Neighbourhood and Wellbeing Delivery Alliance Progress Report 2022-23

Strategic Priority 3: Complex Care

Our priority outcome: helping people with chronic pain get the care and support they need

The chronic pain workstream brings together services and people in Lambeth to work collaboratively so people living with complex chronic pain receive more holistic care.

Context and key challenges

Chronic pain, also called ‘persistent pain’, lasts longer than it should after an illness or injury has healed, usually after three months. Chronic pain can happen to anyone, and it can affect any part of the body. Accidents or injuries can cause many health conditions, like arthritis. However, people can also have chronic pain when they don’t have a clear illness, injury, or health condition. This doesn’t mean that chronic pain isn’t real, but it does show that it can be a very complex problem.  

Chronic pain is linked to health inequalities in the UK.

people living in chronic pain
2nd most common long-term health condition

12.5 % of people in Lambeth live their lives in chronic pain, making this the second most common long-term health condition in the borough. It is more common among older adults, women, people who live in poor areas, and people of black ethnicity.

In addition, we know a large number of people are not being supported to manage pain as well as they could and this can lead to them using services more than they want to. In Stockwell, we have seen that residents living with chronic pain are needing lots more GP appointments, but are not getting to see the same clinician. We aim to provide support so that we can develop personalised care plans to help people achieve their goals in managing chronic pain.

What we offer

The Chronic Pain Register

In 2022 we set up a new register within general practice. This records anyone who is in chronic pain, making it easy for GPs to make sure they’re offered support in a more timely way. This has allowed social prescribing link workers to offer patients a chronic pain review with their GP or pharmacist, which can include a review of their medication.

“I enjoy finding out what really matters to people and supporting them to explore different approaches to living well.

Vidal-Tunkara, Social Prescribing Link Woker, Hills, Brook and Dale Primary Care Network

Pain: Equality of Care and Support within the community (PEACS) Project

PEACS was established to give an alternative solution to supporting people living with chronic pain, and particularly those from black backgrounds who have poorer outcomes. PEACS works with GP practices to identify people with chronic pain and then works with them to help manage their pain. This includes having a health check, an in- depth assessment with a GP, and attending lifestyle workshops that look at both the mind and body impacts of living with chronic pain.

The PEACS model was developed through working with patients living with chronic pain, their carers and clinicians, and aims to help people gain the necessary skills and knowledge to allow them to better manage their experience of living with chronic pain. You can read more about the project in the PEACS Year One Report.

Chronic Pain Patient Advisory Group (PAG)

We’ve set up a Chronic Pain Patient Advisory Group, involving eight Lambeth residents. The aim of the group is to:

  • improve the quality of the patient experience for those who access chronic pain related services
  • influence the local provision of health and social care for people with chronic pain and guide decision-making in the health system

Chronic Pain Education

We ran and study day in July for GPs hear the latest on how to support people with chronic pain.

Our impact

Chronic pain training

Over 100 clinicians from all GP surgeries in Lambeth attended training to learn the latest information on how to support people living which chronic pain.

The Chronic Pain Register

Patients on the chronic pain register
Patients supported by the PEACs Project

So far 29,111 patients are on the chronic pain register. The benefit of this is that patients can be easily identified and be better supported by their GP practice as outlined above, with a focus on improving continuity of care and using the strengths of the full clinical team in practices.

Pain: Equality of Care and Support (PEACS) Project

The PEACS service has been delivered across five GP practices supporting 597 patients.

Improved chronic pain hospital referral

We’ve worked together to develop a joint referral form for hospital pain management. This has made it easier for people to be referred to support services.

Our next steps

We will continue to improve timely identification of patients with chronic pain who could benefit from a holistic approach (that considers mental and social factors as well as physical). Additionally, we will continue to explore how we can improve services for our staff to cope with increased demand. In this way, we’ll support the development of more personalised care that is more effective for patients and more efficient for the people and services who support them.

This will involve, for example:

  • Expanding the PEACS project to more neighbourhoods.
  • Working with pharmacies, hospital trusts and GPs to develop a virtual chronic pain team. This team will bring health and care professionals together and think about how to best support patients with chronic pain. This will make it quicker and easier for people to get support from a variety of health professionals in one place, without the need for multiple appointments.

Case studies: Chronic Pain Patient Advisory Group (PAG)

Diana’s chronic pain journey started in the 1990s when she was diagnosed with Lupus. Although she didn’t particularly find the pain clinic helpful, the supplementary treatments of acupuncture, physio, and hydrotherapy did help her pain management. She has a strong conviction and belief in God. This would seem to allow her to ‘smile through her pain’ and keep her strong.

At first Diana was uncertain about joining the Patient Advisory Group, being sceptical of what she might gain. However, she has found it helpful to understand other people’s experiences of chronic pain, especially those who share similar health concerns. She felt that supporting each other with suggestions or just listening has helped her develop a deeper understanding and with her mental well-being. Diana expressed the importance of just giving it a go, as we could all learn from each other by having a safe space to talk in similar situations.

On whether she’d recommend the group to others, Diana says: “I would say just to get involved. Let’s go because, like me, they could learn a little but they could learn a lot. They could also give others in the group the benefit of their experience.”

Diana, Black African female, 55-64 years.

Ben fell from a ladder about seven years ago which has resulted in constant pain in his left shoulder, which limits certain everyday activities. This shoulder pain makes it difficult for him to perform simple tasks such as putting on a jacket or threading loops on his belt. He has sought support from his GP and tried physiotherapy, but unfortunately, he felt that it didn’t help much.

The group provided a safe space for people to talk about their pain when they cannot discuss it with their families. The Patient Advisory Group’s WhatsApp group also acts as a good support network and facilitates communication among the group members. This has helped Ben maintain a positive outlook by continuing to listen and broaden his awareness at a suitable pace for him.

Ben had an overall positive experience being a part of the Patient Advisory Group. He expressed that being in the group helped him gain knowledge and motivated his understanding through interacting with fellow chronic pain sufferers. As a result, he has now tried to follow up on his chronic pain issues further with his GP.

In his own words, Ben describes his feelings about what he learnt from the group: “What I learned from it was that a collective sense of solidarity is a great comfort to many people, and I think that shows up in our WhatsApp group and the meetings; I think people do derive a great deal of comfort just from sharing with others who do understand where they’re coming from. They’re not alone, and that’s a great help. I think it’s an extraordinarily worthwhile project. I really do. I highly commend it.”

Ben, male, 65-74 years