Chronic Pain Clinic

Source: an application I (Anne Sutcliffe) made for official funding in 1991 which I never got, and a document written in 1992 to inform the possible merger of my and the QE clinic following closure of BAH

  • In 1981, Mr Colin Seeley had set up a charity of which he was a trustee in memory of his wife, who died very young of bone cancer, to provide pain relieving equipment to hospitals
  • Mike Hailwood was the charity’s Patron. Hailwood was an accomplished motor cycle racer who had died at the Acci after he hit a lorry from behind at high speed.
  • The Joan Seely Pain Relief Memorial Trust contacted BAH February 1982 with an offer to fund the establishment of a chronic pain management clinic in his memory. 
  • Anne was asked to liaise with Mr Seeley and establish the clinic. 
  • After the equipment was delivered, the clinic opened in January 1982. 
  • At first, only BAH patients were accepted. 
  • Uptake was low but it meant that the clinic was able to offer 30 minute appointments 
  • This revealed that listening to the patient and taking time to explain to them exactly why they were in pain was as helpful, if not more so, than the treatment subsequently provided. 
  • There was ongoing support from the Birmingham Lions, who provided equipment, which allowed the service to expand
  • Given that there were so few BAH patients who needed help, in 1983, the service was opened to all SBHA in-patients and to local GPs.
  • By 1991, the management of chronic pain was entering the mainstream and although previously unavailable funding was promised, so too were constraints on appointment times and the ability of consultants to work flexibly to look after their patients. At this point the service was abolished, due to lack in funding and staffing, which shortened the time available to spend with patients in order to treat them sufficiently.

Staffing

  • Given the three-week cycle of Team commitments, the clinic was run on Thursday mornings – 2 weeks out of three (during the third week Anne had a burns list). 
  • The clinic was held in out-patients – unfortunately there was irregular nursing or anaesthetist support. Sometimes nurses did attend for training. (this meant that whenever Anne was away the clinic was cancelled)
  • In the early years, Mr Mathuru (BAH chiropodist) provided an acupuncture service.
  • Later Anne trained as an acupuncturist. 
  • After patient’s first visit, some required no more than a brief visit to check how they were getting on, others needed more counselling. 
  • During weeks were there were no clinics, follow up clinic phone calls were made. Some patients were admitted as day cases for various treatments requiring sterile conditions. (my surgical colleagues were generous by allowing me to temporarily use their beds as were the theatre staff for allocating an ODA to assist me and a porter to transport patients to and from theatre).
  • The service provided home visits, and others were visited in in-patients at Selly Oak and St Mary’s Hospice to reduce waiting times. 

Treatments Available

  • At that time, chronic pain management was in its infancy and most Pain Clinics were run by a single consultant often with limited support. 
  • The Joan Seeley Pain Relief Memorial Trust funded a Lloyd Neurostat (this had a cryo probe with which I could freeze nerves) and 10 Spembly 900 Transcutaneous Electrical Nerve Simulators which were useful for chronic back pain. 
  • Anne was also trained to do guanethidine blocks (akin to Bier’s blocks) for neuropathic arm pain and epidurals with local anaesthetic and steroid which were thought at the time to be useful for lower back pain. 
  • There were also various analgesic combinations which if taken regularly, often reduced the cycle of chronic pain. In particular a combination of amitryptilline and carbamazepine worked well for patients with post-herpetic neuralgia. 
  • By 1991, 60% of referrals were given a transcutaneous nerve stimulator. 
  • Acupuncture also worked well although this may have been a placebo effect.

Expenditure

  • Although there was no formal budget:
    • The pharmacy was willing to provide patients with two week starter prescriptions
    • The main theatres and MIU provided local anaesthetic and steroids
    • The main theatre also provided guanethidine and EBME checked transcutaneous nerve stimulators and provided new leads and electrode pads. (I think this happened because the clinic was so cheap to run.)
  • In 1991, each pain clinic patient cost an average of £20 per annum excluding the cost of staff time (which consisted of Anne’s work with patients and a secretary who spent approximately 4 hours per clinic writing letters to GPs.)
  • Luckily the patients’ cause was taken up by the Birmingham Lions who regularly provided more transcutaneous electrical nerve stimulators. 
  • By 1991, there were 75 in circulation.
  • All possible measures were taken to reduce costs – e.g. Anne discovered that Sellotape worked as well for fixing electrodes as did micropore

Diagnoses

  • Back pain 58%
  • Limb pains 18.5%
  • Neuralgias 4%
  • Miscellaneous 19.5%

Measuring and Recording Outcomes

  • From 1982 to 1991, the standard method for measuring the severity of pain was the 10cm line with no pain at 0cm and unbearable pain at 10cm. Patients were asked at initial and follow up attendances to mark on the line the severity of their pain. However, often the mark made by patients on the did not correlate with patients’ reported pain relief. 
  • Therefore, at each first appointment, patients were asked to describe how their pain limited their life and what they hoped from treatment with respect to the activities they most wanted to be able to do again. 
  • This became the end outcome goal. Although patients were still somewhat limited, they were able to do most of the activities they wanted to do, and so outcomes were relatively good
  • The clinic’s results are as follows 33% cured and 33% helped. 
  • There was a significant possibility that the placebo effect could have influenced results. However, it was believed that for some patients, being able to talk and be listened too, while being offered an explanation for their pain, along with never being promised a cure, significantly improved the outcomes for some patients. 
  • Unfortunately, some patients could not be helped. 
  • Patients were never treated who hadn’t been; thoroughly investigated, had a confirmed diagnosis and had not responded to any treatment other health professionals had previously offered.

Statistics for 1991

  • Patients on books 129 pa
  • New referrals 71 pa
  • Discharges and rare deaths 48 pa
  • Consultations / treatments 367 pa