|Pain management services have suffered from a historical failure of full integration within hospital management systems, leaving them with a heritage of poor resources. This has had a negative effect on service development. Effective organisation and management at all levels is vital if a modern, efficient and cost-effective service is to be provided. Crucial to this is the realisation that medical personnel (who are most likely to have the vision, understanding, expertise and influence to develop services) should have dedicated time for such non-clinical aspects.
Pain clinics were developed because it was appreciated that there were certain individuals who experienced persistent pain who might benefit from injection techniques provided by anaesthetists. The needs of the service were simple: an outpatient room for one session a week, access to an operating theatre to perform nerve blocks and some secretarial support for booking clinics and typing letters.
The needs of a modern pain management centre are vastly different. They may employ over a dozen staff of different disciplines, and the service may interact with many hospital departments, primary care organisations and external agencies. If an effective efficient service is to be maintained, good organisation is paramount. Unfortunately, the heritage of single-handed specialist clinics treating a small but complex group of patients has not attracted the policy support within the NHS that it requires. The Clinical Standards Advisory Group reports that pain services suffer from poor integration and logistical support in the organisations in which they function. If pain services are to play the crucial role that they should in the management of chronic illness and symptom management, their integration and organisation must be properly financed and supported.
The International Association for the Study of Pain has published terminology for the various levels of service and organisation offered by pain services. These range from single modality clinics offering acupuncture or medication treatment, to interdisciplinary pain management centres offering a range of invasive procedures, cognitive behavioural rehabilitation and teaching and training. There are few such centres in the UK. Many services are called pain clinics, although some centres, especially if acute pain treatment is integrated, prefer the term ‘pain service’. The term ‘pain management centre’ should be reserved for facilities offering a complete range of treatment options, including research and training.
Effective pain management requires an interdisciplinary team (Figure 1). Many small units are forced to manage with a few consultant sessions and some nursing support, but most aspire to a larger team, including dedicated psychology and physiotherapy staff. However, it is uncommon for such appointments to be assigned to the same management structure as the medical staff. This perpetuates one of the main problems of personnel management within the NHS; that a team seldom has a unified management structure.
Given that the purpose of a pain service can be clearly defined, and that it comprises a highly self-motivated group of individuals with clearly defined roles and purpose within the larger organisation, management theory suggests that a single management structure is logical and would produce the most efficient use of resources. Such a system would require a full-time professional as the head of the service (not necessarily a doctor), with line management responsibility for the team. Part-time members should be responsible to the head of service for the part of the week that they work in the service. Administration and clerical staff should be included under the management umbrella. Such a structure favours the high level of communication and common sense of purpose required for the interdisciplinary management of patients with pain and can best implement quality management strategies.
Alas, in the NHS it is usual to find that there is no one in effective charge; the consultant, who takes clinical responsibility, has no managerial control; and all the therapy and nursing staff have their own line management, often through individuals who understand little of the aims and purpose of the service. Whatever the structure, the importance of a good secretary and office manager cannot be overemphasised. Resources must also be provided for audit and data collection. Far too often, this is seen as a luxury and is left inadequately resourced.
The job plans of consultants taking an organisational role must allow for sufficient unassigned time for developing the service effectively. This often clashes with the short-term pressures on the service relating to reducing waiting times and increasing patient throughput.
Pain services do not sit easily within the clinical directorate system of modern Trusts. In the UK, most consultants with responsibility for the treatment of chronic pain are anaesthetists. While it is logical for acute pain services to be closely linked to perioperative services or anaesthesia, this is less true for chronic pain management. This poses problems that do not have simple solutions. The anaesthetic link allows for understanding of the difficult balance specialists in pain medicine have to make between the demands on their time (on-call duties, audit, clinical meetings, continuing professional development) and allows for better rostering of junior staff. Set against this are the different clinical commitments of specialist physicians (e.g. neurologists) and the implications this has for their working week. There are advantages for the specialist in pain medicine to be seen as a physician, rather than an anaesthetist let loose from the operating theatre for an hour or two. The author thinks that the continued link with the anaesthetic department has had a detrimental effect on the development of effective pain management services.
The ideal structure is one in which the needs of the service and the demands of the patients are best served; alas, this is not always achieved in the modern NHS Trust. For all but the smallest clinics, a dedicated pain services manager should be appointed. Typically, this role will be the main link between central hospital management and the clinical service. A good, committed middle manager who understands the peculiarities of Trust management, and can support the service within it, is invaluable. It is crucial that close links are fostered between other departments in the hospital, particularly rheumatology, orthopaedics and cancer management. Effective interactions might involve joint clinics and the development of common algorithms or clinical-care pathways.
Within the health system
With increasing understanding of the significant burden posed by chronic pain on the healthcare system, there will be a gradual diversion of funds to chronic illness management. At the moment this is directed to disease-based problems (e.g. diabetes, asthma, arthritis) but there is an awareness of the contribution that less poorly categorised pain states make to the toll of disability and unhappiness that affects one person in five in the UK. Pain management services have an important role in the treatment of these conditions, but are often unexploited due to poor local resources, failure of integration of clinical services or poor communication with commissioning bodies such as Strategic Health Authorities and Primary Care Trusts.
Pain clinicians appreciate the biopsychosocial dimensions of chronic illness and are increasingly familiar with rehabilitation models in the form of pain management programmes. This makes them better placed than other hospital services (orthopaedics or rheumatology) to offer effective strategic planning advice as to how secondary care can link with primary care and community-based providers to improve access to appropriate early interventions. Most pain clinicians have ideas about how their local service could be developed, with appropriate triage systems using readily available clinical algorithms, staffed by trained therapists and supported by a range of medical staff. Alas, most services never discuss these issues with their local key decision makers.
In the few places where services have turned their focus to the community, the demand is for cognitive behavioural approaches aimed at enhancing self-management and restoration of function. In this context, the pain service may be providing education, training, support and leadership as much as clinical treatment of individual patients.
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