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NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - AUTUMN 2005
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FROM THE EDITOR
world to attend this IASP congress but Ican’t wait to jet off to the next one in threeyears, I wonder where that is going to be….??Finally, it is now three years since I became Editor of Threshold and, much as Ihave enjoyed producing this little treasure,I feel it is time to hand over to anenthusiastic new Editor. I hope to beannouncing the identity of the new Editor at the meeting on Friday 11th November. If you would like to be considered, feel freeto drop me a line.Many thanks for reading Threshold over the last three years and I’m looking forwardto an NBPA meeting without writingfuriously and pestering people for their  photograph.In the meantime my contact details are below:-Dr. Colin P. RaeConsultant in Anaesthesia and PainManagement,Department of Anaesthesia,Stobhill Hospital,133, Balornock Road,Glasgow.G21 3UWTel. No. 0141 201 3005Fax. No. 0141 201 4167Email colin.rae@northglasgow.scot.nhs.uk Website www.nbpa.ac.uk 
REPORT FROM ANNUALGENERAL MEETINGFriday 6th May 2005
The Annual General Meeting wasattended by 63 members. In the Chairman’sreport, Dr. Nicola Stuckey outlined theactivities of the previous year. Both theSpring Scientific Meeting “Needles andPins” and the Winter Scientific Meeting“Pain in the Brain” were very successful.The McEwen report had been published andCouncil were involved in taking thisforward. There had been a draft documentcirculated from NHS QIS Scotland onchronic pain management which was under review.Dr Janet Braidwood gave the treasurersreport. Since she had been in office therehad been a great increase in expenditure,as she does like to shop(only joking). Themain expenditure had been items includingT-shirts, pens and prizes for the highlysuccessful NBPA stall at the Pain Societymeeting in Edinburgh. The stall had resultedin the recruitment of 18 new members.Due to a change in charities law there isa possibility that the society’s accounts willWelcome to Threshold, the newsletter of the North British Pain Association. I wouldlike to thank Napp pharmaceuticals onceagain for their support without whichThreshold would not be possible. Thissummer there have been manydevelopments in pain management at botha local and national level. We have the ear of the Health Minister (and we’re not givingit back until he helps us) and are possiblycloser than ever before to developing anational strategy for chronic pain. There has been a consensus conference to discuss theMcEwen report at which there was greatconsensus amongst everyone present apartfrom the Deputy Chief Medical Officer, Dr.Aileen Keil. The Kerr report has also been published. There is much talk of managedclinical networks, community health partnerships, integrating primary andsecondary care, the role of the voluntarysector and patient centred management. It’s just as well you can rely on Threshold totranslate all this management lingo for you- so read on.The main meeting of the summer wasthe IASP Congress in Sydney, Australia. Iam indebted to Jonathan McGhie, Specialistregistrar in anaesthetics from Glasgow, whoacted as Threshold roving reporter and hassubmitted a summary of the goings on. Iam afraid I was unable to travel round theneed to be externally audited and Dr.Braidwood was going to investigate this.Five positions on council have becomevacant due to the retirement of Kath Smith,Mhoira Lheng, Lyndia Greene, Anne Kellyand Professor Danny McQueen. Dr. SueFleetwood-Walker has been appointed thenew basic sciences representative. She will be known to many of you already and has presented at a previous NBPA meeting.Dr. Martin Dunbar (Glasgow) was votedin as new psychology representative, JudithLaird (Dundee) as nursing representativeand John McLellan (Edinburgh) as physiotherapy representative.Congratulations to all of them. New Northof England and Palliative Carerepresentatives have yet to be appointed.Winners of the prize raffle from the NBPA stall at the Pain Society meeting inEdinburgh were Sharon Dolan who won£70 worth of book tokens and Shona Yatesand Kate Scullion who received USB sticks. No entries had been received for the prize essay competition and this matter will be under discussion at forthcoming councilmeetings.
