Reducing surgical waiting times for people with complex pain management needs

Stockport NHS Foundation Trust aimed to reduce the waiting times for patients living with complex pain management needs to access elective surgery. Recent multi-agency guidance for such cases recommends individualised pain planning and assessment. Unfortunately, access to such assessment has been challenging. 

The waiting list to see a pain management consultant was around 8 months at the beginning of the Q Lab process. This was a significant barrier to people accessing the advice and guidance they needed in a timely manner before their surgery. 

There was also a trend of increasing persistent opioid use in the community. Meanwhile, the expanding surgical waiting list had led to some people being prescribed opioids for the very problem they were awaiting surgery for. Opioid use is usually inappropriate in this scenario and confers significant short- and long-term risks. Mitigating these risks was a key goal. 

These complex issues required the project team to think outside current structures to tackle them in a novel way. Consultant time is at a premium. With no facility to increase consultant sessions, they investigated alternative ways of providing high quality, rapid access and consistent advice and guidance. 

The Core Standards for Pain Management Services suggest the inclusion of multiple professions within a pain management service. The project team called on the clinical nurse specialist team and a specialist pharmacist who were skilled in assessing and managing people with complex pain management needs, as they work with such inpatients daily. 

This multidisciplinary clinic with access to consultant support allowed the team to see patients more rapidly. It also allowed them to create individualised plans with patients for before, during and after their hospital stay. This provided patients continuity of care, as the same team met them again during their inpatient stay.

The team located their clinic within the surgical preoperative clinic suite. This aided timely referrals into the service to maximise time working with patients. It also allowed the preoperative nursing and anaesthetic teams to liaise with them directly and kept the service front of mind to maintain referral levels.

The team also collaborated with patients to undertake safe and appropriate opioid reviews and tapering where possible. 

The team’s work was punctuated by regular Q Lab workshops and coaching calls. This kept quality improvement methodology at the forefront of their work, exposed them to new techniques and enabled them to practice methods that fit their needs in a safe space. It also gave them confidence to take these new learnings away and apply them to their project. 

The team had high levels of turnover and staff absence through the Q lab period. However, this provided an opportunity to bring others into the work. For example, another clinical nurse specialist is now undertaking clinics rotationally, giving the service added resilience and lowering the impact of annual leave.

The reduction of preoperative opioids is a relatively novel idea and not well covered in medical or nursing curricula. Knowledge and awareness regarding the rationale for this was often limited. Additionally, referring clinicians were already overworked and experiencing change fatigue within a very busy preoperative assessment department. Both factors restricted preoperative clinic staff engagement in the project. However, through education and positive feedback, resistant behaviours could be challenged, and this maintained the team’s interest in the project.

While the team have undertaken many quality improvement initiatives, setting up a new service required more specialist knowledge in quality improvement methodology. The early stages of the Q Lab – for example, process mapping – helped to better predict potential problems and consider solutions. Engaging key stakeholders in the process also helped to minimise disruption to the project’s goals. 

The project achieved its key goal of improving access to preoperative pain management appointments.

Other successes include:

• greater than 80% patient engagement with the clinic, with a negligible did-not-attend rate
• positive patient feedback, with 100% recommending the service to others
• positive staff feedback, with preoperative staff noting it was reassuring to know the service existed to support them
• 3,376.8 miles less travelled from carrying out remote consultations, saving around 1,350.7kg of CO2e and the financial costs of travel and parking for our patients
• presentation of the work at the National Acute Pain Symposium, winning first prize for a poster and presenting orally at the conference
• wider understanding of socioeconomic factors and how they may play a part in future work
• team confidence in promoting change management and undertaking quality improvement.

The project has had an impact at individual, organisation, regional and national levels:

• Individually, the team are all now more confident managers of change. They continue to utilise skills learned during this process to inform other quality improvement work in the team.
• At an organisational level, the service has facilitated stronger collaboration with key departments, including preoperative services, anaesthesia and surgical specialties, all aligned in the shared objective of optimising patient outcomes.
• Regionally, the project has been integral to the formation of Greater Manchester guidance on medicines use after surgery.
• On a national level, the team’s success at the National Acute Pain Symposium led to significant interest from trusts around the country.

All this was accomplished despite the team being small and all relatively early in their senior careers. This shows that it’s possible to make a big difference where there is a clear goal and sufficient passion and drive.

Providing regular updates and constructive feedback sustains stakeholder motivation and enthusiasm. It is important for staff feedback to be considered and incorporated into service design to help them feel listened to and included.

This provides the opportunity to hear patient perspectives, their commentary on needs and how particular options for building a service might best meet these.

The present financial constraints of the NHS are often cited as reasons to avoid undertaking change management. But this can be overcome with sufficient thought and foresight. Working closely with business intelligence and business management can help. It is also well worth time to seek savings – for example from bed day reduction, reduced failed discharge rate and reduced surgical adverse events.

Continued support for development and opportunities for team members are essential. 

Faculty of Pain Medicine. 2021. Surgery and Opioids: Best Practice Guidelines 2021. London: Faculty of Pain Medicine.

Faculty of Pain Medicine. 2021. Core standards for pain management services in the UK. (2nd edn.) London: Royal College of Anaesthetists.