## The National Pain Audit Third Report

f o c u s  o n  s a f e t y  a n d  o u t c o m e s

# The National Pain Audit Third Report

f o c u s  o n  s a f e t y  a n d  o u t c o m e s

## Foreword

Just over four years ago the British Pain Society made a successful bid to run an audit of specialised pain services throughout England and Wales — the first of its type in the UK. The audit systematically determined the current services available for patients in chronic pain, followed by the types of condition presenting and the impact that this had on their lives. The final part of this audit has determined the safety of services and patient outcome following specialist care in both the short and long term. The audit has clearly illustrated the devastating impact that chronic pain has on the huge number of individuals with this condition. Specialised services are not available throughout the country and the quality of the service varies considerably. 

It is essential that commissioners and NHS providers address this major shortfall by establishing appropriately trained multidisciplinary services in a timely fashion, to prevent the ongoing suffering of such a huge population. There is an urgent need for ongoing audit of services and patient outcome, to confirm that an effective service is being delivered, to confirm that the best care is delivered and that the best use is made of NHS resources. This work could not have taken place without the dedicated input of Dr Cathy Price leading the clinical group and the support of the Dr Foster team.

## Dr William Campbell

President, British Pain society October 2013 

## Introduction And Background

Pain services were developed in response to the recognition in the 1960s that some people in pain may benefit from additional specialist care. Advances in the understanding, prevention and treatment of chronic pain have continued at a pace since then. Specialist pain services have provided a crucial leadership role in advancement of care for people with chronic pain. 

The National Pain Audit was set up in response to find­ ings from successive reports that specialist pain services were struggling to keep up with demand. There was clear variation in provision of service, a lack of visibility and no agreed standards of care. 

The National Pain Audit has explored the quality of specialist pain services provided to people with longterm pain, sought to evaluate them against known stand­ ards and, where necessary, to develop new standards in consultation with clinicians and patients. This audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). This is the fourth round of the audit.

Previous audits have covered:

- Round 1: Organisational arrangements of 

services audit
- Round 2: Case mix - Round 3: Outcomes of care - Rounds 2 and 3 were reported together in the 

Final Report

This fourth round, an extension of the audit, has ex­
amined one-year outcomes of pain service intervention, and sought to understand current models of care that 

exist and establish which safety procedures are in place to safeguard patients against unexpected sequelae of treatment.

As this was an extension, the audit has used existing methodology established in previous rounds with few additions or changes.

## Executive Summary

The National Pain Audit has been an important exercise for the specialty. For the first time, clear standards have been developed and measured, changes recommended then re-audited.

- Information on pain is not delivered in a way that 
many patients can grasp the essentials.

## The Fourth Round Of The National Pain Audit Has Found:

- There has been a substantial improvement in 
- There is no good understanding of optimal models 
participation of services.
and levels of service provision.
- Non-English speakers were poorly represented. - Multidisciplinary provision appears to be increasing.

## Actions Needed:

- Patients need multi-modal treatment.
- Competencies developed for non-medical 
practitioners in pain management. 
- One case study on healthcare usage demonstrated 
- Differing levels of service provision that can match 

to need.
reduced healthcare costs in outpatients but not inpatients.
- 8% of patients are very severely affected by their pain.
- Guidance on standards of care expected 

from services.
- There are some gaps in managing risk.
- A review of best practice in delivery of patient 
- There is wide variation in service delivery.
education in pain.
- Clear standards for risk management on assessment 
of people in pain.

## Some Of The Underlying Issues Identified In This Audit Are:

- Better integrated working between services across the 
healthcare system.
- Appropriately skilled staff to deliver treatment are 
frequently not available.
- Subgroup analysis to identify whether some cohorts 
of patients respond better than others.
- Lack of understanding as to deliver highly specialised 
- Guidance on best interventions to return people in 
care is very small, meaning there are is no regional leadership structure in the specialty.
pain to work.
- The necessity of specialist pain services to be cross-
- An inpatient pain audit to improve quality of pain 
care in hospitals.
cutting in nature and integrated with other services is poorly recognised, meaning access to specialist advice may be delayed.
- The work has not been done to assess the impact of 
improved pain management on other aspects of the healthcare system. 

## Recommendations Services

- A model service specification for specialist services (i.e. services commissioned 
by Clinical Commissioning Groups) is urgently needed. The service specification needs to be independent of setting and integrated with other specialties and providers, with clear treatment protocols in place. The Faculty of Pain Medicine is currently revising its recommendations and it would be helpful to include these.
- Safety protocols need to be reviewed in many services to ensure that mental health 
risk assessment and a full case review of missed diagnoses are included and that training is given to identify and manage those at risk. This requires discussion with the National Health Service Special Commissioning Board as patient safety now falls within its remit.
- As pain occurs across many if not all branches of medicine, multispecialty clinics 
and specialist non-anaesthetist led activity requires application of the treatment function code 191 while retaining background specialty. Guidance is needed from the Health & Social Care Information Centre on this. 
- Specialised pain services need to work in an integrated fashion across a wide 
geographical area as virtually no single provider has the capability to manage patients at the severe and highly specialised end of the spectrum such as those patients presenting with highly complex needs. Options to achieve this are 
currently being scoped by the Specialised Pain Services Clinical Reference Group.
- There needs to be clearer linkage of level of services to patient need.

A classification of services, such as that described for neuro-rehabilitation services, may be useful.
- Clinics need to audit patients' understanding of persistent pain and of treatment 
options. This could be included in the Royal College of Anaesthetists Audit Recipe Book.
- Services should link with vocational rehabilitation experts and occupational health 
physicians to develop new ways of working that would return people to work. The Chronic Pain Policy Coalition is currently developing this, subsequent to the first English National Pain Summit.

## Standards

- Standards that have been demonstrated as feasible to collect and measure data that 
are meaningful should be reviewed and considered for more formal adoption by bodies with responsibility for quality improvement e.g. NICE, Royal Colleges.
- Non-medical healthcare professions such as Physiotherapy, Nursing and 
Psychology should develop National Occupational Competencies with Skills for Health. The British Pain Society could usefully co-ordinate this development.

## Future Audits

- Should build upon the extensive learning from this audit with regards to clinical 
engagement, governance, methodology, recruitment and sampling.
- Need to improve the case-mix adjustment to allow meaningful comparisons 
between providers.
- Need to improve diagnosis coding. - Should include comorbidity to improve case-mix adjustment. - Should assess if appropriately skilled staff are available to deal with complex 

pain problems.
- Need to have permission to use NHS numbers to allow data linkage, to identify and 
track patient across service, capture comorbidity and healthcare resource use.
- Should investigate the contribution of specialties other than Anaesthetics to 

pain medicine.

## Patient Summary

The audit is all about the people that the service looks after and about what happens to them in the service, with the goal of learning how to provide pain relief and to help individuals live with their pain. This audit has shown that many parts of the country have poor provision for people living with pain.

it apart (gently) to examine how it works and if it can be 
improved. The participation rates of services in this audit 
were excellent; the will to be under the microscope was 
                                                          

admirable.

The audit does show that multi-component treatments are better but these need to fit the patient's needs rather than to be provided in a single format. Some patients need regular attendance at a specialist service to manage their pain effectively. Some are very severely affected by their pain and it is not clear how their needs are being met. Most have a very poor quality of life with work most affected.

the *Find a Clinic* pages and work out if a clinic near them is in a position to help them in the way they choose. This is a significant step forward.

In contrast, staffing levels that can deliver multidis­

## "Most Patients Think The Nhs Is

ciplinary treatment are inadequate in many clinics and cannot be ignored. The number of clinics setup for spe­ cialised care is too low, meaning there is no regional lead­ ership. Worryingly low numbers of non-English people are accessing pain services. 

Patients need information about a service to be able to ask for it and need good information at a rate that is right for them. The audit found that many people do get the right information and it was helpful; however a substan­ tial minority do not. This needs more work.

Developing a cycle of continuous audit, evaluation, 

the same all over. The National 
Pain Audit is proof that this is not 
true and has highlighted the poor 
quality of life that people living 
with pain experience"

consultation, implementation and audit again takes courage and leadership, as does making changes that are indicated by the findings. It also takes humility to evalu­ ate something you have developed over time and to pull Patients can now look up how their clinic is doing on 

## Finding Of The Previous National Pain Audit Rounds

In total, 161 pain clinics were located in the audit. Some PCTs had multiple providers within the same locality, but 28 PCTs did not appear to have any pain services. Just 91 clinics (56% of those identified) returned information in Round 2 on 9,588 patients who completed the questionnaires about themselves and the impact of pain on their lives. In Round 3, 4,414 patients returned follow-up questionnaires six months after their initial assessment; 3,192 of these were complete and provided a good understanding of what is happening to patients in 80 of these services.

## The Key Findings Of The Previous Audit Rounds 2 And 3 Were:

- Quality of life among patients attending specialist pain services is poor and is improved by 

these services: The overall mean quality of life score (EQ5D-3L) of 0.4 represents severe impairment, and 
is lower than many individual long term conditions. This low score might be attributed to the collective im­ pact of the comorbidities present in these complex cases. In total, 56% of providers reported post-treatment improvement in EQ5D-3L score, and 76% reported improvement specifically in pain-related quality of life.
- **Healthcare resource utilisation is high:** 16% of respondents reported visiting A&E to seek help in the 
six months prior to clinic attendance, despite having seen their GPs. By contrast, only 9% of respondents reported visiting A&E for pain-related events in the six months after attending their pain clinic. 
- **There is wide variation in staffing and skills mix of services:** only 81 out of 204 English pain clinics 
(40%) were able to fulfil the criteria for a fully multidisciplinary pain service, as defined by the presence of a physician, physiotherapist and psychologist. In Wales, six out of the ten pain clinics were fully multidisci­
plinary. Wales has a clear pain strategy and implementation plan in the form of directives.

Recommendations from the audit in the second re­
port were diverse and included improvements in 
coding, diversity of skills available, the information 
gathered and advice being more accessible to patients 
and healthcare planners. Though while the audit was 
published less than a year ago, some progress has 
been made in key areas. These include development 

of local joint strategic needs assessments based upon 
the data from this and the Health Survey for England, 
clear links on service outcomes on the NHS Choices 
website and submissions of topic suggestions to the 
National Institute for Health Research's health ser­
vice and delivery programme on models of care for 
people in pain.

## Why And What? Why Was A Re-Audit Of Services Needed?

management services from a small number of tertiary 
pain management providers in England. The specifica­
tion was developed by the clinical reference group for 
pain management during 2012/13 and is to be adopted 
formally from the 1st October 2013. Importantly, it is 
still unclear whether current services meet patient 
needs and the landscape of how services are provid­
ed across the tiers of pain management provision

Rounds 2 and 3 of the audit showed that the quality of 
life of people referred to pain clinics is very poor. Most 
patients have more than one health problem. Clarity 
was needed as to whether pain services had processes 
in place to deal with such a disabled population includ­
ing accuracy of diagnosis and assessment of suicide risk. 
Organisational data was displayed on the National Pain 
Audit website www.nationalpainaudit.org and visible 
to patients. These have been linked to other sources of 
                                                      

## What Further Information Is Needed From Patients?

information on pain services such as NHS Choices 

During Round 3 of the audit it became evident that 

www.nhs.uk and the British Pain Society website 

www.britishpainsociety.org. However, due to the fact that most people had not completed their pain treatment, more time was needed before publishing outcomes.

