Abstract
What an honour to be asked as a GP to write an editorial in a specialist journal for pain. It is however quite appropriate as the overwhelming majority of pain is managed either by patients on their own, or with the support of GPs, pharmacists, or nurses working in the community.
I want to start by highlighting a scene from one of my favourite films. Inspector Clouseau (Peter Sellers), is checking into a hotel, he sees a little dog standing by reception. He asks the clerk ‘does your dog bite?’, the clerk replies ‘non’, Clouseau goes to stroke the dog and it bites him. ‘Aaaarh, I thought you said your dog did not bite!’. Says the clerk ‘That’s not my dog’. Similarly there is much in the field of pain management that is not as many might expect.
In my own clinical experience I have practiced as an anaesthetist, and GPwSI in chronic pain, working in a specialist-lead, hospital based pain clinic. I have seen how successfully the medical model works for some patients, where a cure can be stimulated by an injection or medication change. I have experienced how the, multidisciplinary approach to pain education can move some patients permanently from a situation of fear, confusion, and dysfunction, to one of coping and self-control. However it has been in my role as a GP working ‘in the community’ that I have realised the huge unmet need, and the inability for the current healthcare model to provide a sustainable system of care for all those people living with persistent pain. Unfortunately all too often skills for dealing with pain management in general practice are poor, and the article by Jenkins et al illustrate innovative ways of improving education in this group.
It is worth pausing at this point to check what we mean by ‘community’. Wikipedia (a community generated resource) offers two definitions, 1) ‘a social unit with shared common values’, or 2) ‘a group of interacting living organisms sharing a populated environment’. It could be said that we, the readers of this journal, are part of a pain community, sharing the aims of wanting to improve quality of life for people living with pain. However it is with reference to the second definition that most draw distinction in healthcare. Traditionally people would attribute ‘in the community’ to any care that is delivered outside a hospital.
There are advantages to patients in receiving ‘care closer to home’ (as specified in the same named government paper 1 ), not least patient convenience and saving on carbon production. Large medicalised institutions such as hospitals, or even large clinics, can be intimidating, unfamiliar, and far removed from a concept of normal everyday life.
Simm et al and Barker et al’s papers highlight how novel pain management techniques can easily, and effectively be delivered outside the hospital setting.
But I would suggest that ‘community’ implies a more significant difference than simply geographic location of clinics, and that the advantages go deeper than savings on car parking and travel costs. To me, ‘community’ in a healthcare setting goes beyond the Wikipedia definitions. It describes an ethos of care whereby a holistic, patient centred approach, is contextualised in the settings where people exist. Increasingly leaders in health care are realising the value of ‘supported self management’ 2 , supporting people to understand their health conditions, and to take a lead in managing their own care. The Year of Care collaboration, reminds us that on average people with LTCs spend 3 hours a year in consultations with health care professionals and the other 8,757 self managing in their communities 3 . This sort of approach appears to yield significant improvements in the outcomes that matter to patients living with long term conditions (LTCs). Of course we now recognise persistent pain to be one of the most prevalent and impactful of these LTCs.
In supported self management clinicians support patients to formulate goals and strategies that are relevant to their own values and priorities. The context for this is within the communities in which they live their everyday lives. Should it not be in these community settings, in the broadest sense, that we teach people to craft their own support system? Helping people to draw on the assets in their own communities and relationships, forming lasting networks of support. These networks might involve local leisure centres, parks, or allotments; peers, friends or support groups. They might utilise the evolving technology in social media as tools to facilitate these networks. They should improve the quality of the interactions that people have with their health care professionals. We know patients continually test out their health values with friends, family and key people in their world. People need communities to help them make sense of what is happening to them. I would propose that the more disconnected the care is from their everyday setting, the less likely it is to develop a sustained improved outcome for that person.
It is within this paradigm of ‘support from next door, not care from up high’ that the paper by Harris at al explores the use of health trainers in supporting people with chronic pain to achieve their goals. Health trainers, who are effectively lay people with some skills in supporting self management, can compliment those brief clinical interactions with more sustained support that links in with community resources.
In the paper by Hart and Ryton, we are reminded that it is not always easy to change practice in community settings. Their audit paper describes the difficulties of implementing screening tools in general practice, and the benefits of successfully doing so.
Maybe in the future we can create systems where people are more activated to self manage, in communities that understand and support this approach. Then it will be the patients themselves who will be deciding what level of support they need, and where and how it is delivered.
I hope you enjoy this edition, and that it stimulates you to think outside the box in terms of future management of pain, and maybe saves you getting bitten by someone else’s dog!