Over the past few weeks, some outpatient services have changed, but these changes are a tiny element of what's possible. The model is still missing opportunities to enhance our health and wellbeing and provide a step-change in how we experience them.
These vital services face a series of challenges and now is the opportunity to reset these services into a completely different model, for the benefit of us all.
My own experience from a few years ago highlights some of the issues. Following a GP referral initially, all was well. Following investigative surgery, the follow-up appointment was cancelled and not rescheduled. Six months later, speaking to the consultant secretary, I discovered the hospital had discharged me with the only route to a follow-up appointment for my GP to re-refer me, which he did. Three months later, after cancelling some work-related events to attend, the outpatient processes allocated me to the wrong clinic, something I discovered on arrival. Another three months wait, followed by three low-value follow-ups. Only when I managed to speak briefly with the consultant (via phone) was I able to understand then the result of the investigative surgery and what would happen next. Subsequent surgery then ran very smoothly.
There are lots of similarly poor experiences of outpatient services, here's one such story from a former colleague. These experiences point to some fundamental problems with these high-volume hospital services.
Current challenges
My experiences as a patient, but also in leading change in outpatients emphasises several challenges. Below I outline these and 11 ways that could improve outpatient services. First, the challenges:
- Long waiting lists - longer as a consequence of Covid19 lockdown, and predicted to double by the end of the year.
- Poor internal and cross-organisation processes – a fundamental issue of poor design and inconsistent application that hampers efficiency and safety in every hospital in which I've worked.
- An outdated model - that hasn't fundamentally changed since the inception of the NHS.
- Traditional culture around these services - reinforced through policies, systems, processes and structures.
- Lack of executive focus – as NHS performance targets draw attention to A&E, Theatres, Inpatients and finances.
- Long waits in clinic waiting rooms – probably the most common complaint from patients.
- Limited car parking space at most hospitals - high volumes of people visiting outpatients contribute significantly to this issue, causing undue stress for many.
- Technology - poor infrastructure, piecemeal design, and implementation capability impact acceptance. Lots of helpful technologies do exist, but effective adoption is low.
These are significant challenges and addressing them benefits everyone, win-win. Patients get better services, easier access, and improved outcomes. Hospitals get higher efficiency, reduced admissions and lower demand to aid staffing challenges. The Secretary of State receives shorter waiting lists and lower NHS costs. Win-win.
High-level modelling suggests that the eleven changes central to this article would result in a reduction in demand for appointments of between 12 and 30% while improving outcomes. What's not to like?
So, here are 11 ways to tackle these challenges, ways in which outpatients services could benefit your health and the broader health system:
1: More virtual appointments – Telephone or video consultations are convenient for patients, reducing stressful visits to hospital, releasing car parking capacity and creating greater flexibility for staff. During Covid19 lockdown, they've become increasingly common. However, the worry is, when the lockdown is relaxed, that the systems, processes and contracting arrangements will drive the default back to face to face appointments again.
2: Better and earlier triage of patients – Specialists identify at least 10% of people attending clinic don't need to be there; they are better served by other professionals. Shifting hospital resources upstream to triage earlier and seeking more information through diagnostics, phone calls etc. would reduce demand on appointments and redirect people to the right service faster.
3: Better clinical team preparation - Common practice is for patient notes to be reviewed on the day of the clinic, leading to reactive on the day planning. Evidence highlights the beneficial efficiency impact of nurse run pre-clinics, using patient notes, allowing the planning process to begin days earlier.
4: Easy access to specialist advice and guidance for clinical staff - GPs, community, A&E and other hospital consultants value the experience of their expert colleagues. Rapid access to advice and guidance from these specialists would and does help to reduce unnecessary referrals, admissions, and improve knowledge and skills at the same time. Consultant Connect is one of many products that can help establish these links.
