Specialist Pain clinics at the Chelsea & Westminster following COVID-19: We continue no matter what - Dr Susan Childs: Consultant Clinical Psychologist, Lead Therapist for Pain Management Services

I have written and provided specialist pain management services at the Chelsea & Westminster Hospital for over 14 years now. Every Trust has a unique and differing inward population into their services and in the last decade I have dedicated myself to understanding our unique populations and writing / providing appropriate pain management services for all. More recently I have become engaged with the NWL CCG who are making a valiant attempt to think with a macro plan for pain services in this commissioning body. Watch this space for a new thoughtful, evenly accessible pain service across these boroughs.

The bulk of our population has changed since the onset of the pandemic. Traditionally, we would have seen these patients with moderate levels of pain with related mood issues. Patients still present with a sense of being worn down by constant painful sensations and a downward sliding ability towards loss of function in their lives - who have avoided many life activities due to pain and ended up having their entire life focus around their pain. I wonder whether post COVID difficulties with getting a GP appointment has influenced the loss of patients who are more physically and psychologically able with pain, as we have noticed a reduction in this population. I wonder whether the more able pain patients perhaps are waiting for things to ‘settle’ before seeking help or that only patients who are active in asking are getting referred or even that other services are managing these patients effectively. Whatever the reason there does seem to be a shift in the populations being referred. I don’t think we could attribute this to the fact that the service was closed as we remained open (with reduced capacity) through-out all of the waves of COVID-19.

We continue to offer a wider range of programmes and therapy input stretching from patients who have chronic pain but still manage to live their lives (but often overdo and end up in a repetitive cycle of boom and bust) to patients who are afraid to make even basic movements associated with everyday life (these patients need encouragement to live without fear of increasing pain). It is not the patients so much but how we offer these services that has shifted post COVID. During the first wave the hospital was very stretched and we saw many of our team step bravely up to work in ITU supporting roles. During this time we continued on – managing all that we could and shifted as many services as we could into telephone and video appointments. Both our patients and our clinicians had to work adaptively to offer a type of service that had previously only been offered in few places with little proven efficacy.

This did mean that some of our specialist services (such as those aimed at helping survivors of torture, translated group services and psychologically supported exercise groups for people with high pain who need the concept of a basic activating routine and help with fear of pain) did have to be paused in part. We have restarted some but other services such as the Arabic speaking women’s group has requirements we still cannot provide at the moment. These will return as the tide changes back towards allowing multiples of people in a single room setting. There are still restrictions upon how many people can be in any one room and groups by their nature require a big space with access to gym equipment. During the waves of COVID-19, the few larger spaces we had were converted to online working spaces and even with these opening up, many clinicians need space for 1:1 patients and we are all vying for the same space. Face to face groups (more specifically the specialist groups) who are less able to manage a virtual setting have been given 1:1 or dual appointments. These are popular with patients but the strong evidence for change is within group settings over numerous weeks. Through-out these difficult times with altered ways of working and altered expectations of both clinicians and patients alike we have seen some success stories. Our pain management therapy groups have shifted online (and are now attempting to shift back as the restrictions reduce and opportunity arises) and our outcome data shows that the magnitude of change is comparable to face to face services for patients diagnosed with Fibromyalgia, patients’ who attend a yoga programme for long term painful conditions and a more traditional broadly mixed group of patients with chronic pain. These effects have been withheld over 3 months post participation and we are looking at the longer term data now. We will be looking at the data to see if attendance improves with online services as they disrupt people’s lives less and allow people who live further away access.

Our groups remain focussed around the Acceptance and Commitment Therapy Model (ACT) which at its heart helps people to learn how to be more psychologically flexible in the face of life’s difficulties (of which pain is only one), so offers life skills alongside targeting their pain. We still offer specialist services for patients who are seeking a pain modulating device called a spinal cord stimulator which is a distinct pathway that offers a focussed pain management programme alongside the implanted device, alongside dual physiotherapist and psychologist sessions where the mind and body are taken into consideration to help people shift away from pain being the dominant focus in their lives.

Good things have come from working differently as well as the struggles. We have formulated a new first patient multidisciplinary team assessment clinic that cut through the COVID related wait times and has seen general wait times for the service dramatically improve. We have restarted our survivors of torture medications and psychology one stop clinics that promote mind and body wellness and have a reduced, but still running, therapy group that they can enter into. We have returned to a whole team and are beginning to work as a large, multidimensional unit again. We have reviewed the service and seen how online therapy can work. We have been amazed by our patients and our resilience and a sense of willingness to roll with a world that is different and scary. The psychologists were generously offered funding by the CW+ charity for training in Eye Movement Desensitisation and Reprocessing therapy training as the level of people with pain who have trauma co-morbid with pain is thought to be rising. This will allow us to help people with an issue that feeds their pain picture without waiting extended time for a specialist service elsewhere. We have worked with patients to help them manage their reactions to their pain, modify their behaviours and identify the things that value and helped them to step towards these in the same model as we promote: living alongside difficulty. We have mirrored the same processes with the way we work and what we offer: identifying our professional reactions, modifying services and holding the things we value about the NHS nearby. So, even more in this post COVID world I can say: we have struggled to keep providing through-out COVID but we will not give up. We stand with people who struggle with their lives because of pain that doesn’t go away. We will continue to speak for the unheard populations not matter what the world throws towards the NHS.

Content provided by Dr Susan Childs:
Consultant Clinical Psychologist,
Lead Therapist Chelsea and Westminster Hospital
NHS Foundation Trust