The NHS has changed considerably between the orig­

treatment was often incomplete at six months, so an 
understanding of the full impact of services on people 
in pain required further follow-up. Additionally, ethnic­
ity data had not been collected from patients and it was 
agreed that it was needed.

inal data collection and now. Many trusts have merged 
and some services were commissioned to provide a 
county-wide service, e.g. Somerset and Gloucestershire.

methods to answer those questions that proved difficult 
to answer with the methods originally proposed. For 
                                                       

During the first audit round it became clear that some 

example, to understand the relationship between hospi­
tal emergency admissions and services, a case study has 
been performed. This should provide better information 
to plan future audits.

services were very unstable with some providers report­
ing extreme difficulty or no longer in existence. The char­
acteristics and capability of specialist out-of-hospital 
pain services was poorly understood. The emergence 
of independent Any Qualified Providers introduced an

element of competition and it was unclear whether such 
services truly existed and whether they could be accu­
rately described as specialist pain services.

Clinical Commissioning Groups were intro­

duced in 2011–12 and their impact on pain service 
                                                 

provision needs to be understood. A national Service 
Specification for specialised pain management has since 
been published for contracting with specialised pain 
management centres/services. NHS England now has 
direct commissioning responsibility for specialised pain 

Round 4 of the audit has had to introduce new 
                                             

## Further Information

 Organisational data is available on the National Pain Audit website www.nationalpainaudit.org

## Methods Round 4 Of The Audit Consisted Of Two Audits

1.	 12-month patient follow-up from those who responded to the six-month follow-up, 
a subsample of those who provided data at the baseline.
2.	 Resampling of the organisational audit with the aims of:
a.	 Gaining as complete as possible representation of clinics, to include com­
munity clinics, treatment centres, and those under Any Qualified Provider.
b.	 Reviewing clinical governance processes to include:
i.	 Protocols to manage serious untoward events.
ii.	 Treatment fidelity, i.e. appropriate skills and processes in place to 
carry out treatments offered.
iii.	 Clarification of accountability, e.g. if a community clinic was in place,

was this an outreach service from the acute trust, standalone, or did it have some other form of accountability?

## A: 12-Month Follow-Up Patient Data

The questionnaire administered to patients was simi­
lar to that administered at six months, with some minor 

revisions in the light of the six month follow-up responses. For example, poorer response rates were noted where a re­ sponse was contingent on a previous response. 

## The Overall Recommendations Were:

- Questions should be unconnected. - Expected answers should be as simple as 
possible, preferably represented by a sliding scale or range.
- Groups of questions that followed a single 
conceptual theme and response format (BPI, EuroQol) seemed to perform well, so questions should aim to be consistent with these as far as possible.
- Some questions that were missed were possibly 
not relevant to all respondents. Where possible, questions were worded more generally, or where necessary, specific application should be clearly signalled (though that risks creating complexities 

of its own).

## Note

 This audit round 
focused on safety and long-term outcomes

These recommendations were reflected in the design of the 12-month patient questionnaire.

Only those patients who replied at six months were 

sampled. Some patients had died by the first follow-up 
period; given the poor health of many in Round 2, there 
was some risk of sending questionnaires to people who 
                                                      

had died in the intervening 12 months.

There was a deeper analysis of previous rounds to 

focus on healthcare use, since a key finding had been 

high use of emergency care, which decreased signifi­

cantly following treatment in a pain service. The 

audit's scientific advisors felt it would be of 

value to examine whether this decrease was 

sustained.

Ethnicity was also included in this ques­

tionnaire as it was felt this was an important 

omission from previous questionnaires.

 Appendix 1 shows the final 12-month follow-up 
                                              

patient questionnaire

## B: Provider Questionnaire

Round 1 of the audit focused on identification and char­
acteristics of specialist pain services. A re-sampling of these data was important for a number of reasons:
matched to these providers. To ensure that no services were missed and that all responses were complete, par­
ticipation was maximised as follows:

- A number of services had been reconfigured.
- The audit was included in the How Safe is Your 
- Identification of providers had been incomplete, 
Hospital? survey run annually by Dr Foster with a high 
response rate.
especially where provision was in the community. 
- The British Pain Society Primary and Community 
- Providers were being encouraged to devolve services 
out of the acute hospital setting.
Care Special Interest Group reviewed the questionnaire to ensure it was appropriate to non-
- Increasingly safety is an issue, with an 
emphasis on staff levels.
Rounds 2 and 3 demonstrated the com­

- The British Pain Society emailed all members and 
included reminders in its newsletter.

plexity of case mix in those attending spe­
cialist pain services. In the time that the 
audit has been undertaken, guidelines 
have been introduced for pathways of care 
(for example, the British Pain Society's Map 
of Medicine persistent pain pathways). The audit 
therefore examined whether the services have govern­
ance processes in place to deal with the challenges of a 
complex case mix.

This audit round has also examined whether the staff­

ing and skills are in place to deliver treatment according 
to guidelines.

dependently contacted, with support offered to complete 
the audit, and reminders sent.

A list of all potential NHS providers was extracted 

 Data items for the provider questionnaire are fully 

downloadable from www.nationalpainaudit.org

from the NHS Choices website. Each hospital, inde­
pendent NHS provider and community trust website 
was searched for pain services offered, and respondents 

## Quality Of Life Questionnaires Data Analysis

Detailed audit standards are outlined in Appendix 3. Data were analysed against each of these standards and reported per item.

Two items were considered important to report: average 
pain and mean general activity interference. These were 
displayed graphically. Other data items are reported in 
chart form.

## Key Audit Standards

chronic pain for either the EuroQol or Brief Pain Inven­ tory Questionnaire pain severity scores does not exist and thus was not included.

## A: Patient Questionnaire

- Advice and guidance on managing pain - Quality of advice given 

Round 3 of the audit. Given that the audit returns per pro­
vider were too small for comparisons to be reliable and the 
model used was over-dispersed when it came to bench­
marking, case-mix adjusted scores are not reported.

- Additional support provided - Involvement in planning care

## B: Provider Questionnairre

- Number of sites that the provider was operating 

## Patient Outcomes

- Waiting time for treatment

 Advice rated: 

 Support:

- Number of patients receiving multidisciplinary care

good/excellent 
good/excellent 

- Type of service:
hospital services.
- The British Pain Society Pain Management Programmes Special Interest Group 
reviewed the items to ensure that these types of rehabilitation services were able to respond.
- The audit was posted on the bulletin board 
for UK pain consultants and reminders sent 
through the group painconsultantsgooglegroup.
Clinical leads for services of non-responders were in­
Robust evidence on clinically significant change in Case-mix adjustment methods were described in 

a.	 We looked at this using standard definitions used 
by the International Association for the Study of Pain (IASP) services criteria. However, as all spe­
cialist pain services might reasonably be expect­
ed to be multidisciplinary in nature, we described clinics by: 
i.	 Level 1: able to deliver CBT-based treat­
ments for less complex cases and review medication. Required minimum staff­ ing of psychologist, physical therapist and physician.
ii.	Level 2: able to deliver pain services ac­
cording to Faculty of Pain Medicine of the Royal College Of Anaesthetists' guidelines on comprehensive pain services that takes into account level of disability and the need to have a wide range of skills avail­ able including at bare minimum psychol­ ogist, physical therapist, physician and one other.

iii.	Level 3: services offering multispecialty 
clinics i.e. cross-cutting services.

## Note

|  Key standard for organisational    |  All services to be multi-         |
|-------------------------------------|------------------------------------|
| levels of service                   | disciplinary with skills specified |

## Case-Mix Adjustment Single Centre Study

problematic. The population appears to be extremely heterogeneous and items that might contribute, such as socioeconomic data and comorbidities, have not been routinely collected. HES data on outpatients does not include comorbidity and so it was not possible to link data, as had been originally intended, to understand these factors. Therefore, for this round, case-mix was not adjusted. Further analysis of healthcare usage needed to be better understood through linkage to HES data. In order to test the assumptions on healthcare resource used to make recommendations for future audits, a case study was carried out on data from one centre where comorbidity and other items had been routinely collected at individual patient level. 

- Protocols in place for review of missed serious 
pathology and assessment of suicide risk.
- Supporting professional activities time; engagement 
in routine audit.
- Governance on treatment;
a.	 Prescribing guidance on opioids agreed. 
b.	 CBT carried out by appropriately qualified 
practitioner(s).
c.	 Interventional pain medicine adverse events 

reporting protocol. 
d.	Multidisciplinary team meetings. 

Sites were displayed by geographical location. In a pre­
vious audit, the density of clinic provision was reported 
per head of population. As clinics served a number of 
commissioning groups, site and clusters of clinics was 
thought to be more meaningful.

Information on services was displayed on a Find a 

Clinic function on the National Pain Audit website and 
links created to the British Pain Society website and

NHS Choices.

 
 Graded at three levels

to match patient needs
These data were amalgamated with 
data from the audit and included emergency admissions. We tested: - A&E attendances six months/

12 months prior to attendance. 
- Admissions six months/12 months 
prior to attendance.

- A&E six months/12 months post 

attendance. 
- Ward Admissions six months/

12 months post-attendance.
- Outpatient attendances in various 
specialties.
Permission to link data had been sought at the outset of the PROMS data collection. If consent was not given to share data then they were not included.

## Results Providers' Organisational Questionnaire Results

 Responding organisations are listed in Appendix 3 
Of these, 121 submitted data in sufficient time to be in­ cluded in the analysis (66%). The other 35 were uploaded to the Find a Clinic function on the National Pain Audit website and can be viewed individually. 127 acute trusts with adult services in England submitted a return, nine reported they had no pain clinic, and 21 failed to reply a total of 156 acute trusts.

Three mental health trusts submitted a return, one failed to reply and 47 reported no pain clinic (total 51).

Six community providers submitted a return with four failing to reply and 14 with no pain clinic (total 24). One independent sector treatment centre responded, one failed to reply and four were reported as having no service.

Two Welsh Health Boards submitted data, with the oth­
ers responding too late to be formally included, though all services have now responded.

## Note

 221 clinics representing 121 
providers submitted complete data sets for analysis
 Six specialised children's pain 
services submitted data
 20 providers failed to respond

Three Any Qualified Providers submitted data. Six 

specialised children's pain services submitted data. 
Thus out of the total identified providers, 146 out of 182 
responded in time for the data analysis, representing a 
response rate of 80%. In all, 20 providers who were iden­
tified as having a pain service did not submit a return. 
This is a substantial improvement from previous rounds.

