1. The Centre for Active Lifestyle Management (CALM)
Dr Stephanie Jarrett
Consultant Clinical Psychologist
Pain Management Unit
University Hospital Lewisham

2. Setting the scene Chronic pain - British Pain Society definition:
“continuous, long-term pain of more than 12 weeks or after the time that healing would have been thought to have occurred after trauma or surgery”
Diagnoses:
Osteoarthritis
Degenerative changes/disease
Spondylosis
‘Wear and Tear’
Complex Regional Pain Syndrome
Fibromyalgia
Chronic widespread pain

3. Setting the scene People living with chronic pain: 7.8 million
Prescriptions for pain: £584 million
The cost to the NHS of chronic (long-term) back pain alone is estimated to be £12.3bn per year
The management of chronic pain in primary care accounts for 4.6 million GP appointments, costing around £69 million per year
Patients with chronic pain experiencing depression: 49%

4. Setting the scene
Comprehensive, multi-disciplinary group programme is the most efficacious and cost-effective treatment for patients with chronic pain (Gatchel & Okufuji, 2006; Guzmán et al 2001)
Multidisciplinary group pain management programmes (PMPs) are recommended for patients with chronic non-malignant pain by
The British Pain Society
European Guidelines
The International Association for the Study of Pain
Report by Dr Foster (2003) identified the patchy provision of PMPs in the UK.

5. Lack of PMPs in South-East London
Northwick Park
National
Hillingdon
Ealing
INPUT
Chelsea
Wolfson
-Multi-professional PMP, recommended by British & international guidelines
Kingston
COPE
Epsom

6. Lack of PMPs in South-East London
Northwick Park
National
Hillingdon
National
Hillingdon
Ealing
INPUT
Ealing
Chelsea
INPUT
Chelsea
15k Diameter
CALM
Wolfson
Kingston
Wolfson
-Before we existed, only other option was to refer for individual psychology
-INPUT not feasible because of work and family commitments
-Walking / struggle to walk to high street / public transport
20k diameter
Kingston
COPE
COPE
Epsom

7. Past:
2001 – Recruitment of Clinical Psychologist to Chronic Pain Service, University Hospital Lewisham
2002 – Pilot Programme
2004 – 1st Business plan put forward
2009 – Obtained 12 month funding
2010 – 6 month extension
2011 – 12 month extension until March 2012
2012 – Mainstream funding
-2002: pilot programmed. Not sure how they did it = admin time
-Hospital not interested. Then went to PCT
-No decision really made so Stephanie and Sarah continued to lobby PCT
-Funding came with certain conditions

8. Present: The CALM team – Consultant Clinical Psychologist
Clinical Physiotherapist Specialist
Pain Nurse Specialist
Psychology Assistant
Administrator
All 0.4 wte
-Multiprofessional is why this approach is the most effective. Psychologist ≠ medication or physiology. Nurse/physiotherapist ≠ psychological distress
-Introductions
-Part time service runnign 2 days a week

9. The CALM Programme The CALM programme aims to help patients:
Develop strategies to reduce the distress & disability caused by pain
Decrease reliance on medical professionals
Improve quality of life
-Acceptance
-Reduce psychological distress (Let their pain take over their lives, socialising, hobbies, catastrophizing thoughts)
-Reduce disability (avoided most forms of gentle exercise).
-Teach them the importance of movement and help them lead an active lifestyle
-Decrease reliance patients have on healthcare professionals
-Giving them tools to use in their everyday lives so they’re the experts
-Most healthcare professionals don’t know how to help someone with chronic pain. GP can only do so much

10. Referral Referrers - secondary care pain related services
Chronic Pain service
Rheumatology
Orthopaedics
Musculoskeletal assessment and triage (MSK) service
Physiotherapy
Referral process
Check patient is registered with Lewisham GP
Check patient eligible for CALM programme:
No ongoing litigation
No ongoing medical intervention (other than medication)
No ongoing investigations
No active psychosis
Discuss referral with patient
If patient in agreement – send referral letter to CALM team
Discharge patient to care of CALM team

11. Referral letter received
Programme suitable - offered place
Patient phones to arrange individual assessment
Patient phones to arrange date for group information meeting
Attends group information meeting. Invited to contact CALM team to arrange date for individual assessment
Seen individually by psychologist, physiotherapist & nurse for assessment
Patient sent letter inviting them to phone and arrange a date to attend a group information meeting about the CALM programme
DNA group information meeting
DNA assessment
Programme not suitable – referred to more appropriate service
No contact to arrange assessment appointment within 28 days
No contact from patient within28 days
Discharged – inform referrer and GP

12. Weekly group sessions
for 10 weeks
6 months later –
Second follow-up
group session
Assessment – offered place on programme
6 weeks later –
First follow-up
group session
Open invitation to yearly ‘booster’ session

13. Outcome Data – Quality of Life
Distress
Depression (Beck Depression Inventory II)
Catastrophising (Pain Catastrophising Scale)
Fear of movement (Tampa Scale of Kinesiophobia)
Disability
Sit-to-stand (number per minute)
Pain interference (British Pain Inventory)
96 patients reached 6 months follow-up
Complete data available for 90 patients
Bonferroni’s correction for multiple analyses p<0.008

14. Outcome Data – Quality of Life
N = 90 Patients who had completed programme and returned questionnaires
Statistically significant improvement by end of week programme
Statistically significant improvement at 6 month follow-up
Distress:
p ≤ .008
Depression (BDI II)
Yes
Catastrophising (PCS)
Fear of movement (TSK)
Disability:
Sit-to-stand (No. per minute)
Pain interference (BPI)

15. Outcome Data – Health Care Use
Computerised appointment system
Secondary care pain-related appointments
Physiotherapy appointment s
Contacted GPs to get data on primary care pain-related appointments

16. Outcome Data – Health Care Use
Total number of appts
(N=55 patients who finished programme >1 year ago)
12 months pre-programme
12 months post-programme
% Reduction
Secondary Care Pain Appointments
142 13
91%
Physiotherapy Appointments
206 20
90%
NHS Lewisham Target
80%
Primary Care Pain-Related Appointments
(N=25)
156 66
58%

17. Outcome Data – Health Care Costs
Clinical coding department to get accurate costs for:
Secondary care pain-related outpatient appointments
Physiotherapy appointments
Interventions (e.g. Epidural, trigger point injection etc.)

18. Outcome Data – Health Care Costs
Cost of appointments
(N=55 patients who completed the programme >1 year ago)
12 months pre-programme
12 months post-programme
% Reduction
Secondary Care Pain appointments
£21,115.46
£2,328.20
89%
Physiotherapy appointments
£14,584.80
£1,122.60
92%
Secondary Care Pain Related Interventions
£12,178.39
£2,989.27
75%

19. Happily Ever After?
Pilot phase ended and taken into mainstream funding in April 2012
But...
Trust Special Administrator’s draft report “Securing Sustainable NHS Services” - Consultation on the future of South London Healthcare NHS Trust and the NHS in South East London (November 2012)

20. Thank you
The CALM Team
Sarah MacNeil – Clinical Physiotherapy Specialist
Tamzin Bunton – Pain Nurse Specialist
Ajay Clare – Psychology Assistant
Reuben Richards – Administrator
Lewisham support:
Dr Tom Smith – Consultant in Pain Management
Ashley O’Shaughnessy – Head of PBC and Services Redesign, NHS Lewisham
Lewisham Practice Based Commissioners
Hilary Rankin, Consultant Clinical Psychologist and her team at COPE, Sutton Hospital
INPUT