Health and service needs, priorities and initiatives of primary health networks related to chronic pain

Keywords: chronic disease, chronic pain, delivery of health care: integrated, health services: accessibility, health services: needs and demands, implementation, primary health care, secondary prevention.

Chronic pain is a major public health issue and is increasing due to the aging population (Blyth et al. 2019). It has been classified as a disease in itself through the World Health Organization (WHO-ICD 11) (Treede et al. 2019).

Secondary prevention of chronic pain focuses on those at risk of developing chronic pain in the post-surgery and post-injury phase. Risk factors for poor recovery are well documented and often modifiable; for example, depression, pain catastrophising, avoiding movement or activity, lack of social support and poor job satisfaction (Glare et al. 2019).

Given that multidisciplinary tertiary pain services cannot meet patient demand, greater involvement of primary care is needed (Hogg et al. 2021). Furthermore, the upscheduling of codeine to a prescription-only medication by the Therapeutic Goods Administration in Australia in 2018 provided a greater focus on the over-reliance on pain medications and its negative consequences and a desire for alternatives based on non-medication, multidisciplinary options.

Australian primary health networks (PHNs) have an important role in strategic planning, commissioning services, supporting general practices and other healthcare providers and supporting the integration of local healthcare services (Australian Government 2018); however, little is known about the scope of work of PHNs related to the management and secondary prevention of chronic pain.

The aims of this study were to understand the needs and priorities of Australian PHNs related to the management and secondary prevention of chronic pain; map current PHN chronic pain initiatives and identify gaps; highlight key enablers to implementation; and highlight solutions identified by PHNs to increase capacity to commission initiatives.

This study comprised mixed methodologies and an emergent complexity-informed approach as a way of prioritising actionable knowledge linked to context that is appropriate to address practical questions for PHN decision-makers (De Allegri et al. 2020).

Phase 1 focused on understanding the needs and priorities of PHNs and mapping their current chronic pain initiatives, via the following methods:

1. A review of publicly available core PHN needs assessments 2017–18 (n = 31) to understand the issues of PHNs related to chronic pain. Methods and additional results are described in a recent paper (Walker et al. 2021).

2. Consultation with executive-level staff and program managers from PHNs, and one state PHN alliance (the WA Primary Health Alliance (WAPHA) – an alliance between Perth North PHN, Perth South PHN and Country WA PHN), via telephone interviews and online surveys (December 2018 to February 2019) to understand the priorities, needs and issues of PHNs related to chronic pain; map current PHN chronic pain initiatives; identify key enablers to implementation of these initiatives; and assess PHN representatives’ awareness of chronic pain initiatives in other PHNs. All PHNs and WAPHA were invited to participate in the consultation. Potential participants were identified via the PHN Cooperative Executive Officer, and the networks of the research team and steering group. PHN representatives were also encouraged to forward the invitation to any other PHN representatives that they thought would be interested in participating in the consultation using a snowballing sampling approach. Telephone interviews were recorded and transcribed verbatim.

3. A face-to-face workshop for PHN executive-level staff and program managers was conducted (March 2019) to report the findings from the consultation (outlined above), provide an opportunity for PHN representatives to discuss their chronic pain initiatives and foster collaboration between PHNs. Invitees included PHN representatives involved in the consultation. PHN representatives were also encouraged to forward the invitation to any other PHN representatives that they thought would be interested in participating in the workshop. Data collection included: PHN representatives’ presentation slides from the workshop; audio recording of the group discussion; authors’ notes from the workshop; and participant evaluation surveys.

Phase 2 sought to address a gap identified in Phase 1 of the study, PHN initiatives related to the secondary prevention of chronic pain, via the following method:

1. A deliberative dialogue (Lavis et al. 2009) with PHN executive-level staff and program managers was conducted (October 2019) to discuss relevant initiatives related to the secondary prevention of chronic pain; to identify initiatives that may be feasible for PHNs to implement considering their needs, capacity and local context; and to foster collaboration between PHNs. A rapid evidence review developed by the authors was pre-circulated to participants before the deliberative dialogue. Invitees included PHN representatives involved in the consultation (outlined above). PHN representatives were also encouraged to forward the invitation to any other PHN representatives that they thought would be interested in participating in the deliberative dialogue. The deliberative dialogue included presentation of the rapid review evidence by the authors, whole group discussion and smaller group discussions. Data collection included: audio recording of the final whole group discussion; authors’ notes from small group discussions and whole group discussions; butcher’s paper notes taken by PHN representatives in small group discussions; and participant evaluation surveys.