An example of the Find a Clinic audit pages is shown 

below. The ticks represent standards met, the crosses 
where they were not. There are four themes to the pages; 
general information as shown below, facilities, staffing 
and patient safety. A further screenshot is being developed 
for clinical effectiveness and patient experience together 
with benchmarking data. Any patient, commissioner or 
healthcare professional can access this information.

 Results are reported by individual standards as in In total, 221 different sites were reported by the 121 services. These varied hugely from subspecialty clinics within a single hospital to county-wide services over a large geographical area. This made it difficult to establish what skills and treatments were available to the patient. Services were thus analysed both by provider and by site. 

## Numbers Of Sites Providers Operating:

| No. of                                            | Type of
           | No. of        |
|---------------------------------------------------|-----------|---------------|
| sites                                             | providers | provider      |
| Type of clinic                                    | Number    |               |
| 1                                                 | 76        | Mixed         |
| Single modality clinic                            | 5         |               |
| 2                                                 | 16        | Acute         |
| Pain clinic                                       | 27        |               |
| 3                                                 | 16        | Acute & 1 AQP |
| Multidisciplinary pain clinic                     | 111       |               |
| 4                                                 | 5         | Acute         |
| Multidisciplinary pain centre                     | 34        |               |
| 5                                                 | 3         | Acute         |
| 6                                                 | 0         |               |
| 7                                                 | 1         | Acute         |
| 8                                                 | 1         | Acute         |
| Types of clinics according to IASP classification |           |               |
| (by clinic rather than provider)                  |           |               |

## Multidisciplinary Standard

|                                 |   Met by clinic |   Not met by clinic |   Met by provider |   Not met by provider |
|---------------------------------|-----------------|---------------------|-------------------|-----------------------|
| Type 1: non-complex service     |             106 |                 115 |                81 |                    40 |
| Type 2: FPM standard service    |              30 |                 191 |                28 |                    93 |
| Type 3: multispeciality clinics |              17 |                 204 |                15 |                   106 |
| Multidisciplinary meetings      |             180 |                  41 |               108 |                    13 |

## Levels Of Provision

|  One-third of providers failed to provide even
                                                     |  14% of providers offered cross-cutting       |
|-----------------------------------------------------|-----------------------------------------------|
| the most basic multidisciplinary care               |                                               |
| Two-thirds of clinics did not fulfil the Faculty of | 34% of providers offered an inpatient service |
| Pain Medicine standards for Chronic Pain Services   |                                               |

Appendix 2 with different forms of service described in Appendix 3

## Note

 During the process of gathering data, many 
staff fed back that services felt fragmented with no clear sense of direction
 Many reported that they did not have a clear 
service specification, and were uncertain as to where accountability lay for care
multispecialty clinics

## Inpatient Service For Complex Cases

Fifty-three clinics out of 220 (24%) clinics provided an 

inpatient service for complex cases with 41 out of 121 
(34%) at an overall provider organisational level.

## Protocols For Assessing Risk And Reporting Untoward Events

These are reported at organisational level only (i.e. 121 providers submitted returns in time for analysis) as it is assumed they will be implemented across all sites.

- 53 (44%) had a suicide risk assessment protocol. - 53 (44%) had a clear process for acting on 

misdiagnosis: in all of these providers they were 
reported as serious untoward events. Many ticked 
not applicable although all reported that their 
organisation had a serious untoward event reporting 
mechanism. 

- 114 (94%) had a process for recording drug errors. - 104 (86%) had pain prescribing guidance with 94 
(77%) having opioid prescribing guidance for noncancer pain.
- 88% of those providing interventional pain therapy 
had a process in place for managing accidental misplacement of an injection, with 92% having a process in place to manage adverse events with interventional pain therapy.

## Specific Treatment Protocols

- 47 (39%) graded referrals according to IASP guidance 
for immediate, urgent and routine referrals. It was unclear how patients were prioritised otherwise.

## Results Of The Patient Questionnaire At 12-Month Follow-Up

1,799 patients replied to the follow-up questionnaire at 12 months; this represents 38% of those were who sent the questionnaire. Overall this represents 17% of those who returned a questionnaire at baseline, i.e. Round 2. Of the 1,799 who responded, 1,626 (92.9%) continued to have pain. Their mean age was 59.4 with a standard deviation of 14.4, a minimum of 15 and maximum of 96 years.

Responder analysis revealed that the average age of the 12-month responders was 59 years (standard devia­ tion 15); range from 6 to 96 years with women account­ ing for 65% of patients. 70% had been referred by their GPs. 17% had neuropathic pain only, and the rest was a very mixed picture. In terms of site of pain, 77% had spinal pain including low back, neck pain and sciatica. Only 38% had been discharged by one year. This may be 

- 84 (69%) reported that cognitive behavioural therapy 
for pain was delivered by someone trained in CBT; 
none ticked not applicable. It appears the remaining 31% received CBT delivered by non-qualified individuals, which is of some concern.

## Appropriate Infrastructure In Place To Deliver Care

In total, 114 out of 121 (94%) of providers had sufficient ad­
ministrative support. All had wheelchair access. All had 
sufficient access to IT support to allow electronic letters; 
106 (88%) had sufficient access to carry out audit and all 
these reported carrying out regular audit. 

All multidisciplinary pain centres carried out 
                                              

audit and research.

## Note

 Less than half of services had a suicide risk 
assessment protocol or a process for acting on misdiagnosis 
 Most had a process for recording drug errors The majority had pain prescribing guidance, 
including opioid prescribing guidance 
 Most had a process in place for managing 
accidental misplacement of an injection and

adverse events

realistic in the sense that many patients are reluctant to be discharged, hence the fairly wide use (17%) of phone contact if necessary.

This responder cohort is in comparison with average 

age of the total cohort entered into Round 2 audit of 53 
years (range 1 to 98 years). Women account for 64% of 
patients and 22% had neuropathic pain alone. Therefore 
the average age of responders was slightly older than the 
original cohort. 

Ethnicity was collected for the first time in this audit 

round. The overwhelming ethnicity of respondents was 
white, reported at 92.9%. This may be a reflection either 
of the engagement in the audit at 12 months by a pre­
dominantly white population or of poorer access to pain 
clinics for non-white patients.

## Patient Quality Of Life And Pain Questionnaires

The full comparison of 12-month follow up data with zero and six month data can be found in Appendix 5. Outcomes are reported as a whole. Case-mix adjustment and by-site reporting is not reported for the reasons outlined in Methods (p13).

## Brief Pain Inventory

BPI pain
Pain average
Pain worst
Pain least
Pain now
Minimum
0
0
0
0
1st quartile
5
6
2
4
Mean (s.d.)
5.85 (2.19)
7.27 (2.29)
4.48 (2.63)
5.86 (2.77)
Median 
6
8
4
6
3rd quartile
7
9
6
8
Maximum
10
10
10
10
(N = 1712)
BPI interference
Total 
General 
Mood
Walking 
Normal 
Relationships
Sleep
Enjoyment 
interference
activiy
ability
work
of life
Minimum
0
0
0
0
0
0
0
0
1st quartile
4.29
5
3
4
5
2
4
4
Mean
6.13
6.51
5.76
6.33
6.67
4.78
6.12
6.46
(s.d.)
(2.58)
(2.87)
(3.07)
(3.12)
(2.97)
(3.27)
(3.17)
(3.03)
Median
6
7
6
7
7.5
5
7
7 
3rd quartile
8.29
9
8
9
9
8
9
9
Maximum
10
10
10
10
10
10
10
10
(N = 1712)
EQ-5D at 12 months
Overall health state 
Overall 

(0.100)
EQ-5D
Minimum
0
-0.07
1st quartile
30
0.20
Mean (s.d.)
50.99 (23.12)
0.43 (0.23)
Median
50
0.43
3rd quartile
70
0.66
Maximum
100
0.85
(N = 1712)
Mobility
Self-care
Usual activities
Pain
Anxiety/depression
EQ-5D
N 
%
N 
%
N 
%
N 
%
N 
%
No problems
340
18.9
874
48.6
211
11.7
85
4.7
614
34.1
Some impact
1,372
76.3
803
44.6
1,214
67.5
920
51.1
881
48.9
Severe impact
37
21
70
3.9
326
18.1
723
40.2
250
13.9
Invalid responses
50
2.8
52
2.9
48
2.7
71
3.9
55
3.1
Total
1,799
100
1,799
100
1,799
100
1,799
100
1,799
100

## Change In Average Pain Of The 12 Month Responders At Zero, Six, And 12 Months (Brief Pain Inventory) Information About Pain

1.	 Did you want information from your NHS service about your pain? 2.	 Were you given information about your pain from your NHS service?
3.	 If you were given information about your pain, how helpful was it? 
Of those who wanted information, 70.4% got it. Of those who got information, whether they had wanted it or not, 86.7% rated it fairly or very helpful 

| Yes                            | No   | Invalid   |
|--------------------------------|------|-----------|
| about your pain?               |      |           |
| 1,090                          | 447  | 69        |
| Review of information received |      |           |
| Yes                            | No   |           |
| Were you given information?    |      |           |
| Very helpful                   | 223  | 117       |
| Yes                            | 767  | 341       |
| Fairly helpful                 | 431  | 175       |
| No                             | 129  | 45        |
| Not at all helpful             | 108  | 45        |
| Do not recall                  | 185  | 61        |
| Do not recall                  | 5    | 4         |
| Invalid                        | 6    | -         |

4.	Which of these forms of information were you given, if any?

| Total receiving this form
                                        | % of 1,111 respondents   | Only form of information
       |
|----------------------------------------|--------------------------|-------|
| of information                         | given                    |       |
| Verbal information from your clinician | 1,091                    | 98.2  |
| Information leaflets                   | 575                      | 51.8  |
| Self-help guide                        | 230                      | 20.7  |
| How to access online resources         | 42                       | 3.8   |
| Other                                  | 102                      | 9.2   |
| I did not receive any information      | 277                      | 24.9  |
| No response                            | 173                      | -     |
| Total                                  |                          |       |
| -                                      | -                        | 1,284 |

## Advice About Managing Pain

5.	 Did you want advice from your NHS service about managing your pain? 6.	 Were you given advice from your NHS service about managing your pain? 7.	 If you were given advice about managing your pain, how helpful was it?

| Yes                            | No   | Invalid   |
|--------------------------------|------|-----------|
| managing your pain?            |      |           |
| Review of information received |      |           |
| 1,278                          | 411  | 58        |
| Yes                            | No   |           |
| Did you get information?       |      |           |
| Very helpful                   | 195  | 65        |
| Yes                            | 842  | 270       |
| Fairly helpful                 | 496  | 154       |
| No                             | 185  | 55        |
| Not at all helpful             | 140  | 42        |
| Do not recall                  | 166  | 55        |
| Do not recall                  | 11   | 9         |
| Invalid                        | 6    | -         |

8.	 Which of these forms of information were you given, if any?

|                                                       | Total   | % of 1,060 respondents   |   Only form of advice |
|-------------------------------------------------------|---------|--------------------------|-----------------------|
| Verbal information from your clinician                | 1,061   | 95.8                     |                   488 |
| Referral to another clinical or service for advice    | 407     | 38.5                     |                   134 |
| Advice leaflet                                        | 459     | 43.4                     |                    71 |
| Self-help guide                                       | 188     | 17.7                     |                    26 |
| How to access online resources                        | 41      | 3.9                      |                     6 |
| Other                                                 | 162     | 15.3                     |                    42 |
| Subtotal                                              |         |                          |                       |
| 767                                                   |         |                          |                       |
| I did not receive any advice on how to manage my pain | 299     | 28.2                     |                   299 |
| No response                                           | 170     | -                        |                   170 |
| Total*                                                |         |                          |                       |
| 3,042                                                 | -       | 1,230                    |                       |

## Treatments And Treatment Effects

9.	
What treatments did you receive from your NHS pain service?
10.	 Did you find these treatments helped to reduce your pain?

