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NOTES

Here you will find documents, correspondence and other actions related to attempts to relieve the plight of pain sufferers through the years in the UK and (mainly) in Scottish , my arguments in favour of  the integration on Complementary and Alternative Medicine (CAM) in the NHS, the need for regulation and other related issues. It is set up in chronological order with newest at the top.  Sections in yellow mark my direct input.

This page has been set up to promote transparency so that anyone interested in chronic pain (especially chronic pain sufferers) can follow the progress of government measures to deal with issues related to chronic pain and understand the reason for my campaign for patients’ equal rights to choose and access drug-free pain management and treatment regardless of their income.

This issue is NOT against pharmaceuticals but about patients’ choice to access different models of pain and health management.  This page is also meant to be a resource for those who are interested in the issue.


NHS Quality Improvement Scotland (QIS) has now been replaced by Health Improvement Scotland (HIS)  (The creation of NHS Quality Improvement Scotland in January 2003 was designed to integrate and coordinate work on clinical effectiveness and the quality of patient care. But, as its name signals, the new board has an even more important purpose: ensuring that all this effort results in improvement across NHS Scotland in the quality of patients’ experience and in clinical outcomes.

Healthcare Improvement Scotland is a health body formed on the 1 April 2011. It has been created by the Public Services Reform (Scotland) Act 2010 and marks a change in the way the quality of healthcare across Scotland will be supported nationally.  Our organisation has the focus and key responsibility to help NHS Scotland and independent healthcare providers deliver high quality, evidence-based, safe, effective and person-centred care; and to scrutinise services to provide public assurance about the quality and safety of that care.


The Scottish Intercollegiate Guidelines Network  (SIGN) is found here (The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence based clinical practice guidelines for the National Health Service (NHS) in Scotland. SIGN guidelines are derived from a systematic review of the scientific literature and are designed as a vehicle for accelerating the translation of new knowledge into action to meet our aim of reducing variations in practice, and improving patient-important outcomes.)


Scottish Chronic Pain Steering Group  (In a public speech on the 22 April 2009, the Scottish Government Minister for Public Health and Wellbeing, Shona Robison, announced a decision to appoint Dr Pete Mackenzie as the lead clinician for chronic pain in Scotland to ‘provide professional leadership, and take responsibility for driving forward the GRIPS work’. In this speech she said:

There’s been no lack of enthusiasm over the years on the part of clinicians for taking forward chronic pain services. Many have succeeded, but the services created have inevitably been patchy, and have not been part of the NHS boards’ strategic planning. Coupled with that, we don’t want the GRIPS report to suffer the same fate as the 5 previous reports on the subject.’

On 12 May 2009 the inaugural meeting of the newly constituted Scottish Chronic Pain Steering Group was held.


The minutes of the Cross-party Group on Chronic Pain (Scottish Parliament) can be found HERE
“If alternative pain management services are not provided by the NHS, the demand will need to be fulfilled  elsewhere”.  

(Rao et al 1999, Haetzmann et al 2003) and (NHS Practice Improvement Scotland, The Management of Chronic Pain in Adults, Best Practice Statement Feb 2006)

Date

yy mm dd

Document

Narrative

14 06 25

Further issues regarding chronic pain CAM in the NHS and chronic pain patients benefits assessment issues

Submitted at the meeting/AGM of 25th June 2014 to ask for agreement regarding these 2 issues to be included on the CPG’s working plan.  Co-convener and chair for the meeting (Jackie Baillie MSP) suggested that the issues could be discussed on the next meeting of the group.

13 12  12

Launch of SIGN Guideline on  the ‘Management of Chronic Pain


Improving Chronic Pain Services in Scotland


AIMS:

- Launch the SIGN guideline on the ‘Management of Chronic Pain’ and accompanying patient  booklet

- Share progress in improvement of chronic pain services, showcasing examples of good practice

- Form a network of chronic pain service improvement groups


The guideline recommends massage/manual therapies, acupuncture and manipulation as first line interventions for low back pain,  neck pain and  osteoarthritis. (similar recommendations for persistent non-specific low back pain by NICE in 2009)


Patient booklets can be found HERE

Quick Reference Guide can be found HERE

Full guideline can be found HERE

13 09 15

Specialist chronic pain service consultation (Paulo)

This consultation seeks views on the possible options for the future provision of specialist residential pain management services in Scotland.


This is the new consultation distributed after the first one was cancelled.

13 05 29

Improving Chronic Pain Debate (video)


Improving Chronic Pain Debate (transcription)

Health Secretary Alex Neil said the Scottish government had a "total commitment to improving the chronic pain service throughout Scotland" as he led a debate on the issue on 29 May 2013.


Alex Neil has promised Scotland’s own residential centre for chronic pain, along with better day services.


The video is on http://www.scottish.parliament.uk/newsandmediacentre/41498.aspx

The transcription of the debate is on http://www.scottish.parliament.uk/parliamentarybusiness/28862.aspx?r=8176&i=74191&c=1488999

13 05

Complementary & Alternative Therapies in the Scottish NHS  Pain Management Service


(draft summary)

Draft document submitted to members of the Cross-party Group on Chronic Pain (this document is being developed and is intended to be published in full in 2014)

12 02 06

Suggestions for the Cross-party Group on Chronic Pain (Scottish Parliament) (Paulo)

Regarding:

1- Clarification of Cross-party Groups: scope, remits, duties, etc (basically what can we or can we not do as well as what we must do)

2- Communication/Information sharing: The work of the Group has changed from involving hundreds of people from the UK and abroad to the work of a handful of people. Not diminishing the value of the work done by those few people, there should be wider consultation on decisions and sharing of information.

3- Collaboration: Many organisations both in the UK and around the world have found (partial) solutions to various chronic pain issues. It would be helpful to interact with them to drive the aims of the Group

4- Activation of Group decisions: To maximize effectiveness, we need to be clear what decisions/actions must go through the conveners and which can be activated directly by the Group’s secretary.

5- Publicity: We should have more access to and interaction with newspapers, TV and radio to publicise the work of the Group and chronic pain issues. This also supports number 2 above (' Communication and information sharing).

6- People in pain need help now: Through our work, we must be able to address some chronic pain issues quickly by whatever means available.

7- Implementation of McEwen Report and Best Practice Statement ~ February 2006 ‘Management of chronic pain in adults’

8- Use of Complementary and Alternative Medicine (CAM) as enhanced choice of tools for the management and treatment of chronic pain


Full document HERE

12 02

Regarding GP Referrals to CAM therapists, Referral pathway and Payment for CAM below


Direct question (Paulo)


Reply by

Naureen Ahmad

Scottish Government

Long Term Conditions Unit

Health and Healthcare Improvement

QUESTION: Sorry about this but Gillian Gunn gave me my question as an answer (perhaps she did not receive the background to the questions?) ie


(My) Question 1: The Government has often quoted the Guidance issued to NHS Boards in August 2005 which makes clear that, “if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care”. What mechanisms are there in place to allow a GP to be satisfied with the competence of any given practitioner


Answer (given): 1 - Guidance HDL (2005) 37, issued to NHS Boards in August 2005 sets out the framework for the provision of these services in the NHS and clarifies that any NHS clinician wishing to make a referral for alternative treatment would be required to be satisfied of the value of the treatment and competence of the practitioner. The guidance is available online and can be found at [1]http://www.show.scot.nhs.uk/sehd/mels/hd...


I asked the question because the Guidance (or any other documents I'm aware of) does not make the issue clear. Incidentally, I was the instigator of the above Guidance as a result of my meetings with Andy Kerr and the Dept. of Health so I have the original and know the document well)


The same applies to questions 2 and 3. I have been aware of the mentioned BMA "guidance Referrals to

complementary therapists" since it was published. We all know that, whilst the guidance applies to all GPs in Britain, it does not mean that they can be implemented in Scotland (different commissioning rules, for instance.


As there is a clear pathway for patient referral to a physiotherapist, psychologist, secondary care in general, etc, all I want to know is what the referral pathway is for alternative therapies (as the Guidance states "“if they (GPs) choose to refer a patient for alternative treatment, . . .")


Perhaps I've complicated the questions by putting all three of them on the same request - should I make 3 fresh requests?


My guess is that there are no mechanisms that would make it practical to implement the statements of the Guidance. But I would like to confirm it. If I could confirm that there aren't proper non-defensive answers, then that would allow me to do something to help implementation.


ANSWER: With regards to question two - 'what is the referral pathway for alternative pathways?

Our response is the same to what we previously provided that: 'It is up to NHS Boards to determine the needs of their local population and deliver services to meet these. It is up to the Boards to establish the appropriate referral pathways' [so, it means that there is no referral pathway - Paulo].


