Transforming outpatient services is key to delivering…

This article was first published in Health Management

Key Points

Balancing the competing priorities of reducing patient waiting times whilst making outpatient care more personalised and improving access for patients will be a challenge for all health providers and systems to deliver.
The patient journey to receiving care in an outpatient setting can be a complex one, with multiple stakeholders involved, across multiple departments and organisations.
Transforming delivery of outpatient services should begin before an appointment even takes place.
Strategies to safely reduce unnecessary follow-up attendances could play a significant role in supporting elective recovery.
Digital solutions have a crucial role in the delivery of transformation in outpatient services.

The NHS’s delivery plan for tackling the COVID-19 backlog of elective care focuses on solidifying and embedding changes to ensure elective services are fit for the future. This builds on the long term plan which outlined the need to redesign traditional outpatient services to make them more sustainable. Balancing the competing priorities of reducing patient waiting times whilst making outpatient care more personalised and improving access for patients will be a challenge for all health providers and systems to deliver. Alternative models of care, leveraging the opportunities from digital technologies and establishing frameworks to make it easy for care providers to work seamlessly together are essential pillars to deliver on these aims.

Pre-appointment Processes – A Full Clinical Triage Model Should be the Default

The patient journey to receiving care in an outpatient setting can be a complex one, with multiple stakeholders involved, across multiple departments and organisations. Transforming delivery of outpatient services should begin before an appointment even takes place.

Leaders can start by putting in place robust, well designed and outcome focused pre-appointment processes. Implementing a full clinical triage model (supplemented by accessible and well defined referral pathways and criteria) will increase the number of patients who are seen in the correct healthcare setting, reduce administrative time rearranging appointments to the right clinic and increase outpatient capacity for patients requiring specialist consultations. For example, identifying patients who require investigations prior to their first appointment will maximise the opportunity for a decision to be made and treatment started at the earliest point in the pathway – potentially even negating the need for an appointment at all.

To make this successful and sustainable, leaders should:

design clinical teams through careful mapping of the current pathway, future pathway and agreeing the transition plan to implement full clinical triage.
standardise the processes within each speciality or care pathway across a system through clear guidelines, protocols and communication to those triaging and those who are referring.
ensure clinical triaging is included in job plans as direct clinical care. By ensuring an appropriate amount of time is dedicated to triage activity, this will minimise the number of unnecessary appointments and support specialists to develop alternative management plans for patients.
complete detailed capacity and demand modelling to ensure that adequate time is allocated for triaging referrals. This will be challenging to do without negatively impacting on waiting times in the short term unless alternative models for outpatient care are adopted at scale and at pace.

Release Capacity for Clinical Triage by Reducing the Demand for Follow-Up Appointments

Follow-up appointments account for approximately two-thirds of all outpatient activity within the NHS. Strategies to safely reduce unnecessary follow-up attendances could therefore have a significant role to play in supporting elective recovery. In our experience, there are two alternatives that should be prioritised in every outpatient transformation programme:

Patient Initiated Follow-up (PIFU): Empowering patients to make the judgement on whether they need a follow-up is a powerful tool to develop shared decision making and self-management. It can also reduce workload in primary care if the criteria to initiate a PIFU is well communicated and understood, giving the patient access to a specialist within a time-bound period without the need for a re-referral.
Remote monitoring solution: Research predicts that, by 2035, 2.5 million people over the age of 65 (17%) will have four or more chronic illnesses (with arthritis, diabetes and dementia being diseases expected to grow significantly in prevalence) and around two thirds of over 65s will have at least two. Remote monitoring puts patients at the centre of recording and managing their condition, enabling them to avoid unnecessary appointments when their condition remains stable. For example, inputting data into a smartphone app or using smartwatches to track vital signs. This will be essential to a sustainable model of care, allowing multiple specialists to track multiple conditions and monitor key diagnostic indicators without necessarily seeing the patient. Equally, it will help in identifying warning signs earlier to prevent a potential admission and reducing the need for patients to come for an appointment to be told “all is well”. This will not be achievable with the current outpatient models of care.

Harnessing the Full Potential of Digital Solutions

The most common barrier to transforming outpatient service is technology. Many of the solutions to transforming outpatient services are not novel, but their full potential has been unrealised due to inadequate infrastructure which create barriers to change and discourage change to happen.

Healthcare providers need to ensure their IT and digital interfaces “speak” to each other, avoiding the need for multiple logins or handoffs between different IT systems to enable both staff and patients to utilise different outpatient models based on need.

Equally important is having a clearly defined and resourced digital strategy that makes the best use of digital technologies but not at the expense of high-quality patient care and outcomes. To increase the adoption and success of digital enabled outpatient services, there are four things Trusts can do:

harness the enthusiasm of early adopters – create change champions who can give real examples of the positive impact on their patient care.
make the change easy for staff and patients – through co-design by understanding and removing/mitigating any potential barriers to adoption.
increase the capability of digital technology – through investment where required, based on user feedback.
continuously review and share success – through clear definition and quantification of KPIs, such as patient experience scores and impact on patient outcomes.

Transforming outpatients cannot be done in isolation. New models of care need to be joined up with the entire patient pathway and balance the needs, wants and requirements of each individual patient. But one size will not fit all and some models will be more applicable to some specialties than others. For example, asthmatic patients who can remotely check and record their peak flow and respond to patient-reported outcomes digitally will not necessarily require an appointment immediately. This approach, as an example, serves to avoid unnecessary outpatient appointments which can positively impact their health and wellbeing when attempting to integrate this into busy social and working lives.

Digital solutions have a crucial role in the delivery of transformation in outpatient services. They need to be harnessed correctly to reduce potential unintended consequences such as a focus on digital first. For example, defaulting to a digital first appointment could contribute to a rise in follow-ups, and further add to the backlog challenge unless referrals are properly triaged.

Rethink Outpatients to Recover Elective Services

Although COVID-19 has disrupted elective services, it has also expedited several fundamental changes to the traditional model. Redesigning outpatient services will be a key driver of success to recover elective services. To be sustainable, the transformation needs to breakdown traditional barriers and optimise the patient’s experience and outcomes. Implementing value-adding pre-appointment processes and embedding clinical triage are two vital components to this – as is harnessing digital technologies and solutions to enable change to happen. Without rethinking how to deliver the broader services during this critical time, the same cyclical changes will continue and prolong the much needed recovery in elective care.