Treatment
Total N
As only 
Very helpful Moderate help
Little help
No help
treatment
Injections
1,034
247
68
65
64
46
Advice on medication
713
118
-
41
54
-
Physiotherapy
779
72
-
-
-
24
Pain Management Programme
518
54
-
-
-
-
Neurostimulation e.g. TENS
496
29
-
-
-
-
Psychology
123
12
-
-
-
-
Complementary therapies
194
3
-
-
-
-
Injections, physiotherapy
100
-
-
29
33
25
Injections, advice on medication
60
-
-
24
-
-
Injections, advice on medication, physiotherapy
50
-
-
20
21
-
Other
880
49
-
-
-
-
(N = 1158)

Most treatments were given in combination, as can be seen by the difference between the total number of 

Total responses to helpfulness of treatment questions
% of 1,672 
N
respondents
Very good help
263
15.7
Moderate help
486
29.1
Little help
576
34.4

patients who said they had each particular treatment and 
the number who had only that treatment. The most com­
mon combinations are represented, but there were many 
more reported by fewer than 20 respondents. Unfortu­
nately, the 'other' category was provided on the question­
naire without a request for further information, so it is 
unknown what respondents included in this category.

| No help   | 347   | 20.8   |
|-----------|-------|--------|

Helpfulness is only reported where 20 or more

| No response   | 115   |
|---------------|-------|
| Total*        |       |
| 1,787         | -     |

respondents endorsed the answer. Many gave sev­
eral answers, not only when they had received more 
than one treatment but even within a single treatment,

such as injections.

11.	 Did you need more than one type of treatment to gain pain reduction?

N
% of 1,652 
respondents
Yes
1,317
79.7
No
184
11.1
I do not recall
151
9.1
No response
147
-
Total
1,787
-

## Treatment Delivery

12.	 Do you feel that you were given adequate information about the risks of the treatments offered? 13.	 Do you feel that you were given adequate information about the benefits of the treatments offered?

|                 |       |             |                 | % of 1,691    | % of 1,682    |
|-----------------|-------|-------------|-----------------|---------------|---------------|
| Risks           | N     | respondents | Benefits        | N             | respondents   |
| Yes             | 1,118 | 66.1        | Yes             | 1,124         | 66.8          |
| No              | 319   | 18.9        | No              | 299           | 17.8          |
| I do not recall | 253   | 15.0        | I do not recall | 257           | 15.2          |
| No response     | 108   | -           | No response     | 117           | -             |
| Total           |       |             |                 |               |               |
| 1,799           | -     |             |                 |               |               |
| Total           |       |             |                 |               |               |
| 1,799           | -     |             |                 |               |               |

Two-thirds of patients felt they had enough information about the risks and benefits of treatment. There is room for a substantial improvement in this

## 14.	 How Satisfied Were You With Your Involvement In Planning Your Treatment?

% of 1,702 
N
respondents
Very satisfied
459
27.0
Fairly satisfied
743
43.7
Not satisfied
247
14.5
5
0.3
Not satisfied: I was not involved
248
14.6
I was not involved in planning my treatment
No response
93
-
Total
1,795
-

## 15.	 Were You Given Enough Time To Discuss Your Condition And Treatment?

% of 1,705 
N
respondents
Yes
1,142
67.0
No
329
19.3
I do not recall
227
13.3
7
0.4
I did not want to discuss my condition and treatment
No response
89
-
Total
1,794
-

## 16.	 Were You Offered A Point Of Contact If You Needed More Information After The Consultation?

% of 1,721 
N
respondents
Yes
807
46.9
No
600
34.9
I do not recall
314
18.2
No response
78
-
The number who reported a positive consultation and support afterwards was approximately to two-thirds of patients. It is unclear what patient expectations of care were. Variation between clinics was relatively small
Total
1,799
-

## 17.	 Have You Been Admitted To Hospital In The Past Six Months Due To Your Pain Condition?

% of 1,728 
N
respondents
Yes
279
16.1
No
1,429
83.0
I do not recall
20
1.2
16% of patients had been admitted to hospital due to their pain condition. Given the overall cohort this is unsurprising. However, not all hospitals have a specialist inpatient service to cater for their needs
No response
71
-
Total
1,799
-

## 18.	 Have You Been Discharged Completely From The Pain Service?

% of 1,476 
N
respondents
No
615
41.7
A substantial minority (40%) had not yet been discharged from care
Yes
605
41.0
256
17.3
Yes but I can contact the pain service for help e.g. by phone
No response
108
-
Total*
1,584
-

## 19.	 Does Your Pain Prevent You From Working Or Seeking Work?

% of 1,714 
N
respondents
No
387
22.6
Yes
566
33.0
Not applicable
761
44.4
No response
85
-
Total
1,799
-

## 20.	 If You Are In Work, Have You Had To Reduce Your Hours Due To Your Pain?

N
% 
No
247
56.0 of those in work
As with previous audits the ability to work is severely impacted by pain
Yes
194
44.0 of those in work
Subtotal to whom applicable
441
Not applicable
1,122
71.8 of respondents
No response
229
-
Total*
1,792
-

## Most Severely Affected Patients Single Site Analysis Of Healthcare Resource Use

(Heart of England Trust and Birmingham North and East Community Clinic)

To try to make some clinical sense of the case mix, we 
decided to extract the numbers of patients who scored in 
the 'severe' range (7–10) of both pain severity and pain 
interference on the BPI, and those who scored a total 
EQ-5D in the lowest quartile (< 0.151). This produced 768 
                                                      

patients (8%), with a median age of 53.

A more conservative criterion for the EQ-5D required 

This service has both in-hospital and out-of-hospital spe­
cialist pain services. 232 patient data were used to ana­
lyse healthcare resource use before and after attendance 
at pain management services. The hospital clinic re­
ported EQ-5D score of 0.34 in the hospital and 0.44 in the 
community clinic on arrival (i.e. below average), mean­
ing their overall quality of life was very low.

that patients scored <30/100 for overall health, had at 
least some problems in mobility and self-care, reported 
extreme pain, and moderate or extreme anxiety or de­
pression, and inability to perform usual activities. These 
criteria were decided on by three clinician authors, and 
produced 344 patients with a median age of 52.

in terms of EQ-5D 0.01, BPI severity 0.63, 0.99 change in 
pain interference. The hospital clinic changed by 0.02 in 
EQ-5D, 0.33 in BPI severity and pain interference of 0.45, 
despite the severe case-mix.

## Outpatient Attendances

|                  |     |       |     |     | Mobility   | Self-care   |
|------------------|-----|-------|-----|-----|------------|-------------|
| New              | Fup | Total | New | Fup | Total      | % reduction |
| Code description |     |       |     |     |            |             |
| Orthopaedics     | 56  | 112   | 168 | 34  | 70         | 104         |
| Rheumatology     | 10  | 73    | 83  | 6   | 28         | 34          |
| Total            | 66  | 185   | 251 | 40  | 98         | 138         |

Outpatient attendances fell by 45% overall, with rheumatology showing the greatest overall reduction. Other conditions were too small in number to be meaningful For A&E, pain-related attendances reduced from 56 to 50. Back pain and non-specific abdominal pain were the most common reason for attendance. Minor soft tissue injuries accounted for a significant number of attend­
ances (39), perhaps a reflection of overall poor function.

Although numbers fell overall there was a small 

non-admitted patients. These numbers were small and 
may be within normal fluctuations. Patients reported 
overall 21% attendances and 19% to A&E which correlates 
with Hospital Episode Statistics. Thus, despite heath 
gain being reported by patients, a substantial number 
are reliant on hospital services to manage their pain.

increase in hospital admissions and a decrease in 

## Discussion Services

Pain services have learned a great deal from this and pre­
vious audit rounds. Understanding of what is important, 
acceptable and possible to collect has been established. 
We have established clear methodologies, we understand 
where there are gaps, and the data generated will serve as 
a useful resource to shed further light on pain services.

Our findings from this audit suggest wide variation in 
how services are provided. Many services told a story 
of mergers and splits, with staff having to shift across 
boundaries to remain as a cohesive team. A typical 
scenario is a consultant providing nerve blockade in a

hospital setting with only fixed sessions, with the 
                                                      

Engagement in this audit round was far greater than 

remainder of the team in the community, communica­
tion is limited, risking fragmented care for patients. 
                                                  

It also entails serial referrals from one part of the service 
to another, rather than more effective and economical 
joint sessions.

previous audits. Services also seem to have been able to 
broaden the skills mix available to treat patients i.e. have 
become true multidisciplinary clinics. However much 
could be done to ensure that services are well matched 
to patient need.

number of services that fall into the specialised services 
specification is very small at present based on staffing 
levels and provision of highly specialist interventions. 

Overall, the community clinic improved quality of life 

Other providers cover huge geographical areas. The 

Darzi modelling of services was based on volume not on outcome, but we take the view that bigger clinics are not necessarily best.

The increase overall from 40% of providers to 67% 
being able to deliver multidisciplinary care represents a significant shift, though this may be a function of better data quality from this audit. Most treatments were given in combination; this is appropriate as most (almost 80%) of patients stated that they required more than one type of treatment to improve. This underlines the need for a multidisciplinary, multi-component approach.

However, many services continue to have a skills shortfall. Fewer than half were able to provide basic care at a clinic site through lack of sufficient skills, although a provider overall may deliver such treatments across a wider geographical area. This suggests that even the more straightforward patients will need to travel to re­ ceive treatment.

## Safety

While nearly all centres have policies in place to manage the complications of treatment and methods of treat­ ment, the majority have nothing in place to cover more fundamental issues such as review of misdiagnosis, and suicide risk. Both of these potentially carry a mortality risk and thus are important areas for guidance protocols for all staff. The lack of clear risk management protocols for suicide risk (44%) is concerning given the level of dis­ tress in this population. The lack of processes to learn from a missed serious pathology again questions the gov­ ernance of some services. The fragmentation of services may exacerbate shortcomings in governance. 

