Jerry Buttimer (Cork South Central, Fine Gael)
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I thank all the witnesses and members for their patience and commitment to the second meeting this afternoon, on the issue of chronic pain management. I thank all our witnesses and Deputy Mary Mitchell O'Connor who, like me, recommended that this meeting be organised.
I welcome Mr. John Lindsay, chairperson Chronic Pain Ireland, CPI; Professor Laserina O'Connor, president, The Irish Pain Society, IPS; Dr. Josh Keaveny, dean, faculty of pain medicine, College of Anaesthetists of Ireland, CAI; Ms Cathy Sexton, president, Irish Pain Nurses and Midwives Society and Dr. Brona Fullen, lecturer, School of Public Health, Physiotherapy and Population Science in the Health Science Centre at University College Dublin, UCD. I also welcome Ms Gina Plunkett and Mr. Niamh Molloy who are involved in CPI and the Irish Pain Nurses and Midwives Society, and Ms Orla Scott and Ms Kay Brennan, all of whom are in the public Gallery.
I apologise to our guests for the delay in starting the meeting. Parliamentary democracy occasionally involves votes and this afternoon we had a vote. I apologise for holding people up and I thank them for being here.
I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if a witness is directed by the committee to cease giving evidence in regard to a particular matter and continues to do so, the witness is entitled thereafter only to a qualified privilege in respect of his or her evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.
I call on Mr. John Lindsay to make his opening remarks. He has five minutes speaking time.

Mr. John Lindsay:

On behalf of everybody associated with Chronic Pain Ireland I thank the Chairman and members of the committee for inviting us here today. In my written submission I stressed the importance of having pain medicine declared a medical specialty and having chronic pain declared a disease in its own right and how important it is to develop a national pain strategy. There are others here better qualified to talk about those areas so I will leave that to them.

Chronic pain has a devastating effect on people's lives. In the few minutes available I would like to read out accounts of the impact chronic pain has had on the lives of some of our members. I will not give their names, just where they are from. This will give the committee some idea of this impact. These are real people with very serious, complex medical conditions and they have difficulty accessing appropriate treatments and services.

A lady in Headford, County Kerry, says that through chronic pain she has lost seven years of her life and it has cost her the babies she can never have. It has changed her to a shadow of her former self, has made every single task an unbearable pain, taken her dignity, her love of life, her joy. She says each day is a challenge to endure.

A gentleman in Dunboyne, County Meath, says he does not know how much longer he can put up with the pain before he kills himself to end it.

A gentleman in Dublin says chronic pain is controlling his life, his being and humanity. He says life should be easier. His life revolves around the pain and everything suffers. Sometimes he wonders is it worth coping with.

I have approximately 100 accounts, all very similar, along those lines. If many of these people had had early access to appropriate interventions and treatments they would probably be back at work and not a burden on the State, as they are today. Most of the members we represent tend to be at the severe end of the spectrum.

All are unemployed and in many cases, spouses have had to give up employment in order to help them to cope. It is a devastating problem that needs to be dealt with. As I stated in the submission to the committee, chronic pain costs the State more than the cost of cancer and diabetes combined. Professor Charles Normand's research has found that the cost to the Irish State for chronic pain is €4.6 billion a year. This could be addressed if appropriate resources were put in place. Some services are available but we have no doubt that significant money would be saved by appropriate services and early stage intervention and referrals. At present, on average, most of our members have been to see seven health care professionals before eventually getting to see a consultant specialising in the particular condition.

Jerry Buttimer (Cork South Central, Fine Gael)
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I compliment Mr. John Lindsay on his tremendous commitment and dedication to the group he chairs. It was a pleasure to meet him and to speak at a number of the group's events.

Professor Laserina O'Connor:

The Irish Pain Society is a group of clinicians of all disciplines who are committed to making a difference for the person in pain across the continuum of care. People with chronic pain can find interacting with the health care system complicated and stressful and it often results in high use of health care services and unrelieved pain. It has been shown that across Europe, one quarter of people have to wait up to five years to receive a diagnosis or reason for their pain and a further 11% must wait longer to receive a diagnosis and treatment. The impact on quality of life is an issue. Chronic pain rates are likely to rise for several reasons such as the ageing of the population which means that a growing number of people will experience the disease with which chronic pain may be associated such as diabetes, cardiovascular disorders, arthritis, stroke and cancer among others. The increasing presence of obesity is also associated with chronic pain conditions and painful symptoms are associated with diabetes and associated neuropathy and osteoarthritis.

