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Chronic pain: the hidden health issue

 As NHS spending is cut, many areas of care will be ‘deprioritised’. Beginning Pf’s series focusing on different therapy areas, Alan Jones looks at one health issue that is currently low on the political agenda.

Despite the political mantra from the new coalition Government that healthcare spending will continue to rise in real terms over the next few years, the NHS is still heading for possibly a decade of austerity. Money will be extraordinarily tight. Even the £15/20bn QIPP efficiency savings are no longer real bottom line savings and, if they can be realised, will only cushion the NHS against rising demands from an ever-ageing population and the arrival of new technologies. It is the ‘robbing Peter to pay Paul’ strategy. Real difficult choices lie ahead and just as in the benefits system, where some payments will now be stopped, some NHS care may well have to be ‘deprioritised’.

With a much tighter financial envelope and growing demands, a new battle for priorities is likely. A first sign of this comes from the National Quality Board (NQB), which says that the Department of Health has been wrongly prioritising illnesses such as anxiety disorders and neglecting those such as Parkinson’s disease and back pain. As the NQB is now commissioning NICE to develop a range of new clinical standards in a number of therapy areas, there will be major implications for companies here at the national level.

At the local commissioner level, the priorities war will be fought between infinite demand and diminishing resources. The battle lines will be drawn around health needs assessment. It is thus worth remembering the ‘roadmap’ that payers use here. A commissioning cycle was launched at the outset of world class commissioning (see figure below), which essentially starts at the needs assessment stage at 10 o’clock in this diagram. If this is new to you, you too will need to start here in terms of payer account management and be able to demonstrate real burdens of disease in order to better align your clinical area against local NHS priorities.

It will certainly be much harder now to start at the bottom and work your way up, but if you have a National Service Framework (e.g. Renal) or a National Strategy (e.g. COPD) in your clinical area, much of the work may have already been done for you. If there is no such designated priority, it will be much more of a struggle for payers to put resources into your clinical area. Good prevalence and incidence data will be key, as will having a real epidemiological story to tell. Chronic pain is an excellent example of a low priority area.

The ‘story’ of chronic pain

It is some ten years since the Clinical Standards Advisory Group reported on care for patients with acute and chronic pain and on access and availability of services, but thereafter, for most of the Noughties, pain disappeared off the NHS radar, with the National Service Frameworks dominating priorities. Then, just over a year ago, it reappeared in the Chief Medical Officer’s 2008 Annual report. One brief chapter highlighted that some 7.8 million people are affected by pain and that chronic pain appears to be more common than ever with the numbers affected continuing to rise.

Chronic pain not only has a huge impact on both the sufferers and their families, but the burden to the economy as a whole is significant. People with chronic pain account for a significant proportion of GP appointments each year and are relatively high users of accident and emergency and outpatient services. However, in primary care, the provision of pain services appears to be very patchy. Significant numbers of chronic pain sufferers report inadequate control of their pain, while only 2% of them will see a specialist. It is the indirect costs, however, which lead to the biggest bill. In 1998, it was estimated that the cost to the UK of back pain alone was £12.3 billion and the main part of this cost (£10.7 billion) was due to work days lost, with chronic pain being the second most common reason for claiming incapacity benefit.

With chronic pain having a major impact on both people’s lives and the economy, Professor Liam Donaldson concluded that much more needed to be done to improve outcomes for patients. Picking up on this challenge, an All-Party Parliamentary Chronic Pain Group was established in May 2009 and, in November 2009, the APPG met with the then parliamentary-under-secretary for health to discuss the Department of Health’s progress towards implementing the pain recommendations in the Chief Medical Officer’s Annual report. Not much progress had been made and a BBC news report in March this year reported comments from a frustrated Chronic Pain Policy Coalition that perhaps it was time that chronic pain was recognised as a disease in its own right.

Europe meets to discuss the issue

Considering this background, it is significant that many of the UK protagonists in this area decamped to Brussels last month where they were joined by many more interested parties from across Europe. The symposium brought together over 150 people from 28 separate European countries to examine more closely the societal impact of pain and the implications for healthcare policy makers. Even the National Institute for Health and Clinical Excellence (NICE) and the Scottish Medicines Consortium (SMC) were represented. The symposium was organised by the European Federation of International Chapters (EFIC) of the International Association for the Study of Pain (IASP) and supported by Grünenthal GmbH.

