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

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

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%

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.

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

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

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

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

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

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

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

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

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

Outcome Data – Quality of Life N = 90 Patients who had completed programme and returned questionnaires Statistically significant improvement by end of 10 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)

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

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%

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.)

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%

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)

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