We have made great progress in saving the lives of people with catastrophic injuries but this creates a group of relatively young people who are at risk of lifelong chronic pain. People who are survivors of chronic illness such as cancer may develop neuropathic pain related to chemotherapy. All surgical patients are at risk of acute and chronic pain and several of those patients may develop a persistent pain and 20% of those patients may become new chronic pain patients. Greater public awareness is required. Chronic pain is a public health challenge.

The Irish health care system is undergoing profound changes. Health care reform can offer new opportunities for the more effective prevention and treatment of pain. In prescribing the basket of health care services, the Government's White Paper on the path to universal health care 2014 recognises health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Adequate pain relief lies very comfortably with that definition as does rehabilitation for chronic pain.

Chronic pain can be conceptualised as a public health challenge for a number of reasons. Mr. Lindsay alluded to the fact that one in five people may experience chronic pain. New statistics inform us that one in three people may experience chronic pain and that they may endure this pain for anything up to 20 years and at the least for five years. Substantial disparities exist in the management of chronic pain and the vulnerable population includes older persons and the cognitively impaired. The cost to the system in caring for them is a cost to the nation's economy.

There are social, economic and physical environments which need to be addressed with regard to this pain. Chronic pain is costly to the nation and it can cost €5.34 billion annually, which is 2.86% of GDP. Opiad and analgesic medications for pain could be subject to misuse and abuse and cross-departmental actions may be required to deal with this problem.

Professional education may be required because education is central to the necessary cultural transformation of the approach to chronic pain. Public health offers a great strategy for countering the misunderstanding that hinders the management of chronic pain. An interdisciplinary approach is required. I refer to Australia where a national pain strategy has been created. It is a 94-page document which emphasises the need for co-ordinated interdisciplinary assessment and management involving at a minimum physical, psychological and environmental risk factors for each patient, recognising that interdisciplinary care has the strongest, evidence-based information and should be available at all levels.

There are two group-based public multidisciplinary programmes in Dublin for chronic pain patients. The research community should pursue pain research with the same vigour expended on other serious and disabling chronic conditions. The origins of chronic pain are in musculo-skeletal conditions as well as conditions such as headache, arthritis, migraine, fibromyalgia, visceral diabetes, cancer and shingles. It is important to note that one patient may have several causes of his or her pain. Mr. Lindsay has provided the testimony of patients and I refer the committee to appendix No. 2 of the submission which contains a testimony of living with chronic pain. That testimony demonstrates that a sufferer of chronic pain may make seven to ten visits to a GP in one year but research has shown that 38% of patients reported that their pain was not adequately treated. Appendix No. 3 demonstrates the prevalence of chronic pain in Europe. In 2006, Ireland had a rate of 13% but now, 25% to 35% of adults experience chronic pain. I refer to the emotional toll of chronic pain and the four Ds which are disability, despair, depression and disuse.

Dr. Josh Keaveny:

Chronic pain is a very difficult problem to deal with. It is a problem of the sensory and emotional systems. One of the difficulties with chronic pain is that there is not a definite marker for pain as is the case with other disorders. Chronic pain is recognised as a disease of the central nervous system and in time it will be recognised as a disease in its own right. In Ireland chronic pain is a silent disorder which has a significant social effect. Approximately 14% of the population is afflicted with chronic pain. The disease is a problem for the individual, for society, for families and is a significant financial burden on the country. The cost is approximately €4 billion a year which is a staggering amount. This is made up of the cost of treatment, care and loss of income. Of those who claim long-term medical disability, 70% of people quote pain as one of their main complaints. The figures show that people with chronic back pain have a less than 10% chance of ever returning to the workplace. For example, I refer to a young person in his or her 30s with chronic back pain who is married with a family.

Such a person is sent from one consultant to another before finally being transferred, 12 months, 18 months or even two years later, to a pain clinic. The chances of that individual ever getting back to work are very slim and the cost to the State is colossal.

Over time, many advances have been made in the diagnosis and treatment of pain and rehabilitation programmes for patients. When people can avail of those services in a timely fashion, the chances of their returning to the workplace improve dramatically. Unfortunately, the availability of these advances has not kept pace with services for chronic pain sufferers in this country because those services have not been adequately funded. The Irish Medical Council, following a submission from the faculty of pain medicine, recommended recently that pain medicine be given specialty status. We are waiting for the Minister to sign off on that recommendation and would be grateful for the committee's support in this regard.

Affording pain medicine speciality status would enhance our ability in the faculty of pain medicine to improve undergraduate and postgraduate education, which is absolutely crucial into the future. It would also strengthen our training and fellowship programmes, thereby facilitating the provision of doctors with specific training in pain medicine. As it stands, we are very much underfunded as health professionals with a special expertise in dealing with the complexities of pain management, with only 14 or 15 whole-time equivalent posts at consultant level for the entire country. The European recommendation is one pain specialist per 100,000 population, which would equate to the provision of 45 full-time consultant posts across the various hospitals. We are equally underfunded at all other levels, including advanced nurse practitioners, physiotherapists and psychologists. As Professor O'Connor pointed out, we have only two proper pain management programmes in the entire country.