“Pain is a significant health problem that affects millions of people in Europe,” declared Giustino Varrassi, EFIC’s President at the symposium opening. He added: “And it must be addressed not only in terms of direct costs to national health care systems but also in terms of the wider societal costs, costs on welfare systems and the negative impact on the economy.”

Many speakers suggested that pain was simply not recognised as an important public health issue by national healthcare systems, whilst at the same time they were being overwhelmed by the high societal costs related to pain. Improving the situation would thus reduce not only healthcare expenses but also improve worklessness, increase productivity, reduce incapacity benefits and add to Exchequer revenues. There were suggestions that because of its high prevalence and impact on both patients and society, its treatment should be recognised as a health quality indicator for healthcare systems, and, further, that freedom of pain should be regarded as a universal human right, not because of the economic impact, but rather due to the tremendous human suffering resulting from it. It was described as a disease with no name and the ‘invisible disease’. And with chronic unresolved pain being a major problem all over the world, pain management must be made a much higher priority by governments and health providers.

A whole systems approach

A key take-home point from the conference was a real need for a ‘whole systems perspective’ on chronic pain. ‘Brick walls’ often exist between health and work systems, operating as parallel universes with mismatched agendas and conflicting targets. More integrated approaches are therefore needed.

As Professor Ceri Phillips from the University of Swansea said, “It is vital that pain and its management is moved higher up in the political agenda and featured more prominently in government policies. It is also essential for a joined-up cross-agency approach to be adopted, involving all those who have an interest in preventing ill-health, treating ill-health and rehabilitating those who have suffered from pain.”

The NICE speaker admitted that he was ‘embarrassed’ that the Institute hadn’t done much about pain, but that this was largely because health ministers have not asked them to look at chronic pain. For pharma, therefore, this might be a good route to take to achieve a higher priority for chronic pain with such clear clinical evidence of unmet need. Although the societal impact of pain is profound, possibly being as high as 1.5% GDP and consuming as much as 22% of healthcare expenditure, and chronic pain is such a serious healthcare problem, decision makers are simply not aware of the size of the problem. As mentioned in England, other clinical areas have had national service frameworks and yet healthcare costs seem comparable. Coronary heart disease costs the NHS £1.73bn a year, diabetes £1.77bn and chronic back pain £1.63 billion (but with £10.67 billion on informal care and societal costs). The results from an EU-wide survey on the impact of pain in the big five EU countries (including the UK) suggested that the typical pain patient in Europe was 48 years old, female and with low income and low educational attainment, implying that healthcare inequalities in managing chronic pain in lower socio economic groups and socially disadvantaged groups could be a further issue.

So where are we now?

Although more countries are collecting data on pain treatment/outcomes and direct/indirect costs, it appears that there is still insufficient focus on the impact of pain on work and work related activities, while a ‘bunker mentality’ to different budgets makes it difficult to take an integrated approach to pain treatment. Better education and implementation of pain guidelines is also key. However, some countries do appear to be investing in better care for patients, with one notable example being Scotland. The Scottish Government has recently made a commitment to recognise chronic pain as a long term condition and there is now a chronic pain Czar. Chronic pain managed clinical networks are also rolling out across the country.

For England, the unmet need in chronic pain continues to be great and it could be time that the Government looked at this area again. If chronic pain is going to be a disease in its own right, does it need a unique code? If it is going to be a basic human right, should it be in the Care Quality Commission’s essential standards of quality? If it is to move to a priority status, should this be suggested to the National Quality Board? It might also be a good idea for it to be incorporated into QOF. There is no doubt that chronic pain is a big public health issue and deserves to be a much higher priority, but at a time of healthcare recession and financial cuts it may continue to live in the shadows. Despite being common, chronic pain just isn’t very sexy. Perhaps the simplest answer is to call in Joanna Lumley.

Alan Jones is an occasional contributor to Pf. He commentates and presents widely on the ongoing reform within the NHS and its implications for pharma. He is also a consultant to Wellards, an independent healthcare policy analyst, adviser and NHS trainer. Email: alan.jones28@virgin.net.

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