Chapter 11: Guidelines for the Provision of Anaesthesia Services for Inpatient Pain Management 2024

Published: 23/01/2024


From their inception, IPS have provided acute post-surgical pain management to promote a balance of symptomatic relief and early restoration of function to improve patient experience and surgical outcomes. An ongoing and important role of the IPS is the consistent training and education of staff and students across the wider hospital trust. Other responsibilities continue to expand into such areas as acute pain management in medical patients, acute exacerbations of chronic pain, recognition and assessment of evolving transitional pain, opioid stewardship and perioperative patient education and optimisation. As such, the multi-disciplinary formulation of the IPS team expands with this role and might include representatives from pharmacy, psychology, occupational therapy, physiotherapy, addiction services and others, while the day-to-day service continues to be run by specialist nurses with leadership from appropriately trained and accredited acute pain physicians. 

The scope of each IPS will be determined by local requirements, although the standards set out here provide a baseline for attainment. This chapter should be read alongside the Faculty of Pain Medicine’s collaborative Core Standards for Pain Management Services in the UK (CSPMSUK) document, which provides further recommendations for routine practice in this field.1

The remit of GPAS is to supply a framework for how IPSs might be structured, including staffing, resources, equipment, training and development for the performance of their role, particularly in areas of special requirement. This framework also highlights how IPS might engage with quality improvement, audit and research to reflect on current, and inform future, practice. Importantly, this is not a clinical guideline. Historically, a UK survey shows high variability in resources for IPS with, in many places, a staffing deficit and non-concordance with GPAS standards.2

The intention for this updated chapter is to evaluate and assimilate new evidence and working practices from relevant literature since the previous iteration. In particular, changes in the curriculum for anaesthesia, credentialling for pain medicine and an increasing body of evidence to support multi/inter-disciplinary working and the use of multi-dimensional assessment tools have led to some key and novel recommendations.3,4

It is clear that recovery from the impact of COVID-19 on elective services will be felt across the entire health service IPS are no different and are encouraged to take an active role in national proposals for tackling the backlog. An expanded waiting list is an opportunity to engage patients in preoperative optimisation of established pain complaints, medicines management and active self-management techniques and to provide education and resources to promote more timely and meaningful recovery.

The role of the IPS continues to evolve on a national scale. We encourage teams to use this chapter to assist in their own evolution locally.

1. Staffing Requirements


IPS should be staffed by multidisciplinary teams (MDTs) led by appropriately trained autonomously practising anaesthetists (see Glossary). The minimum training requirement for new appointments to IPS lead roles is stage 3 Special Interest Area Pain Medicine training.1.3

C Strong

Anaesthetists in an IPS post need to demonstrate an ongoing significant interest in pain management by involvement in continuing professional development (CPD), appraisal and job planning. The minimum training requirement for new appointments of IPS anaesthetists is stage 3 special interest area in acute inpatient pain. 

GPP Strong

The IPS should have a clinical/ specialty lead with time identified for leadership and development roles within their job plan. Time, in programmed activities should be allocated proportional to the size of the organisation and service provided.

GPP Strong

Adequate staffing and systems should be in place to provide timely pain management to all inpatients. Out of usual working hours, this may be delivered by appropriately trained IPS nursing staff or anaesthetic staff. A clear point of contact for expert advice should be available at all times. 

GPP Strong

Patients under the care of an IPS should be reviewed by the IPS regularly, with patients receiving epidural analgesia or other continuous local anaesthetic infusions being seen at least once daily (including weekends).6

B Strong

Adequate numbers of clinical nurses in pain medicine should be available to fulfil the following roles within working hours:

•    review of patients in pain with appropriate frequency to provide a safe and effective service
•    provision of advice to ward staff and other healthcare teams regarding all aspects of pain management        
•    liaison with an appropriate pain medicine specialist to highlight clinical or systematic problems
•    ensuring that systems are in place to support non specialist healthcare staff to safely and effectively manage acute pain overnight and at weekends if the IPS is not immediately available
•    ensuring that systems are in place to support advance pain management techniques for acute pain management.