The study also involved communication with PHN representatives who had participated in the study, via email, to provide study updates and exchange relevant information about PHN chronic pain initiatives.

Quantitative data in the online surveys were synthesised using descriptive statistics. Thematic analysis (Miles et al. 2014) of the qualitative data was conducted by the authors (SDM and PW) across the study components related to the following themes: (1) PHN health and service issues related to chronic pain; and (2) key enablers to implementation of PHN chronic pain initiatives. The subthemes were derived from the data by the primary author (SDM) and reviewed by the second author (PW) for validation, resolving any disagreements by discussion and consensus.

The contents of this published material are solely the responsibility of the individual authors and do not reflect the views of the National Health and Medical Research Council (NHMRC) or funding partners. The research was approved by the University of Sydney Human Research Ethics Committee (HREC) Phase 1 Project no 2018/885 and Phase 2 Project no 2019/765.

The research team consulted with executive-level staff and program leaders from all PHNs, apart from one metropolitan PHN in Victoria, (N = 27/28 PHNs and one state PHN alliance, WA Primary Health Alliance (WAPHA)), via: (1) online surveys (N = 26 representatives from 25 PHNs and WAPHA); (2) telephone interviews (N = 30 representatives from 22 PHNs and WAPHA); (3) a workshop (N = 28 representatives from 20 PHNs and WAPHA); (4) deliberative dialogue (N = 21 representatives from 16 PHNs and WAPHA); and (5) email consultation (representatives across PHNs and WAPHA who had participated in the study). Overall, the majority of PHN representatives who participated in this study participated in all study components. Metropolitan PHNs have ≥85% of the population in ‘major cities’, as defined by the Australian Bureau of Statistics. All other PHNs are classified as ‘regional PHNs’.

Chronic pain was reported as a health and/or service need by approximately half of PHNs; that is, 12 out of 25 PHNs and WAPHA; and a priority by 9 out of 25 PHNs and WAPHA who participated in the telephone interviews/online surveys. All states and territories in Australia apart from the Northern Territory and Tasmania identified chronic pain as a priority in at least one PHN. Only 2 out of 13 regional PHNs (excluding one regional PHN as part of WAPHA) identified chronic pain as a priority.

Supplementary File S1 outlines PHN health and service needs related to chronic pain and the supporting qualitative evidence across the study components (PHN needs assessments, telephone interviews, online surveys, workshop and deliberative dialogue).

PHN health and service needs related to chronic pain identified across the study components included high prevalence of chronic pain in the community due mainly to musculoskeletal conditions (e.g. arthritis and back pain); increasing prevalence of chronic pain due to the aging population; poor access to specialist pain clinics with workforce shortages and increasing demand, compounded by limited reach to regional areas; a need for greater involvement of primary care in chronic pain management using a multidisciplinary approach; high opioid prescribing especially in regional areas; poor understanding of chronic pain among consumers and the general community; a lack of community-based consumer pain programs; poor access to allied health providers due to workforce shortages, particularly in regional areas, and cost barriers; and a need for greater education and training for primary care providers related to chronic pain.

Reasons highlighted by PHN representatives for not identifying chronic pain as a need or priority are outlined in Fig. 1.

Fig. 1.  Reasons highlighted by PHN representatives for not identifying chronic pain as a need or priority.

The findings from the consultation with PHNs (including the telephone interviews, online surveys, workshop, deliberative dialogue, and email consultation) informed the mapping of PHN chronic pain initiatives.

The map is based on three goals, adapted from the goals of the National Pain Strategy (Painaustralia 2010) and aligned with PHNs’ remit (Australian Government 2018). Table 1 outlines the types of PHN chronic pain initiatives.

Table 1.  Map of primary health network (PHN) chronic pain initiatives.