5: Alternative to admission - Being an inpatient in hospital impacts negatively on your health, unless you really need to be there. Studies show that at least 20% of people admitted to hospital beds didn't need to be. For many, access a suitable outpatient clinic appointment within 1 to 2 days, would better meet their health needs. Planning for and having the flexibility to do this would provide genuine alternatives to admission.
6: Consultation at home - For some people a trip to the hospital is extremely stressful, challenging, and requires either complex ambulance transport or help from family and friends, meaning that a clinic appointment can be a whole day event. For a tiny number of people, it would be particularly helpful if specialists were able to examine them at home.
7: Patient-centred services - Almost every UK hospital has a Division of Surgery and another for Medicine. Collaborative working across these divides varies, however for patients these are unhelpful divides. Patients see the world in terms of their conditions or symptoms. Designing services around symptoms or conditions provide much higher value for patients. Examples include a headache pathway with medicine and surgery working together in the same clinic (St. George’s University Hospitals NHS Foundation Trust), or an ankle pain integrated clinic drawing Rheumatology, Orthopaedics, Pain and Physiotherapy (Manchester University NHS Foundation Trust). Both are much better for health and prevent handoffs between specialities and functions.
8: Direct access diagnostics - Delays impact your health and so removing a step in the process can often add value for people. For many conditions, people see specialists before they are then referred for a diagnostic, adding delay. With the right triage, criteria and pathways, referrals can be made directly for diagnostics, for example, chest x-ray for suspected lung cancer with the report then reviewed by a specialist. In this example, three positive things can happen. One group of people are informed of a negative result and never have the stress of attending hospital. Those with a potential cancer diagnosis receive value-adding care faster. And finally, for others, they are diverted to the most appropriate clinic or specialist quicker.
9: Break the follow-up autopilot - Outpatient culture often drives a risk-averse and paternalistic approach to follow up appointments, usually requesting people return in 1, 3, 6 or 12 months for no other reason but to monitor them. Most specialists acknowledge this cultural default. Many have developed alternative appropriate ways to monitor patients that don't involve face to face appointments. However, as contractual arrangements reward follow-up appointments, the culture, and the model, has been slow to change. Rapid access to services when diagnosed conditions exacerbate is one particularly effective way to ensure follow up appointments are timely and relevant.
10: People take ownership of their health - Supporting people to take control of their health and care generates ownership, enables people to sustain their health at home, and reduces demand. Taking ownership of care would mean people contacting services when health deteriorates (rather than waiting for the next follow up appointment), taking part in decision making or actively engaging with their health records.
11: Longer appointments when required - Scheduling has determined that everyone receives a standard amount of time; however, patients aren't all the same. Inappropriate time constraints lead to rushed or inconclusive appointments, driving up the numbers of follow up appointments. If triage and clinic preparation is working effectively, identifying people who need longer appointments could be achieved, and schedules adapted accordingly. Many people would benefit from feeling listened to and not have to return to clinic quite so often.
Many of these elements exist across the NHS in pockets, but the vast majority of patients experience the same worn-out outpatient approach that's been around for decades.
To tackle the challenges and implement these 11 changes requires; a strategic and systematic approach, a clear and owned vision, redesign of processes, collaboration with GPs and community services, a clear roadmap, a change strategy and finally, contract changes that incentivise and reinforce positive behaviours. See our case study outlining the positive impact such an approach can have in a short period, even in the most difficult of circumstances.
These 11 ways improve people's health and benefit everyone but need a shift in culture and a phased approach. The recent excitement about a change to more virtual appointments is an excellent first step. However, the need to plan for further steps is crucial to creating the most value from outpatient services.
Evidence referenced in the blog can be found from the following sources:
Royal College of Physicians- Outpatients: the future
Health Improvement Scotland - Improving Productivity and Efficiency in Outpatient Clinics (2012)
NHS Improvement – Guide to reducing long hospital stays https://improvement.nhs.uk/documents/2898/Guide_to_reducing_long_hospital_stays_FINAL_v2.pdf