Context A service evaluation of the pain education available to junior doctors at an acute tertiary hospital in England. A project led by a junior doctor in collaboration with the trust’s acute pain team. This project is aimed at leaders/healthcare professionals designing postgraduate training for junior doctors.

Issue/Challenge

• Anecdotal reports of low confidence by junior doctors around pain management in patients with pre–existing pain.

• Reports of prolonged hospital admission due to issues with pain management and opioid weaning

• Assessment of issue and analysis of its causes

• To fully appreciate the scope of the problem locally, a service evaluation was carried out in two steps:

• –Firstly, through an audit of all pain management resources available at the trust against the curriculum set out by Health Education England and the Faculty of Pain Management for foundation doctors

• –Then survey of foundation doctors at the Trust to assess the perceived level of confidence in managing the patient group and key problem areas

Issue/ChallengeResults of the evaluation were shared with the medicine governance committee at the trust; gaining the views of the multidisciplinary specialists on different interventions that would help address the critical issues identified.

Impact Chronic pain is a global health challenge with a profound socioeconomic burden on healthcare systems. The number of patients with chronic pain admitted for inpatient care is rising and junior doctors manage these patients during their admission. Inadequate pain education among non-pain specialists has been highlighted as a barrier to effective pain management. This evaluation has been instrumental in championing change around the pain education of doctors locally. The interventions hope to address the inequity of care that these patients might experience.

Intervention Findings revealed a gap in education and resources for chronic pain. The local teaching focused on acute pain. Trust guidelines available were for postoperative pain and there were no pathways to seek expert advice for inpatients with chronic pain. Junior doctors demonstrated good awareness and use of trust guidelines on acute pain, however, there were variations in opioid prescribing practices, with some deviations from national best practice recommendations. Based on these findings, a multimodal intervention that addresses the gaps identified is being implemented:

• New chronic pain and opioid prescription guidelines

• Redesign of the pain teaching for junior doctors

This project was initiated and led by a foundation doctor at the trust who identified the need for change through peer feedback. Findings from the evaluation provided a visual demonstration of the inequity of care that this patient group might be experiencing, which helped create a sense of urgency for change at the trust and in the process of implementing the interventions, a guiding coalition of senior colleagues from multiple disciplines has been instrumental in helping navigate some of the bureaucratic barriers to change.

Involvement of stakeholders, such as patients, carers or family members:

The design of the teaching programme and patient information leaflet is hoping to incorporate input from patients and carers on the factors that are important to them in their care. There is scope for further evaluation of patients‘ experience of their inpatient pain management.

Key Messages It is essential that frontline clinicians are supported to be empowered followers and effective leaders. Learning from this project can be used at other trusts to support junior doctors to champion the change that they want to see based on their valuable frontline experience. However, the rotational nature of junior doctors through hospitals can create a problem with the sustainability of change hence a greater need for an MDT involvement in improvement projects.

Lessons learnt

• Change can be slow but requires continuous work to make it sustainable.

• Team involvement provides not just a diversity of views but creates a coalition of change champions

• However, navigating various authorising bodies in the NHS organisations to make a small change has been challenging.

Measurement of improvement

• Evaluation of interventions by surveying foundation doctors before and after the interventions outlined.

• Re–audit of opioid practices at the Trust

• Patient experience questionnaires on key wards.

Strategy for improvement This project is still ongoing with the delivery of the education programme due to be delivered in December 2022. A ‘pain working group’ has been created at the trust consisting of the acute pain team, lead pharmacist, GP, foundation doctor, and community chronic pain team to address the problems highlighted by the evaluation.