We are calling for the appointment of an administrator within the Health Service and-or the Department of Health with whom we, whether doctors or support groups, can liaise in order to develop our funding mechanisms. A lead clinician in pain medicine should be appointed to each hospital group to liaise with the various pain departments and develop cohesive plans for each group. At the moment, many parts of the country have no pain clinics; there might be some health professionals with an interest in pain management working in those areas but there are no dedicated clinics. The small number of clinics we do have are inundated, with waiting times for new patient referrals and treatments going way beyond the nine-month limit set down by the HSE.

Since 2008, the population of this country has increased by approximately 8%, while funding for health services has declined by some €4 billion in that period. At the same time, the number of people aged over 65 has risen by 14%. The growing numbers of older people who are anxious to stay fit, active and healthy mean that our clinics are swamped. In our efforts to treat these people, the younger patients who make the greatest financial contribution to the State are not getting an opportunity to receive treatment. We would be grateful for a recognition from the committee that the problem exists and for its support in developing structures to secure funding for enhanced services throughout the country.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you, Dr. Keaveny. I invite Ms Cathy Sexton to make her opening statement.

Ms Cathy Sexton:

I am grateful for the opportunity to engage with the committee today. I represent the Irish Pain Nurses and Midwives Society, a very new specialist organisation representing the 32 full-time nurses working in pain management. These nurses are educated and trained to a very high level. I work in the HSE's north-eastern area, where, apart from my own expertise in this area, there is no service for patients with pain. The same situation applies in 15 inland counties, all of which are trying to access the limited service that exists in the coastal counties. Our focus is on developing a strategic plan for pain management. We cannot work in a vacuum, which is what we are currently obliged to do. It is an ongoing battle to penetrate services that are simply not available to us. We are trying to support patients who are struggling greatly in a service that has very little to offer them. There is no co-ordination between primary and secondary care, which is a real difficulty for us in trying to manage patients on a day-to-day basis.

Our cohort of clinical nurse specialists, CNSs, and advanced nurse practitioners, ANPs, are in a position to add considerable value to primary care services by taking up placements in a co-ordinated manner in communities throughout the State. This would allow us to begin treating pain at a much earlier stage rather than, as Dr. Keaveny and Professor O'Connor described, seeking to provide a service in an entirely unco-ordinated way. At the moment we are each working in pockets on our own and there is no cohesive plan for service delivery. There are only two major multidisciplinary pain centres in Ireland and the majority of people cannot access them. Patients are instead obliged to access a number of different specialties that are outside the pain management remit. We find that significant numbers of our patients are looking to alternative therapists to provide some type of relief from their pain.

As pain is a disease in its own right, there should be a national structure to address it and that structure must come from the HSE. We need to develop a task force which brings together all the stakeholder groups. A national pain strategy must be delivered within a partnership framework, with the necessary resources provided to deliver the service. A hub and spoke model similar to that developed under the paediatric clinical programme must be developed. There are plenty of models we could look to in this regard. None of us can do this alone and, as such, it is vital to put in place multidisciplinary teams. We must provide relevant education and training to patients, health care professionals and the community.

Satellite clinics, with clinical nurse specialists and advanced nurse practitioners, should be provided within communities. We are aware that these types of changes are being considered as part of the strategy for expanding and extending nursing services. It is something we hear about constantly. Now is the time to put the money into the service. Advanced nurse practitioners and other allied health professionals must form a core part of primary care provision, helping to deliver concrete services for patients suffering chronic pain. If we had satellite clinics in GP centres, it would extend and develop the service we currently provide. CNSs and ANPs are also prescribers and represent a huge resource to community services and to specialist services in acute services hubs. Moreover, such a service would be cost effective. We can play a significant role in the development of a national pain management strategy. We hope members will take our views on board and give them due consideration.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you, Ms Sexton. I invite Dr. Brona Fullen to give her opening statement.

Dr. Brona Fullen:

I thank the committee for the opportunity to participate in this discussion. I propose to summarise the research that has been undertaken by Dr. Brian McGuire and his team in the centre for pain research at NUIG and by my team and me at the UCD school of public health, physiotherapy and population science. This research has provided the first comprehensive picture of the problem of chronic pain in Ireland and the efficacy of current services for patients.