 Drs. Gavin Gordon, Ruhy Parrisand Mick Serpell  Dr. Mike Basler, IT whiz kid  Phil Sizer of Pain Association Scotland, Heather Wallace of Pain Concernand Colin Rae, Threshold Editor 
 
REPORT FROM SPRINGSCIENTIFIC MEETINGFriday 6th May 2005“The McEwen Report– The Way Forward”
Dr. Ruhy Parris chaired the morningsession.
Dr. Nicola Stuckey
started thesession with a summary of the
16recommendations of the McEwenreport
. Due to lack of space, these can be found on the NBPA website.
Dr. Mick Serpell
, from Glasgow,followed Nicola with
“The 10 PointPlan”
, reporting an action plan for Scotland which had been formulated bya Working Party on Pain consisting of members from pain medicine,rheumatology, pharmacy, QualityImprovement Scotland (QIS), PainAssociation Scotland (PAS) and primarycare. The 10 action points are as follows:-1.There should be full commitment tothe declaration that pain relief is ahuman right. (WHO, Geneva, 11October 2004)2.The social and financial impact of chronic pain needs to be recognisedand the necessary resources for effective management should be ahigh priority on the health agenda for Scotland.3.Health Service providers andcommissioners should implementintegrated care pathways for chronic pain, which involve community, primary and secondary care.4.Education in the management of painshould form part of the corecurriculum for doctors, nurses, alliedand other health care professionals.5.Health service providers andcommissioners should make acommitment to provision of trainingin pain management for all healthcare professionals.6.To improve services for people withchronic pain the NHS should work with the voluntary sector.7.Management of chronic pain should be patient-centred in partnership withhealthcare professionals.8.People in all geographical areasshould have equality of access toappropriate services for themanagement of their pain.9.Evidence-based pain management and best clinical practice should be usedand audited by the healthcare providers.10.Research into pain managementshould be promoted and conducted tofill the current evidence gaps.These action points fit in well with therecommendations of the McEwen report.
Dr. Gavin Gordon, ConsultantAnaesthetist
from Glasgow gave the nexttalk of the day on
‘Managed ClinicalNetworks’
.Dr. Gordon is a keen Aberdeensupporter and he started by looking back on a glorious year for the Dons – 1983.Quite how he managed to link this in to atalk on Managed Clinical Networks Ican’t remember. He recounted theGlasgow experience. Glasgow has a population of 866,000 and has over 20medical chronic pain sessions with somenursing, physiotherapy and psychologyinput. The Victoria Infirmary areacatchment borders Lanarkshire.Lanarkshire has a population of 533, 000and only has 3 medical sessions for chronic pain. It is this type of geographical inequality that it is hopedManaged Clinical Networks will address.A Managed Clinical Network(MCN) isa way of working. The model should bedeveloped by a partnership of patients,clinicians and managers and thereforeshould be effective in delivering care ina local context. A MCN focuses on adisease or condition. The purpose of aMCN is to improve patient care byimproving access, quality and co-ordination. Work undertaken is evidence based, outcomes are measured and anannual report is produced. Networks aremultiprofessional with patientinvolvement.What would the advantages of a MCNfor pain management services? At present,there is little co-ordination of staff  between primary, secondary and tertiarycare. There is a lack of clarity of roles.Referral patterns to secondary care painclinics are haphazard depending onindividual General Practitioners andclinic guidelines. There is a lack of evidence base for many of the treatmentsused in a pain clinic and concerns aboutthe use of resources.Several MCNs have already beendeveloped in Scotland, the mostcomprehensive being diabetes, stroke andischaemic heart disease. Others include palliative care, epilepsy and vascular services.While MCNs are not a directmechanism for increasing your budget,they are a mechanism for implementingstandards (SIGN, NQIS) and they do fitin neatly with the recommendations of McEwan. Downsides to MCNs are manytime consuming meetings, difficulties inengaging primary care and potentialfriction between specialists andgeneralists. NBPA President,
Dr. Nicola Stuckey