GPP Strong

The IPS must have dedicated pharmacy resources and should aim to provide multidisciplinary assessment and management of pain where needed. This should involve collaborative working with other registered healthcare professionals including pharmacists, physiotherapists, clinical psychologists, liaison psychiatrists and addiction medicine specialists.7,8 

C Strong

IPS should consider integrating clinical psychologists into their MDT. Areas which could benefit from clinical psychology involvement includes inpatients with complex pain. Certain patients may benefit from preoperative psychological interventions and within the framework of post-discharge transitional pain clinics.9

C Strong

Outpatient (chronic) pain management teams should be available to provide advice to the IPS during working hours. This activity should be supported through job planning. 

GPP Strong

Pain services should be integrated, with collaboration between the inpatient and outpatient (chronic) pain services.10

B Strong

There should be clear communication between the inpatient and outpatient (chronic) pain services so that patients can be referred directly into the outpatient service post discharge (where appropriate).  

GPP Strong

2. Equipment and facilities



All equipment and disposables must be compliant with local and national safety policies. There should be an adequate supply of the following:11,12,13,14 
•    infusion pumps for neuraxial analgesia (epidural infusion/patient-controlled epidural analgesia and potentially intrathecal infusions)15  
•    infusion pumps for use with continuous regional analgesia catheters
•    patient-controlled analgesia infusion pumps
•    infusion pumps for other analgesic drugs 
•    disposables for the above, including neuraxial and regional block devices e.g., NRFitTM.16 

C Strong

Availability of other, non-medical equipment required to provide pain management in specific scenarios and patient groups (e.g., virtual reality during painful paediatric medical interventions, transcutaneous electrical nerve stimulation machine) should be considered.17,18 

A Strong

Ultrasound scanning, nerve stimulators and all equipment and drugs necessary to perform local and regional analgesic techniques should be available.19

C Strong

Pumps and infusion lines should be single purpose, appropriately coloured or labelled and conform to national safety standards.11,12,13,14,20 

C Strong

All equipment used for regional anaesthesia and regional analgesia should have NRfit connections.19

M Strong

Drugs for epidural use or for continuous regional anaesthesia infusions should be prepared and stored in compliance with local and national medicines management policies.11,12,13,14 

C Strong

Local anaesthetic drugs should be stored separately from intravenous drugs and other infusion bags to reduce the risk of accidental intravenous administration of such medication.21,22 

C Strong

Controlled drugs must be stored and audited in compliance with current legislation.23,24,25

M Mandatory

Arrangements should be in place to minimise the risk of drug administration errors and ‘never events’ and there should be a robust mechanism through which to learn from these events should they occur.26,27,28,29,30,31

C Strong

Clinical areas caring for patients receiving analgesic techniques that may result in cardiovascular, respiratory or neurological impairment should have appropriate facilities and adequately trained staff to provide appropriate monitoring.32 

C Strong

Drugs and equipment for the management of the complications associated with analgesic techniques should be readily available.31

C Strong

Equipment, protocols and training should be in place to allow the safe delivery of regional analgesia. Postoperative pain scores and function may be improved by the use of continuous regional analgesia after appropriate procedures.33

C Strong

There should be a planned maintenance and replacement programme for all pain management equipment, with agreed local, multi-professional arrangements should be in place to respond in a timely manner to supply shortages of equipment or medicines.

GPP Strong



There should be proportionate office space to the size of the IPS and adequate informatics and administrative staff to support all areas of the IPS.

GPP Moderate

There should be appropriate storage facilities for analgesic devices and drugs. 

GPP Strong

3. Areas of special requirement

Acute on chronic pain

Acute exacerbation of chronic pain conditions is a growing problem. Patients with these conditions require more time and resources of the IPS. Patients with such exacerbations require complex MDT planning to facilitate improvement and early discharge.


National data indicates that patients with exacerbations of chronic pain require high levels of input from the IPS. Outpatient pain services should be collaboratively involved with these patients’ care. While they are inpatients, there should be an MDT approach. 

GPP Strong


Recommendations on the provision of anaesthesia services for children are comprehensively described in Chapter 10: Guidelines for the Provision of Paediatric Anaesthesia Services.