Chronic pain is defined as pain experienced on a daily basis for three months or more. It can vary in intensity and in the extent to which consequent disability and psychological distress can affect patients. Most people with chronic pain have been suffering for several years before they access specialist services, assuming such services are available in their area. In addition to long waiting lists to access services, multidisciplinary pain management teams - by which I mean teams comprising a chartered physiotherapist, occupational therapist, clinical psychologist, pain nurse and consultant pain specialist - are the exception. People attending pain programmes tend to be significantly impaired by their pain, with both physical dysfunctions and psychological dysfunctions such as anxiety and depression. This makes it more difficult to achieve outcomes that can make a discernible difference to the patient's quality of life.

Research at NUIG has established that the pain prevalence in Ireland is up to 35%. Lower back pain, at 47%, was identified as the most common site of pain in patients, which is line with the international literature. However, more than 80% of patients reported having pain at more than one site.

Some 12% were unable to work or were on reduced work hours owing to pain. Of those with chronic pain, 15% were diagnosed with clinical depression, whereas the number for those without pain was 3%.

NUIG also provided data on the economic cost of pain. Over a one year period and from a sample of 140 patients, the average cost per patient was €5,665. That cost increased as the severity of the pain also increased. This correlates significantly with the length of time for which patients have had pain. A small proportion of patients accounted for the bulk of costs. In other words, there was a mean cost of €30,000 per patient per year among the top 5% most expensive patients. This accounted for 26% of the overall cost among the 140 patients sampled. As Dr. Keaveny stated, NUIG extrapolated from this data and estimated that the total cost to the State in 2008 was €4.7 billion or 2.55% of GDP.

Resources for the management of chronic pain are scarce. In UCD we undertook some research into the need for a national pain strategy, aptly named, and of the 28 pain clinics nationwide, only eight of the 18 which classified themselves as multidisciplinary met the International Association for the Study of Pain criteria for multidisciplinary pain clinics. Similarly, only three out of the ten clinics that classified themselves as pain clinics met the recommended criteria. These clinics also report long waiting times to access services as new patients.

There is evidence that managing patients according to international best practice is effective both in the community and secondary care settings. In UCD we have reviewed the effectiveness of the Ulysses cognitive behavioural pain management programme in Tallaght Hospital over an eight-year period. As Professor O'Connor mentioned, this is one of only two publicly funded, group based, multidisciplinary cognitive behavioural therapy programmes in the State. The second programme is run by St. Vincent's University Hospital. We reviewed 550 patients and discovered that, on average, people had experienced pain for over eight years before they could access the service. They had significantly high levels of functional disability. Some 76% of the patients involved were diagnosed with clinical depression and 85% as being clinically anxious. Six months post the four-week pain management programme there were clinical and statistically significant improvements in the context of both physical and psychological dysfunction. There was also a significant improvement in patients' quality of life. However, with resources, we should be targeting these patients earlier in the progression of their disease. Dr. McGuire and his team at NUIG have identified that targeting people with low back pain for less than one year can, as Dr. Keaveny mentioned, increase return to work levels among and reduce depression and fatigue in such persons. This suggests the type of rehabilitation to which I refer is beneficial in facilitating patients with back pain to return to work.

The findings of research conducted in Ireland demonstrate that pain is both a prevalent and costly health care problem and that chronic pain services are generally and significantly under-resourced. However, there is evidence that improved co-ordination and better management of patients via multidisciplinary rehabilitation programmes, in both the community and health care settings, are effective. The development of a national pain management strategy would enable us to make best use of limited resources, treat patients earlier, reduce long-term disability and associated costs and, most importantly, improve quality of life.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. Fullen. Dr. Brian McGuire was invited to come before us today, but he cannot be here. I thank both Dr. Fullen and Dr. McGuire for working together on the presentation. I take the opportunity to acknowledge the presence of Dr. Hugh Gallagher. I have received apologies from a number of members who cannot be present for the proceedings, including Deputies Regina Doherty, Robert Dowds who was present earlier, and Seamus Healy and Senators Imelda Henry and Jillian van Turnhout.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I, too, wish to apologise to our guests for the small number of members in attendance.

Our guests made a common point in all of their presentations on the need for a national pain management strategy. They cited a number of international models of practice. I presume the case for such a strategy has been made. I will not direct a question at any one of our guests because each of their respective contributions was complementary and all referred to the single objective of a national strategy being developed. Would it be possible for one or more of them to indicate where the case for the latter rests at this point? What is the reason for the inaction of the Department of Health or the HSE or for their failure to find a driver of this proposition? Will our guests provide a sense of the barriers and obstacles and indicate how the committee might assist them with the objective of having a national pain management strategy developed and, most importantly, implemented?

