04e SCHEDULE 2 THE SERVICES A. Service Specifications This is a non-mandatory model template for local population. Commissioners may retain the structure below, or may determine their own in accordance with the NHS Standard Contract Technical Guidance. Service Specification No. Service Commissioner Lead Provider Lead Period Date of Review Community Chronic Pain Management Service 1. Population Needs 1.1 National context The British Pain Society National Audit 1 (November 2011) describes pain as a complex bio psychosocial experience. Pain that persists longer than expected can be difficult to accept and to treat. Most people are able to manage their pain effectively; some require referral to specialist pain services. The definition of a specialist pain service for the purpose of coding in the UK is described as the diagnosis and management of complex pain disorders, requiring a multidisciplinary approach. The British Society National Pain Audit estimated prevalence of chronic pain at 6.4%, annual incidence of 8.3% and annual recovery of 5.4%. Research evidence and the resultant policy guidance that has emerged in the last 30 years for pain services in the UK have clearly indicated that the most effective approach for pain services is multidisciplinary working. 1.2 Local context Ealing Joint Strategic Needs Assessment 2 projected that White ethnic group population is expected to have a small drop in numbers between 2010 and 2025 (from 167,000 to 163,900), but would then rise again to 2010 levels by 2040. For all other ethnicities the projections show a steady rise in numbers over the 30 years period: Asian/Asian British by 41%, Black/Black British by 49%, Chinese by 38% and population of other ethnic origin by 87%. It is estimated that by 2020 there will be a 19.5% rise in the number of people over 65 years of age, and a 48% rise in the number of people over 85 in Ealing. The population is very diverse with a steady rise projected for BAME groups at 52% 3. The prevalence of musculoskeletal disorders rises with age, and is higher in women than men at all ages. One-third of the population over 75 will have a chronic musculoskeletal 1 https://www.britishpainsociety.org/mediacentre/news/national-pain-audit-final-reportnovember-2011/ 2 https://www.ealing.gov.uk/downloads/download/1018/ealing_joint_strategic_needs_assessment 3 https://www.healthiernorthwestlondon.nhs.uk/sites/nhsnwlondon/files/documents/nwl_stp_october 1
problem. The long term musculoskeletal can be divided into three exemplar areas to allow local planning for primary and secondary prevention. Ealing CCG currently does not have community chronic management service which is a known gap and highlighted in the Ealing Joint Strategic Needs Assessment (JSNA) 2017. In addition, both Ealing and Northwick Park hospitals do not have a chronic pain management service, therefore, Ealing patients are referred to Imperial, Hillingdon and Chelsea & Westminster hospitals. Table 1: The burden of musculoskeletal disorders in Ealing, 2017 Exemplars Specific Conditions Available metrics Ealing Estimate (Rounded) Painful musculoskeletal 1.3 Evidence base All musculoskeletal Low back pain Hip and knee osteoarthritis Admissions for Falls age >55 ONS Sickness absence (All MSk Conditions) (Days lost) Incapacity and ESA benefit claims (all MSk ) ARUK Online Musculoskeletal Calculator, accessed August 2017 HSE Labour Force Survey: Self-report work related back pain 2015/16 Incapacity and ESA benefit claims (Back Pain) Units 210,000 Working days lost per year 1,400 People 16-64 55,000 People 13,800 People 16-64 500 People 16-64 ARUK Online 31,100 People Musculoskeletal Calculator, accessed August 2017 SUS Data 500 People Ealing residents falls data summary 2016/17 1,300 People 65+ The evidence base considered includes: - NICE Guidance [CG177], Osteoarthritis; the Care & Management of Osteoarthritis in Adults. Feb 2014 - NICE Guidance, Rheumatoid Arthritis; the Management of Rheumatoid Arthritis in Adults. Feb 2009 - National Service Frameworks where applicable (Long Term Conditions, Older People) - Care Quality Commission Core Standards - The Chartered Society of Physiotherapy Core Standards and Service Standards - Evidence suggests that a service that can provide quick access and effective treatments can improve patient outcomes and avoid patient from becoming chronic 4 - There is also evidence nationally that prior to MSK triage services being introduced, up to 70% of all secondary care orthopaedic referrals were inappropriate 5 4 Department of Health 2006. The Musculoskeletal Services Framework A Joint Responsibility: Doing it differently (England). 5 NHS Institute for Innovation and Improvement 2009. Delivering Quality and Value Focus On: Musculoskeletal Interface Services (England 2
2. Outcomes 2.1 NHS Outcome Framework Domains & Indicators: Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with long-term Domain 3 Helping people to recover from episodes of ill-health or following injury Domain 4 Ensuring people have a positive experience of care Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm 2.2 Local defined outcomes - Improvement in patients functioning and quality of life. - Improvement in patients pain (less certain). - Patients would be supported to effectively self-manage their condition. - Reduction in the amount of medication use or more effective use of medication. - Reduction in the need for patients to access specialist secondary care pain services. - Reduction in healthcare utilisation e.g. GP and consultants appointments and further scans. 