Oberursel, January 4, 2016. Pain medicine care close to home is a pious wish in Germany. At the “National Pain Care Forum” on November 12, 2015 in Berlin, patient representatives, pain experts and representatives of the German Association of General Practitioners called for graduated, outpatient, freelance care with a sufficient number of pain doctors, clearly defined interfaces and systematic needs planning.

“The care in Germany is completely inadequate for the more than 2.8 million patients with severe pain. There are black holes in countless regions where there is no adequate care,” stated Birgitta Gibson, Vice President of the German Pain League (DSL). Significantly more pain doctors and a better geographical distribution of therapeutic offerings are needed: “Pain doctors must be accessible close to home and not 20 or more kilometers away. Some pain patients today are expected to drive 200 kilometers. That does not work like this."

Organization, coordination, creating structures

Reality shows that today it is not even possible to speak of a functioning supply management system, says Prof. Dr. Bertram Häussler, head of the IGES Institute. This was demonstrated by the low referral rates and the large number of untreated patients. “Whether a patient is referred to the right address depends on the extent to which the individual family doctor or specialist is informed about pain medicine offers and how seriously they take them.” Prof. Dr. Hartmut Göbel, head of the Kiel Pain Clinic, shared this experience: “Undercare does not arise from a lack of treatment options. It arises from a lack of coordination and networking of therapy offers!” From his point of view, it would be helpful to have a local contact point where all information about previous diagnoses and therapies is centrally bundled. This must also coordinate the progress and success monitoring and adapt the treatment individually. “This interface should be as close to home as possible. It should be networked with national competence centers. These tasks also require a specialist in pain medicine with highly specialized qualifications.”

According to Dr. For Silvia Maurer, Vice President of the DGS, this point of criticism affects specialist areas such as psychotherapy in two respects: “The distinction between psychological and medical psychotherapists is difficult to understand. Among the latter, it is difficult or impossible for a patient to find out who works with pain patients because there is no adequate term for it.” It is different for psychological psychotherapists, who can undergo further training from the German Society for Psychological Pain Therapy and Research (DGPSF). “These pain psychologists could be found for the patient through the DGPSF - but there are only 265 of them in the whole of Germany. In Rhineland-Palatinate, for example, there are 26 - and they are only allowed to treat adult patients. That’s just not enough.”

Deficits at all levels of care

Dipl. med. Ingrid Dänschel from the German Association of General Practitioners was able to confirm many of the problems described by pain societies and patient representatives: “The main problem from a general practitioner’s perspective is the interfaces of care. When do I transfer where? The existing supply control does not work optimally here. We need a good network of pain doctors. But these must then be achieved in a timely manner.” From Ingrid Dänschel’s point of view, a possible step towards better care could be pain-specific selective contracts. She referred to the “Pain Care Landscape” designed by her association together with the Professional Association of Doctors and Psychological Psychotherapists in Pain and Palliative Medicine in Germany (BVSD), for which general practitioners and pain specialists have jointly developed structured treatment paths. “The key points of this integrated care concept are the division of tasks and work as well as cooperation between all doctors and other disciplines involved with the aim of avoiding pain chronification at an early stage or ensuring better pain care. Diagnostics, therapy and cooperation go hand in hand according to a certain algorithm,” explained Prof. Dr. Dr. Joachim Nadstawek, BVSD chairman. At the same time, Nadstawek drew attention to the problem of young pain doctors: “In the next five years, around two thirds of the pain doctors currently working will be retiring and there will be almost no new blood. Ensuring supply is therefore at acute risk.”

Supply close to home

Dr. Johannes Fechner, deputy chairman of the KV Baden-Württemberg, explained: “The family doctor must be the first point of contact, close to home, and the basis for pain medicine care.” In his view, specific succession problems for contract pain medicine doctors could be solved locally if the new requirements planning guidelines of the Federal Joint Committee are appropriate Provide opening clauses and statutory health insurance doctor positions can also be filled from outside the specialist area if they have pain therapy qualifications. This option is for the President of the German Society for Pain Medicine (DGS), Dr. Gerhard Müller-Schwefe, not sufficient: “The replacement from a non-specialist area is a poor emergency solution. It does not provide security of supply or nationwide coverage. At best, she receives the existing inadequate supply, as this means that no further pain medicine facilities can be created despite the blatant undersupply.

Tiered care with clear responsibilities

For Müller-Schwefe, a tiered care landscape made up of freelance, outpatient doctors is the only model that is suitable for ensuring comprehensive pain care. In this model, the first point of contact would be the family doctor, who should have proof of pain medicine expertise. Specialists with an additional qualification in pain therapy as well as a specialist in pain medicine required by DSL, DGS and the BVSD form the next levels for Müller-Schwefe.

Pain medicine must be included in requirements planning

Such graduated care can only be implemented if the need for pain doctors is systematically identified and met. “Pain medicine must become part of the requirements planning of the statutory health insurance associations,” says Müller-Schwefe. Requirements planning and ensuring supply are based on specialist doctor titles. Since there is currently no specialist in pain medicine, there is not a single association of statutory health insurance physicians nationwide that has pain medicine requirements planning and therefore no guarantee of care. All forum participants agreed that the need for pain physicians is currently not nearly met. It is also not guaranteed that medical practices with a focus on pain medicine will retain this focus when the previous practice owner retires. The reason: Doctors' positions may only be filled within the specialist disciplines.

National Pain Care Forum of the German Society for Pain Medicine eV (DGS), the professional association of doctors and psychological psychotherapists in pain and palliative medicine in Germany eV (BVSD) and the German Pain League eV (DSL) “Pain medical care on an outpatient basis and close to home”, November 12, 2015, Berlin