Clinical governance in pain management

Field: Health Professions (Health Sciences)

I was disappointed to see that a recent editorial: ‘Meeting the challenge of clinical governance in pain management’ (Lee. Anaesthesia 2003;58: 205–6) and an accompanying article: ‘Clinical governance and chronic pain: towards a practical solution’ (Griffiths et al. Anaesthesia 2003; 58: 243–7) stimulated little comment from the distinguished members of The Pain Society and the clinicians heading the leading pain management centres in the country. Few pain clinicians would argue with the fact that there is an urgent and real need for a robust system to audit outcomes of clinical intervention and therapeutic modalities in the management of patients with chronic pain, and that monitoring activity, clinical audit and benchmarking are pursuits that all chronic pain services should actively engage in. However, I would be very surprised if many agree that PACS (the Pain Audit Collection System) is the tool capable of delivering it at a local, or indeed a national level as has been claimed in the article by Griffiths. PACS was designed for the Clinical Information Special Interest Group (CISIG) of The Pain Society and was distributed free of charge to encourage uptake. It was intended to be a tool for collecting dataset items to enable comparisons between pain clinics and to generate useful reports for individual pain clinics and pain clinicians to monitor their activity and audit treatment outcomes for clinical governance purposes. What it has collected at a national level so far is masses of demographic data and case mix. There is nothing in the multicentre downloaded data presented in the article that will help establish clinical standards or guidelines. Although many pain clinics keen to participate in audit at a local and national level were quick to embrace the PACS, there is little evidence that they have used it or found it useful for local audit and clinical governance purposes. Data entry with this system is arduous and time consuming, and the output barely justifies the time and effort required to input the data. Some effort and time should have been invested by the CISIG in carrying out a nationwide survey of the uptake and usefulness of PACS in achieving its objectives before hailing it as a ‘high-quality clinical database designed to meet the needs of pain clinicians in implementing clinical governance and monitoring pain clinic activity’. There is always a danger of assumption that those pain clinics that have not adopted the PACS system are not engaging in relevant audit at a national level with possible implications for future funding and allocation of resources. Thank you for giving me the opportunity to reply to Dr Vashisht. She raises several points, which I hope I can answer. Like Dr Vashisht, I am concerned that the article has generated so little debate. The future of pain management depends on robust clinical governance procedures and part of this is being able to describe case mix, activity levels and define outcomes. There are several steps to be taken to achieve this. We need to define what information it is feasible to collect in our everyday practice as opposed to well-funded clinical research. The article on PACS describes how that process was achieved and what elements have been established as a result of the process. This would not have been possible without the free distribution, feedback and the co-operation of other centres. One of the lessons we learned is that ‘one size does not fit all’. Providing one software package to operate effectively in every centre is difficult and probably not achievable. We have now published the minimum dataset and specified the requirements precisely so that each centre can write their own software package and yet still submit downloads to compare outcomes. The PACS software programme should therefore be regarded as a stopgap. I would dispute that the amalgamated data does not represent any value. This year we have been funded to provide each centre with a breakdown compared against a national average. We have found, for example, in my own institution that our case mix is substantially worse than average, yet we achieve above average outcomes. This has been an extremely important message to provide to our purchasers when they ask about our performance. Having hard evidence to support our case has proved invaluable. There is no other system available at a national level. More work is required on validation of the database, which in itself is a time consuming and expensive procedure that requires funding. Dr Vashist raises an important point. Collecting data is time consuming but forms are available to assist with this. Relying on hard-pressed clinicians to perform this task is, however, a poor use of clinicians' time. Recommendations are also needed for the funding of the appropriate staff and technical support as well as provision of a minimum dataset. Audit within pain clinics is now off the bottom rung of the ladder with much work still to be done to reach the top of that ladder. PACS represents just the start of that process. C. Price Chair, Clinical Information Special Interest Group, The Pain Society, Southampton SO14 0YG, UKE-mail: cathy.price@suht.swest.nhs.uk