then spoke on
“The McEwen Report onChronic Pain services in Scotland – apsychological perspective”
.Eight of the mainland boards havededicated psychologists in their painservices. Lothian has the highest number. No other board is near the 1994recommendation of 1 whole timeequivalent psychologist per 200,000 of the population.Professor McEwen recognised thecomplex case-mix in chronic pain and theimportance of ensuring appropriate staff and resources are available. Herecommended that pain management programmes should be provided by eachhealth board and that training andemployment of generic pain professionalsshould be examined.There is a national shortage of staff inall areas of psychology but funding issuesrather than recruitment difficulties isoften the problem. Current postgraduatetrainees are keen to do placements inchronic pain which may help recruitmentin the future.317 clinical and applied psychologistswork in Scotland. There are 61 places inScotland for postgraduate training in psychology.Of people with chronic pain attendingthe pain management programme, 25%were moderately depressed and 22%severely depressed. 47% had a mediumto high fear of harm and damage fromactivity with 66% requiring individualwork rather than a group PMP.There were high levels of suicidalideation, post traumatic stress disorder, previous sexual and physical abuse,relationship and family breakdown,driven behaviour, heightened anxiety andanger control issues. Nicola concluded that all boardsshould provide adequate psychologycoverage for their population.Appropriate triage of patients shouldoccur which will require significant psychological input. Research skillsshould be encouraged to provide a clear evidence base for psychologicaltreatment.
 Dr. Nicola Stuckey and Professor Ian Power 
The next talk was given by yours trulyand was titled
“The Integration of Primary and Secondary Care for theManagement of Chronic Pain”
.Many of the themes had been coveredin previous talks. The merits of primaryand secondary care were contrasted anda case history involving Granpaw Broongetting the shingles used to illustratesome of the deficiencies incommunication between these two
 Dorothy Grace Elder addresses the meeting 
 
settings. This nicely highlighted thefragmented journey the averageindividual with chronic pain has throughthe current healthcare system.Other chronic illnesses includingdiabetes and depression have moved to amore integrated service and devolved alarge proportion of management to primary care via the development of aMCN.The afternoon session was chaired byDr. Bill MacRae and was divided in tofive lectures.The first lecture,
‘NHS QIS – Whatwe do’
, was given by
Jan Warner
,Director of Performance Assessment andPractice Development, NHS QIS. NHS Quality Improvement Scotlandwas established in 2003 by the merger of six organisations. They work closely withthe Scottish Medicines Consortium andthe Scottish Health Council.The aim of NHS QIS is to improve thequality of healthcare in Scotland bysetting standards, then reviewing andmonitoring performance against thesestandards.Twenty five sets of standards have been finalised to date. Most have beencondition or service specific.Performance assessment is a large part of QIS work.A Best Practice statement for ChronicPain had been undertaken in 2005. Therehad been a wide consultation process andthe draft document had attracted manycomments. There followed a wide rangingdebate on the role of the QIS document,the consultation process, it’s relevance tothe multidisciplinary nature of chronic pain management and whether it would be used as a standards document.There followed two talks fromrepresentatives from the voluntary sector.
Heather Wallace
from Pain Concerngave a talk on
‘The Role of the VoluntarySector’
. She outlined the work of PainConcern. They provide a listening ear through the Pain Concern telephonehelpline and via email correspondence totry and break the isolation of manychronic pain sufferers. They provideinformation leaflets on a variety of chronic pain topics and also publish amagazine ‘Pain Matters’.Pain Concern campaigns in the media,working with journalists, providingarticles for health columns and there iseven to be a chronic pain story line in asoap opera! They are active on the CrossParty Working Group for chronic pain atthe Scottish Parliament and also atWestminster.
