Providing alternative outpatient delivery channels

This article was first published in Health Management.

The COVID-19 pandemic is putting global healthcare systems under immense pressure and outpatient services are not excluded. The need to transform and reduce outpatients has never been greater. If we can reduce outpatient numbers, this would allow clinicians to focus on the sickest patients and reduce face-to-face contact without limiting access to acute clinical decision-making. Whilst the NHS Long Term Plan (NHS 2019) established the need for outpatients to transform over the next five years, COVID-19 has become the burning platform to realise this change in a matter of days.

While this accelerated transformation is a challenge, it is possible. Focusing on virtual consultations and other alternative outpatient delivery methods can ensure providers improve their productivity, reduce their referral-to-treatment times, and overall demand. A previous redesign programme we conducted of referral pathways for a large NHS Trust converted 2,500 appointments from face-to-face to virtual, releasing capacity for more than 900 extra appointments per year. In the context of COVID-19 demand, such improvements have a significant impact on freeing up vital resources.

In the short-term, guiding patients to the right care setting from the start is key to reducing the pressure on outpatient departments. There are three core principles to ensuring this:

• Think virtual first for low-risk patients.
• Optimise across available delivery channels.
• Keep patients informed.

Think virtual first for low-risk patients

Delay measures that focus on reducing or eliminating face-to-face contact, and therefore demand, are particularly challenging because outpatient appointments are typically deli- vered face-to-face. In 2018/19, NHS figures show less than 3% of first, and 4% of follow-up, appointments were ‘virtual’, with over 53.9 million patients waiting over two weeks for an appointment over the same period (NHS 2019a). So, even before COVID-19, there was a clear need to modernise the model of care in outpatients, including embracing digital to create a more patient-centric and efficient service.

But first you need to decide in which care settings to see patients. A risk stratification approach that separates low and high-risk patients is best for both patients and staff.

Optimise across available delivery channels

Virtual consultations are a great alternative to face-to-face appointments, and yet they are still not widely adopted, missing opportunities for providers to create more productive services. In addition to a digital offer, providers have five other delivery channels available to optimise care and minimise face-to-face interaction:

• Telephone clinics and SMS messaging. Practitioners run appointments via phone and send a review of notes to the patient through text messages.
• Patient initiated follow-up pathways. Patients with an existing condition control the timing of follow-up appointments. Instead of automatically setting them up every six months, patients make an appointment when they need one, such as if their condition flares up.
• Non-consultant led consultations. Appointments conducted by clinical nurse specialists or advanced healthcare practitioners free up consultants. Non-consultants can support patients in areas such as irritable bowel disease clinics, rheumatology non-inflammatory clinics and dermatological clinics.
• Self-care or remote care. Encouraging patients to use, and providing access to, information that helps them manage their conditions. Wearable technologies can also help here.
• Patient care via primary care. Low-risk patients could get treatment through their GP or other community services. This limits patient travel, particularly important as we work to prevent the spread of COVID-19. It also keeps more complex cases for secondary care.

Keep patients informed

In some instances, such as an antenatal appointment, a two-week wait cancer appointment or an urgent referral, there will be a clinical need to see patients face-to-face despite the pandemic. In those cases, providers will need to consider how they ensure the safety of patients and staff and keep them separate from others. For example, they could use different entrances or alternative sites to maintain appropriate infection control processes.

To make any new arrangements work, you need to effectively communicate with patients. Actively engaging with them through SMS, email, social media and automated calls will ensure they understand new arrangements and requirements as the pandemic evolves.

More communication that outlines a wider choice of delivery channels will also encourage patients to cancel appointments that become unnecessary and therefore reduce the demand further. This will give clinicians a more accurate view for scheduling and avoids did not attends, which the NHS National Benchmarking Network Report for Outpatients (NHS 2019b) says cost the NHS around £1 billion a year.

Maintaining momentum from COVID-19 to create legacy

By implementing alternative delivery channels to cope with the immediate crisis, providers need to acknowledge that a transformational step-change is being achieved. But in doing so, they must challenge themselves to ensure any change is truly maintained. Otherwise, behaviours will slip back to the old way of delivering outpatients – those which prompted the NHS Long Term Plan in the first place. Now is a better time than ever to create and maintain a legacy in outpatient service delivery that will help support demand challenges faced once the pandemic is over. There are three key points on how to ensure the changes made are successful:

• Embrace your new baseline. Where changes have been implemented KPIs should focus on measuring the impact. With the work achieved there will be ways to drive efficiency from the change, including improved demand management and utilising resources more effectively. For example, virtual note reviews of patients versus a conventional clinic typically allow a clinician to deal with more patients within the same timeframe. Equally, change presents a great opportunity for providers to engage with their patients, to understand how the new ways of communicating have worked for them, to solidify processes within business as usual.
• Continue at scale. Change creates opportunities to share knowledge and expand learning. Not only does it allow you to upskill the rest of the workforce, it enables an organisation to standardise its approach, reducing variations in patient experience. The initial changes made in the response to COVID-19 are a great platform to expand across organisations. Scale will be required by providers to enable the acceleration of how they address their backlogs and return to “normal” in a post-COVID world.
• Build on behavioural changes. The pandemic has allowed patients and clinicians to think differently about how they deliver and receive care. Providers should work alongside patients to seek feedback to evidence the impact of change and ensure they don’t revert to their old expectation. The demand challenge will remain, but with similar transformations across Inpatients, there are lessons to be learnt, and a collective view on what the new world looks like will ultimately improve access to patients.

The effect of this crisis cannot be underestimated. Clinician and patient behaviour will be forever changed as a result of COVID-19, especially those patients with chronic conditions who have been safely managed remotely both in acute and community settings. Through implementing alternative delivery methods, more productive clinics and reductions in unnecessary attendances can be achieved, to help manage the demand mid-pandemic and when it returns to business as usual across the NHS. The effective triage, vetting, management and discharge of patients have been cornerstones of the revised models of care that have been achieved in a very short space of time. It will be integral to review and redesign the traditional clinical pathways to optimise the patient journey and sustain the disruptive innovation achieved as a result of COVID-19. 

Key points

• In light of the current COVID-19 pandemic, the need to transform outpatient service provision is now more critical than ever.
• Think virtual first for low-risk patients.
• Non face-to-face alternative delivery channels are available.
• Keep patients informed.
• Maintain momentum in a post COVID-19 world through establishing a new baseline, continuing at scale and building on behavioural changes achieved through the pandemic.