Our answer to question three also remains the same - 'how payment is made i.e. who pays for the patients' alternative therapy treatment and what is the payment process'.

'If alternative therapy treatment is provided under the auspices of the NHS Board then this will be free of charge for the patient'.


With regards to question one - 'what mechanisms are there in place to allow a GP to be satisfied with the competence of any given practitioner' - in your last email (below) you ask whether there are any mechanisms that would make it

practical to implement the statements of the Guidance? - I can confirm that there are no mechanisms in place to implement the statements of the Guidance.

12 02

NHS CAM payments  - Direct question (Paulo)


Reply by Gillian Gunn

Directorate for Health and Healthcare Improvement

Long Term Conditions Unit

QUESTION: The Government has often quoted the Guidance issued to NHS Boards in August 2005 which makes clear that, “if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care” (Shona Robison to Andy Kerr, Nicola Sturgeon to Mary Scanlon both in March 2011 and others).


Assuming that all conditions above are met and a GP would like to refer a patient for alternative or complementary therapy today:


QUESTION: How is payment made i.e. who pays for the patient’s alternative therapy treatment and what is the payment process


ANSWER: Clinicians in NHS Scotland can only refer a patient for complementary therapy where their NHS Board agrees to the referral. In such instances the treatment is provided free of charge. Members of the public are free to use complementary therapy services privately if they choose.


COMMENT: This is not what Guidance HDL (2005) 37 above says. It also implies that, if a patient can afford it, the patient can choose to have treatments that are drug-free and free of life-changing side-effects).

12 02

GP referrals to CAM - Direct question (Paulo)


Reply by Gillian Gunn

Directorate for Health and Healthcare Improvement

Long Term Conditions Unit

QUESTION: The Government has often quoted the Guidance issued to NHS Boards in August 2005 which makes clear that, if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care” (Shona Robison to Andy Kerr, Nicola Sturgeon to Mary Scanlon both in March 2011 and others).


Assuming that all conditions above are met and a GP would like to refer a patient for alternative or complementary therapy today:


QUESTION: What is the referral pathway for such referral


ANSWER: It is recognised that complementary therapies may offer relief to some people living with long term conditions, however, the Scottish Government does not fund or deliver complementary therapies directly. It is open to

NHS Boards to make complementary therapy services available to their populations based on an assessment of needs within their respective areas.


It is therefore for individual NHS Boards to determine whether to make complementary therapies available in accordance with national and local priorities and in line with the health needs of their local population. Guidance HDL (2005) 37 referred to above, sets out the framework for the provision of these services across NHS Scotland.


COMMENT: Reply simply refers me back to my question ( Guidance HDL (2005) 37 does not have a referral pathway) (see also Jackie Baillie’s same questions HERE)

12 02

GP referrals to CAM - Direct question (Paulo)


Reply by Gillian Gunn

Directorate for Health and Healthcare Improvement

Long Term Conditions Unit

QUESTION: The Government has often quoted the Guidance issued to NHS Boards in August 2005 which makes clear that, “if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care” (Shona Robison to Andy Kerr, Nicola Sturgeon to Mary Scanlon both in March 2011 and others).


Assuming that all conditions above are met and a GP would like to refer a patient for alternative or complementary therapy today:


QUESTION: What mechanisms are there in place to allow a GP to be satisfied with the competence of any given practitioner


ANSWER: Guidance HDL (2005) 37, issued to NHS Boards in August 2005 sets out the framework for the provision of these services in the NHS and clarifiesthat any NHS clinician wishing to make a referral for alternative treatment would be required to be satisfied of the value of the treatment and competence of the practitioner. The guidance is available online and can be found at: [1]http://www.show.scot.nhs.uk/sehd/mels/hd...



COMMENT: Reply simply refers me back to my question!!!  From the reply It seems that, although GPs can (technically) refer, in practice they are not able to and patients do not have access to drug-free treatments if they chose and their GP agrees. (see also Jackie Baillie’s same questions HERE)

12 01

Jackie Baillie’s question to the Scottish Executive on my behalf (through the Cross-party Group on Chronic Pain at the Scottish Parliament) (Paulo)


Reply by Michael Matheson MSP

BACKGROUND: The government has quoted the Guidance issued to NHS Boards in August 2005 which makes clear that , “if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care” (Shona Robison to Andy Kerr and Nicola Sturgeon to Mary Scanlon both in March 2011).


QUESTION S4W-04905 Jackie Baillie: To ask the Scottish Executive what the referral pathway is for a patient with chronic pain who is referred for alternative therapy.


ANSWER: We recognise that complementary therapies may offer relief to some people living with long term conditions including chronic pain, however, the Scottish Government does not fund or deliver complementary therapies directly.


It is open to NHS Boards to make complementary therapy services available to their populations based on an assessment of needs within their respective areas. It is therefore for individual NHS Boards to determine whether to make complementary therapies available in accordance with national and local priorities and in line with the health needs of their local population.


Guidance HDL (2005) 37 issued to Boards in August 2005 sets out the framework for the provision of these services across NHSScotland. The guidance is available online and can be found at: http://www.show.scot.nhs.uk/sehd/mels/hdl2005_37.pdf


COMMENT: So, there is no referral pathway

12 01

Jackie Baillie’s question to the Scottish Executive on my behalf (through the Cross-party Group on Chronic Pain at the Scottish Parliament) (Paulo)


Reply by Nicola Sturgeon MSP

BACKGROUND: The government has quoted the Guidance issued to NHS Boards in August 2005 which makes clear that , “if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care” (Shona Robison to Andy Kerr and Nicola Sturgeon to Mary Scanlon both in March 2011).


QUESTION S4W-04906 Jackie Baillie: To ask the Scottish Executive what mechanisms are in place to enable a GP to assess the competence of an alternative therapy practitioner to whom a patient with chronic pain is referred.


ANSWER: Guidance HDL (2005) 37, issued to NHS Boards in August 2005 sets out the framework for the provision of these services in the NHS and clarifies that any NHS clinician wishing to make a referral for alternative treatment would be required to be satisfied of the value of the treatment and competence of the practitioner. The guidance is available online and can be found at:


http://www.show.scot.nhs.uk/sehd/mels/hdl2005_37.pdf


The British Medical Association’s (BMA) guidance Referrals to complementary therapists regulated by statute - Guidance for GPs contains advice on referrals to complementary therapists:

· regulated by statute

· who are registered with the General Medical Councils GMC, or Nursing and Midwifery Council (NMC); and,

· delegation to other practitioners


The BMA guidance can be viewed at:

http://www.bma.org.uk/images/refcomtherap0406_tcm26-190153.pdf  


COMMENT: BMA guidance does allow a GP to refer to Complementary Medicine but can only be of practical use in England and Wales as they have a register of therapists funded by the English Health Department (the CNHC).  The Scottish Government refuses to acknowledge the CNHC (see HERE) and has stated that they have no intention of creating a Scottish equivalent.(see HERE)

12 01

Jackie Baillie’s question to the Scottish Executive on my behalf (through the Cross-party Group on Chronic Pain at the Scottish Parliament) (Paulo)


Reply by Nicola Sturgeon MSP

BACKGROUND: The government has quoted the Guidance issued to NHS Boards in August 2005 which makes clear that , “if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care” (Shona Robison to Andy Kerr and Nicola Sturgeon to Mary Scanlon both in March 2011).


QUESTION S4W-04907 Jackie Baillie: To ask the Scottish Executive whether alternative therapy treatment for which a patient with chronic pain is referred is provided free of charge.


ANSWER: Clinicians in NHS Scotland can only refer a patient for complementary therapy where their NHS Board agrees to the referral. In such instances the treatment is provided free of charge.


COMMENT: So the answer seems to be ‘no’. Please refer to the two questions above .

12 01

Jackie Baillie’s question to the Scottish Executive on my behalf (through the Cross-party Group on Chronic Pain at the Scottish Parliament) (Paulo)


BACKGROUND: The government has quoted the Guidance issued to NHS Boards in August 2005 which makes clear that , “if they choose to refer a patient for alternative treatment, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's care” (Shona Robison to Andy Kerr and Nicola Sturgeon to Mary Scanlon both in March 2011).


QUESTION S4W-04908 Jackie Baillie: To ask the Scottish Executive what research has been conducted on non-pharmacological interventions in pain management, including alternative and complementary therapies, since 2007.


ANSWER (Nicola Sturgeon): The UK Clinical Research Network Portfolio Database is a register of all research funded by the UK Government, Research Councils and Partner Charities. It documents that 16 studies on the non-pharmacological management of pain have been completed since 2007 with a further 12 ongoing. Details of these studies can be accessed at http://public.ukcrn.org.uk/search/. The Scottish section of the register, which can be accessed at http://scotland.ukcrn.org.uk/, records 3 ongoing and 3 completed studies.