Phil Sizer
from Pain AssociationScotland (PAS) gave the next talk titled
‘Who we are. What we Do’
. PAS issixteen years old. It is a charity that provides community based self-management training and support for  people with chronic pain regardless of thediagnosis. They are professionally led andfocus on dealing with the impact of painon an individual and their family. Theyuse a biopsychosocial model.Many topics are covered within thestandard PAS programme and outcomesare monitored with a coping strategieschart and a variety of validatedquestionnaires. Patients come to PASfrom pain clinics, primary care, self referral and from training days. PAS has been involved in setting up the West FifePrimary Care Pain Pilot Project which has produced encouraging results.Phil summarised the role of PAS as toimprove coping skills and understandingof chronic pain, improve quality of lifedespite pain and to enable the transitionfrom clinical to a community basedapproach.to the geographical area in question and,liaising with the pain teams in that area,deliver a PMP to a pre-selected group of  patients. There would be a varying degreeof involvement by the local team. Theidea had been explored in Tayside andGlasgow but so far there were no firmoffers on the table. The concept created agood deal of interest amongst theaudience.The final talk was given by
ProfessorIan Power
from Edinburgh. He had beenasked to talk on
The integration of PainMedicine
. He had taken part in a debateat the Pain Society meeting inBournemouth in 2002 titled ‘This HouseBelieves that Acute and Chronic Painteams should merge’. Professor Power  believes that acute, chronic and cancer  pain share common mechanisms and thatthere should be a merger of thesespecialties.Professor Power was heavily involvedwith the Faculty of Pain Medicine inAustralia. He is very aware of the benefitsand recognition that formation of a painfaculty had brought to the specialty.A recent exciting development in theUK is the appointment of Regional PainAdvisors and the formation this year of aFaculty of Pain Medicine within theRoyal College of Anaesthetists.The afternoon session continued with
Dr. Blair Smith
from the University of Aberdeen on
‘The McEwen report: aprimary care viewpoint’
.It is easy to forget in secondary carethat the majority of healthcare is providedin the primary setting. Blair published anarticle in
 Rheumatic Disease in Practice
in 2002 titled ‘Chronic Pain: a primarycare condition.’He pointed out that all the professionsinvolved in a multidisciplinary painmanagement team are present in primarycare.15-22% of all consultations in primarycare are for chronic pain. These patientsconsult five times more frequently. Theconsultations are often unsatisfactory dueto communication issues, mis-matchedexpectations and cure seeking as opposedto rehabilitation approach.Many management options areavailable in primary care and pain clinicreferral is a rarity. Patients will return to primary care after the pain clinictreatment.Blair felt that referral guidelines areneeded. He hoped for primary care painclinics, better education andcommunication systems.The penultimate talk was given by
Dr.Ian Yellowlees
on
‘A Peripatetic PainManagement Programme’
. Peripateticmeans working between two or moreestablishments (of course). We are allaware of the lack of pain management programmes in many parts of Scotland.Ian had the idea of a mobile PMP as asolution to this problem which might beattractive to clinicians and to health boards. Ian works with a team of healthcare professionals who would travel
 Dr. Blair Smith and Dr. Bill MacRae
WORLD PAINCONFERENCE UPDATEDr. Jonathan McGhie
The 11th World Congress on Pain took  place in Sydney in August. Theconference was well received by over 5000 delegates. Working in Sydney thisyear, I was fortuitously placed to take inthe congress and Colin has kindly invitedme to summarise the main topics for thisissue of Threshold.Although criticized by some attendeesas having too great a ‘basic science’ slantin the plenary sessions, the main lecturesof the conference provided the mostinsight into new developments and future paths for pain medicine. The overalltheme was of movement from thetraditional teaching of anatomical tractsof pain and simple neuronal transductionand transmission to an awareness of the plasticity of the CNS at all levels. Mostof the scientific work concentrated on thedorsal horn. The first lecture, by CliffordWoolf, outlined that more than 1200genes alter in the DRG and dorsal hornfollowing nerve injury. The difficulty nowlies in unravelling the importance of thesechanges.
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