I thank Dr. Fullen for her contribution. The Irish Pain Nurses and Midwives Society is relatively new. I had not been conscious of its existence, for which I apologise. I am married and my wife and I have five children. I am aware, because I was present on each occasion, of what she went through during the births of all five. In the light of the definition of chronic pain, particularly in the context of the period of time to which Professor O'Connor referred, would it be possible for our guests to give a layman such as myself a sense of the direction midwifery, nursing care and obstetrics are taking in this regard? I am trying to appreciate chronic pain in the context of the definition provided and the period of time after which pain is classified as chronic. Will our guests comment on this matter in order that I might obtain a clearer understanding of the definition and how it is applied?

Dr. Keaveny referred to the need for improved pain management and the appointment of a lead clinical director for pain services. Is he referring to someone who would operate at national level and within the structures of the HSE? Would that person have oversight of pain management services throughout the acute hospital system? I suggest we are referring to an individual. Will Dr. Keaveny elaborate on this matter and provide a clearer picture of that for which he is arguing?

Dr. Keaveny stated, "We should consider a pain strategy based on the Australian pain strategy." Mr. Lindsay and one or two of our other guests also referred to the experience in New Zealand and Australia. Dr. Keaveny mentioned the huge social and financial cost of chronic pain. A greater understanding of the latter would act as a driver of an increasing realisation and awareness of and, I hope, encouraging some movement in addressing the problem. I must admit that I am a service user and that I am aware of the dreadful and debilitating reality of chronic pain.

It is sad that we must talk in terms of social and financial costs, particularly the latter, as a driver when, for me, the reality of the debilitating chronic pain with which the individuals and their families have to cope should be the key driver.

Regarding Professor O'Connor's contribution, I note from the Irish experience and the Europe-wide survey that approximately one in five people in the general population report having chronic pain, some for up to 20 years. That seems to be a huge number of people. I must admit that I would not have been conscious of that, and there are different degrees of pain. Of the people who report having chronic pain, I imagine they are not all on the one page in terms of that experience. Professor O'Connor might briefly expand on that.

The Irish Pain Society has asked that the members of the committee report on this issue to the Minister. I propose that we do so, and that the collective of the five written contributions go as a joint submission from this committee to the Minister, Deputy James Reilly. It is a practical step we can take. I have no doubt colleagues will fully support that proposal.

On the impact of severe chronic pain on all aspects of the lives of its sufferers, I will share a small comment. My mother is advancing to her middle 80s and has early-onset Alzheimer's. Because of that circumstance I hear her not only once but repeatedly say, "But thank God I have no pain." She says it over and over again. Jokingly, I have quipped back "But you are," and she takes it in good stead.

Regarding Mr. Lindsay's contribution, the subtext of the decision of the Medical Council of New Zealand to recognise pain medicine as a specialty in its own right is that this is not the case here and it is something we need to have. I have no doubt that if any of us as members of this committee had chronic pain as part of our daily reality, we would take no convincing whatsoever. It is always the case that none of us knows what is ahead of us at any time, and now is the time for us to act. I very much welcome and thank each of our guests for their contributions. I hope that our subsequent efforts will be complementary to the achievement of a real advance in this area.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I thank the expert witnesses for their comprehensive presentations. I would like to respond briefly to Deputy Caoimhghín Ó Caoláin, who wanted to know about the pain experienced by a person with chronic pain. I happened by chance to attend the society's annual general meeting, which was held, as I recall, in the Convention Centre last year, and it is a day I will never forget. There were brilliant presentations, but I remember seeing the people there and many of them stood out. There were probably 300 in the room. One could feel their pain, and I do not mean that in a smart-alec way. They could hardly speak, they were so debilitated. I came away from that meeting and promised that day that I would try to help in some way. That is one of the reasons I pushed the Chairman to deal with this issue.

Deputy Caoimhghín Ó Caoláin referred to Australia, and I heard the expert from that area speak. Do countries such as England and Scotland recognise pain medicine, or do they have a pain management strategy?

Dr. Brian McGuire's name was mentioned. He stated that chronic pain is a significant cause of work absenteeism. I am pushing the witnesses to help us to make a case. Can they quantify the exact level of absenteeism it is causing? If sufferers were to receive pain therapy, would they return to work? Can they explain how we can make a difference to the lives of those people whom I saw at the meeting?

I wish to ask about the logistics of such treatment. I heard Professor O'Connor say there are only two main regional hubs delivering the system at present. There are pain specialists and pain therapists, but much of the treatment is being delivered by anaesthetists. I want to know about the logistics of it. Is the society going to have pain therapists, anaesthetists and both together, which would be a three-tiered system? If the anaesthetists who want to continue in pain therapy are taken out of the system and go to work in the area of pain therapy, who will carry the can for the anaesthetists that are left in the hospitals? I have heard a number of people raise this issue.

