Meeting: IPG Date: 3 rd September 2009 Item: 35/09 NORTH OF SCOTLAND PLANNING GROUP Pain Management Programmes Estimation of Potential Demand in Scotland Introduction The purpose of this paper is to provide the Regional Planning Chief Executives Sub Group with information on the potential demand for residential 1 Pain Management Programmes 2 in Scotland. However, given that the demand for residential places is interlinked with the demand for Outpatient Pain Management Programmes, the demand for both is investigated. The Sub Group requested this information to support them review the current situation, prior to giving consideration to the NSD position on whether the current arrangement, within the risk share arrangements, should continue in 2010 onwards. The paper builds upon previous information submitted to the group at the meeting, 21 st April 2009, which highlighted the provision of specialised chronic pain services provision across Scotland. Specialised chronic pain services include Pain Management Programmes, (PMP), Spinal Cord Stimulators, (SCS), and Intrathecal Drug Delivery, (IDD). Background In October 2008, Professor Tony Wells, Chief Executive, NHS Tayside, approached the National Services Division (NSD) about a potential application on residential pain services in Scotland to the National Services Advisory Group (NSAG). Mrs. Deirdre Evans, Director, NSD, replied that with the information available to her, it appeared that NHS Tayside were almost exclusively accessing services from the Royal National Hospital for Rheumatic Disease in Bath, more specifically, the residential PMP. Therefore there was a marked geographical imbalance of patients in Scotland accessing the specialist pain management service in Bath and clearly the uptake of this service was not national. It was suggested that NHS Tayside should engage with the North of Scotland Planning Group in the first instance to explore the gaps in the north region services. 1 There are two main reasons for the requirement of a residential place. The first is that the patient requires highly intensive services such as those delivered in Bath and only a residential place would suffice. The other is for logistical reasons, where it is decided that a patient would benefit from a PMP, however because of the distance and travel required to attend on a regular outpatient basis, for the period of time required, they are unable or unwilling to do so. 2 A Pain Management Programme is a formal structured cognitive behaviour intervention run by a multi-professional team with pain expertise. 1
The paper submitted on 21 st April 2009, identified the following; There is no residential PMP in Scotland. There is no Outpatient PMP in the north region. Specialised pain management services such as SCS and IDD are carried out in the three regions. A multi-disciplinary, Outpatient PMP is provided in Forth Valley, Edinburgh and intermittently in Fife. Glasgow provides an Outpatient PMP and has established a weekly satellite PMP at Inverclyde Royal Hospital. Overall the availability of, and access to, chronic pain services in general across Scotland is patchy and inconsistent. Further information on demand for PMP was requested by the Sub Group, to be reported back in the autumn. Estimating the Potential Demand for Pain Management Programmes It is established that there has been no residential PMP in Scotland for at least 15 years. Table 1 below provides information on uptake of the residential PMP in Bath and shows that most of the referrals for a residential PMP are from the north region and within that region most referrals are from NHS Tayside. Table 1: Bath Patient Activity 2005-2009 2005/06 2006/07 2007/08 2008/09 2009/10 New referrals 38 40 29 1 st attendances 60 94 61 Inpatient ordinary spells 33 34 OP Review 22 Post programme review Pain management programmes 3 week course -29 4 week course-1 Adolescent In-hospital course -2 3 week course-26 4 week course-3 Adolescent Young adult In-hospital course - 3 Pain management programme -20 (no further breakdown available) (Total 20*) Tayside -17 Grampian - 8 A & Arran- 2 Highland 1 Argyll & Clyde-1 Lanarkshire- 1 Lothian -1 Fife -1 Tayside -4 Grampian -2 A & Arran- - 2 Fife -2 Highland 2 Lothian -1 F Valley-1 (14 - to July 09) (Total 33*) (Total 34*) (Total 32) Total Activity cost 142,390 207,855 209,218 244,004 73,192** *Established that most of the referrals were from NHS Tayside, ** to date 2
The available information identified an average demand of approximately 36 patients per annum, from Scotland as a whole, accessing a residential PMP, which is a small number that, clinicians believe, underestimates demand In a paper provided by Dr. Martin Dunbar, Consultant Clinical Psychologist, Glasgow, he outlined a number of key reasons why he believes that using the numbers accessing Bath will result in underestimating demand. In particular; The greatest source of referrals is from the north region where pain services are underdeveloped. The GRIPS Report identified NHS Highland as having the poorest provision of pain services in Scotland and there are gaps in the multi-disciplinary pain teams in both Grampian and Tayside. Residential Pain Management Programmes may deter some patients who may be unwilling to travel and/or be away from family and friends for a period of time. There is evidence that over time referral rates have been increasing. Dr. Dunbar