Similar question as above asked directly by me


Replied by Dr Elaine Moir

(Communication and Support Manager

Chief Scientist Office)

Would you please tell me how much funding has been given for research of non-pharmacological interventions (including

complementary and alternative therapies) in pain management in the last 5 years in Scotland ?


The Chief Scientist Office (CSO) within the Scottish Government has responsibility for encouraging and supporting research into health and healthcare needs in Scotland. . . . CSO has not provided funding for any research in the area of

non-pharmacological interventions in pain management in the last 5 years.


Full answer here.


COMMENT: The answers above show that the Government has not funded any alternative therapy or other drug-free treatments for chronic pain at least within the past 5 years.  The Government cannot refuse to fund drug-free alternatives to chronic pain management and, at the same time, say that they cannot allow those types of  treatments to be delivered through the NHS as there is no evidence.  This means that there is no intention to allow people to have a choice ever on this matter.


With respect to research funded by the UK Government, the studies referred to in the answers involve main stream therapies eg physiotherapy but no other kind of alternative therapies.  There is also the fact that, regardless of what research is done by a UK-wide organisation, this will be irrelevant in terms of  patients benefits as the Scottish Government seem to pick what is most convenient: they will quote UK-wide research but not accept UK-wide conclusions and guidelines (as it is the case with NICE’s guidelines for the treatment of non-specific lower back pain). See also here

11 10

Comments on 15th June 2011 meeting of the Cross-party Group on Chronic Pain   (Paulo)

Regarding:


incongruent government approach to policies: on one hand declaring support for the evaluation of  nonpharmacological approaches to chronic pain management whilst actively negating practical steps to allow it to happen


putting harm/benefit balance of drugs and alternative medicine in context


chiropractics clarification

11 08

SIGN GUIDELINES

The Scottish Intercollegiate Guidelines Network (SIGN) is developing guidelines for the Assessment and Non-pharmacological treatment of patients with non-malignant chronic pain.


The guideline development group is scheduled to start in August and will present its initial findings in an open consultation meeting in autumn 2012. Further information on SIGN is available from the SIGN website, www.sign.ac.uk .


In development

Remit: Develop a new guideline to improve patient management in both primary and secondary care that covers investigation, referral criteria, and pain management eg pharmacological options, specialist interventions, physical therapies; and psychological strategies.


Estimated publication date: Winter 2013

11 05 19

Back pain guidelines ignored

College of Medicine survey.

Despite acupuncture, massage and manipulation being recommended in more serious cases, 32 per cent of GPs have not actioned them. Yet guidelines have been in effect nearly 2 years.

11 03 19

Low back pain: early management of persistent non-specific low back pain - NICE guidelines  (Paulo)


(SCOTLAND)

Some of the main recommendations contained in the referred NICE guidelines have already been agreed by QIS a few years ago and I wonder how much longer patients suffering from chronic pain in Scotland will have to wait for the right to choose drug-free treatments.


For instance, the use of acupuncture for chronic low back pain since 2008 in response to an enquiry from NHS Highland and the GRIPS Report of 2006 acknowledges that "There is evidence to suggest that some complementary therapies have a positive effect on chronic pain".


When is the final SIGN/QIS guidelines on non-specific LBP expected to be published?


Does it mean that patients suffering from chronic non-specific low back pain need to be referred to England for the moment if they wish to have the treatments outlined in the NICE guidelines (under the NHS)?


Answer (From Directorate for Health and Healthcare Improvement - The Scottish Government ):

With regard to the provision of services, NHS Boards in Scotland are responsible for providing NHS services in accordance with national and local priorities and in line with the health needs of the population. Decisions regarding the care of individual patients are a matter of professional judgement for the clinician responsible for the patient's care.

11 03 19

Regulation of Complementary and Alternative Medicine. Question about the Complementary and Natural Health Council (CNHC) (Paulo)


(SCOTLAND)

As you may already know, the Department of Health in England instigated the creation of the CNHC in order to give GPs and other medical practitioners the confidence to be able to refer patients to CAM when they think this may be beneficial. This has been a long standing issue for medical professionals as they are ultimately responsible for the welfare or their patients .


2 - If the CNHC is not recognised in Scotland (my understanding of 'no endorsement'), and the Scottish Government has no intention of creating a CAM regulatory body, how would NHS Boards in Scotland be able to provide CAM treatments to patients deemed to benefit from such treatments?


And how would clinicians in Scotland be able to make direct referrals if they judged it appropriate for their patients if there is not a way for them to recognise properly qualified therapists and they cannot commission directly as is the case in England?


3- As you mention the HPC in relation to my original question, is the intention of the Scottish Government to appoint the HPC as a regulatory body for CAM in the near future?



Answer (by HD: Regulatory Unit - Scottish Government): [Still not answering the questions! - Paulo] The key point is that the CNHC are a UK wide voluntary regulator. They operate a model of voluntary self regulation of practitioners.


 . . . Guidance issued to NHS Boards in August 2005 sets out the framework for the provision of complementary and alternative medicine services in the NHS in Scotland. The guidance is available via: http://www.sehd.scot.nhs.uk/mels/HDL2005_37.pdf  [same document as 05 08 24 below - Paulo]


. . . a GP or hospital clinician may refer a patient for complementary and alternative medicine (CAM) therapy. In doing so, the GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's medical care.


The UK White Paper `Enabling Excellence' maps out the UK Government intention to use a system of assured voluntary registers to be enabled through the Health and Social Care Bill for healthcare workers across the UK.

[But the Scottish Government implies throughout this page that healthcare regulation in England does not apply to Scotland! - Paulo]


. . . in the future theoretically an accredited voluntary register for complementary therapies could be operated by the HPC or CNHC or another voluntary regulator. However, there is currently no intention to appoint the HPC or any other body as a regulatory body for CAM in the near future.

11 03 16

Parliament Question - Mary Scanlon MSP to Nicola Sturgeon (on my behalf)


(SCOTLAND)

To ask the Scottish Executive whether it will recommend the provision of complementary and alternative medicine through the Complementary and Natural Health Council for the treatment of chronic pain.


Answer: The Complementary and Natural Healthcare Council (CNHC) is a non-statutory project, funded and assessed by the Department of Health in London. There is no duly appointed Scottish representative on the CNHC, and no endorsement or funding has been sought from this government.


. . . It is open to NHS boards to provide these therapies, based on their assessment of the needs of their local population and in line with national guidance on treatment. Guidance on complementary and alternative medicine was issued to NHS boards in August 2005 in HDL (2005) 37, . . .



11 03 16

Low back pain: early management of persistent non-specific low back pain -

Mary Scanlon MSP to Nicola Sturgeon re NICE guidelines (on my behalf)


(SCOTLAND)

To ask the Scottish Executive whether it will recommend sequential therapies for the treatment of persistent non-specific low back pain.


Answer: (NICE) Clinical Guideline on Early Management of Persistent Non-specific Low Back Pain (May 2009) refers to the use of sequential therapies, in the section dealing with research recommendations. It suggests that further research is needed . . .


[not an answer then - most  research related to pain therapies (physiotherapy, etc) suggest that further research is needed. In spite of that, those guidelines also recommend sequential therapies, etc according to best current evidence of effectiveness - Paulo]

11 03 11

Shona Robison reply to Andy Kerr re CAM in NHS  and NICE guidelines


(ref 11 02 07 below)


(SCOTLAND)

(in brief - more information in the actual document)


NHS  QIS  have established  a  Scottish  Chronic Pain  Steering  Group to take forward recommendations in the Getting to  GRIPS  Report.  Part of this work will  be to develop  a SIGN  guideline on  aspects of chronic pain  management.

NICE Clinical  Guidelines have  no formal  status in  Scotland

We are aware of the Complementary and  Natural  Health Council's work in  England  [CHNC] and  are monitoring their progress with interest. [!!!] (see 11 02 09)


Guidance  issued  to  NHS  Boards in  August 2005  sets out the framework for the provision of these services in the  NHS.  This guidance is available from  http://www.sehd.scot.nhs.uk/mels/HDL2005  37.pdf

 

The  guidance  makes  clear that,  if they choose to  refer a  patient for alternative treatment,  the GP or hospital  clinician would  "require to  be  satisfied  of the  value  of the treatment and  the  competence  of the  practitioner,  and  would  remain  responsible for the  patient's care".

11 02 07

Andy Kerr to Nicola Sturgeon re NICE guidelines and CAM regulation (on my behalf)


(replied by Shona Robison on 11 03 11)


(SCOTLAND)

Low Back Pain - Early Management of Persistent Non-Specific Low Back Pain


I am aware of the NICE Guidelines published in May 2009 with regard to the above matter and  I  would  wish  to  know  if  any  steps  been  taken  in  Scotland  by  QIS  to  make recommendations  based  upon  the  NICE  Guidelines  or  whether  there  is  work  being undertaken?


