Developing a Structure for Delivery of Care

This model aims to resolve the inequality around provision of care. Improving care around pain requires a significant financial investment to develop all tiers of care from primary to tertiary. The HSE and NPA have demonstrated the inequality but to make changes two key issues must be resolved by the CRG for specialized pain services. First, a Health Survey Analysis of costs needs to be undertaken which would involve a detailed assessment of the current expenditure, demand for specialised provision and current available capacity within existing specialised pain providers, the costs of enhancing the service and the savings that such an approach would realise. The second requires innovating a system that will be able to identify patients with pain through coding and facilitate the tracking of those patients and more importantly their response to interventions.

The Enhanced model of UGP care delivery in England. The BPS patient maps form the basis of a structured approach to the provision of care for those suffering with abdominal, pelvic and urogenital pain. They aim to clarify the process of early identification of problematic pain, as well as triage, support, education, and self-management. They emphasise the importance of multiple levels of care, combined with multispeciality and disciplinary input, along with a holistic approach.

PRACTICAL IMPLICATIONS

It is well recognised that patients suffering with abdominal, pelvic, and visceral pain have unique diversity requiring us to consider multiple tiers of seamless care depending upon the needs of the patient. A minimal number of specialist centres will not be capable of meeting the needs of this significant patient population and given their complexity a management regime involving solely primary and community care is not a feasible option. In recognition of this fact NHS England is investigating seamless care modeled on vertical integration with regional centres working closely, and communicating regularly, with secondary care centres, which in turn support community services. Equitable access depending on need must also remain a policy cornerstone.

Seamless care and integrated care are concepts that have been repeatedly used throughout this chapter and are topical regarding health policy. Current thinking regards them as a panacea for the inefficiency that almost inevitably accompanies any large corporation or institution. However, they are rather nebulous terms that neither identify the root cause of a problem nor offer a tangible solution? Currently primary, secondary and tertiary care all communicate with each other therefore is care not already integrated? Given the acknowledged power of leadership, teamwork, efficiency and knowledge sharing an integrated service indeed sounds like a panacea but how does one go about creating it functionally, and more interestingly why are we not employing these seemingly simple and obvious principles already?

The WHO defines integrated care as a concept bringing together inputs, delivery, management and organization services related to diagnosis, treatment, care rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency. As an endpoint, this definition provides great clarity, however, the question remains as to how one might go about achieving it? To use a term first coined by Rittel and Webber creation of such a service is a proverbial “wicked” problem [18].

There are major obstacles aside from the lack of clinical resources. First is the issue of communication. The referral process still utilises the delivery of physical letters, and patient records are almost totally inaccessible between institutions, resulting in the slow and often neglected or erroneous passage of information. A universal network of electronic patient records is the first requirement for integration however recent costly failures in this area and the politically sensitive nature of accessible personal information has made this an unsavory concept in the NHS.

Another issue is around referral. Given the subjective nature of pain and the absence of reliable metrics, and despite the emergence of pathways to guide primary care, when is the correct juncture to refer patients? Additionally given the financial implication of sending patients to specialists, do primary care physicians delay referral in an attempt to avoid this cost when in fact it is merely delaying the inevitable at patient’s expense? Does there need to be a paradigm shift whereby instead of primary care being in essence financially punished for referring patients, should they instead be rewarded for the timely referral of appropriate cases?

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