Among existing PHN practice, two exemplar evidence-based initiatives were identified: face-to-face multidisciplinary community-based pain programs implemented in six PHNs (including metropolitan and regional PHNs) and WAPHA, and an online health professional capacity-building initiative, Project ECHO (chronic pain), implemented in one regional PHN.

Gaps identified by the mapping included: initiatives related to the secondary prevention of chronic pain (post-surgery or post-injury), digitally enabled consumer and health professional chronic pain initiatives, and chronic pain initiatives for specific population groups such as Aboriginal and Torres Strait Islander people.

A lack of shared knowledge among PHN representatives about chronic pain initiatives implemented by PHNs was demonstrated across the study components. Most PHNs rated their knowledge of chronic pain initiatives in other PHNs as ≤3 out of 10. Furthermore, feedback following the workshop and deliberative dialogue highlighted that PHN representatives highly valued the opportunity to engage with each other:

This is one of the few opportunities I have to talk to other PHNs about a problem that affects us all, and I really value it. (PHN representative, deliberative dialogue)

The key enablers to implementation of PHN chronic pain initiatives identified by PHNs are outlined in Table 2.

Table 2.  Key enablers to implementation of Primary Health Network (PHN) chronic pain initiatives with supporting evidence across the study components.

PHN representatives identified limited resources as a barrier to commissioning chronic pain initiatives:

We don’t always have the resources to be able to do the stuff that maybe our region really needs. (PHN representative, interview)

Solutions proposed by PHN representatives are outlined in Table 3.

Table 3.  Solutions proposed by Primary Health Networks to increase capacity to commission initiatives with supporting evidence across the study components.

Chronic pain has been classified as a disease in itself through the World Health Organization (WHO-ICD 11) (Treede et al. 2019) and our analysis indicates a widespread lack of recognition of this by PHNs, perhaps due to the lack of timely data related specifically to chronic pain available to PHNs to inform their PHN planning documents. PHNs recognising chronic pain as a distinct condition in PHN needs analysis and data collection would lead to more dedicated funding to support chronic pain initiatives and reduce the burden of chronic pain in their regions.

The mapping of PHN chronic pain initiatives in our study identified initiatives related to the secondary prevention of chronic pain as a gap, with no initiatives identified, despite evidence that these types of initiatives can be effective (Nicholas et al. 2011; Katz et al. 2015). Specifically, our study identified a gap related to upskilling primary care providers to identify people at risk of developing chronic pain after injury or surgery using risk-based assessments within the context of their own clinical reasoning and shared treatment decision-making with patients (Sowden et al. 2011). In addition, our study identified a gap related to initiatives to improve communication about pain care between hospital-based healthcare professionals and primary care providers in the transition of patients from hospital to home, with no initiatives identified. Australian data show that excess opioid supply at post-surgical discharge is widespread (Allen et al. 2020) and there is evidence that <10% of hospitals provide general practitioners with a pain management plan or an opioid de-escalation plan (SHPA 2018). Even among hospitals implementing opioid stewardship programs, there is inadequate communication between hospitals and general practice, occurring in only 18–22% of hospitals (Allen et al. 2019). PHNs are well placed to support better integration of primary and secondary care services (Javanparast et al. 2018; Swerissen et al. 2018) and to link to opioid stewardship programs to improve communication with general practitioners and ensure they are provided with a pain management plan. General practitioners also require skills to implement opioid tapering with patients using patient-centred communication (Darnall et al. 2019) and a self-management approach (Nicholas and Blyth 2016), and this training could be incorporated into current PHN education opportunities for primary care providers.

Digitally enabled health professional capacity-building initiatives such as Project ECHO have been implemented internationally to upskill health professionals in best practice pain care, particularly in regional areas to reduce healthcare disparities in the provision of pain care services between metropolitan and regional areas (Hassan et al. 2021). Our study identified two digitally enabled health professional capacity-building initiatives related to chronic pain, Project ECHO (chronic pain) implemented in one regional PHN and the Webinar Skills Training in Pain Self-Management (Pain Management Research Institute, University of Sydney) implemented in one metropolitan and three regional PHNs. Given that the COVID-19 pandemic has precipitated the rapid introduction of digitally enabled health professional education and increased confidence in using technology for education purposes (Shah et al. 2020), there is an even greater potential for PHNs to implement e-learning and hybrid education delivery models.

