic pain service. There are quite a few validated clinical outcome = forms used throughout the world but most do not include all the = recommended markers in this report (eg Brief Pain Inventory, =D6rebro = Musculoskeletal Pain Questionnaire, Oswestry Disability Index, Pain = Beliefs And Perceptions Inventory, Quebec Back Pain Disability Scale, = West Haven-Yale Multidimensional Pain Inventory and so on). Most of = those require a great amount of time consuming data and are very = specific about the subject of the data collected (psychological, back = pain, etc). The Glasgow Pain Questionnaire, a generic measure of pain, = is easier and quicker with a 'Yes/No' system of ticking boxes but does = not incorporate all the recommended markers in the HTAR 12. The US = Department of Veteran Affairs has a series of outcome evaluation = measures (POQ scoring templates) but, again, address different pain = circumstances. Perhaps a dedicated evaluation system can be developed borrowing from = the various validated assessment tools. When we did this at our = organisation, we came out with a seven page evaluation tool (which, = although does not specifically take into account 'cost effectiveness', = this can be derived from the existing questions in the evaluation = document). This 'First Consultation Form' considers all possible known = biopsychosocial factors known to be related to pain including = nutritional, lifestyle and some known drug-related forms of pain such as = the use of biophosphonates which are suspected to cause intense pain = even after patients stop taking them. It was interesting to note that the HTAR 12 illustrates the benefits of = the use of a 'gatekeeper'. The same concept could be also applied to = general chronic pain (rather than just acute back pain) but they would = have to be trained beyond the levels described in the report. =20 I particularly welcome the findings on the use of 'alternative' = therapies. Given that approximately 14-20% of patients with chronic = disease have consulted Complementary Practitioners and about 75% of the = public support NHS access to complementary medicine (according to the = Prince of Wales Foundation's report 'Integrated Healthcare - A Way = Forward for the Next Five Years?'), there is a real need for evaluation = of CAM effectiveness and standard/uniform regulation for their use in = chronic pain management - even if only to address the issue of = patients' choice and safety. It is well know that there is a lack of 'good' evidence research, = employing the usual 'gold standard' of RCT. But, because the benefits = of some therapies are not suitable for this type of evaluation, a = starting point for evaluation could be along the lines of the wider = encompassing mechanisms detailed in the King's Funds' report 'Evidence = and Public Health'. =20 Whatever the arguments are against the use of complementary/alternative = therapies and against their possible role as one of the standard = interventions in a multi-disciplinary pain management approach, the = issues that they raise need to be addressed. It is because of the many papers and reports written so far and their = very few immediate practical benefits to pain sufferers that we decided = to form our Community Interest Company. This circumvents the existing = lack of funding and will give a snapshot of what a truly integrated, = multi-disciplinary model can achieve (the service includes mainstream = and complementary interventions following a biopsychosocial model - but = no medication - and aims at working with health providers, specially at = primary care level, assisted by an advisory board comprising mainstream = and CAM specialists). I am sorry I will miss the meeting tonight. The 'new' format seems = great with the inclusion of speakers on specialist subjects. Best regards Paulo * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Confidentiality: This e-mail and its attachments are intended for the = above named recipient(s) only and may be confidential and/or privileged. = If they have come to you in error you must take no action based on = them, nor must you copy or disclose them or any part of their contents = to any person or organisation; please reply to this e-mail and = highlight the error immediately and delete this e-mail and its = attachments from your computer system. =20 This footnote also confirms that this email message has been swept by = AVG for the presence of computer viruses. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * = * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *=20 Intlife Pain Management Services CIC - Registered in Scotland Number = SC313871 ------=_NextPart_001_015F_01C8785C.51AA51A0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable
 
Dear Helen/Gillian
 
Please pass on my apologies as I will not be able to attend = tonight's=20 meeting - again, and thank you for forwarding me the minutes of the last = meeting=20 and all the documents.
 
With reference to the NHS QIS report (Getting to GRIPS), it is the = most=20 complete report yet produced on the Chronic Pain services and I = feel that=20 there is a need for positive action now rather than endlessly debating = the=20 subject and going round in circles.  The report really has = everything=20 that's needed for action and provides a framework for restructuring the = delivery=20 of services to chronic pain sufferers.
 
On the other hand, trying to put myself on the government's = position, the=20 task seems so enormous that I can understand why there's so much = difficulty in=20 putting recommendations into place.  I feel that, one way we (the = X-party=20 group) could help the government to have a clearer view of how to put=20 appropriate mechanisms in place which would match the recommendations of = the=20 many reports published so far, would be the provision of one = initial=20 practical strategic plan showing HOW the service could be = delivered.  This=20 would include not only mechanisms for referral, fairly detailed staffing = needs=20 and costs.
 
Perhaps the appointment of an independent pain service=20 Regulator/Minister with powers and responsibilities, working with = his/her own=20 advisory team, specialised on each of the points outlined in = the NHS QIS'=20 action plan would help implement and maintain an effective, standardised = chronic=20 pain service.  There is much already in place in terms of=20 existing advice, from QIS' 'Getting to GRIPS' and 'Health = Technology=20 Assessment Reports' to Managed Clinical Networks and the of = extended scope=20 practitioners (ESPs).  I feel that there are 'too many = cooks' (of the=20 best calibre, I'd like to add) but no one putting it all together.
 