Professor O'Connor and Ms Sexton spoke about the hub-and-spoke model. For that to work, a whole team is required. It is not the case that a sufferer goes into a unit, gets an injection and then goes out the door. A whole team and a rota of pain consultants are needed. Qualified specialist registrars are needed to refill spinal pumps and qualified pain nurses are also needed. Is that the type of service to which the witnesses were referring when they spoke about regional hubs in each of the areas and, if so, have they carried out a cost benefit analysis and do they have a figure for what it would cost the taxpayer?

Colm Burke (Fine Gael)
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I thank our guests for their presentations. They provided a great deal of information in what they had to say. I wish to touch on one or two issues. Reference was made to the hospital groups, and from the map presented it is obvious there are some areas of the country where no service is available. Taking into account the new hospital groups, what numbers would need to be employed to ensure that each hospital group had people to deal with this issue? Are we talking about many people, taking account of consultants, nursing staff and clinical support staff? Has any analysis being done on that under the new hospital groups setting?

The second issue relates to my area in Cork city, where I have met a large number of people, ranging in age from 55 upwards, who are now unemployed but would have been involved in manual employment over the years. Many of them have been unemployed for two, three or four years and would have left work with a back problem or a pain problem, but they do not see opportunities to return to the workforce. There has not been a huge improvement in how they view their future in that they do not see any prospects for themselves from an employment point of view. Does this contribute to the problem? The volume of manual employment has decreased. As a result of that, do our guests see a decrease in the number of problems they come across, or is the incidence likely to remain as it has been?

I know it is not tied in to manual employment but from where we have come from 20 years ago to now, given that we are far more conscious about health and safety, do the witnesses believe a lot more could be done in the area as well? I would welcome the view of the witnesses in that regard.

Sandra McLellan (Cork East, Sinn Fein)
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I thank the witnesses for their comprehensive presentations which have been most informative. Chronic pain is not something people talk about much, other than in terms of migraine or pains in one’s arm or leg. It is not considered as serious as life-threatening illnesses.

It was stated in more than one of the presentations that the treatment of chronic pain costs €4.6 billion a year, more than the cost of treating cancer and diabetes combined. When people hear about cancer or diabetes they think of them as being life threatening whereas with chronic pain is just seen as someone having an ache or pain and it will go away. They do not attach the same level of seriousness to it. Ms Sexton said there was no pain specialist in 15 counties in the country. I find it unbelievable that people do not have anybody to go to, that they have to travel to Dublin, Cork, Galway or wherever for treatment and that it could take five years or eight years for a diagnosis.

Sometimes people come to our clinics who are out of work and are on jobseekers' payments. They might have chronic pain such as severe back pain or fibromyalgia but when they apply for their benefits even the medical assessors do not recognise the problem as a serious illness or something that will mean the person will be out of work for more than 12 months to 24 months. Such people find it difficult to obtain disability allowances or invalidity pensions.

Could the witnesses outline the services available in Britain and explain why they are so much better than ours? How could interaction with health care systems be less stressful than is the case currently? How do the services in this country compare with our EU neighbours? Could the witnesses outline some of the benefits of the European and Australian models?

Dr. Brona Fullen:

I will respond to what has been asked about absenteeism from work. Dr. Maguire’s study from NUIG showed that by managing patients earlier in the process one can get them back to work. The study was on patients with back pain, which is the most prevalent condition that manifests in pain clinics and that maps to the international literature. The approach used was to target patients specifically with regards to their disability, lack of movement and fear of movement – a lot of patients with back pain are afraid to move in case they make the problem worse - thus educating patients around the benefits of exercise both from a physical point of view and a psychological point of view as that will promote early return to work. That was shown in the study in Galway.

In terms of the cost-benefit analysis, they are doing a health economic evaluation of the study that was done that showed that compared to a control group of patients, of patients who underwent early intervention at six months 20% of them were back to work compared to 12% of patients who were managed based on ordinary standards of care. I could ask Dr. Maguire to forward the health economics paper when it is available. Anecdotally, there are significant cost benefits and getting patients back to work will eventually cost the State less. We need to target patients physically and psychologically but the success rate is high if one does that. Again, that maps with international findings.

Ms Cathy Sexton:

I wanted to address Deputy Ó Caoláin’s question on midwifery, staff nurses and registered general nurses. There is a difference between acute and chronic pain. I do not wish to get into definitions but acute pain is short lived and chronic pain is greater than three months. That is basically how we diagnose it. A number of conditions cause chronic pain. Surgery is probably the one that comes to mind. If one has surgery, when one signs the consent form one of the things one is signing for is that it might result in long-term pain. Often, in the acute hospital setting when patients come in and have their surgery if pain is not well managed at that stage it can lead to a chronic pain condition in the future for the patient. That means the GP will have to pick up and manage it when the patient is discharged.