In  particular,  I  would  be  interested  to  know  the  position  in  Scotland  with regard to sequential interventions therapies as part of chronic pain  management services.  The NICE Guidelines  indicates  support  for  manual  therapy,  exercise  and  acupuncture  as  being appropriate for patients, as well as being cost effective.


It is also my understanding that in October last year, the  Department of Health  in  England published a bulletin which went out to GP's encouraging them to recommend Complementary  and  Natural  Health  Council  (CNHC)  registered  practitioners  to  patients looking for complementary healthcare.


Again, I would be obliged if you could advise me of the position of the Scottish Government with  regard to this  matter,  particularly on  the  provision  of complementary and  alternative medicines through CNHC therapists.


Answer: See above

11 02 09

Low back pain: early management of persistent non-specific low back pain -

Question re NICE guidelines (Paulo)


(SCOTLAND)

In May 2009, NICE published guidelines for England and Wales recommending the use of ‘sequential therapies’ (eg massage, acupuncture, etc)for the treatment of persistent non-specific low back pain.


Given the level of good evidence and cost effectiveness detailed on those guidelines, is the Scottish Government also adopting them in Scotland through QIS?


In particular, what is being done with regards to provision of NICE’s named ‘sequential therapies’ as part of the NHS chronic pain service?


Answer: NICE Clinical Guidelines have no formal status in Scotland as the Scottish Intercollegiate Guidelines Network (SIGN), part of NHS QIS has responsibility for producing clinical guidelines in Scotland.

11 02 09

Regulation of Complementary and Alternative Medicine.

Question about the Complementary and Natural Health Council (CNHC) (Paulo)


(SCOTLAND)

In October of 2010, the Department of Health (in England) published a bulletin which went out to GPs encouraging them to recommend Complementary and Natural Health Council(CNHC)- registered practitioners to patients looking for complementary health care.


In 2010, the CNHC was also asked by The Secretary of State for Health to register practitioners supplying herbal medicines to members of the public in England.


As the CNHC is a Government-sponsored, voluntary registration body for complementary health care practitioners, is the Scottish Government also supporting the provision of complementary and alternative medicine through CNHC-registered therapists or does the Health Minister support an independent Scottish CAM regulatory body, which takes into consideration the differences between the English and Scottish health systems?


Answer: There is no Scottish Government representative to the CNHC and no endorsement or funding from the Scottish Government has been sought or given. At present there is no intention to create an independent Scottish CAM regulatory body.


...it is open to NHS Boards in Scotland to make such services available based on an assessment of needs

10 03 02

Scottish Chronic Pain Steering Group Minutes


(The Steering Group has the responsibility for driving forward the GRIPS work under the leadership of lead clinician for chronic pain in Scotland.

Minutes of meetings are found HERE)


(SCOTLAND)

SIGN application for a guideline on the Management of Chronic Pain –  covered under agenda item 4.


Pete Mackenzie had received information from Blair Smith and Stewart Mercer regarding Chronic Pain and its links with mortality and morbidity in deprived areas. After some discussion it was decided that the information should be used carefully and channelled (and referenced) through the project steering group processes.


GRIPS Priority Action 2 – there is an aspiration to arrange a consensus conference or equivalent around redesign of chronic pain services once the NHS QIS project initiation document has been finalised.


Pete Mackenzie gave updates on the ‘Improving Services for People with Chronic Pain’ Day


Pete Mackenzie advised  that the Glasgow MCN was moving towards implementation of its agreed service

model and is therefore a useful model for other health boards setting up SIGs.


Pete Mackenzie advised the group of positive conversations about remote access services for people with chronic pain.


It was agreed to include signposting towards Pain Concern, Arthritis Care and the Arthritis Research Campaign in the narrative below the service model.


(Re NHS QIS Chronic Pain Project Plan) Pete Mackenzie advised that it was hoped that this process will be completed by the next project steering group meeting in June. It was thought that this process will lead to a 3 or 5 year project plan for NHS QIS.


Some discussion took place between group members regarding the 18 weeks referral to treatment (18WRTT) and how it relates to chronic pain. This item would be carried over to the next meeting.

09 11

Response to ‘A Joint Consultation on the Report to Ministers from the DH Steering Group on the Statutory Regulation of Practitioners of  Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practices in the UK’

by the Council for Healthcare Regulatory Excellence (CHRE)

The Council for Healthcare Regulatory Excellence (CHRE) is an independent body accountable to the UK Parliament. Our primary purpose is to promote the health, safety and wellbeing of patients and other members of the public. We scrutinise and oversee the health professional regulators, work with them to identify and promote

good practice in regulation, carry out research, develop policy and give advice.


“We are not convinced that statutory professional regulation is the most appropriate course of action for these three areas of practice. The report from the Extending Professional Regulation working group demands an open discussion about other options that may address risks in the most proportionate fashion. We believe it offers

a useful way to proceed.”

09 11 16

A joint consultation on the Report to Ministers from the DH Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other Traditional Medicine Systems Practised in the UK

(Website with all related documents)

This consultation seeks respondents’ views on whether, and if so how, to regulate acupuncturists, herbal medicine practitioners and traditional Chinese medicine (TCM) practitioners. It focuses on the purpose of regulation – public protection - explains the difference between professional regulation (whether statutory or voluntary) and system regulation, and explores the links between the work of the DH Steering Group on the statutory regulation of acupuncture, herbal medicine and TCM and the Regulation White Paper Working Group on Extending Professional Regulation.

09 07 01

Joint UK-wide consultation on the Report to Ministers from the DH steering Group on the Statutory Regulation of Practitioners of Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK

(This is the actual report)

Cross Ref: Pittilo report

Government needs to decide whether to agree to the statutory regulation of Acupuncture, Herbal Medicine and TCM and if so, what form such statutory regulation should take.


This joint consultation, on behalf of the four UK Health Ministers, seeks respondents’ views on whether, and if so how, to regulate acupuncturists, herbal medicine practitioners and traditional Chinese medicine (TCM) practitioners. It focuses on the purpose of regulation – public protection – explains the difference between professional regulation (whether statutory or voluntary) and system regulation, and explores the links between the work of the DH Steering Group on the statutory regulation of acupuncture, herbal medicine and TCM and the recommendations from

the UK White Paper Working Group on Extending Professional Regulation.  

09 07 16

Response to the Report of the

Extending Professional Regulation Working Group


(inc SCOTLAND)

The Extending Professional Regulation Working Group was established by the Secretary of State for Health in England, with the support of Ministers in Northern Ireland, Scotland and Wales, to progress work signalled in the White Paper Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century, published in February 2007.  Its role was, in relation to emerging professions, to develop criteria to determine which roles should be statutorily regulated.

08 06 16

Report to Ministers from the Department of Health steering group on the statutory regulation of practitioners of acupuncture, herbal medicine, traditional Chinese medicine and other traditional medicine systems practised in the UK

The Department of Health Steering Group was established in summer 2006 by Jane Kennedy, then Minister of State at the Department of Health, and was invited to prepare the ground for the regulation of practitioners of acupuncture, herbal medicine, traditional Chinese medicine and other traditional medicine systems practised in the UK.


In particular, the Steering Group was asked to identify issues and propose options in relation to education and training, registration, fitness to practise and other essential aspects of regulation.

09 06 08

Parliament Question - Jamie McGrigor to Nicola Sturgeon


(SCOTLAND)

To ask the Scottish Executive whether it considers it a worthwhile use of NHS funds to offer complementary treatments such as physical therapy and massage to people with chronic back pain.


Answer: The Scottish Government recognises that complementary or alternative medicine may offer relief to some people suffering from a wide variety of conditions and leaves it open to NHS boards to provide these therapies based on their assessment of needs in their areas and in line with national guidance about treatment for the condition(s). The treatment of individual patients is a matter of professional judgement.

09 05 27

Early management of persistent non-specific low back pain

NICE guideline (England, Wales)

5.1.4     Offer one of the following treatment options, taking into account patient preference an exercise programme, a course of manual therapy or a course of acupuncture. Consider offering another of these options further if the chosen treatment does not result in satisfactory improvement.


Evidence: (Manual therapies in these guidelines are spinal manipulation, spinal mobilisation and massage)


7.2.1     Massage: Consider offering a course of manual therapy including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.

7.3.1.2  Massage: Eight RCTs were identified, four conducted in the USA (466 patients), three in Canada (235 patients) and one in Germany (190 patients).

One RCT comparing massage to inert treatment (sham laser) showed that massage was superior. The other studies compared massage to different active treatments. They showed that massage was equal to corsets and superior to self-care education. The beneficial effect of massage in patients with chronic low back pain lasted at least a year after the end of treatment.