3. Scope 3.1 Aims and objectives of service The service will provide a community based pain management service that: - Offer assessment and treatment to individual patients with musculoskeletal chronic pain using a bio-psychosocial approach and provide advice on medication and medical interventions. - Provide an exit strategy for revolving door patients that are repeatedly referred to community physiotherapy and interface clinics with no substantive improvement in their symptoms. - Complement secondary care services and it would include a multidisciplinary and combined physical and psychological treatments. - Educate and support other healthcare professionals in the early intervention of pain management techniques and encourage collaborative working with of psychological and mental health services. 3.2 Service description The provision of community based multidisciplinary pain management service, which may be consultant-led or receive consultant input, offering medication, assessment and treatments appropriate for individual patients. This service will work as a component part of MSK services and will provide: - Provide MDT approach to chronic MSK pain management within the service - Provide bio-psychosocial assessment to patients referred with chronic pain. - Provide pain assessment and care planning with patients. - Use shared decision making to deliver support and programmes to patients living with chronic pain to enable them to understand and come to terms with their pain. - Manage less complex cases and provide earlier access to treatment. - Refer to secondary care where appropriate. It is expected that a proportion of patients will be referred to hospital care for specialist interventions, in accordance with NICE guidelines and interventional procedure reviews, and North West London CCGs PPwT and Low Back Pain policies. 3
- Supported self-management and sign posting patients to self-help resources and support groups - Combine Physical and Psychological (CBT-approach) interventions; The Provider will need to integrate with specialist pain management services in hospital to facilitate direct referrals for specialist interventions. Referrals to hospital pain services may include patients who have failed initial therapies, those with high Opioid demands and those requiring specialist diagnostic procedures and interventions. 3.3 Referrals - The service will be accessed via the Single Point of Access. 3.4 Response Times Receipt of referral at SPA to treatment Routine Within 4 weeks 3.5 Population covered - Patients registered with an Ealing GP practice, and residing (temporarily or permanently) within 1 mile from the boundaries of Ealing who are eligible to receive NHS care - Patients who reside within the boundaries of Ealing who are not registered to a GP 3.6 Exclusion criteria including Red Flags - Any patient residing outside of the Borough of Ealing who is not registered with an Ealing GP practice. - Patients with an MSk condition that has not been assessed by MSk service - Known pathology requiring further investigation. - Suspected cancer or cancer related pain. - Palliative pain. - Complex regional pain syndrome. - Post-operative or post traumatic complications. - Suspected Fracture/Infection. - Cauda Equina Syndrome or other condition requiring emergency treatment. - Patients receiving care from another pain management service. - Patients requiring a surgical opinion. 3.7 Interdependences with other services/providers: Referral sources - Patients clinically triaged via the Single Point of Access as requiring community pain services, or as identified following assessment by MSK services Interdependencies - This service will work and form a component part of community MSK services - Interface with other community health services, such as: diagnostic providers, podiatry service, community psychological therapy services, dietary services and exercise on prescription. - At point of referral, the provider is to ensure that where necessary, imaging services shall be available for patients referred to imaging. - Referral Management Service - GPs - Diagnostic services 4
- Acute/secondary care - Tissue Viability Service - Practice Nurses - Bio-mechanical podiatry - Dietetics - West London Mental Health Trust - Community Occupational Therapy Services - Local Authority and Re-ablement 4. Applicable Service Standards 4.1 Applicable national standards (e.g. NICE): - NICE Guideline, Low Back Pain and Sciatica (2016) - NICE Pathway Musculoskeletal 6 5. Applicable quality requirements and CQUIN goals 5.1 Applicable Quality Requirements (See Schedule 4A-C) Not applicable 6. Self-Care and Patient/Carer Information Patient self-care must be promoted through education and supported self-management plans. A variety of tools and techniques should be utilised to support patients in understanding their, what the treatment plan may be and that they are involved along the pathway of care. A specific focus on patient support and care planning for patients with long term is essential. On discharge from the Service, patients should receive care-planning support, supported by a self-management care plan. This will describe the patient s self-care action plan and a copy will be held by the patient, the GP as well as the Service. The care plan should be developed jointly with a patient, respecting the specialist opinion and advice, and be inclusive of maintenance, exercise and other relevant advice (e.g. diet advice). More complex patient s care plans may be uploaded on to a shared care record system with access by secondary care with the consent of patients. 7. Location of Provider Premises Within the London Borough of Ealing 6 https://www.nice.org.uk/guidance/-and-diseases/musculoskeletal- 5