Dr. Josh Keaveny:

Deputy Ó Caoláin asked why we are where we are. In terms of pain as a symptom, when I was a medical student it was quite simple: the patient had a pain, and we diagnosed the cause of the pain. If we could not find the cause of the pain, the patient did not have a pain; it was in their mind, and they should go away. Pain as a condition was never on the radar, and there was never funding to treat it. Interestingly, over time, people got involved in treating pain. They were primarily anaesthetists, because they were able to inject into nerves that supplied particular areas, which reduced the pain. However, that was done on a hodgepodge basis. It was a small, little-funded, special-interest-type problem. Pain has never been at the table, so to speak.

The other interesting aspect is that recently there has been a bigger push to treat cancer pain. It is accepted that survivors of cancer have legitimate pain from either the disease or the treatments, and therefore they need to be seen by pain people. There is a recognition in neurosurgery also that many people with back pain will not be cured by an operation and they need to attend pain clinics. Pain is now appearing on the map. The important thing for us is having pain recognised as a specialty and therefore featured on the list of specialists at the Medical Council, which helps us in regard to undergraduate and postgraduate training.

The College of Anaesthetists developed a faculty of pain medicine in the mid-2000s, and we were one of the first groups in Europe to set up diplomas and fellowship examinations in pain medicine to try to bring a small number of people to a level at which they had a specialty interest in it. The trend over time now is that the pain posts are changing from an anaesthetist with a small commitment to pain medicine to full-time pain posts. In the next three to five years I believe the majority of people who are appointed to pain medicine posts will be full-time pain medicine people. They will no longer do anaesthetics. That seems to be the international trend.

People ask why pain management is better developed in the United Kingdom. One of the reasons is that for the past number of years they have had time limits on outpatient attendance, which I understand is currently down to 16 weeks. The patient has to be seen within 16 weeks or the person providing pain management is financially penalised. Thus, they have had to expand the number of people providing pain medicine or be fined. There has been a growth in the number of practitioners of pain medicine in the UK, as there has been in other countries.

There are a number of reasons we have not gone further down the line in this regard. That might be our own fault in that some of us are probably overwhelmed with work and we have not been able to devote the time to it. In terms of the way the health service is developing, if one does not have a clinical director as a lead clinical director one is not at the table in regard to funding, getting posts in the future, and getting the back-up to develop the resources needed to provide the service.

We have had meetings with Dr. Áine Carroll, but recently the HSE has been re-examining the clinical director role throughout the country. Therefore, we have not got to the level at which we have a clinical director. I assume that with the changes in the hospital groups, that model will change also. In terms of the group model, I believe there will be a lead clinical director for each group, as well as specialty directors. It is important for those of us in pain medicine that we have a specialty director in pain medicine in each group who can identify the demand for the services and the way they are funded and resourced within each group. As Ms Sexton said, it may well be that in future there will be centres in each group with smaller peripheral clinics, but the current model as it exists is collapsing, and we have a huge problem in that regard. My area is north Dublin and Dublin north east. When the physician in the pain clinic at Our Lady of Lourdes Hospital in Drogheda left, the clinic was closed down, and general practitioners got letters stating that the service had ended and they should refer patients to Dublin, but those of us in Dublin were not informed. The service is hodgepodge because there is no one responsible for it within particular areas.

We are without a doubt way behind cancer services, for example, but we need some support. The support we get as a medical specialty is a big step forward. It is an advance in training for all allied health professionals, not just doctors but physiotherapists, psychologists, nurses and so on with a special interest in pain. That is the first stepping stone we need. We must also look at getting in touch with a person we can deal with in the Department of Health or in the Health Service Executive who will help us quantify the problem, develop the funding and develop a strategy for the future.