In pregnancy women come in with pain which has to be managed. That can be a huge difficulty for us because of medication management and the use of medications in pregnancy. We have a high percentage rate of caesarean sections in this country, and internationally the way things are going, and a high rate of pain can be associated with the post-caesarean section stage. We also have quite a lot of pelvic conditions associated with women’s pain, including chronic pelvic pain. I will not go into the conditions in detail now but issues arise for women both in the maternity setting and post their treatment in maternity services.

From the point of view of nurses managing pain both in a hospital setting and a primary care setting, one of the main reasons patients attend a health care system is because of pain. The assessment and management of pain is a huge part of our role in every single health care setting. When patients present with pain we have to try to manage it. If it is acute pain we generally have a very good team around us that can manage it very well for the patient. We try to find a causative reason for the pain. With chronic pain sometimes we do not have a causative reason for the pain. We talked about fibromyalgia and some of the chronic conditions that cause pain but then there are some pains for which we really do not have a reason, but the patients still have it and they still have pain sensations and must live with it over a long period.

For us it is about managing diseases such as diabetes and arthritis and other conditions associated with chronic pain. The big area is care of the elderly and the amount of pain conditions that are associated with the ageing population. The other cohort of patients is patients post-cancer treatment. Pain is one of the side effects of the treatment. Another area relates to the condition itself causing pain. We also have the whole area of palliative care and end-of-life care. There is a large cohort of pain conditions associated with chronic pain.

In response to Deputy Mitchell O’Connor’s question I wish to refer to the hub and spoke model. A number of countries have developed strategies and models of care such as Australia, the United Kingdom and we also have one in Scotland and in Northern Ireland. There are different models being used and there is a lot of research related to what works and what does not work. We have good evidence to say that if one has major pain centres that deal with the interventional therapies that we require and if one needs an interdisciplinary team to manage patients’ pain, that should be done in the hub hospital. If we are talking about stratifying services in Ireland, and we are looking at hospital groupings, the main hospitals should have the multidisciplinary team working there. In primary care we are talking about having a cohort of allied health professionals, nursing and GP services managing with very structured processes. That is why we need the strategy; so that we are all educated and trained in management. That is what they have done in these countries. They have educated GPs, nurses, physiotherapists, occupational therapists and psychologists - the whole team - to be able to manage pain better and to be able to interface with those patients at a much earlier stage.

It does not mean that every patient needs interventional therapy or a multidisciplinary team, but a cohort of patients will always require that. I will let some of the other speakers talk about that, but for me the hub-and-spoke model would give us an idea of what we are looking for in a strategy. I do not think we have a cost analysis done on that, but I will let the other speakers talk about it.

Deputy McLellan asked me about the British model. Many countries have strategies on pain management, including America, Canada and Australia. The United Kingdom, Scotland and Northern Ireland have a strategy also. In that respect, therefore, we have a good deal on which to work. In terms of the cost benefit, what we see is that waiting times for patients to see a specialist have been reduced. If I am correct it is about 28 weeks in the UK, whereas in my area one could be waiting up to three years to see a pain consultant. That is the difference, and that is the point I was trying to make. I thank the committee for allowing me an opportunity to address it.

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.

Professor Laserina O'Connor:

If I give a sense of what is in the national pain strategy it might be helpful to us. There are six components to it: people in pain - that is a national priority; knowledgeable, empowered and supported consumers; skilled professionals in state of the art pain care; access to interdisciplinary care at all levels; quality, improvement and evaluation, which is a key component; and research, which is key to all of this area.

I thank members for their questions. Deputy Ó Caoláin asked about a long timespan of pain of more than 20 years. What the patient tries to do is self-manage their pain at first before going back and forth to their general practitioner. Eventually, if it is an orthopaedic problem they get to see the orthopaedic surgeon, but by the time they access a pain service they have developed several causes for their pain and they continue to go back and forth to their GP for different key aspects.

What we are saying, in terms of the model in other areas, is that they have simple analgesics, and then the person can get access to a service. It is a much different process. What is important about the UK - all members asked about this - is how they generated savings. They generated savings of 35% per patient by taking an interdisciplinary approach. That meant that the number of patient visits to the GP was reduced, which was key because, as I said earlier, seven to ten visits a year per person is the norm.

As Ms Cathy Sexton said, we need to span out interdisciplinary care, which starts at primary care level. In terms of the multidisciplinary care, with which I have experience, the GP comes in on that. That is key, because we cannot work without the GPs, who are the first port of call for these patients in pain. I thank the members and I hope that answers that component of it.

I gave members the testimonies which prove that patients are struggling in their pain.