The standard of care for neonates, infants, children and young people should be the same as that for adults, with specific arrangements made for the management of pain in neonates, infants, children and young people.34,35 

C Strong

The children’s IPS should be delivered by an appropriately trained and experienced MDT, with specific skills in paediatric pain management and paediatric anaesthesia. The team may include clinical nurse specialists, anaesthetists, paediatricians, surgeons, pharmacists, child psychologists and physiotherapists. 

GPP Strong

All tertiary paediatric centres should have access to paediatric chronic pain services to assist in managing complex cases. Other centres should develop a network to provide access to paediatric chronic pain services for advice and guidance.

C Strong

Emergency department


IPS should aim to work collaboratively with the emergency department (ED) to improve pain management for patients while they are in the ED.36   

C Strong

Specialist acute pain management advice and intervention should be available in the ED. 

GPP Strong

IPS should provide assistance in developing management plans for groups or individuals who attend ED frequently with pain. This should be in the context of a wider MDT including chronic pain services, primary care and clinical psychology. Opioid therapy continuation on ED discharge is associated with risk of tolerance and misuse.37

C Strong

Opiod stewardship


The IPS should be champions of opioid stewardship across all clinical areas. Trusts could consider setting up an opioid stewardship committee. 

GPP Strong

Responsible opioid stewardship should be practiced as described by the Faculty of Pain Medicine Opioids Aware guidelines and Surgery and Opioid: Best Practice Guidelines 2021.38,39 Patient information material about opioids should be available for patients.

C Strong

There should be clear discussions about the risks of opioids with all patients started on opioids. Discussions should include information on safe storage and disposal, safe driving and the anticipated duration of therapy. All discussions should be documented with a clear agreed plan to de-escalate and stop usage when the acute pain phase is over.37,40 

C Strong

Patients taking high-dose opioids during pregnancy should be identified and involved in a review in an antenatal obstetric anaesthesia clinic, with referral to specialist pain services as required.40,41 

C Strong

Opioid doses should be adjusted accordingly to take into consideration a patient’s medical history and any comorbidities.37 

C Strong

Discharge prescriptions for opioids should be for a maximum of five days to reduce the risk of persistent postoperative opioid use.40,42,43

C Strong

The need for ongoing analgesia may represent a surgical complication such as infection or nerve injury and so a primary care physician should review the patient before re-prescribing these drugs.37,40

C Strong

Initiation of modified release opioids should be avoided for acute pain.37,40,44 

C Strong

The service should have access to chronic pain outpatient clinics that specialise in opioid de-escalation.37,39,40    

C Strong


General guidelines for preoperative assessment and preparation are comprehensively described in GPAS Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients.


The inpatient pain team should be involved in the perioperative care of patients with complex pain needs, including those at risk of severe pain postoperatively, chronic post-surgical pain and persistent postoperative opioid use.

GPP Strong

Patients at high risk of developing pain complications should be identified preoperatively e.g., patients with preexisting chronic pain and high-dose opioid use (including a recording of their Oral Morphine Equivalent dose per 24 hours). The perioperative care of these patients should be planned in advance.

GPP Strong

Perioperative care of patients at risk of developing pain complications should include prehabilitation to optimise the management of preoperative pain, including psychological preparation, education and expectation management. 

GPP Strong

Patients with complex pain requirements should be referred to specialist outpatient pain services to optimise their pain management and where appropriate, opioid tapering should be considered.45  

C Strong

All patients (and relatives, where relevant) should be fully informed regarding their planned pain management and should be encouraged to be active participants in decisions concerning their care. 

GPP Strong

Management of patients post discharge

A gap exists between acute and chronic pain management and there is a need to provide continuity of care for inpatients with complex pain needs after discharge from the hospital. This includes but is not limited to, patients with abnormal trajectories of pain resolution and/or opioid use. Developing post-discharge services linking inpatient and outpatient pain services can bridge this gap.46 


The inpatient pain team should aim to follow up patients identified as high risk of progression from acute to chronic pain post discharge. This could be in the form of a transitional pain clinic and is time limited.

