Developing a new service for people with chronic pain
12% of people in the UK live with high impact chronic pain that disrupts their daily life. Understanding what is needed to help and providing the right support can be hard.
Frequently people living with chronic pain also experience anxiety and depression. Associated fatigue and reduced motivation can make it harder for them to manage everyday work, but also to engage with activities that might help with their pain and improve their mental wellbeing. Although analgesics can offer short-term pain relief, they are less effective for people living with long term pain. They can also have debilitating side-effects, be addictive and make pain feel worse through pain sensitisation.
There’s a limit to what can be achieved in a short GP consultation - so what more can we do?
One option is to refer people to specialist care and pain clinics. But these clinics can have long waiting lists and once a patient has been seen, they often come back to general practice with the same, or potentially worse symptoms 1-2 years later…
We know from previous work that the use of behavioural activation techniques by GPs can help patients engage in making positive changes. For example, to balance their burdens (e.g., stress at work) against more positive, driving forces in their daily lives (e.g., time with children/hobbies). The WISDOM course has examples of how GPs could apply these techniques in practice.
However, patients in chronic pain, often need more than a brief intervention. They need ongoing support to help them understand, try out and so learn from behavioural activation techniques. GPs often lack the capacity to follow through this approach, so could support be provided by other professionals in the extended general practice team?
Could occupational therapists (OTs) within primary care networks (PCN) provide the key?
In North Staffordshire a team decided to find out...
Drawing on research evidence and the expertise of their team, a group of OTs working in the Leek and Biddulph PCN set up a new service to support patients with chronic pain, fatigue and mental health problems. Moving beyond the traditional role of OTs, making an assessment for equipment to help patients improve their functioning and independence, the team offer wider support, tailored to individuals over time. See the flowchart opposite for examples of their intervention. Click on the image to enlarge...
With a current wait time of less than a month for review and the personalised care approach over time, the new service has provided clinicians with a valuable resource to support struggling chronic pain patients. Feedback from patients has been positive:
“I feel supported, understood, accepted…. This has greatly improved my lifestyle.”
“…this service has changed my life in a very positive way and has given me a tool kit and a pathway forward to be healthier, happier and back in control.”
Where does WiseGP fit in?
This new service is a key example of knowledge work in action!
WiseGP are aiming to highlight and support this distinct work beyond guidelines which enables the innovation required to sustain general practice for the future.
If you wanted to implement a system in your PCN to help patients with chronic pain, following knowledge work steps (explore, explain, evaluate) would help you develop the required knowledge-in-context to shape the service design for your specific PCN. See the steps followed in this example opposite. Click on the image to enlarge.
What did the team learn from developing this new service?
Supportive management was valued by the OTs, with the PCN lead supporting a bottom-up led approach to service development, taking advantage of the experience of those involved.
There were certain challenges. Some clinicians were frustrated after their referrals were rejected due to being inappropriate, whilst others didn’t feel a referral form should be needed to access a service within the same PCN - they felt this added unnecessary work.
This suggests there were some gaps in the knowledge work underpinning establishment of the service- some clinicians lacked a shared understanding of who could access the service and what would be delivered. In response, further training to explain the role of OTs and the new service was delivered to clinicians, whilst the referral form was simplified.
Is a bottom-up led approach the solution?
GPs don’t passively follow guidelines and pathways. They do skilled and complex (knowledge) work to convert simple guidelines into a nuanced understanding of practice better suited to their local context and population. This work has been described as the generation of “mindlines”.
As described in a WiseGP blog on mindlines, research summarised in guidelines is an important form of knowledge for practice – but is also insufficient. We need to redesign practice to recognise and enable local knowledge generation as a crucial part of everyday professional practice, supporting a bottom-up led approach (as described by the PCN lead in this case), to help clinicians address the real-world challenges faced.
Could you take a WiseGP approach to tailoring a service for people with chronic pain, fatigue and mood problems in your PCN?
How are you utilising the expertise of new PCN staff?
We’d love to hear from you at WiseGP!
Thank you to Vicky Jones (First Contact Practitioner Occupational Therapist) and Dr Neil Briscoe (Clinical Director of the Leek and Biddulph PCN) for providing information for this Wise General Practice story.