Dr. Keaveny answered Deputy Mitchell O'Connor's question regarding anaesthetists and specialised pain consultants.

I am involved in the Ireland East health care group, which involves the university and 11 hospitals. That will be strategic in this process because, as Dr. Keaveny said, we can have the centres of excellence, but this magnet component is important also. That is key for all our patients.

A key point for me when one is talking about an interdisciplinary approach is ensuring everybody gets to the table and that they all work together. It is difficult because it often means that we need a physiotherapist, an occupational therapist, a pain nurse, a pain consultant and a psychologist. In some cases, it must be remembered that the use of opioid medication will be a key issue. Opioid addiction is at epidemic levels in the United States, which is why we need true interdisciplinary teams. Substance abuse and psychiatry also have to be considered in that regard. That is not to say patients in pain are not entitled to opioid analgesics, but the misuse of such drugs will be a key component. Our patients are surviving all of their treatments.

What is interesting about diabetes is that an enormous amount of funding has been put into dealing with the problem, which is welcome. Diabetes can result in many complications from the head to the toe. However, what is missing from the picture is the fact that the majority of diabetes sufferers develop chronic pain. That is another co-morbidity factor in its own right. I hope I have answered all of the questions posed.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you, Professor O'Connor.

Mr. John Lindsay:

Deputy Caoimhghín Ó Caoláin asked what the first step would be and Dr. Keaveny has referred to it. It would be ideal if the Minister nominated somebody within the Department of Health or the HSE, preferably the latter, with responsibility for chronic pain services. Preferably, that person would be Dr. Áine Carroll who has responsibility for dealing with long-term conditions.

On Deputy Mary Mitchell O'Connor's question about services elsewhere, we have been studying the national pain audit that has just been completed in England. There is clear evidence that while services in the United Kingdom are hit and miss, they are vastly superior to what is available in Ireland, both acute services and, in particular, community care services. Community care services for people with chronic pain are non-existent here. In the North of Ireland they are working on their pain strategy. Everybody with chronic pain has a right to access a multidisciplinary community care team to help them self-manage their pain. Providing for self-management is very important, if not the most important part of the work we do. To give the committee an example of how effective it is, we had one member who contacted us on Monday or Tuesday of this week to say she had followed her self-management-self-care programme and was off all medication. Her particular medications were costing the State €15,000 a year, a considerable sum of money. There are probably 120,000 people living with chronic pain, at a persistent, severe level. With appropriate community care services, we could probably reduce the State's drugs bill substantially, improve the quality of people's lives which is hugely important and, in many cases, prevent them from entering mental health services which many, unfortunately, do because they are not receiving the appropriate treatment. When one looks at the North of Ireland or the Scottish model, one sees that everybody with chronic pain has access to multidisciplinary teams in the community, which has made a huge difference. We are following a model in Kirklees in Yorkshire where dependency on social welfare has been reduced considerably by developing self-care bundles for each individual. I hope we could follow with something similar in Ireland in the years ahead. We realise the resources are not available to throw millions at the problem, but we honestly believe the Exchequer could save hundreds of millions of euro if appropriate services were put in place, both in acute and community care services.

Jerry Buttimer (Cork South Central, Fine Gael)
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Arising from proceedings at this meeting, I put it to the committee that we should call on the Minister and the HSE to establish a national strategy for chronic pain management similar to other international models. We will also call on them to appoint within the HSE a lead clinical director and a specialty director for pain management. We will call on them to ensure appropriate and adequate resources, funding and personnel, are provided for pain services and to recognise pain management and pain medicine as a clinical specialty within the health service. Is that agreeable to the committee?

Colm Burke (Fine Gael)
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Yes.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does anyone have anything further to add?

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I express my thanks to Dr. Camillus Power who has put a lot of effort into dealing with issue.

Jerry Buttimer (Cork South Central, Fine Gael)
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I should also mention Dr. Dominic Hegarty in Cork. I had hoped he would be able to attend this meeting, but I believe we got our wires crossed regarding the invitation. He does a lot of good work in Cork in this regard.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Regarding the earlier session and the decision made in private session about correspondence from the committee, could we have-----

Jerry Buttimer (Cork South Central, Fine Gael)
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What does the Deputy wish to raise in that regard?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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We have agreed to furnish the reports-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes. The Deputy is referring to our earlier discussion on sickle cell disease.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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We have also made a similar decision in the context of the earlier discussion and an item of correspondence. I ask that copies of each be circulated to members of the committee, not only to those who were present but also, more importantly, to those who were not.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is fair enough. I thank the delegates for their presentations. During the course of the meeting I received a text message from a person whose mother had made a submission to Mr. Lindsay's group and had been watching the proceedings. We are being watched far and wide. I thank everyone for being here.