GPP Strong

There should be a mechanism in place for patients who continue to have complex pain requirements beyond the scope of transitional pain services to be referred to specialist outpatient chronic pain services. 

GPP Strong

Specific patient groups


Specific arrangements and guidelines should be available, where applicable, for the care of subgroups of patients with additional complexities, including but not limited to: 

•    patients with acute exacerbations of chronic pain
•    patients with opioid tolerance47
•    patients with multiple trauma or significant blunt chest wall trauma
•    critically ill patients
•    patients with significant organ dysfunction 
•    pregnant and breastfeeding patients
•    older and/or frail patients48,49,50
•    patients with dementia
•    patients with physical or learning disability
•    patients with problem drug and alcohol use51 
•    patients with coexisting mental health problems
•    patients who do not speak English.

C Strong

The IPS should liaise with relevant anaesthetic colleagues for those patients requiring specific acute pain-related interventional procedures outside the context of immediate surgery e.g. continuous regional anaesthesia for patients with rib fractures.52,53 

B Strong

4. Training and education


IPS should actively contribute to a hospital environment in which education, training and staffing levels ensure the safe care of patients being treated for pain.

GPP Strong

IPS should provide education delivered by appropriately trained individuals.54  Training should include the recognition, assessment and treatment of pain, which includes using a management plan.

GPP Strong

Training should be provided as part of employment induction and should be repeated at regular intervals thereafter for anaesthetists, ward staff, doctors in training and other registered healthcare professionals.

GPP Strong

All staff should know how to obtain expert advice when required, including being able to access relevant guidelines and protocols.

C Strong

Members of the IPS should have access to internal and external CPD appropriate to their roles. Funding and time should be available for staff to attend this training.55 

C Strong

Training for anaesthetists to attain stage 1, stage 2 and stage 3 competencies in pain medicine, as specified within the Royal College of Anaesthetists (RCoA) 2021 curriculum should be provided.3 Training opportunities can include allied health professional led reviews with appropriate education supervision from a recognised RCoA trainer. Where stage 3 training including Specialist Interest Areas in acute inpatient pain or pain medicine are not feasible within an individual hospital, it should be available within the region.56

GPP Strong

Inpatient pain nurse specialists providing education on the wards should have dedicated time for this role distinct from direct clinical duties.

GPP Strong

Training should include consideration of the use of simulation where feasible e.g. role play with the pain team simulating a patient with a failed epidural. 

B Strong

Simulation training should improve exposure to regional anaesthesia/ analgesia techniques.57

GPP Strong

Members of the IPS should engage in outpatient (chronic) pain CPD.

GPP Strong

5. Clinical governance, quality improvement and research


The IPS should be an active part of their organisations quality and safety structure including:
•    incident reporting and investigations
•    maintaining a risk register
•    compliance with their organisation’s patient safety and patient experience audits
•    compliance with mandatory training and appraisal
•    awareness of and benchmarking against national quality and safety standards and guidance
•    projects focusing on continuous quality improvement.

GPP Strong

The IPS should have protected time for audit and research activities.58 

C Strong

The IPS should consider facilitating anaesthetists in training to participate in inpatient pain audits and research as part of their training.57 

C Strong

The IPS should maintain a prospective database of activity and outcome data and this should be used for quality improvement and early recognition of potential harm.15,59,60

C Strong

The IPS should actively engage in benchmarking against national standards e.g., GPAS, CSPMSUK, ACSA, Raising the Standards: RCoA Quality Improvement Compendium.57,61 62,63,64 

C Strong

Electronic patient records and NHS business intelligence should be considered to improve data collection. 

GPP Strong

Where possible, the IPS should encourage engagement in research in pain medicine, including recruitment into well designed national and international multicentre studies.65  The IPS should be encouraged to be research-aware.66  

C Strong

6. Organisation and administration


Clear lines of communication and close working with other services such as surgical and medical colleagues, outpatient (chronic) pain, palliative care, emergency medicine and primary care should be in place.67  

B Strong

Advice for the management of step-down analgesia should be provided for primary care team, where required.