provided the referral rate to the Astley-Ainslie Hospital PMP to demonstrate the increasing rate of referrals, (Table 3), which shows an increase of approximately 33% over the period 2005-2008. It is anticipated that with the increased recognition and the potential development of the regional MCN for chronic pain, this trend is likely to continue. Table 3: Referral rate to the Astley-Ainslie PMP, 2005 to 2008 Period Numbers of Lothian patients referred 01/01/2005 31/12/2005 241 01/01/2006 31/12/2006 307 01/01/2007 31/12/2007 343 01/01/2008 31/12/2008 361 In an attempt to confirm that these figures were representative of demand across Scotland, further information about referral rates for the PMP was requested from the regions. It was found that in the north region, there was limited information available as they do not provide this service, though they refer patients for the PMP elsewhere in the UK. In the West region, the Glasgow service is a new and developing service put in place over the past year, therefore there is no trend data available, though they are aware of a rapid increase in referrals since establishing the service. On the basis that there was no suitable trend data available, the Astley-Ainslie Hospital figures were used as a proxy upon which to estimate the 3
likely demand for both outpatient and residential PMP in Scotland. Using the figures for the adult population in Scotland published by the General Registrar Office 2008, the potential annual demand in Scotland is approximately 2,255 referrals as shown in Table 4 below. Table 4: Estimated demand for PMP in Scotland % Population demand by Board/region Lothian baseline North Adult population 2008 Multiplied 0.053 Tayside 328524 174* Grampian 444541 236 Highland 255837 136 Orkney 16409 9 Shetland 17719 9 Western Isles 21676 11 Total 1084706 575 South and East Lothian 678413 360 Borders 92304 49 Fife 296787 157** Total 1067504 566 West Lanarkshire 454757 241 Ayrshire & Arran 302670 160 Dumfries & Galloway 123423 65 Forth Valley 235911 125 GG & C 985995 523 Total 2102756 1114 TOTAL 4254966 2255 GROS population published 2008 (Adult 16+years) *NHS Tayside does not include approximately 50,000 North East Fife population within their catchments area ** NHS Fife includes approximately 50,000 North East Fife population 50,000 population equates to a potential demand of 26 patients The potential demand in the north is assumed unmet need as there is no PMP. Travel is a major factor in the consideration of patients accessing a PMP. While an Outpatient PMP is established in Edinburgh, Forth Valley, and Glasgow and intermittently in Fife, ease of access remains a problem. As Dr. Dunbar has highlighted, there are travel issues even between hospitals in Glasgow, particularly for patients with more severe and complex chronic pain. Given the geography of the north, travel will be a particular problem for a number of these potential patients, particularly, though not specifically, in the Highland and Island Boards, which is likely to deter some patients from accessing a programme. Therefore some 4
patients would only be able to access a PMP if there was a residential place and clinicians strongly recommend that access to the residential PMP in Bath should continue. A larger number of patients would benefit from a local Outpatient PMP or Outpatient/satellite site service and it might be assumed that if the Outpatient/satellite site model was established in the north, the demand for residential programmes would reduce, as most of the uptake is from this region. However, access problems would remain an issue for some patients for reasons outlined above and therefore the demand for a residential PMP would continue. In Southampton, population 231000, there is a comprehensive pain management service with out-patient PMP available. The Southampton pain service refers 10 complex cases each year to Bath. Although there are difficulties in extrapolating this information to the Scottish context, it reinforces the need for Scottish patients to have access to a residential as well as out-patient PMP In the consideration of the establishment of a residential PMP in Scotland, the choice of location would be important, as travel would remain a particular issue. At one time there was a suggestion the Perth may be a potential location though the suggestion was never formally pursued. It would appear that no one site would be ideal for this particular population due to the distance, travel, family issues, etc. and there is a risk that a residential PMP would be of most benefit to the population located near the service, disadvantaging those who lived further away. Clinicians however, suggest that Edinburgh or Glasgow would be a suitable location for a residential PMP in view of excellent travel links. Summary The total demand for Pain Management Programmes in Scotland has been estimated. Some of this demand is already being met by local out-patient PMPs. Referral patterns to the residential PMP in Bath are consistent, underestimate the true demand, are low in volume but high in cost per patient. Referrals to this PMP from other Boards in Scotland are growing due to increasing awareness. It is anticipated that access to the residential PMP in Bath will continue to be required, and potentially escalate until there is improved access to out-patient and residential Pain Management Programmes in Scotland. 5