 There were significant gaps in clinical governance in relation to dealing with mental health risks and missed serious pathology

## Health Gain On Eq-5D And Bpi

Health gain on the questionnaires used was relatively 
modest overall. However, this may mask some patients 
who made substantial gains. The requirement to persist, 
as a recent review suggests, may mean that treatment 
may take a substantial period of time (beyond the time 
period of this audit).2 Services which fall short of recom­
mended provision are hoping that medical interventions 
will not only reduce pain but also reduce disability and 
distress, despite a large body of research showing that 
once pain has become chronic, it is unlikely that disabili­
ty and distress will be so easily improved. Hence the need 
for physical and psychological therapy to coincide with 
or follow medical treatment. Services clearly see a wide 
variation in severity, i.e. they are attempting to cater for a 
wide variety of needs on very stretched resources. 

As pain management is multispecialty, a better under­

standing of who is involved in managing patients with 
severe pain would be useful. There is currently no train­
ing programme in pain for non-anaesthetists. Recent 
studies report undergraduate education in pain remains 
                                                     

woefully poor with teaching confined to the classroom 
rather than out on the wards and in everyday practice. 
This deprives students of the opportunity to practise 
complex skills such as communication, problem solving 
and clinical decision making. It may also hinder staff re­
cruitment as practise of more advanced skills is confined 
to those who have decided to commit to working in such 
clinics. The number of multispecialty clinics was small 
(14%) implying that pain as a cross-cutting issue is not 
prioritised. 

## Responder Analysis

In terms of case mix we are aware that the sampling 
methods appear to have introduced bias against non-
white ethnic groups. It is unlikely that lack of fluency in 
English, the language of the questionnaire, accounts for 
a large part of this. The ethnicity of patients attending 
UK pain clinics has not been previously recorded; the 
non-white population was previously reported as under-
represented in a Canadian study.1 It would be useful to 
understand this better.

The current paper-based sampling was used in anticipation of the elderly population being substantially 
represented among respondents. Future audits need to 
utilise multiple sampling techniques, including web-
based. 

A significant minority is being admitted with compli­

cations of chronic pain yet inpatient services for these 
patients barely exist. How much gain is possible is un­
known for the general pain population. Very few get to 
pain rehabilitation programmes.

 Health gain is modest. When patients have an 
extremely poor quality of life and pain severity is high, substantial improvements are hard to achieve 

## Case Mix Healthcare Resource Use Single-Site Analysis

We now know more from other audits and from our own 
experience about what is important. In relation to co­
morbidity, the list of possible comorbidities can be made 
less daunting than a full set for patients to complete 
themselves. Very severely affected patients who might 
reasonably expect to require significantly enhanced 
                                                   

levels of care accounted for 8% of the case mix. It was 
                                                       

difficult to establish whether services are matched to 
need; this requires deeper analysis of the data.

ics but not across clinics because we have not allowed, 
for instance, for the deprivation index and other possi­
ble sources of difference. Future audits urgently need to 
identify other factors that can account for variation in 
referral rates of particular groups.

The single-site analysis showed that attendance at A&E changed very little over a longer time period, at variance to the patient report as per the *Final Report 2012*. Of note is that significant numbers of patients continue to be admitted for pain. This number fell within the first six months but further falls in hospital admissions did not occur. Further work needs to be done to characterise this population and the importance of having inpatient pro­ vision needs to be highlighted when planning services. However, attendance at musculoskeletal outpatients, such as orthopaedics and rheumatology, was significantly reduced. This outcome would have a large im­ pact on healthcare resource if the impact were the same throughout England and Wales.

 The single-site case study on healthcare resource 
use demonstrated a significant fall in outpatient attendances

## General Information On Pain

setting that is appropriate to need. Some pain clinic ad­
vice (notably to try to remain active or to increase the 
level and range of activity) goes against 'common sense' 
advice from family and friends, and not infrequently 
from healthcare providers, to rest and wait for the pain 
to remit.3 

and this varies considerably between individuals. Pain 
                                                      

The information collected from patients on processes of care was invaluable and sheds a useful light on the value of advice and information in this cohort. Much of this was verbal alone (55%). Although the sample size was relatively small, the fact that the proportion of patients reporting whether advice and information was useful did not vary by clinic suggests that it is important to derive tailor-made solutions that fit with a patient's processing ability.

For those patients who wanted information, 85% 
found it helpful. This compares favourably with back pain booklet trials and the usefulness of informationgiving on health in general. 90% of people reported that they had received advice on managing pain from a vari­ ety of sources.

Patients also seem to require far more information 

reduces concentration and attention, making processing 
of information even more difficult. Information needs 
to be provided in a way that is meaningful and retriev­
able, and is consistent across healthcare staff. Some writ­
ten/website information is available and of good quality 
(IASP, ARC, and others) and could be given to patients. 
However, this does not happen for multiple reasons. 
Usually it's nobody's job to restock information stands 
for patients, or on staff's desks, but also it takes time to 
establish what patients do and don't understand, and to 
try to make information relevant to their particular his­
tory, situation and level of comprehension.

than is anticipated by services. Many people who attend a service are likely to struggle to maintain concentra­ tion. Further research is needed into how patients wish to receive information and in what form in a pain clinic Outcome data can be compared internally within clin­

 Very severely affected patients who might 
reasonably expect to require significantly enhanced levels of care accounted for 8% of the case mix

Patients need to be able to process information, 

## Information On Treatments

Nearly 19% of patients reported that they were not given 
adequate information on the risks of treatment. Only 18% 
felt that they had insufficient information on the benefits 
of treatment. This suggests that there is still some way to 
go on fully informed choice. A majority (71%) were satis­
fied with being involved in planning treatment, although 
many reported wanting more time to go over options and 
further contact to discuss these. This suggests that de­
cision aids4 and the process of shared decision making, 
which is an NHS priority, could work well in this setting. 
Services need to evaluate the need for more information 
on treatment choices to improve outcomes. 

45% reported treatment as being moderately or very 

helpful. Treatment helpfulness has been previously ex­
plored5 and it is vital that centres understand which 
treatments patients attending their service are finding 
the most helpful.

 Many patients report needing more time to go 

over treatment options

## Learning For Future Audits

This audit produced a much greater response than the 
initial audit. This has been seen in other national audits, 
where participation rates have grown as the outputs be­
gin to have an impact. In terms of provider responses the 
multiplicity of pain service models is a challenge and re­
quires greater understanding before determining how to 
contact each site in the future.

In terms of patients the response rate overall was 
                                                  

better than expected. However, future audits should 
use multiple methods of engaging with patients, such as online tools and paper copies to cover more of the 
population. 

Greater investment in clinical engagement and clini­

cal input to future audits is needed. The need to engage 
with colleagues and a depth of understanding of poten­
tial idiosyncrasies would greatly improve the quality and 
quantity of data returns.

## Work

Patients report that work is severely affected by pain and this continues to be the case a year after treatment. 

Services should include specific vocational rehabilita­
tion to either return people to new work or retain people 
in their employment. This has previously been trialled 
successfully and NICE guidance is available yet seems to 
be ignored by service planners.6

Thought needs to be given to this prior to future 

sampling in order to ensure case-mix adjustment is 
                                                  

adequately covered. Factors such as comorbidity, ethnic­
ity and socio-economic factors may be important. 

The web-based Find a Clinic function has worked well 

and led to significant feedback from clinics. Linking to 
                                                        

patient facing websites has also been useful. 

A recent Improving Access to Psychological Therapies 
audit commented that routine data collection is crucial, and should be part of training and treatment protocols. We would support clinics developing collection systems and some of the standards developed can be useful to support audit within clinics. Clinics are often short of time, staff, and software to assess routinely and to ana­ lyse data, and this needs further discussion.

## Conclusions

Participation in the National Pain Audit has been generally good. The audit has demonstrated that it is possible to develop measures and apply clear standards of care to pain services. Many of these standards could now be adopted nationally. Case-mix adjustment is in its infancy for pain management; significant development is needed. The case study on healthcare resource use yielded interesting data but requires wider testing. 

governance in the area of clinical assessment is less ro­
bust. A great deal is now known about treatment of peo­
ple with moderate to severe pain, but less is known about 
services where pain is part of another condition and spe­
cialist care is not accessed. people in pain, characterised them and looked at the 
quality of care provided by them. Future audits should 
seek to understand in greater depth how patients are 
benefiting from this care and the impact of such services 
on NHS resources. 

A significant proportion of patients are severely disabled and distressed and there needs to be clear provision for this cohort. Skills available to manage these patients still fall short of what is needed, though the increase in multidisciplinary care is encouraging. There are many levels of provision, and services go from very small to very large. Services can be frequently fragmented, lead­ ing to patients having to move between providers. As patients are highly disabled and struggle to maintain concentration, this fragmentation may be expensive for both the patient and commissioner. Whether services are matched to need requires greater attention. Pain has a major impact on work, yet there is little research on how health services can best help people in pain return to work or retain work. 

Whilst safety protocols are apparent for treatment, This audit has found where specialist services are for 

## Appendix 1 12-Month Follow-Up Questionnaire Items

Brief Pain Inventory follow-up questionnaire (11 items) EuroQol 5D-3L (six items including thermometer) Ethnic Group (one of six items)

## Did You Want Information From Your Nhs Service About Your Pain?

- Were you given information about your pain from your NHS service? - If you were given information about your pain, how helpful was it? - Which of these forms of information were you given, if any?

## Did You Want Advice From Your Nhs Service About Managing Your Pain?

- If you were given advice about managing your pain, how helpful was it? - What forms of advice about managing your pain were you given? 