This was a high quality systematic review with a very low risk of bias


Alexander Technique: structured programmes of Alexander Technique and exercise prescription compared to usual care were effective at reducing pain and functional disability.

This was a well conducted RCT with a low risk of bias.


10.2.1   Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who:

•  have received at least one less intensive treatment and

•  have high disability and/or significant psychological distress


10.2.2   Combined physical and psychological treatment programmes should include a cognitive behavioural approach and exercise


No opioids or tricyclic antidepressants and only some NSAIDs have a UK marketing authorisation for treating low back pain. If a drug without a marketing authorisation for this indication is prescribed, informed consent should be obtained and documented.

09 05 13

Impact Assessment of the Statutory Regulation of

Acupuncture,  Herbal  Medicine  and  Traditional  Chinese

Medicine

There  is  evidence  of  risk  to  public  health  from  the  unregulated  practice  of  acupuncture,  herbal

medicine  and  traditional  Chinese  medicine.  The  risks  derive  from  incompetent,  unscrupulous  or

inadequately trained practitioners,  and/or practitioners who may be unable to communicate effectively

in  English.  Therefore,  for  purposes  of  public  protection  there  may  be  a  need  for  some  form  of

regulation, statutory or otherwise, for these professions.


However,  any  regulation  should  be  proportionate  to  the  level  of  risk  and  should  reflect  cross-

Government  principles  of  better  regulation.  The  proposed  consultation  asks  whether  and  if  so  how

these groups of practitioners should be regulated.

09 05

Early management of persistent non-specific low back pain


Commissioning factsheet -

Implementing NICE guidance

While a lack of evidence of effectiveness does not equate with evidence of ineffectiveness, it is only sensible that investment in treatments for non-specific back pain should be concentrated on those interventions for which effectiveness is supported by good quality research and evidence of good outcome from that treatment.


Potential benefits of commissioning services  


The principal potential benefits of commissioning services for the early treatment and management of persistent or recurrent non-specific low back pain through improving efficiency and effectiveness, and therefore reducing costs within the local health economy, are:  

  • reducing the number of people who undergo unnecessary investigations or treatments, such as MRI scans, X rays, injections of therapeutic substances into the back and radiofrequency facet joint denervation
  • reduced sickness absence from paid work (owing to a decrease in physical and/or emotional disability caused by low back pain)
  • a reduction in the length of time for which people are unable to carry out normal activities
  • increased effectiveness of low back pain services  
  • improved patient choice
  • a possible reduction in waiting lists for consultant referral.


Although additional services are recommended, they represent options that are both clinically and cost effective compared with interventions currently offered by PCTs which are not supported by evidence of effectiveness. The recommended treatments are:

  • a structured exercise programme  
  • manual therapy, including manipulation
  • acupuncture  
  • a combined physical and psychological treatment programme


* Manual therapy includes spinal manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), spinal mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues).

08 09

Acupuncture for low back pain (QIS)


(SCOTLAND)

In response to an enquiry from NHS Highland.


  • Acupuncture is more effective than no  treatment and sham acupuncture in the short-term for pain relief in chronic LBP.
  • Adding acupuncture to usual care (or specific treatment) is more effective than usual care (or specific treatment) alone for chronic LBP.
  • Two economic evaluations suggest adding acupuncture to usual care is cost-effective compared to usual care alone for subacute and chronic LBP.

08 05

PITILLO Report

The recommendations in this report have taken account of emerging health policy over the past decade relevant to protecting patients and new ways of working for healthcare professionals. There has been positive discussion with statutory regulatory bodies, particularly with the Health Professions Council (HPC) which is the proposed new regulator for acupuncture, herbal/traditional medicine and traditional Chinese medicine as well as with professional bodies and practitioners. The report is therefore framed within the context of existing health policy.

08 02 26

Cross-party Group on Chronic Pain Meeting


Comments and suggestions (Email)

(Paulo) (SCOTLAND)

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.


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.


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.


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.  


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'.  

08 01 07

Service delivery organisation for acute low back pain


(Health Technology Assessment Report 12)


(SCOTLAND)

The objectives of this HTA were:  

• to consider the clinical and cost effectiveness of service delivery models for the management of acute low back pain which utilise different triaging referral models.

• to assess the impact of various parameters on a service delivery model to optimise its clinical efficacy and cost effectiveness.


This report highlights the existing evidence for the treatment of low back pain which NHS boards should consider when developing services. This includes the Prodigy and European guidelines  and  other  publications.

07 12

Getting to GRIPS with Chronic Pain in Scotland - Getting Relevant Information on Pain Services

The GRIPS Report’


(SCOTLAND)

NHS Quality Improvement Scotland (NHS QIS) was approached by representatives from the Royal College of Anaesthetists, the Cross-Party Group on Chronic Pain, the North British Pain Society and by a range of healthcare professionals and patients all asking whether we could together act as the catalyst that would bring about change.

We have worked with all these groups and individuals, and with NHS Boards and we thank them sincerely for their openness and support during the preparation of this report. In particular we acknowledge the work of Janette Barrie who has co-ordinated this project from start to finish.


Together we have delivered the most comprehensive stocktake of chronic pain services ever produced and we have reported from every perspective: that of the patients, that of the healthcare professionals providing services; and that of the NHS Boards responsible for strategic planning, funding and delivery of the services. The messages are stark and the actions are clear. We need to stop talking about what is not working and start improving these services as a matter of priority. With ‘Better Health, Better Care’ and the Scottish Government’s Long Term Conditions Alliance we have never had a better opportunity to make a difference and we hope this report will indeed light the touch paper of improvement and change.


Key Findings


  • Despite four nationally commissioned reports in the last ten years and data from surveys indicating high prevalence  (18% of Scottish population), chronic pain is not recognised as a ‘condition’ and is not currently included in the key long-term conditions to be addressed by the Long Term Conditions Alliance. As a result, it is not regarded as a priority by Scottish Government Health Directorates (SGHD) or by NHS Boards. (Priority Action 1)
  • The provision of chronic pain services within Scotland is patchy and fragmented particularly for core secondary  services. Service provision and access to services varies considerably between and within NHS Boards and we found little evidence of needs assessment or strategic planning for chronic pain services. Very few NHS Boards have dedicated funding streams for these services. The quality and effectiveness of these services is rarely monitored. (Priority Action 2 and 6)
  • None of the NHS Boards could provide a complete or accurate description of the chronic pain services provided, or of the resources available to provide them. (Priority Action 2)
  • There are significant discrepancies between the descriptions of available services as reported by NHS Boards and services actually provided, as reported by healthcare professionals and service users. In the main, clinicians providing services did not recognise and could not reconcile actual service provision with the service provision reported by NHS Boards. (Priority Action 3)
  • Some information was available on services provided in the secondary care sector but very little feedback was provided on primary and community healthcare services although we are aware that most patients are cared for in this setting. (Priority Action 3)
  • Access to specialist services is limited, with GPs often reluctant to refer and waiting times are long. (Priority Action 2)
  • There is a general lack of knowledge about chronic pain and awareness of treatment options and services in NHS Scotland. (Priority Action 4)
  • Very few Boards offer pain management programmes (PMP) and very few patients have access to these. (Priority Action 5)

06 02

Management of Chronic Pain in Adults (QIS - 2006)

(Use of complementary therapies in the management of chronic pain on Section 10)

(SCOTLAND)

Best practice statement on the management of chronic pain in adults


This best practice statement has been developed by a multidisciplinary working group of relevant specialists, which included people living with chronic pain and carers.  A multi-professional reference group has advised on and overseen the work of the working group.


This Best practice statement refers to the management of chronic pain in adults; it does not address the needs of children who suffer chronic pain.


There is evidence to suggest that some complementary therapies have a positive effect on chronic pain (Snyder & Wieland 2003, Stephenson & Dalton 2003).


The interaction between the patient and healthcare professional may be an important mediator in treatment outcome.

06 01 27

Meeting with Scottish Department of Health authorities

Two of the the three most senior Health Department officers were not given my original document and were completely unaware of its contents.


I was only prepared to clarify points in my document and it was impossible for me to talk about the entire content of the document within the allocated time.


My overall ‘impression’ - by the end of the meeting - was that the officers I met with were personally in favour of Complementary and Alternative Medicine (one of them was meeting Dr David Reilly that week at the Homoeopathic Hospital) but seemed to be unable to implement it as they could not be seen to directly promote alternative medicine.  

05 10 12

Letter from Andy Kerr (Minister for Health) organising a meeting between myself and the Scottish Dept. of Health


(Paulo) (SCOTLAND)

Please find  attached a paper given to me by a local constituent but also well known in the above  field.