GPP Strong

There should be regular audits of standards of care, guidelines and protocols, and critical incident reporting within locally agreed timeframes to ensure the continued development and improvement of IPS.68,69 

C Strong

There should be mechanisms to disseminate national safety alerts from groups such as the Safe Anaesthesia Liaison Group.70 

C Strong



Analgesia guidelines, including those for specific analgesic techniques, should be widely disseminated and easily accessible.15,71,72,73 

C Strong

All guidelines should have a clearly documented author and review date and should be published in line with local clinical governance policies with appropriate oversight.

GPP Strong

Guidelines for the management of specific patient groups (as listed in recommendation 3.25) should be available.

GPP Strong

Where good evidence exists, consideration should be given to procedure-specific analgesic techniques.

GPP Strong

Where possible, guidelines should be shared locally, between hospitals and nationally.

GPP Strong

Assessment and record keeping


Pain, its management and side effects (including sedation and opioid-induced ventilatory impairment) should be regularly recorded in the patient notes and/or observation chart using validated tools for each clinical setting. Consistent tools should be used throughout the patient pathway.74

C Strong

The use of functional assessment and goals should be considered to complement pain scoring in assessing analgesic requirement and recovery progress.37,40,75,76,77,78 

C Strong

7. Patient Information

The Royal College of Anaesthetists has developed a range of Trusted Information Creator Kitemark accredited patient information resources that can be accessed from our website. Our main leaflets are now translated into more than 20 languages, including Welsh.

Recommendations for the provision of patient information and obtaining consent are comprehensively described in Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients. Specific recommendations for IPS are listed below.

All patients (and relatives where relevant) should be fully informed and provided with adequate time and support to understand the information they are provided with so that they can be active participants in decisions concerning their care. Patient information resources, including leaflets, online resources and videos can help facilitate shared decision-making discussions and form part of the informed consent process.79 


Patient information should be available in a range of formats that take into account the information needs of patients with additional complexities as listed in recommendation 3.25 and they should be accessible electronically. 

GPP Strong

Patient information leaflets should be made available to provide information on analgesia in general, and on specialised analgesic techniques such as epidural analgesia, nerve blocks, specialist drug infusions and patient-controlled analgesia.80 

B Strong

Leaflets should explain pain management after discharge, including a step-down analgesic plan and how further supplies of medicine can be obtained. Patient information should emphasise the need to avoid harm from long-term opioid use and should give clear advice on the impact of analgesics on driving, acknowledging the current Driver and Vehicle Licensing Agency guidance.38,81,82,83,84

C Strong

Patients should be supported with appropriate information so that they can provide informed consent for invasive analgesic procedures, and this should be documented following the General Medical Council advice on informed consent.78,85 Details should be explained to the patient in an appropriate setting and in language they can understand.

C Strong

Patient education regarding expectation of pain and analgesia after surgery should be given to all patients in the preoperative period.82

C Strong

8. Implementation support

The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, provides a set of standards based on the recommendations contained in the GPAS chapters. As part of the scheme, departments of anaesthesia self-assess against the standards and undertake quality improvement projects to close the gap. Support is provided by the RCoA in the form of the good practice library, which shares documents and ideas from other departments on how to meet the standards. Further advice can be obtained from the ACSA team and department’s assigned College guide.

The ACSA standards are regularly reviewed on at least a three-yearly basis to ensure that they reflect current GPAS recommendations and good practice. This feedback process works both ways and the ACSA scheme regularly provides CDGs with comments on the GPAS recommendations, based on departments’ experience of implementing the recommendations.

Further information about the ACSA scheme can be found here: 

Areas for future development

Following the systematic review of the evidence, the following areas of research are suggested:

•    transitional pain management86
•    perioperative pain management
•    psychology and inpatient pain87,88 
•    establishment of a national database (organisational and patient level data)
•    opioid stewardship and persistent postoperative opioid use 
•    chronic post surgical pain
•    pre-emptive and preventive analgesic strategies.


Autonomously practising anaesthetist – a consultant, or an associate specialist, specialist doctor and speciality doctor (SAS) doctor who can function autonomously to a level of defined competencies, as agreed within local clinical governance frameworks.


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