## Treatments Received From An Nhs Pain Service

- Requiring more than one treatment to reduce pain - Treatment helpfulness

## Involvement In Treatment Planning

- Do you feel that you were given adequate information about the risks of the treatments offered? (Y/N) - Do you feel that you were given adequate information about the benefits of the treatments offered? (Y/N) - How satisfied were you with your involvement in planning your treatment? (VRS four items) - Were you given enough time to discuss your condition and treatment? (Y/N) - Were you offered a point of contact if you needed more information after the consultation? (Y/N)

## Work-Related Questions

- Does your pain prevent you from working or seeking work? (Y/N) - If you are in work, have you had to reduce your hours due to your pain? (Y/N)

## Appendix 2 A: Patient Questionnaire

Brief Pain Inventory
Clinically significant change = 1 point or half a SD on BPI interference subscale mean Both pre- and post-case-mix adjustment
Excellent/good
80% reported receiving advice and guidance 
Number who wanted information on managing pain reporting it as helpful
Excellent/good
80 % reported excellent/good
Number who wanted advice on managing pain  reporting it as helpful Additional support provided
Excellent/good
80 % reported excellent/good
Help and advice 
Excellent/good
80 % reported excellent/good
Involvement in planning care 
Excellent/good
80 % reported excellent/good

## B: Provider Questionnaire

| Item                                                    | Audit standard                                       | Demonstrated by                     |
|---------------------------------------------------------|------------------------------------------------------|-------------------------------------|
| Report overall number of providers who returned a       |                                                      |                                     |
| questionnaire (internal audit standard)                 |                                                      |                                     |
| Identified service completed data                       |                                                      |                                     |
| return                                                  |                                                      |                                     |
| Data completeness                                       | 100 % fields completed                               | % of questionnaire fully completed  |
| Data correctness                                        | 100% completed correctly - for location and          |                                     |
| treatments as inpatients reported                       |                                                      |                                     |
| Staffing: clinical                                      | Level 1: multidisciplinary team of psychology,       |                                     |
| doctor and physio                                       |                                                      |                                     |
| Involvement in planning care                            | Level 2: enhanced multidisciplinary team: multidisci­ |                                     |
| plinary team plus at least one of nursing, pharmacy or  |                                                      |                                     |
| occupational therapists as per RCOA guidance            |                                                      |                                     |
| Level 3: multispecialty service: enhanced multidiscipli­ |                                                      |                                     |
| nary team plus more than one medical specialty          |                                                      |                                     |
| as per service specification                            |                                                      |                                     |
| Co-ordination of care: multidisciplinary team           |                                                      |                                     |
| meeting to discuss patient care                         |                                                      |                                     |
| Presence of inpatient pain service for complex cases    | 100% acute providers                                 |                                     |
| 24/7 availability of staff                              | Report                                               | Staffing inpatients with persistent |
| pain (hospital-based services only)                     |                                                      |                                     |
| Established risk assessment protocol for acting         |                                                      |                                     |
| on potential suicide risk                               |                                                      |                                     |
| For neuro-modulation and                                |                                                      |                                     |
| intrathecal pump insertion                              |                                                      |                                     |
| (spinal cord stimulation) services                      |                                                      |                                     |
% of patients attending facility who achieved clinically significant change
% returned/total number of known providers Cross tab with known data from HES, routine statistics under 191 code 100% No standard applied, just report No standard report, numbers only 100% 100% providers
| Item                                                   | Audit standard                                         | Demonstrated by                   |
|--------------------------------------------------------|--------------------------------------------------------|-----------------------------------|
| Mental health support                                  | Established risk assessment protocol for acting on     |                                   |
| misdiagnosis                                           |                                                        |                                   |
| Missed diagnosis                                       | Staff have easy access to the policy                   | 100% providers easy access        |
| SUI policy access                                      | Yes/No                                                 | 100% yes                          |
| Drug errors recording process                          | Yes/No                                                 | 100% yes                          |
| Yes/No                                                 | 100% yes                                               | Organisational guidance on pain   |
| prescribing                                            |                                                        |                                   |
| Opioid prescribing guidance                            | Yes/No                                                 | 100% yes                          |
| CBT by CBT practitioner                                | Yes/No                                                 | 100% yes                          |
| CBT review after six sessions                          | Yes/No                                                 | 100% yes                          |
| Yes/No                                                 | 100% yes                                               | Interventional treatments wrong   |
| placement policy                                       |                                                        |                                   |
| Yes/No                                                 | 100% yes                                               | Interventional treatments adverse |
| events protocol                                        |                                                        |                                   |
| Administrative support                                 | Access to administrative support                       | 100% providers                    |
| 100% have access 2.1 GPAS                              | 100% providers                                         | Access to pharmacy support for    |
| medicine advice                                        |                                                        |                                   |
| Administrative Support                                 | Access to administrative support                       | 100%                              |
| Wheelchair access                                      | Wheelchair access                                      | 100%                              |
| IT support                                             | Service has computerised access to notes and for audit |                                   |
| purposes                                               |                                                        |                                   |
| Timely access to care                                  | IASP standards on waiting times                        |                                   |
| < 1 week for emergency cases                           |                                                        |                                   |
| < 1 month for urgent  cases                            | Report figure                                          |                                   |
| < 1 month for urgent  cases                            | Report figure                                          |                                   |
| < 8 weeks for routine cases                            | Report figure                                          |                                   |
| < 18 weeks for UK time to first treatment              | Report figure                                          |                                   |
| Carry out regular supporting                           |                                                        |                                   |
| professional activities                                |                                                        |                                   |
| Teaching  students - for those listed as multidiscipli­ |                                                        |                                   |
| nary pain centre by region                             |                                                        |                                   |
| Audit - all centres                                    | 100% audit                                             |                                   |
| Research - for those listed as multidisciplinary pain  |                                                        |                                   |
| centre by region                                       |                                                        |                                   |
| 100% providers                                         |                                                        |                                   |
| 100%                                                   |                                                        |                                   |
| Report figure                                          |                                                        |                                   |
| 100% teach                                             |                                                        |                                   |
| 100% research                                          |                                                        |                                   |

## Appendix 3 Shape And Form Of Participating Providers

|                                                     | Provider   | Type of provider                                 |
|-----------------------------------------------------|------------|--------------------------------------------------|
| Taunton FT                                          | Acute      | 8                                                |
| Dorset County                                       | Acute      | 2                                                |
| Bristol                                             | Acute      | 3                                                |
| St Helens and Knowsley Hospitals NHS Trust          | Acute      | 2                                                |
| Luton and Dunstable                                 | Acute      | 3                                                |
| Harrogate and District NHS Foundation Trust         | Acute      | 2                                                |
| Acute                                               | 3          | Heatherwood and Wrexham Park Hospitals NHS       |
| Foundation Trust                                    |            |                                                  |
| Acute                                               | 2          | Basildon and Thurrock University Hospitals NHS   |
| Foundation Trust                                    |            |                                                  |
| Acute                                               | 2          | The Royal Bournemouth and Christchurch Hospitals |
| NHS Foundation Trust                                |            |                                                  |
| Royal Cornwall Hospitals NHS Trust                  | Acute      | 3                                                |
| Acute                                               | 2          | Peterborough and Stamford Hospitals NHS          |
| Foundation Trust                                    |            |                                                  |
| Royal Berkshire NHS Foundation Trust                | Acute      | 2                                                |
| Acute                                               | 3          | Northern Lincolnshire and Goole Hospitals NHS    |
| Foundation Trust                                    |            |                                                  |
| Acute                                               | 2          | University Hospitals Coventry and Warwickshire   |
| NHS Trust                                           |            |                                                  |
| Bolton NHS Foundation Trust                         | Acute      | 2                                                |
| Acute                                               | 2          | Chelsea and Westminster Hospital NHS             |
| Foundation Trust                                    |            |                                                  |
| Homerton University Hospital NHS Foundation Trust   | Acute      | 2                                                |
| Heart of England NHS Foundation Trust               | Acute      | 3                                                |
| Gateshead Health NHS Foundation Trust               | Acute      | 5                                                |
| Leeds Teaching Hospitals NHS Trust                  | Acute      | 3                                                |
| Wrightington, Wigan and Leigh NHS Foundation Trust  | Acute      | 3                                                |
| Royal Brompton Harefield NHS Foundation Trust       | Acute      | 3                                                |
| Northumbria Healthcare NHS Foundation Trust         | Acute      | 4                                                |
| South Tees Hospitals NHS Foundation Trust           | Acute      | 3                                                |
| Acute                                               | 4          | University Hospitals of Morecambe Bay NHS        |
| Foundation Trust                                    |            |                                                  |
| East Kent Hospitals University NHS Foundation Trust | Acute      | 4                                                |
| North Tees and Hartlepool NHS Foundation Trust      | Acute      | 3                                                |
| Southport and Ormskirk Hospital NHS Trust           | Acute      | 4                                                |
| Pennine Acute Hospitals NHS Trust                   | Acute      | 4                                                |
Number

of services
|                                                      | Provider   |   Type of provider |
|------------------------------------------------------|------------|--------------------|
| United Lincolnshire Hospitals NHS Trust              | Acute      |                  7 |
| University Hospitals of Leicester NHS Trust          | Acute      |                  4 |
| Maidstone and Tunbridge Wells NHS Trust              | Acute      |                  3 |
| East and North Hertfordshire NHS Trust               | Acute      |                  3 |
| Nottingham University Hospitals NHS Trust            | Acute      |                  3 |
| East Sussex Hospitals NHS Trust                      | Acute      |                  2 |
| Mid Yorkshire Hospitals NHS Trust                    | Acute      |                  2 |
| Brighton and Sussex University Hospitals NHS Trust   | Acute      |                  2 |
| Sandwell and West Birmingham Hospitals NHS Trust     | Acute      |                  2 |
| East Lancashire Hospitals NHS Trust                  | Acute      |                  3 |
| The Shrewsbury and Telford Hospital NHS Trust        | Acute      |                  3 |
| Imperial College Healthcare NHS Trust                | Acute      |                  2 |
| South London Healthcare NHS Trust                    | Acute      |                  5 |
| Western Sussex Hospitals NHS Trust                   | Acute      |                  3 |
| Pain Management Solutions                            | AQP        |                  3 |
| University Hospital of North Staffordshire NHS Trust | Acute      |                  3 |

## Services Describing Different Clinics Operating Separately On One Site

|                                             | Provider   | Type of provider                                    |
|---------------------------------------------|------------|-----------------------------------------------------|
| Salisbury NHS Foundation Trust              | Acute      | 3                                                   |
| Acute                                       | 5          | Royal Liverpool and Broadgreen University Hospitals |
| NHS Trust                                   |            |                                                     |
| University Hospitals of Leicester NHS Trust | Acute      | 2 (specialised separately)                          |
| Buckinghamshire Hospitals NHS Trust         | Acute      | 2                                                   |
| Number                                      |            |                                                     |
| of services                                 |            |                                                     |
| Number                                      |            |                                                     |
| of services                                 |            |                                                     |