I would be obliged if he could have a further  conversation with Health Department  Offices with regard to his proposals on use of alternative therapies but also the provision of wellbeing centres which offer both conventional and unconventional medicine and how these can link with the new NHS and be supported by the NHS.

05 10 08

The argument for use of CAM in an integrated pain service


(Paulo) (SCOTLAND)

Points discussed:


1. Demand: Many patients don't go to GP but straight to private alternative therapy practitioner.

This also creates a divide between those who can and cannot pay

2. There is a need for preventive and remedial approaches to tackling pain issues

3. Balancing the need for drugs and their side-effects (risks v benefit)s: especially with regards to children and the elderly.  

4. Vulnerable groups

5. Establishment of an audit system: to initially assess effectiveness of complementary /alternative  therapies in order to evaluate the need for further research.

6. Training: It would be desirable if funds / subsidies were available to offer CPD training in specialist pain management within the various types of alternative and complementary disciplines (specialist training is required for all health providers )

7. This would come at levels 1 and 2 in the protocol suggested by Dr Nicola Stuckey at the chronic pain conference. [She said there was a shortage of clinical psychologists but that care could be provided by properly trained people on three levels.

Level 1 can include all clinicians and involves basic skills like listening to people.

Level 2 involves specially trained clinicians providing interventions like relaxation techniques

Level 3 is for more complex cases and involves clinical psychologists.] (Chronic Pain Conference - Friday 8 July 2005)

8. Evidence of effectiveness: Research reviews on the effectiveness of complementary therapies (such as the Cochrane library and the Centre for Reviews and Dissemination ) tend to show inconclusive evidence for effectiveness rather than conclusive evidence of ineffectiveness or harm.   

9. Filling service gaps:  Alternative and unconventional evidence-based approaches to pain management can fill gaps in the service or, in certain circumstances, provided pain management support in areas where access to pain management service is restricted or non-existent.  

10. There is a misconception that unconventional therapists are not well trained medically and/or not qualified enough to provide pain management  

11. Clearer definition of alternative/complementary therapies:  The very question about which terminology to use (complementary, alternative, conventional, mainstream, unconventional, etc) is, in reality, a key issue for the effective development of policies on the integration of the various modalities of health delivery and is more important than it seems at first.  

12. What is needed is a more complete integration

05 08 24

COMPLEMENTARY AND ALTERNATIVE  MEDICINE -

Scottish Health Department circular to NHS Boards reminding them that they have the discretion to provide complementary and alternative medicine (CAM) through the NHS.


This was a result from a series of meetings I had with the then Health Minister Andy Kerr MSP and the Health  Department (Public  Health  Division)


(SCOTLAND)

The Executive recognises, as successive UK Governments have for many years, that CAM may offer relief to some people suffering from a wide variety of conditions.


A GP or hospital clinician may refer a patient for alternative treatment. The GP or hospital clinician would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's medical care.


If an NHS Board sees a need for the provision of a particular type of CAM in its area it is open to that Board to provide that therapy, at the Board's discretion.


The UK Health Departments recently conducted a consultation on whether acupuncture and herbal medicine should also be regulated by statute. There was a consensus of opinion that there should be a single regulatory council for both disciplines.


The Executive will work with the UK Government and the other devolved administrations to introduce legislation to establish such a council.


Complementary and Alternative Medicine is an area in which there is increasing public interest. Chief Executives are asked to take this into account in the planning of services.

05 03

Observations on Prof McEwan’s report on Chronic Pain Services In Scotland


(Paulo) (SCOTLAND)

Letter sent to Andy Kerr (then Health Minister) proposing strategies to remedy some  of the shortfalls in the Scotland’s NHS Chronic Pain Service as outline in the McEwan Report.


This document is intended to offer potential alternatives and additions to the chronic pain service following certain remarks in the report and previous discussions which have taken place in the Group's meetings.


"The major problem identified in all boards was with recruitment of psychologists". (McEwan Report - p12): As it has been recognised that there is high demand for and a shortage of psychologists in the NHS, any model of non-directive counselling/psychotherapy which includes components of relaxation and cognitive/behavioural restructuring could provide the necessary psychological support in pain management as shown in a number of studies.


Physiotherapy has been well established as a component of pain management and seems to the main physical therapy utilised in the chronic pain services.  Without diminishing its value, there are other evidence-based options immediately available to patients who have limited access to physiotherapy either because of time restrictions, presence of excessive pain rendering them unable to follow exercises, availability or any other reasons.

05 03

Email to Cross-party Group on Chronic Pain re possible solutions to McEwan Report’s recommendations


(Paulo) (SCOTLAND)

Following Prof McEwan's report, I enclose the attached document for distribution to Group members (if appropriate) to see if the Group would support - in principle - the use of counselling and massage for the management of chronic pain as alternatives to psychology and physiotherapy.


This is a subject we briefly discussed in one of the first meetings of the Group and, although there are a few issues that need to be resolved (such as regulation), it may go some way towards meeting patients' needs.


(The McEwan Report states that there is a lack of psychologists and physiotherapists in the NHS chronic pain service adding to long waiting lists: “Virtually all mainland health boards considered that they were inadequately staffed and that patients had a long wait to be seen and often a further long wait for treatment. - Current Services” -p9; “All services considered that they were inadequately staffed to meet the demands on their service.”  -  The Team and Staffing, p12; “With regard to outcome evaluation the contribution of complementary therapy, long-term outcomes, patient functioning and rehabilitation could usefully be included and linked to international research” - Recommendation 14; “The shortage of psychologists is a particular problem” - Recommendation 16)

04

The management of patients with chronic pain : a report of a working group of the national medical advisory committee


Currie J, (1994) The Management of Patients with Chronic Pain, Scottish Office, Edinburg


ISBN  0114952655


(SCOTLAND)

Chronic pain is a common phenomenon affecting large numbers of the population. It encompasses a wide variety of conditions ranging from migraine and low back pain to metastatic malignant disease.


The vast majority of patients presenting with chronic pain are cared for in general practice, but a significant number require referral to specialist services. The report gives an account of the definition, classification and management of chronic pain, describes existing arrangements in Scotland and makes recommendations for future developments.



04 07

McEwan Report


(SCOTLAND)

This review was carried out at the request of the Scottish Executive. In 1994 the Scottish Office had published “The Management of Patients with Chronic Pain” which gave “an account of the definition, classification, and management of chronic pain”, described “existing arrangements in Scotland”, and “made recommendations for future developments”.  The report showed that there was “an excellent basis upon which to build in Scotland in order to provide a service of high quality from the level of primary care to the specialist nationalist centre” 1 .

 

In 2000 the Clinical Standards Advisory Group published “Services for Patients with Pain”  2  which covered both acute and chronic pain and services for adults and children. With respect to chronic pain it produced a number of recommendations directed at those health authorities responsible for providing services as well as professional and other bodies concerned with policy, training, etc.

 

In 2002 the SPICE Report was prepared for the Parliament’s Health Committee and provided an overview of services in Scotland 3 . During the last session of the Scottish Parliament, the Cross-Party Group on Chronic Pain had been established with a wide membership and had argued for developments in services for chronic pain 4.

 

In the introduction to the 1994 Report, it was stated “Chronic pain management is probably one of the most challenging problems in medicine today.  Its origins, assessment and treatment are complex.


Chronic pain is a debilitating condition. Its prevalence is known to be widespread and it is a major claim on health care resources and the national economy”. In the note by the Scottish Office Home and Health Department “Health Boards are invited to decide what priority to give to these developments and the level of resources that they would wish to direct towards them”.


THE REMIT

 

To produce a report that:

 

•  Reviews referral protocols for the treatment of chronic pain;

•  Reviews the current range of services in each of the health boards for treating chronic pain;

•  Draws conclusions about the level of services for treating chronic pain across Scotland, compared to the recommendations made by the 1994 report by a working group of the National Medical Advisory Committee on the Management of Patients with Chronic Pain and the 2000 Clinical Standards Advisory Group Report on Services for Patients with Pain;

•  Makes recommendations on how to improve the level of service across Scotland.

 

It was considered that there was no need to repeat a “needs assessment” as this had been thoroughly covered in other fairly recent publications.  Similarly, as there had been detailed comparisons of individual health boards or trusts in recent publications such as Dr Foster in consultation with the Pain Society 5 , (see also note on limitations of data), it was decided to take advantage of the direct contact in this review to concentrate on the key issues affecting chronic pain in Scotland at present.

 

The review covers adult services for chronic pain, but will discuss links with acute pain and palliative care services. Comparison of the present position will be made with the findings of the 1994 Report and the recommendations made for further development.

