The development of methods to assess the quality of care in pain clinics in England and Wales

Chronic pain has become a growing public health concern both with respect to its prevalence and unsatisfactory treatment. Of particular concern is the rising number of problems associated with long term opioids for chronic non cancer pain with the USA declaring this a Public Health emergency in 2017.It is essential that pain clinics provide leadership in this area. A recent systematic review of large scale surveys of pain clinics in seven countries described wide variation in standards of care. Quality improvement in pain management services is also recognised as challenging. In the United Kingdom, several government reviews highlighted the paucity of data on specialist pain services. Evaluating outcomes in routine clinical practice is a significant challenge for specialist pain clinics due to the complexity of interventions provided and the subjective nature of pain. This work consisted of two methods to measure quality of care. One through development of a patient registry that measured case mix and outcome. This was done twice: firstly, over a four year period in where classifications and outcome measures were developed through the voluntary participation of pain clinics. Secondly, over a further four year period through a National Audit where participation was expected. The other method audited standards of care set by the specialty in the National Audit, quality improvements were made and these were then re-audited. Overall, the body of work contained in this thesis, which includes population data, content and outcomes of care, suggests that pain clinics are partially meeting the needs of the chronic pain population. All results must be treated with caution due to low recruitment rates from many clinics and low returns of the Patient Reported Outcome Measures (PROMs) in both time periods. The necessary integration with social care is unclear and, based on the limited data from the registries, only 31% of patients had had any form of psychological intervention by 6 months. There was geographical variation in the provision of multidisciplinary clinics despite no evidence that patients differed in any way. There was evidence of complex patients being seen by the most basic of pain clinics which, in effect, represents a wasted resource. It is likely that there is a high level of unwarranted variation in the provision of services. There are several methodical improvements that could be made. Firstly, there should be a consensus on datasets and treatment classification. Secondly, is to ensure sufficient patients complete questionnaires. Smaller datasets, slow growth, greater involvement of clinics combined with regular feedback and lengthier support have been suggested based upon others’ work. Sustained funding is required to do this and so future work needs to demonstrate cost effectiveness and have wider societal impact e.g. opioid use or Emergency Department use. Future audits might encompass primary care which would give a better idea of the end to end pathway. Measurement of the level of integration with mental health and social care might help better understand the type of service on offer as would a measure of case mix complexity