## Appendix 4

Providers who successfully submitted returns and were included in the analysis

## Acute Trusts

Ashford and St Peter's Hospitals NHS Foundation Trust Heatherwood and Wrexham Park Hospitals NHS Foundation Trust Barking, Havering and Redbridge University Hospitals NHS Trust Hinchingbrooke Health Care NHS Trust Basildon and Thurrock University Hospitals NHS Foundation Trust Homerton University Hospital NHS Foundation Trust Bedford Hospital NHS Trust Hull and East Yorkshire Hospitals NHS Trust Bolton NHS Foundation Trust Imperial College Healthcare NHS Trust Bradford Teaching Hospitals NHS Foundation Trust Ipswich Hospital NHS Trust Brighton and Sussex University Hospitals NHS Trust Isle of Wight NHS Trust Buckinghamshire Healthcare NHS Trust James Paget University Hospitals NHS Foundation Trust Burton Hospitals NHS Foundation Trust King's College Hospital NHS Foundation Trust Calderdale and Huddersfield NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Cambridge University Hospitals NHS Foundation Trust Leeds Teaching Hospitals NHS Trust Chelsea and Westminster Hospital NHS Foundation Trust Liverpool Women's NHS Foundation Trust Chesterfield Royal Hospital NHS Foundation Trust Luton and Dunstable Hospital NHS Foundation Trust City Hospitals Sunderland NHS Foundation Trust Maidstone and Tunbridge Wells NHS Trust Colchester Hospital University NHS Foundation Trust Medway NHS Foundation Trust County Durham and Darlington NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust Dartford and Gravesham NHS Trust Mid Essex Hospital Services NHS Trust Derby Hospitals NHS Foundation Trust Mid Staffordshire NHS Foundation Trust Dorset County Hospital NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust The Dudley Group NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust East and North Hertfordshire NHS Trust Norfolk and Norwich University Hospitals NHS Foundation Trust East Cheshire NHS Trust North Bristol NHS Trust East Kent Hospitals University NHS Foundation Trust North Cumbria University Hospitals NHS Trust East Lancashire Hospitals NHS Trust North Tees and Hartlepool NHS Foundation Trust East Sussex Healthcare NHS Trust Northampton General Hospital NHS Trust Epsom and St Helier University Hospitals NHS Trust Northern Devon Healthcare NHS Trust Frimley Park Hospital NHS Foundation Trust Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Gateshead Health NHS Foundation Trust Northumbria Healthcare NHS Foundation Trust George Eliot Hospital NHS Trust Nottingham University Hospitals NHS Trust Gloucestershire Hospitals NHS Foundation Trust Papworth Hospital NHS Foundation Trust Great Western Hospitals NHS Foundation Trust Pennine Acute Hospitals NHS Trust Guy's and St Thomas' NHS Foundation Trust Peterborough and Stamford Hospitals NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust Plymouth Hospitals NHS Trust Harrogate and District NHS Foundation Trust Poole Hospital NHS Foundation Trust Heart of England NHS Foundation Trust Portsmouth Hospitals NHS Trust 

## Acute Trusts

Royal Berkshire NHS Foundation Trust The Lewisham Healthcare NHS Trust Royal Brompton and Harefield NHS Foundation Trust The Newcastle Upon Tyne Hospitals NHS Foundation Trust 

Royal Cornwall Hospitals NHS Trust 
The Queen Elizabeth Hospital, King's Lynn. NHS Foundation Trust 
Royal Devon and Exeter NHS Foundation Trust The Rotherham NHS Foundation Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust Royal National Orthopaedic Hospital NHS Trust The Royal Marsden NHS Foundation Trust Royal Surrey County NHS Foundation Trust The Walton Centre NHS Foundation Trust Royal United Hospital Bath NHS Trust United Lincolnshire Hospitals NHS Trust Salford Royal NHS Foundation Trust University College London Hospitals NHS Foundation Trust Salisbury NHS Foundation Trust University Hospital Birmingham NHS Foundation Trust Sandwell and West Birmingham Hospitals NHS Trust University Hospital of North Staffordshire NHS Trust Sheffield Teaching Hospitals NHS Foundation Trust University Hospital of South Manchester NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation Trust University Hospital Southampton NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust University Hospitals Bristol NHS Foundation Trust South Devon Healthcare NHS Foundation Trust University Hospitals Coventry and Warwickshire NHS Trust South London Healthcare NHS Trust University Hospitals of Leicester NHS Trust South Tees Hospitals NHS Foundation Trust University Hospitals of Morecambe Bay NHS Foundation Trust South Warwickshire NHS Foundation Trust West Hertfordshire Hospitals NHS Trust Southend University Hospital NHS Foundation Trust West Middlesex University Hospital NHS Trust Southport and Ormskirk Hospital NHS Trust West Suffolk NHS Foundation Trust St George's Healthcare NHS Trust Western Sussex Hospitals NHS Trust 

## St Helens And Knowsley Hospitals Nhs Trust Weston Area Health Nhs Trust

Stockport NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Surrey and Sussex Healthcare NHS Trust Worcestershire Acute Hospitals NHS Trust Tameside Hospital NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Taunton and Somerset NHS Foundation Trust Wye Valley NHS Trust The Dudley Group NHS Foundation Trust York Teaching Hospital NHS Foundation Trust The Hillingdon Hospitals NHS Foundation Trust

## Independent Sector Treatment Centres Community Trusts

BMI Goring Hall
Central London Community Healthcare NHS Trust
Derbyshire Community Health Services NHS Trust Dorset Healthcare University NHS Foundation Trust

## Welsh Providers

Leeds Community Healthcare NHS Trust Betsi Cadwaladr University Health Board Solent NHS Trust Cardiff and Vale University Health Board

## Any Qualified Providers Children'S Services

Dorking Healthcare LLP
Alder Hey Children's NHS Foundation Trust Angel and Bowden Great Ormond Street Hospital for Children NHS Foundation Trust Pain Management Solutions Royal National Hospital for Rheumatic Diseases NHS Foundation Trust University Hospitals of Leicester NHS Trust Bristol Children's Hospital University Hospital Leeds Manchester Children's Hospital  

## Community Trusts Bridgewater Community Healthcare Nhs Trust Norfolk Community Health And Care Nhs Trust

Cambridgeshire Community Services NHS Trust Pennine Care NHS Foundation Trust Central and North West London NHS Foundation Trust Shropshire Community Health NHS Trust Hounslow and Richmond Community Healthcare NHS Trust Torbay and Southern Devon Health and Care NHS Trust Lancashire Care NHS Foundation Trust Wirral Community NHS Trust Lincolnshire Community Health Services NHS Trust Worcestershire Health and Care NHS Trust Liverpool Community Health NHS Trust

## Mental Health Trusts

Cheshire and Wirral Partnership NHS Foundation Trust Northumberland, Tyne and Wear NHS Foundation Trust Cornwall Partnership NHS Foundation Trust Nottinghamshire Healthcare NHS Trust Coventry and Warwickshire Partnership NHS Trust Oxford Health NHS Foundation Trust Cumbria Partnership NHS Foundation Trust Oxfordshire Learning Disability NHS Trust Devon Partnership NHS Trust Oxleas NHS Foundation Trust Dudley and Walsall Mental Health Partnership NHS Trust Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust East London NHS Foundation Trust Greater Manchester West Mental Health NHS Foundation Trust Somerset Partnership NHS Foundation Trust Hertfordshire Partnership NHS Foundation Trust South Essex Partnership University NHS Foundation Trust Kent and Medway NHS and Social Care Partnership Trust South London and Maudsley NHS Foundation Trust Leicestershire Partnership NHS Trust South Staffordshire and Shropshire Healthcare NHS Foundation Trust Lincolnshire Partnership NHS Foundation Trust South West London and St George's Mental Health NHS Trust Manchester Mental Health and Social Care Trust South West Yorkshire Partnership NHS Foundation Trust Mersey Care NHS Trust Surrey and Borders Partnership NHS Foundation Trust Norfolk and Suffolk NHS Foundation Trust Sussex Partnership NHS Foundation Trust North Essex Partnership NHS Foundation Trust Leeds and York Partnership NHS Foundation Trust North Staffordshire Combined Healthcare NHS Trust

## Acute Trusts

Central Manchester University Hospitals NHS Foundation Trust Ealing Hospital NHS Trust Moorfields Eye Hospital NHS Foundation Trust The Christie NHS Foundation Trust The Clatterbridge Cancer Centre NHS Foundation Trust The Princess Alexandra Hospital NHS Trust Warrington and Halton Hospitals NHS Foundation Trust Aintree University Hospital NHS Foundation Trust Hertfordshire Partnership NHS Foundation Trust Kent and Medway NHS and Social Care Partnership Trust Leicestershire Partnership NHS Trust Lincolnshire Partnership NHS Foundation Trust Manchester Mental Health and Social Care Trust Mersey Care NHS Trust Norfolk and Suffolk NHS Foundation Trust North Essex Partnership NHS Foundation Trust Providers who submitted late returns and thus were not included in the analysis but have been matched on the Find a Clinic function on www.nationalpainaudit.org Barnet and Chase Farm Hospitals Barts and the Royal London University Hospitals Croydon University Hospitals FT Oxford University Hospitals FT Royal Free Hospital Royal Hospital for Rheumatic Diseases The Royal Wolverhampton NHS Trust South Yorkshire and Bassetlaw Pain Management Service Aneurin Bevan Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf Health Board Hywel Dda Health Board Powys Teaching Health Board Mersey Care NHS Trust Norfolk and Suffolk NHS Foundation Trust North Essex Partnership NHS Foundation Trust Providers who were identified as having pain management services but did not submit a return

## Providers Who Confirmed They Did Not Have A Pain Service

Birmingham Children's Hospital NHS Foundation Trust

## Central Manchester Hospitals

Camden and Islington NHS Foundation Trust (CHECK)
The Christie NHS Foundation Trust Derbyshire Healthcare Foundation Trust (CHECK)
The Clatterbridge Cancer Centre NHS Foundation Trust Countess of Chester Hospitals Ealing Hospital Doncaster and Bassetlaw FT
Moorfields Eye Hospital Kent Community Health NHS Trust The Royal Orthopaedic Hospital NHS Foundation Trust Hertfordshire Community NHS Trust Warrington and Halton Hospitals NHS Foundation Trust Humber NHS Foundation Trust Kettering General Hospital Northamptonshire Healthcare NHS Foundation Trust Liverpool Heart and Chest Hospital North Middlesex University Hospital Norfolk and Norwich Hospitals FT Children's Services Oxford Children's Pain Services Pennine MSK Services Robert Jones and Agnes Hunt Hospital Royal  Hospital for Rheumatic diseases Children's Service Southampton NHS Treatment Centre The Whittingdon Hospital London Walsall Healthcare NHS Trust 

## Appendix 5 Changes In Pain Severity, Pain Interference And Quality Of Life Over The 12-Month Audit Period

| Pain average
              | Pain average   | Pain average   | Pain worst   | Pain worst   | Pain worst   |
|--------------|----------------|----------------|--------------|--------------|--------------|
| 0m           | 6m             | 12m            | 0m           | 6m           | 12m          |
| Minimum      | 0              | 0              | 0            | 0            | 0            |
| 1st quartile | 5              | 5              | 5            | 7            | 6            |
| Mean (s.d.)  | 6.49 (1.89)    | 5.85           | 5.85 (2.19)  | 7.86 (1.80)  | 7.24 (2.21)  |
| Median       | 7              | 6              | 6            | 8            | 8            |
| 3rd quartile | 8              | 7              | 7            | 9            | 9            |
| Maximum      | 10             | 10             | 10           | 10           | 10           |
| Pain least   | Pain least     | Pain least     | Pain now     | Pain now     | Pain now     |
| 0m           | 6m             | 12m            | 0m           | 6m           | 12m          |
| Minimum      | 0              | 0              | 0            | 0            | 0            |
| 1st quartile | 3              | 2              | 4            | 7            | 4            |
| Mean (s.d.)  | 4.84 (2.533)   | 4.48 (2.63)    | 5.85 (2.19)  | 6.12 (2.5)   | 5.77         |
| Median       | 5              | 4              | 6            | 7            | 6            |
| 3rd quartile | 7              | 6              | 7            | 8            | 8            |
| Maximum      | 10             | 10             | 10           | 10           | 10           |

