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Re: Chronic pain - a practical approach in the UK?

The refreshing article by Malleson et al highlighted the importance of medically unexplained symptoms within our patient population. He also raised the spectre of the psychological damage to the adolescents who often additionally face educational and social isolation due to their illness. This proportion is growing as a result of changing morbidity patterns within Western society and demands within health care are documented.[1]

The author suggested an interdisciplinary approach to chronic pain which though laudable strains resources especially within mental health. Multidisciplinary teams offer comprehensive assessment and management of problems though rapidly become overwhelmed with referrals. Would a more cost effective model in Britain be the flexible utilisation of existing resources such as community paediatricians who already have educational, medical and some mental health skills function as a second tier assessment? The multidisciplinary Pain team would then act as a third tier. This model is only sustainable through integrated and jointly agreed medical guidelines with continued good communication. This approach reflects other care pathways within medicine though there are significant differences.

Other care pathways depend upon first tier clinicians partly managing and assessing problems in addition to recognising their impact to patients prior to referral. Paediatric training has traditionally and appropriately focused upon organic pathology. Weighting towards the mental health aspect of disease was and is reduced both in terms of structured training and formal assessment within postgraduate examinations. The culture within the Royal Colleges is changing but the fruits may only be visible in the next generation of clinicians.

D NATHAN
Consultant Paediatrician
Child Health Department
Queens Medical Centre
Clifton Boulevard
Nottingham, NG7 2UH, UK