Our study identified a gap in PHN consumer initiatives and health professional capacity-building initiatives focusing on Aboriginal and Torres Strait Islander people with chronic pain, with no initiatives identified. Musculoskeletal pain is an important and poorly recognised issue in Aboriginal health care, and Aboriginal people are at higher risk of disabling musculoskeletal pain because pain conditions often co-exist with other health conditions and are associated with socioeconomic disadvantage (Lin et al. 2019). The experience of chronic pain and culturally appropriate management requires genuine engagement between patients and their healthcare professionals. There are benefits of adopting a culturally sensitive approach to improve health professionals’ communication using, for example, a ‘clinical yarning’ approach (Lin et al. 2016). PHNs’ remit is to support the health of Aboriginal and Torres Strait Islander people and to ensure cultural awareness and competency among primary care providers (Australian Government 2018). PHNs could provide education opportunities for primary care providers to upskill in appropriate communication with Aboriginal and Torres Strait Islander people with chronic pain.

This study highlighted a lack of knowledge among PHN representatives about initiatives implemented in other PHNs and a desire for greater opportunities for communication between PHNs to improve knowledge-sharing, reduce duplication of processes and systems, and undertake collaborative initiatives. Although PHNs are constrained by a lack of a formal national PHN body (Russell and Dawda 2019), networking opportunities could be expanded for PHN executive-level staff and program leaders across PHNs in Australia. In addition, a central repository for evaluation reports (Russell and Dawda 2019) would help to facilitate knowledge-sharing among PHNs.

PHNs also identified a need to establish partnerships with stakeholders in government and non-government agencies to enable shared goals, joint planning and resource sharing. The implementation of HealthPathways in the Hunter New England area of New South Wales is an example of an initiative identified in this study involving successful partnerships and shared governance between the Hunter New England Central Coast PHN and the Hunter New England Local Health District (Gray et al. 2018). Co-commissioning has the potential to promote efficiency, overcome fragmentation and foster a more integrated primary healthcare system (Swerissen et al. 2018; Freeman et al. 2021; Koff et al. 2021); however, resources and support to PHNs are needed to encourage collaborative mechanisms (Freeman et al. 2021). The Ministry of Health, New South Wales state government, has recently developed a program to support co-commissioning between PHNs and Local Hospital Districts called patient-centred co-commissioning groups (PCCGs), jointly responsible for improving care for their communities, with the potential expansion of the program to include payers and providers from public, private, and non-government sectors to facilitate whole-of system integration (Koff et al. 2021).

Our study represents the views and reporting of the PHN executive staff and program leaders who participated in the study only.

The primary focus of the study was to understand the scope of work currently being conducted by PHNs related to chronic pain. Further research would be useful to comprehensively explore the challenges, constraints and solutions identified by PHN representatives.

Few studies focus on Australian Primary Health Networks (PHNs) and little is known about the needs, priorities and scope of work of PHNs related to the management and secondary prevention of chronic pain. This paper describes the needs and priorities of PHNs; maps current PHN chronic pain initiatives and identifies gaps; and highlights key enablers to implementation. As commissioning bodies and supporters of primary care services, PHNs could do more to improve the secondary prevention and management of chronic pain to reduce the burden of chronic pain in their regions. Among existing PHN practice, two exemplar evidence-based initiatives were identified. Key enablers to implementation of PHN chronic pain initiatives have also been highlighted for PHN decision-makers. A self-identified need for greater collaboration across PHNs and co-commissioning with local and state governments and non-government partners would help to build PHN capacity.

Supplementary material is available online.

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

The authors declare that they have no conflicts of interest.

Funding for this research has been provided by the Australian Government’s Medical Research Future Fund (MRFF). The MRFF provides funding to support health and medical research and innovation, with the objective of improving the health and wellbeing of Australians. MRFF funding has been provided to The Australian Prevention Partnership Centre under the MRFF Boosting Preventive Health Research Program. Further information on the MRFF is available at www.health.gov.au/mrff. This research was also supported by the Sydney Medical School Foundation, University of Sydney.