Difficulties in the provision of effective, standardised = chronic pain=20 management service is not only a Scottish/British issue but seem to = apply the=20 world over.  Perhaps we could learn what other countries are doing = about=20 their chronic pain services, take the best of what is relevant to the = British=20 health service and use this together with what we already have to = formulate our=20 own solutions.  There are good examples of organisations that could = be=20 looked at to help develop our own chronic pain services such as the = International Association for the Study of Pain, the US' Department of = Veteran=20 Affairs (which, incidentally has a very good tool kit called 'Pain as = the 5th=20 Vital Sign') and many others.
 
One of the 'Health Technology Assessment Report 12' (HTAR=20 12) (secondary) recommendations is that "Any evaluation of = service=20 redesign should incorporate consideration of both clinical and cost=20 effectiveness and should use validated clinical outcome = measures". =20 Although the report refers to acute back pain, this would also be = valuable in=20 the chronic pain service.  There are quite a few validated clinical = outcome=20 forms used throughout the world but most do not include all the = recommended=20 markers in this report (eg Brief Pain Inventory, =D6rebro = Musculoskeletal Pain=20 Questionnaire, Oswestry Disability Index, Pain Beliefs And Perceptions=20 Inventory, Quebec Back Pain Disability Scale, West Haven-Yale = Multidimensional=20 Pain Inventory and so on).  Most of those require a great amount of = time=20 consuming data and are very specific about the subject of the data = collected=20 (psychological, back pain, etc). The Glasgow Pain Questionnaire, a = generic=20 measure of pain, is easier and quicker with a 'Yes/No' system of = ticking=20 boxes but does not incorporate all the recommended markers in the = HTAR 12.=20 The US Department of Veteran Affairs has a series of outcome evaluation = measures=20 (POQ scoring templates) but, again, address different pain=20 circumstances.
Perhaps a dedicated evaluation system can be developed borrowing = from the=20 various validated assessment tools.  When we did this at our = organisation,=20 we came out with a seven page evaluation tool (which, although does not=20 specifically take into account 'cost effectiveness', this can be derived = from=20 the existing questions in the evaluation document). This 'First=20 Consultation Form' considers all possible known biopsychosocial = factors=20 known to be related to pain including nutritional, lifestyle and some = known=20 drug-related forms of pain such as the use of biophosphonates which are=20 suspected to cause intense pain even after patients stop taking = them.
 
It was interesting to note that the HTAR 12 illustrates the = benefits of the=20 use of a 'gatekeeper'.  The same concept could be also applied to = general=20 chronic pain (rather than just acute back pain) but they would have to = be=20 trained beyond the levels described in the report. 
 
I particularly welcome the findings on the use of 'alternative'=20 therapies.  Given that approximately 14-20% of patients with = chronic=20 disease have consulted Complementary Practitioners and about 75% of the = public=20 support NHS access to complementary medicine (according to the Prince of = Wales=20 Foundation's report 'Integrated Healthcare - A Way Forward for the Next = Five=20 Years?'), there is a real need for evaluation of CAM effectiveness and=20 standard/uniform regulation for their use in chronic pain = management  -=20 even if only to address the issue of patients' choice and safety.
 
It is well know that there is a lack of 'good' evidence research, = employing=20 the usual 'gold standard' of RCT.  But, because the benefits = of some=20 therapies are not suitable for this type of evaluation, a starting = point =20 for evaluation could  be along the lines of the wider = encompassing=20 mechanisms detailed in the King's Funds' report 'Evidence and Public = Health'. 
 
Whatever the arguments are against the use=20 of complementary/alternative therapies and against their = possible role=20 as one of the standard interventions in a multi-disciplinary pain = management=20 approach, the issues that they raise need to be addressed.
 
It is because of the many papers and reports written so far and = their very=20 few immediate practical benefits to pain sufferers that we decided to = form our=20 Community Interest Company.  This circumvents the existing lack of = funding=20 and will give a snapshot of what a truly integrated, multi-disciplinary = model=20 can achieve (the service includes mainstream and complementary = interventions=20 following a biopsychosocial model - but no medication - and aims at = working with=20 health providers, specially at primary care level, assisted by an = advisory board=20 comprising mainstream and CAM specialists).
 
I am sorry I will miss the meeting tonight.  The 'new' format = seems=20 great with the inclusion of speakers on specialist subjects.
 
Best regards
 
Paulo
 
 
 
* * * * * * * * * * * * * * * * * * * * * * * * * * = * * *=20 *
Confidentiality: This e-mail and its attachments are intended for = the above=20 named recipient(s) only and may be confidential and/or privileged. If = they have=20 come to you in error you must take no action  based on them, nor = must you=20 copy or disclose them or any part of their  contents to any person = or=20 organisation; please reply to this e-mail  and highlight the error=20 immediately and delete this e-mail and its attachments from your = computer=20 system.
 
This footnote also confirms that this email message = has=20 been swept by AVG for the presence of computer viruses.
 
* * * * * * * * * * * * * * * * * * * * * * * * * * = * * * * *=20 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *=20
Intlife Pain Management Services CIC - Registered in Scotland Number = SC313871
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