Primary care consultation model

1. Introduce yourself, your role and acknowledge the person in front of you, assisting with the connection and building trust. Tread gently and reassure them that the conversation will be centred around what matters to them and considering the 7-Steps approach.
2. Assess for and manage red flag symptoms²¹,  active mental health problems and the individual’s health beliefs before focusing on pain management. Identify any social challenges e.g. inadequate housing, financial issues or relationship difficulties. Questions to identify health beliefs can include: “What do you think is happening to cause the pain? I have my own thoughts but want to check first, what were you hoping for today?”
3. Validation – summarise their story back to them for example: “Ok I can see you are really suffering and I’m happy to work with you. Firstly let me check I’ve got this right. So X years ago you got X pain at X (part of your body). It’s affected your life especially X and you’ve tried X things so far. Have I got that right?”
4. Check level of awareness of current condition and what the individual expects of the outcomes of the consultation e.g. cure seeking vs wanting a pain management plan. This indicates whether the individual is ready for behaviour change, e.g. “Ok, before we go on can I check what’s your understanding of persistent pain and the outcomes you expect following today?”
5. Be open and candid about limits of medical intervention. Suggested phrases:

• • Acknowledge the impact of pain on their life

“The condition you have is (e.g. osteoarthritis, nerve pain, fibromyalgia, chronic back pain). It is a painful medical condition. Part of having a condition like this is that the pain is persistent. The pain will vary and you may experience flare ups, depending upon many factors, such as how well you respond to various approaches. Most people wish that their pain could be taken away; this is normal.”

• Acceptance of where the person is at that moment, we cannot fix it but can improve management

“I need to be honest here, chronic pain is a long-term condition and unfortunately isn't curable with medication. For most people, pain medication is not effective and even when they work well, they only give around a 30% reduction in pain and can cause side-effects such as drowsiness, dizziness and constipation.”

• Agree a plan

“We know pain management is improved by understanding pain better (everything that matters to you matters to your pain). The goal is to manage it so it doesn't manage you. For example, we know that becoming more active, even slightly, can help pain. Understanding sleep and relaxation can help pain. Reducing worries and fears can also help manage pain.  Understanding your pain is the first step. Here are some resources that you might find helpful. I know this is hard so can you book a follow up consultation with me once you've been through the resources?”

“We can work together to develop a personalised plan that works for you, giving you a package of management skills that you can use in everyday life. This is a combination of information, treatment and support. Here are some resources that you might find helpful. I know this is hard so can you book a follow up consultation with me when you are ready, I suggest four weeks, after you've been through the resources.”

6. Offer support, resources and continuity. Consider learning style e.g. “How do you like to learn new information? For example are you a reader, go online, a people person or prefer one to one? Do you need support to learn new things? “Here are some tools that many people living with pain find helpful (NHS Inform chronic pain resources). When we speak again it’s fine to bring someone if that would help.”
7. Medicines management

• Be clear medication is to improve function and will be stopped if ineffective
• If significant polypharmacy or a risk of harm then ensure reauthorise function on Vision is activated or put medication on acute on EMIS. This can help avoid people being lost to follow up
• Once the medication is reviewed and is to be continued, place on repeat with a limited issue allocation and set a review date. Vision has the facility to set a minimum reorder time. For example, for 28 day prescribing a minimum reorder time of 25 days could be set, to prevent overordering.
• If starting a medication, ensure that it is reviewed regularly, stating a follow up time frame

    8. Coding – use the following read codes:

• #1M52 for diagnosis of chronic pain
• #66n for chronic pain review
• 8B31B for polypharmacy review

What's the matter?

1. Follow-up on resources signposted to the individual.
2. Explore the type of pain, e.g. musculoskeletal or nerve pain. Consider using S-LANSS questionnaire²² to determine if the pain has neuropathic pain.
3. Consider the impact on mood and life. “People living with pain often have problems with their sleep, mood or relationships, does that happen to you?”
4. Consider baseline scores – “On average what is the impact of pain on your day to day life over the last two weeks? Out of 10 with 0 meaning no impact and 10 being unable to get out of bed.”
5. Discuss activity - Identify underactivity or overactivity, or cycling between the two. Introduce pacing. “Often people can do too much then hit the wall – does that happen to you?”
6. Medication review – “Being honest, do you think the medications make a difference or is it hard to tell? Do you get any of these common side effects…?”

What matters to you?

7. Summarise their story, acknowledge impact on life and offer continuity. Acknowledge pain in the context of the whole person e.g. work, family life. “Looking forward to the next three months what things matter the most in your life? What would you like to improve?”

Support for what matters to you

8. Review their learning style and any barriers, match to resources
9. Offer specialist support – pharmacist, physiotherapy, occupational therapy, mental health support, community link workers, third sector
10. Deprescribing –– “If a medicine isn’t helping you then it can be harming you. Can we work together to slowly reduce it and see if this reduces some of your symptoms, which may be side-effects of the medicine?”
11. Offer clinician follow up and read code in EMIS/ Vision using “Chronic pain review/ #66n”

1. Ask if there has been some improvement or if the person feels better – if so what has helped? Acknowledge and reinforce strengths and efforts to help build self-efficacy. Consider asking the individual to document changes and interventions.
2. If there is little or no improvement or if the individual is not satisfied – check that the clinician relationship with the person is constructive, work through options for self-management and use of medication. Consider barriers such as other causes of pain, active mental illness, lack of understanding, fixed health beliefs or motivation issues.
3. If there is still no improvement after several consultations consider referral to specialist chronic pain service. “They don’t cure pain but they are a rehab service to help you improve your quality of life. What do you think about being referred?”

Personal reflections from general practice on a change to managing chronic pain