04 05 05

Parliament Question - Mary Scanlon MSP to M Chisholm


(SCOTLAND)

To ask the Scottish Executive what support is being given to complementary medicine.


Answer: It is open to NHS boards to provide complementary medicine through the NHS in Scotland.

03 11 03

Parliament Question - Wendy Alexander MSP to M Chisholm


(SCOTLAND)

To ask the Scottish Executive what its policy is on use of, or referral to, complementary and alternative medicine practitioners by Gps.


Answer:  The Executive believes that Complementary and alternative medicine (CAM) may offer relief to some people suffering from a wide variety of conditions. A GP may refer a patient for CAM if, in his or her clinical judgement, it is appropriate. The GP remains responsible for the patient’s medical care.

03 01 13

British Medical Association (BMA) - Complementary & Alternative Medicine - submission to public petitions committee


CAM in NHS Scotland response

The BMA is supportive of those forms of complementary therapy for which evidence of claims of efficacy can be demonstrated. We favour those that also have independent regulatory systems in place. It would be premature to place obligations on health boards, statutory or otherwise, to integrate complementary therapies within the NHS in Scotland.


We acknowledge the lack of equitable provision throughout Scotland but we would argue that sufficient evidence of efficacy is not yet available to justify a comprehensive policy on provision. We are not aware of any statistics on the number of practitioners in the various CAM disciplines in Scotland; we submit that reliable and meaningful statistics would only be available where regulatory bodies existed. Extensive research into the safety and efficacy of various therapies is underway across the UK (and to our knowledge also in Scotland) and further afield.


Further research is needed but this should be considered in the context of what is currently being done internationally.

03 01 14

Parliament Question - Mary Scanlon to Mary Mulligan


(SCOTLAND)

To ask the Scottish Executive what evidence exists on the clinical and cost-effectiveness of complementary medicine.


Answer: The Department of Health maintains a National Research Register with details of all on-going and recent medical research, including research into complementary medicine.

03 01 14

Parliament Question - M Scanlon to Mary Mulligan


(SCOTLAND)

To ask the Scottish Executive whether any market research has been carried out to measure what percentage of the public are in favour of complementary medicine being made widely available on the NHS since the MORI poll in 1989, showing 74% of the public as in favour.


Answer: The Executive has not commissioned any such market research, and has not been made aware of any recent poll on the subject. There is no barrier to the provision of complementary medicine through the NHS in Scotland. Decisions on whether to provide any particular form of complementary medicine are for NHS boards to make, based on their assessment of local needs.

03

Adult Chronic Pain Management Services in the UK (2003)

This research, carried out by Dr Foster in consultation with the Pain Society, looks at the specialist chronic pain clinic services available in UK hospitals.


Chronic pain is one of the most significant causes of suffering in the UK


Despite evidence that chronic pain services are cost effective reducing the burden on the health service in many cases it is felt by questionnaire  respondents that the contribution of chronic pain services to patient care within  hospital Trusts is not recognised.


There is scope to improve availability of evidence-based techniques. Only 58% of all clinics currently offer outpatient Pain Management  Programmes despite evidence of efficacy. One third of clinics do not offer individual psychological therapy although there is evidence of efficacy. Most clinics offer TENs despite the fact that this is less well supported by evidence. Almost a third of responding clinics do not collect and audit outcome data for their service.

02 12 10

Parliament Question - M Scanlon to M Chisholm


(SCOTLAND)

To ask the Scottish Executive what consideration it is giving to reviewing the report Complementary Medicine and the National Health Service - An Examination of Acupuncture, Homeopathy, Chiropractic and Osteopathy of November 1996 and recommending the integration of complementary medicine in the NHS.


Answer: There are no current plans to review this report. It remains a matter for each NHS board or trust to make their own assessment of need for such therapies and provide resources, as appropriate.”

02 06 20

Minutes of the Cross-Party Group on chronic Pain -  Scottish Parliament (meeting of 20 June 2002) (Paulo)


(SCOTLAND)

Paulo Quadros: It is difficult to have enough therapists. The Health Minister Malcolm Chisholm knows about this as I have written to him concerning alternative based therapies in counselling, physiotherapy and massage.


In my experience most people [ion pain] have stress or conditions caused by stress. There is a need to put more and more of these centres together. The Possil Centre has 100% funding but in other cases GP's have to find funding for these services from other sources.


Rosemary Stowell:-The local clinic in the Cumbernauld and Kilsyth closed due to lack of funding and was overturned due to lack of campaigns.

Paulo Quadros: Has had similar experience of clinic closure.


Paulo Quadros: There is not a cohesive integrated way of assessing services. What is effective and what is

ineffective. It would be useful to have Centres of alternative medicine.

02 05 10

Parliament Question - Sylvia Jackson to M Chisholm

To ask the Scottish Executive what role alternative and complementary medicine have within the NHS.


Answer (Malcolm Cheaseholm): The Executive believes that complementaryor alternative therapies may offer relief to some people suffering from a wide variety of conditions.

There is no legislative bar to prevent practitioners of such therapies from offering their services, subject only to some general restrictions, such as those on prescribing and supplying medicines and giving injections. A GP or hospital clinician may refer a patient for alternative treatment, but would require to be satisfied of the value of the treatment and the competence of the practitioner, and would remain responsible for the patient's medical care.

02 02 27

Linda Fabiani MSP on chronic Pain and Complementary an alternative Medicine (and others)

(Scottish Parliament Official Report - Col 9759, 17:34)


(SCOTLAND)

Linda Fabiani (Central Scotland) (SNP): First, I thank everyone, headed up by Dorothy-Grace Elder, who has taken part in the debate on this issue in the three years since the Parliament was set up.


I apologise to everyone as I will have to leave early, just after my speech.


I am not an expert in the field, but I have listened to Dorothy-Grace Elder as she has persevered over the past couple of years, as Mary Scanlon said. I have learned with horror about the prevalence of chronic pain and about its many causes. From speaking to other people, I have learned that the cost of chronic pain to the national health service cannot be measured only in hard cash terms, because physical and sometimes emotional and mental illnesses can result from suffering chronic pain.


The social cost was mentioned by Elaine Smith and many others. I wonder whether we should take a much wider view of chronic pain, its causes—of course—and its effects. We should consider other ways of dealing with and managing it. For example, the Chartered Society of Physiotherapy is keen for workplace physiotherapy to be put in place. That could help people to manage their pain and remain in the employment market, which is what they want to do. It must be awful to have the will to carry on with life normally, as everyone else does, but to suffer chronic pain and be unable to do that.


I am keen that we take a step back and take a holistic approach. We should think about a bit of innovation. We should look at alternative therapy, complementary medicine and preventive strategies. Throughout the health service, we do not take enough account of the prevention of illness and place too much emphasis on curing illness.


Pain management programmes and a national framework and guidelines for the management of pain, whether in specialist pain clinics or existing resources, have been discussed. As I said, I am not an expert, but I contend that bodies such as the Chartered Society of Physiotherapy and the Pain Association Scotland, which Dorothy-Grace Elder mentioned, are experts. They are strong on considering such measures, which could have added benefits for the NHS in general, because no one talks about many conditions that cause chronic pain.


Many people suffer chronic pain from various illnesses that are never talked about and on which records are not held centrally, for example. I have asked the Executive about a condition called scleroderma, which is sometimes called systemic sclerosis. The Executive told me that it did not hold figures centrally on various aspects of the illness and that the illness is very rare. Many such illnesses might be rare, but to the people who suffer the illness and its resultant pain, it does not matter that the illness is rare. What matters is that no resources exist to help them. I feel strongly that a national pain strategy and centres could help to unearth some of the hidden illnesses and suffering in our society.


I pay tribute to the voluntary sector, which does a wonderful job all over our country in assisting the national health service and helping people to manage their day-to-day lives while they suffer chronic pain.

02 02 26

Scottish Parliament Information Centre (SPICe) Briefing


Report for the Scottish Parliament Health Committee


CHRONIC PAIN


This Briefing provides background information for the debate on 27 February in the name of Dorothy-Grace Elder on motion SIM-2597: Plight of Chronic Pain Patients. The briefing will consider the terms f the motion as well as draw attention to petition PE 374 and to hose written parliamentary questions answered on related issues.


The wording of the motion for debate is as follows:S1M-2597# Dorothy-Grace Elder: Plight of Chronic Pain Patients—That the Parliament considers that the Scottish Executive and health boards should move the plight of chronic pain patients up the health agenda, chronic pain being regarded as the most neglected health issue in Scotland and possibly the biggest.