## Appendix 6 Changes In Pain Interface

| General activity   | General activity   | General activity   |
|--------------------|--------------------|--------------------|
| 0m                 | 6m                 | 12m                |
| Minimum            | 0                  | 0                  |
| 1st quartile       | 6                  | 5                  |
| Mean (s.d.)        | 7.12 (2.41)        | 6.51 (2.82)        |
| Median             | 8                  | 7                  |
| 3rd quartile       | 9                  | 9                  |
| Maximum            | 10                 | 10                 |
| Walking ability    | Walking ability    | Walking ability    |
| 0m                 | 6m                 | 12m                |
| Minimum            | 0                  | 0                  |
| 1st quartile       | 5                  | 4                  |
| Mean (s.d.)        | 6.70 (3.06)        | 6.28 (3.23)        |
| Median             | 8                  | 7                  |
| 3rd quartile       | 9                  | 9                  |
| Maximum            | 10                 | 10                 |
| Relationships      | Relationships      | Relationships      |
| 0m                 | 6m                 | 12m                |
| Minimum            | 0                  | 0                  |
| 1st quartile       | 3                  | 2                  |
| Mean (s.d.)        | 5.07 (3.14)        | 4.81 (3.23)        |
| Median             | 6                  | 5                  |
| 3rd quartile       | 8                  | 8                  |
| Maximum            | 10                 | 10                 |
| Enjoyment of life  | Enjoyment of life  | Enjoyment of life  |
| 0m                 | 0m                 |                    |
| Minimum            | 0                  | 0                  |
| 1st quartile       | 5                  | 5                  |
| Mean (s.d.)        | 7.06 (2.56)        | 6.54 (2.9)         |
| Median             | 8                  | 7                  |
| 3rd quartile       | 9                  | 9                  |
| Maximum            | 10                 | 10                 |
| Mood               | Mood               | Mood               |
| 0m                 | 6m                 | 12m                |
| Normal work        | Normal work        | Normal work        |
| 0m                 | 6m                 | 12m                |
| Sleep              | Sleep              | Sleep              |
| 0m                 | 6m                 | 12m                |
| 0m                 |                    |                    |

## Changes In Eq5D-3L Scores From Baseline To 12 Months

|               |               | Overall
              | Overall
               | Overall
              |
|---------------|---------------|--------------|---------------|--------------|
| Overall EQ-5D | Overall EQ-5D | health state | Overall EQ-5D | health state |
| (0-100) 0m    | 0m            |              |               |              |
| health state  |               |              |               |              |
| (0-100) 6m    | 6m            | (0-100) 12m  | 12m           |              |
| Minimum       | 0             | -0.021       | 0             | -0.021       |
| 1st quartile  | 30            | 0.238        | 32            | 0.2          |
| Mean (s.d.)   | 51            | 0.49 (0.27)  | 50.44 (22.97) | 0.4 (0.24)   |
| Median        | 50            | 0.534        | 50            | 0.37         |
| 3rd quartile  | 70            | 0.73         | 70            | 0.6          |
| Maximum       | 100           | 0.845        | 100           | 0.814        |

## Stakeholder Feedback Patient Liaison Group British Pain Society

Many people may feel that the National Pain Audit 
is nothing to do with them — it's an audit of services 
that professionals look at to evaluate what is going on 
                                                 

by their pain. In contrast staffing levels that can deliver 
multidisciplinary treatment are a concern for too many 
clinics and cannot be ignored. The number of clinics 
setup for specialised care is too low, meaning there is no 
regional leadership, and worrying low numbers of non-
English speakers are accessing pain services. 

nationally.  In fact it is all about the people that the ser­ vice looks after, what happens to them in the service and to help individuals live their lives with their pain and maybe to relieve pain somewhat.

From the patient perspective you expect to be seen to ask for it, it's a catch 22. How much information do you give patients and their families about your services? es and finding the solutions is not always easy. Develop­ ing a cycle of continuous audit, evaluation, consultation, implementation and audit again is not rocket science but it takes courage and leadership to make changes.

fast (really fast when in pain as every day can feel like a lifetime). You want a service that is safe, efficient and you don't even think that it would be any different anywhere else. Most patients think the NHS is the same all over — the National Pain Audit is proof that this is not true and has highlighted the poor quality of life that people living with pain experience. 

The audit does show that multidisciplinary treat­
ments are better but that it needs to be for a length of time that fits the patient's needs; it is not a one size fits all. Some patients need regular attendance to manage their pain effectively, and some are very severely affected 

still do the day job and do it with compassion and empa­
thy. In doing so more people living in pain will lead more 
fulfilling lives and perhaps return to work. The benefits 
don't just stop with the patient but extend to their family, 
friends and co-workers.

## The Chronic Pain Policy Coalition

recommendations of the first English Pain Summit and will provide vital data to support the continued commis­ sioning of high quality pain services.

Since its inception in 2006, the Chronic Pain Policy Coa­ lition has been campaigning for improved pain manage­ ment services in England. Crucial to achieving this goal has been the availability of robust information on avail­ ability and performance of pain management services. To this end, the National Pain Audit has been a crucial resource and we welcome this fourth stage report. We are particularly heartened by the rise in multidiscipli­ nary pain services and the improved participation in the Audit. This report will be crucial in supporting the 

currently under review and is in a state of flux with con­
sideration of specialised tertiary and specialist second­
ary care pain management services and community and 
primary based services. This Audit has once again pro­
vided robust evidence of their importance and value in 
the management of patients with persistent pain. 

Patients need information about a service to be able Getting to the root of the problems in your local servic­ Pain services need to do this — follow the guidance — 

The commissioning of Pain Management Services is 

## Faculty Of Pain Medicine

The Faculty of Pain Medicine is the professional body re­ sponsible for the training, assessment, on-going practice and educational development of specialist medical prac­ titioners dealing with pain issues in the United Kingdom. Its core mission is to serve the community by promoting professional excellence. Advancing high quality pain practice is thus fully integrated with optimising patient care. 

## Royal College Of General Practitioners (Placeholder)

The authors of the fourth round of the continuing 

National Pain Audit (NPA) continue to give important insight into the complexities of pain services in England (and Wales).  Pain remains a Clinical Priority for the Roy­ al College of General Practitioners, which has a specific responsibility following the National Pain Summit to produce guidance on the commissioning pain services. 

This version of the NPA gives important reflections on some of the changing dynamics in pain services that are happening due to the reorganization of the NHS. The commissioning support document for pain profession­ als is about to be published, and will hopefully address 

The National Pain Audit has provided an impressively 
comprehensive survey of the provision of pain services. 
It has explored the organisational structure and process­
es as well as the fundamental requirement of evaluating 
patient outcomes. The feedback will inform the FPM, as 
a key stakeholder, of the current provision and limita­
tions of services. It will thus help evolve improved stand­
ards in the clinical management, safety and efficiency of 
specialist pain services.

many of the inconsistencies in care that are demonstrat­ ed in this report. However the guidance will not have official prioritisation. As the NPA suggests, nationally agreed standards need to be agreed and adopted.
The report does not specifically address pain services 

in primary care, however the majority of chronic pain pa­
tients flow initially from primary care. Commissioning 
does not necessarily address what happens at the start 
of the treatment pathway. Thus the RCGP, along with the 
Faculty of Pain Medicine, intends to address core stand­
ards in pain services in Primary Care, with an emphasis 
on correct assessment and early treatment.

## National Pain Audit Team Authors Of Final Report

Dr Amanda C de C Williams, Reader in Clinical Health Psychology, University College London Dr Cathy Price, Consultant in Pain Medicine, University Hospitals of Southampton FT
Dr Ola Olukoga, Consultant in Pain Medicine and Expert Working Group Chair for Pain, Information Centre Dr Amanda C de C Williams, Reader in Clinical Health Psychology, University College London Dr Mark Joy, Information Analyst, Dr Foster Intelligence Dr Barbara Hoggart, Consultant in Pain, Medicine, Heart of England FT

## Project Board

Dr Stephen Ward (chair), Consultant in Pain Medicine, British Pain Society Statistical oversight: Dr Alex Bottle, Senior Lecturer in Statistics, Dr Foster Intelligence, Imperial College, London Professor Richard Langford, President, British Pain Society Project management and data analysis: 

Robert Douce, Dr Foster Intelligence Ellen Klaus, Head of Operations, Dr Foster Intelligence Dr Barbara Hoggart, Chair, Clinical Information Special Interest Group, British Pain Society

## Audit Team Project Team

Dr Cathy Price, Consultant in Pain Medicine, Clinical Lead Chair Scientific Advisory Committee Robert Douce, Project Manager, Dr Foster Intelligence Ellen Klaus, Head of Operations, Dr Foster Intelligence Stephanie Stokes, Patient Liaison Group Member, British Pain Society Replaced by Mr Colin Preece, 2012
Stephen Ward, Consultant in Pain Medicine, British Pain Society Dr Cathy Price, Consultant in Pain Medicine, British Pain Society

## Governance Committee

Mark Joy, Statistician, Dr Foster Intelligence Julian Brooks, South West Strategic Health Authority Dr Jess Collins, Information Analyst, Dr Foster Intelligence Professor Richard Langford, President of the British Pain Society Design by design to communicate Douglas Smallwood, Chair, Patient Liaison Group, British Pain Society

## Scientific Advisory Committee Special Thanks

Dr Cathy Price (chair)
Frank de Charro, formerly Executive Director, EuroQol Group Dr Paul Aylin, Clinical Reader in Epidemiology and Public Health, Imperial College Dr Alex Bottle, Lecturer in Medical Statistics, Imperial College London

## References

1 
Mailis-Gagnon, A. Yegneswaran B, Zurowski M. 

 
Ethnocultural and sex characteristics of patients   
 
attending a tertiary care pain clinic in Toronto,

 
Ontario. Pain Res Manag. 2007 Summer;

 
12(2):100–106
2 
Moore A, Derry S, Eccleston C, Kalso E.

 
Expect analgesic failure; pursue analgesicsuccess.

 
BMJ 2013; 346 doi:

 
http://dx.doi.org/10.1136/bmj.f2690
3 
Somerville S, Hay E, Lewis M, Barber J,

 
Van Der Windt D, Hill J, Sowden G. Content and   
 
outcome of usual primary care for back pain:

 
a systematic review. Br J Gen Pract.

 
2008; 58: 790–797.  
4 
Elwyn G, Laitner S, Coulter A, Walker E, Watson P,  
 
Thomson R. Implementing shared decision making

 
in the NHS. BMJ 2010;341:c5146
5 
Chapman SL, Jamison RN, Sanders SH. Treatment  
 
Helpfulness Questionnaire: a measure of patient   
 
satisfaction with treatment modalities provided in  
 
chronic pain management programs. Pain.

 
1996 Dec; 68(2-3):349-61.
6 
NICE: Managing long-term sickness absence and 

 
incapacity for work.