Primary Health Care Research & Development


Mapping care pathways and estimating the number and cost of musculoskeletal chronic pain patients to inform the development and implementation of a new service

Dawn Carnesa1 c1, Jayne Gallaghera2, Sally Hernea3, Elaine Mundaya3, Sara Ritchiea3 and Martin Underwooda4

a1 Barts and The London School of Medicine and Dentistry, Centre for Health Sciences, London, UK

a2 Pain Clinic, Barts and The London Trust, London, UK

a3 Service Improvement, Tower Hamlets Primary Care Trust, London, UK

a4 Warwick Medical School, London, UK


Background Patients living with chronic pain are typically resource intensive, their care requirements are long term and referral to secondary care is not always expeditious. To provide more appropriate, accessible and cost-effective care, Tower Hamlets Primary Care Trust reviewed the needs of the patients, their current care and the numbers requiring treatment for non-malignant chronic pain, initially starting with musculoskeletal pain.

Method We estimated the number of people with chronic pain being treated outside general practice by the NHS in Tower Hamlets. A working group established set criteria to define a chronic pain patient. We surveyed appropriate clinicians to determine the approximate number of patients who fitted our inclusion criteria, the approximate number of follow-up appointments they required and their care pathways. Secondly, we estimated the cost of care for chronic pain patients using NHS national tariff and reference cost data. We also took a convenience sample of chronic pain patients and recorded their history of care.

Findings The routes and pathways of care are complex and multiple. We estimate between 4.0% and 5.5% of new patients in rheumatology, orthopaedics, occupational therapy and musculoskeletal physiotherapy and up to 90% in the pain clinic are people living with chronic pain. The cost of this care ranged from £296 for a course of physiotherapy to £1911 for a patient seen in physiotherapy, orthopaedic and the pain clinics.

Conclusion There is no facility in current management information services that identifies people being treated for non-specific chronic pain; therefore, estimating both the numbers and costs for treating these people is difficult. National tariff and notional cost data provide estimates only, of an ‘average patient’; the real cost of these patients is unknown.

Key words

  • chronic pain;
  • cost;
  • service improvement


c1 Correspondence to: Dr Dawn Carnes, Barts and The London School of Medicine and Dentistry, Centre for Health Sciences, 2 Newark St, London E1 2AT, UK. Email: