One Size Does Not Fit All: Enabling Choice and Patient Centred Care in a Chronic Pain Rehabilitation Service

Purpose

Guidelines recommend that management of multi-morbidity, including symptom complexes such as chronic pain, should develop an individualised management plan taking a person’s needs and preferences into account. The NHS Plan calls for an end to one size fits all and recommends differentiated, personalised care to reduce inequalities for people with long term conditions. Specialist pain management services have tight referral criteria, meaning that individuals may be denied treatment. A process audit was conducted in order to determine whether patients accessed treatment equitably in a pain rehabilitation service.

Approach

Retrospective chart review of 500 consecutive patients attending a pain rehabilitation unit in a secondary hospital between April 2019 and January 2020. Assessments were predominantly conducted by physiotherapists, for some additional psychology assessment was offered. Baseline demographic data, outcome of assessment, physical and mental health co-morbidities were recorded. Cut points on questionnaires which represented severe depression and anxiety were used. Treatment options included; a pain management programme, physiotherapist-led programmes, hydrotherapy, exercise classes or individual physiotherapy. A chi-squared analysis was applied to baseline variables of age, gender, employment status, ethnicity and mental health diagnosis to compare patients offered treatment or discharged and group rehabilitation programme participants versus non-programme participants. The audit was registered with the trust audit department.

Outcomes

Results: Baseline demographic data (%): Sex: Female 73.2, Male 26.8, Mean age: 49.9, Ethnicity: White British 80.4, BAME 11.8, White Other 7.8, Employment Status: Unemployed 42, employed 39.4, retired 14.2, student 2.2, Mental Health: Depression 60.2, Anxiety 28.4, current or past history of trauma 28.4, >2 mental health morbidities 32, Physical health: respiratory disease 15.6, diabetes 9.6, Hypertension 9.4, >2 physical health morbidities 15.6. 95.6% of patients were offered treatment. There were no significant differences between participants offered treatment compared to those discharged. Psychiatric morbidity was significantly associated with being offered a group programme, participants without mental health morbidity were less likely to be offered group programmes.

Conclusion(s): There were no differences in demographic characteristics of participants who were offered treatment versus those that were discharged. Participants with mental health difficulties were more likely to be offered multidisciplinary treatment. A minority of patients were discharged, in contrast to a published audit of practice from a tertiary pain management centre where 44% of patients were discharged. There was a high burden of mental health co-morbidity in our patients. Physical health morbidity was less prevalent. Depression results in reduced ability to exert effort, thus to deny access to treatment may adversely impact physical health. The BAME population were under-represented when compared to the local population demographics. Measures to improve access to pain rehabilitation in the BAME population needs to be implemented.

Cost and savings

No further data 

Implications

Pain rehabilitation services can develop a diverse treatment offer to maximise access and choice for people with complex pain, presenting with physical and mental health co-morbidities. This may minimise health inequality and optimise patient centred care. BAME groups may need to be targeted to improve access to healthcare.

Top three learning points

No further data 

Funding acknowledgements

Not funded