Supported by: Mr Lloyd Quinan, Mr Adam Ingram, Mr Gil Paterson, Tommy Sheridan, Christine Grahame, Fiona Hyslop, Mr Kenny MacAskill, Tricia Marwick, Robert Brown, Michael Matheson, Nora Radcliffe, Mr John McAllion, Kay Ullrich, Ms Sandra White, Colin Campbell, Donald Gorrie, Alex Neil, Fiona McLeod, Mrs Margaret Ewing, Irene McGugan, Ms Margo MacDonald, Mary Scanlon, Dr Winnie Ewing, John Young, Elaine Smith, Mr Duncan Hamilton.


Petition PE 374

Received 11 June 2001, Petition PE 374 by Dr Steve Gilbert called for the Scottish Parliament 'to act urgently to investigate and redress the under funding of Chronic Pain Management Services, to debate the matter in Parliament and to urge the Minister for Health and Community Care and Health Boards to move chronic pain up the health agenda.'

01 06 30

Randomised trial of acupuncture compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck pain


BMJ 322 : 1574 doi: 10.1136/bmj.322.7302.1574

Piece of research mentioned in the Chronic Pain Briefing of 26/Feb/2002 (see above)


Design: Prospective, randomised, placebo controlled trial.


Conclusions: We conclude that acupuncture can be a safe form of treatment for patients with chronic neck pain if the objective is to obtain relief from pain related to motion and to improve cervical mobility. As neck pain may be a chronic condition with considerable socioeconomic impact single forms of treatment may be inadequate, and acupuncture merits consideration.

01 04 20

Letter from Susan Deacon (Minister for Health) and Malcolm Cheasholm )Deputy Minister) (Paulo)


(SCOTLAND)

Reply (by Malcolm Cheasholm - then Deputy Health Minister) to my letter and document regarding the integration of CAM into the NHS sent to Susan Deacon (then Health Minister) through Patricia Ferguson MSP.


a GP or hospital clinician  may refer  a patient  for  CAM treatment. The GP or hospital  clinician  would require to be satisfied  of  the  value  of  the  treatment  and  the  competence  of  the  practitioner,  and  would  remain responsible  for  the  patient's  medical  care.”

00 06 29

East End Independent (Paulo)


(SCOTLAND)

After successfully treating a GP for pain in his shoulders using Dynamic Release, he decided that many of his patients would benefit from this treatment as well.  Glasgow Health Board denied permission for this to happen and a campaign was started, led by the journalist Nuala Naughton then working at the East End Independent.


This is the article Nuala wrote for the East End Independent. which eventually led to the invitation to be a founder member of the Cross-party Group on Chronic Pain led by Dorothy-Grace Elder (then MSP).

00 03

Services for patients with pain: Report of a CSAG committee chaired by Professor Alastair Spence

Author: Department of Health


(Clinical Standards Advisory Group, HMSO)


Prepared by a research team led by Dr Gavin  Thoms of the University of Manchester

School of Epidemiology and Health Science, and Professor David Rowbotham of the

University of Leicester Department of Anaesthesia and Leicester Royal Infirmary.


2.18 Many people in the UK consult a complementary therapist, for various reasons including pain.

The six therapies that account for 75% of all consultations  are  acupuncture,  chiropractic,   osteopathy, homeopathy,  herbal  medicine  and  hypnotherapy  (Goldbeck-Wood,  1996).  Most  complementary therapy is provided outside the NHS.


Some  therapies have also been shown not to be effective; these include the use of transcutaneous  electrical nerve stimulation (TENS)


3.1  The  objectives  of  the  research  study  were  as  follows:

Chronic  and  acute  pain  services

To describe the organisation of pain services for NHS patients.

To  investigate  access  to  and  availability  of  pain  services  in  the  NHS.

To describe the range of treatments available in the NHS for acute and chronic pain.

To  assess  awareness  of  research  evidence,  and  guidelines,  and  clinical  effectiveness  information regarding  the  management  of  pain,  among  hospital  clinicians  and  those  in  general  practice.

To  collate  existing  relevant  guidelines  and  standards.

To describe quality of care delivered in primary and secondary care settings, and co identify critical  success  factors  associated  with  high  clinical  standards.


Chronic Pain Services

  • To  investigate  the  perceptions  of  users,  carers  and  the  public  regarding  services  provided  by  the NHS.
  • To  assess  need  for  further  training  of  health-care  professionals.


4.12  CSAGi  own  study  of  Clinical  Effectiveness   (1997)  has  hs   own  that  information  alone  is  not enough to change practice


Recommendations :


  • Encourage evaluation of complementary therapies and develop referral guidelines to ensure that funding is directed towards effective treatments.
  • Support research into the effectiveness of therapies, particularly those that may prevent acute pain becoming chronic pain
  • Develop evidence-based guidelines for some conditions and therapies.

00 01

Maniadakis Paper

This paper reports the results of a ‘cost-of-illness’ study of the socio-economic costs of back pain in the UK. It estimates the direct health care cost of back pain in 1998 to be £1632 million.


Approximately 35% of this cost relates to services provided in the private sector and thus is most likely paid for directly by patients and their families. With respect to the distribution of cost across different providers, 37% relates to care provided by physiotherapists and allied specialists, 31% is incurred in the hospital sector, 14% relates to primary care, 7% to medication, 6% to community care and 5% to radiology and imaging used for investigation purposes.


However, the direct cost of back pain is insignificant compared to the cost of informal care and the production losses related to it, which total £10668 million. Overall, back pain is one of the most costly conditions for which an economic analysis has been carried out in the UK and this is in line with findings in other countries.


Further research is needed to establish the cost-effectiveness of alternative back pain treatments, so as to minimise cost and maximise the health benefit from the resources used in this area.

98 05 28

Frank Dobson's speech


(Health Minister)

Sent with the reply to the letter to Tony Blair below.


Today's conference is entitled "Integrated Healthcare: A Way Forward for the Next Five Years".


What is very clear is that orthodox medicine has worked wonders.  New technology and new pharmaceutical products have made it possible to treat ailments which could not be treated in the past and to cure conditions which once were fatal. We may well be on the brink of huge breakthroughs which will save

the lives of millions.and transform the lives of tens of millions. I welcome that prospect and want to promote it.


But its equally clear that some people with some conditions do not respond to even the most modern orthodox treatment. It's also clear that some of these people can be and are being helped by forms of complementary and alternative medicine. This fact is reflected in the survey by Sheffield University which showed that 40 per

cent of GP practices in England were providing patients with access to complementary therapists.


The same rigorous standards must be applied right across the board.  And effective complementary and alternative therapies have nothing to fear from that.


The Health Technology Assessment Programme is currently commissioning research into acupuncture for the management of back pain in primary care.


An evaluation of GP prescribing of osteopathy and chiropractics should be completed in September. These should provide valuable pointers for the new Primary Care Groups when they are established.


People practising any form of medicine need to be regulated to protect the public and also to protect the reputation of the good practitioners. I believe that the only feasible system of regulation for the health

care professions is self-regulation. But it must be rigorous self-regulation and involve a lay element. That applies to complementary and alternative practitioners as well as orthodox practitioners.

98 08 05

Department of Health


(Reply to my letter to Tony Blair)

Thank you for your letter to Tony Blair dated 28 May 1998 about the setting up of an agency for complementary medicine.


As this section deals with complementary medicine your letter has been passed to me to reply and I am sorry for the delay in doing so.


You may be interested to know that an independent discussion paper on complementary medicine entitled "Integrated Healthcare - A Way Forward for the Next Five Years?" was published by a charity called the Foundation for Integrated Medicine in October last year.

98 06 24

Tony Blair

As the matter you raise is the responsibility  of the Department of Health,  he has asked that your  letter be forwarded  to that Department  so that they may reply to you direct on his behalf.

98 03 14

Integration of CAM into NHS


(Paulo)

Sent to Tony Blair and Donald Dewar following a comment that new extra funding was just enough to run the NHS for 3 days.  The same amount of money would be sufficient to run about 1000 agencies modelled on effective ‘stress centres’ which were operating within the Glasgow Health Board region (which also co-funded them).

97

Integrated healthcare:

a way forward for the next five years?

Published by The Foundation for Integrated Medicine on behalf of the Steering Committee for the Prince of Wale's Initiative on Integrated Medicine.


The document sets out a suggested programme of action in four priority areas: research and development, education and training, regulation of complementary medical practices, and delivery of integrated healthcare.

94

The Management of Patients with Chronic Pain -  

A report of a Working Group of the National Medical Advisory Committee.  


The Scottish Home and Health Department, HMSO Edinburgh


Published by the Scottish Office


(SCOTLAND)

“an account of the definition, classification, and management of chronic pain”, described “existing arrangements in Scotland”, and “made recommendations for future developments”.


The report showed that there was “an excellent basis upon which to build in Scotland in order to provide a service of high quality from the level of primary care to the specialist nationalist centre”.


- Timeline - 
CAM IN THE NHS.