Outpatients: a new look?

The NHS outpatients model is obsolete. So said NHS England chief executive Simon Stevens, addressing the NHS Confederation conference in June. The periodic trip to outpatients for five minutes with the consultant was unlikely to be delivering great value for anybody, he said. ‘Think of it from the patient’s point of view, think of it from the clinical team’s. Have the conversation of what redesign looks like,’ he said.

There certainly seems to be a growing consensus that this is an area ripe for reform, delivering more value by improving services and convenience for patients and potentially reducing costs or freeing up scarce resources. Elsewhere, the Getting it right first time initiative has launched a review of outpatient services under the lead of consultant ENT surgeon John Hadley.

Reforming the outpatients model is not a new idea. NHS Improvement chief executive Ian Dalton told the same NHS Confederation conference that the service had ‘been talking about modernising outpatients for a long time’. But it has clearly been stuck in the too difficult pile. And there now seems to be a real push to prioritise this particular modernisation.

It is a significant area of expenditure – Mr Stevens said spend was close to £10bn – and it is also a rapidly expanding activity.

According to national statistics, there were nearly 119 million outpatient appointments in 2016/17, of which 94 million were attended by patients. This attendance figure is up from 52 million in 2006/07. Patients aged 60-79 accounted for over 30% of all attendances and 31% (of all attendances) were first appointments, with GPs the source of referral for these in just over half of cases.

The sharp rise in outpatient attendances – rising faster than other types of healthcare activity – has lifted outpatient services up the transformation priority list. But while the model has stayed largely unchanged since the start of the NHS, there have been attempts to stem the rising activity. 

However, Sophie Castle-Clarke, senior fellow in health policy and digital programme lead at the Nuffield Trust, says these have not always been helpful.

‘One activity that’s been used to reduce activity is to change GP referral behaviour – reviewing the appropriateness of referrals through referral management centres,’ she says.

This has involved either an administrative person or a clinician reviewing referral decisions against a set of guidelines before firming up the need to see a consultant.

‘This has been adopted quite rapidly, but there is limited published evidence to suggest it is effective at saving money or cutting inappropriate referrals,’ she says. ‘It often simply adds a delay to the process because of the additional review.’

She says such centres typically carry a large overhead that can outweigh any savings from reduced referrals. And she points at BMJ research that found just 10 out of 72 clinical commissioning groups with referral management schemes could demonstrate savings. Other initiatives have sought to transfer activities traditionally undertaken in outpatient departments to GPs.

But Ms Castle-Clarke says that, with primary care so massively stretched, asking GPs to do more is unlikely to be effective. Instead, she says, referral practice can be improved significantly by strengthening relationships and communication between GPs and consultants. ‘We need to remove the barriers preventing GPs asking consultants for advice – potentially in the presence of patients,’ she says.

One model already having success in this area has been pioneered by Imperial College Healthcare NHS Trust, where general practice-based child health hubs have been established as the central point for child health. The model was one of a number of new approaches spotlighted in a Nuffield Trust/NHS Improvement workshop at the end of 2017.

A hub typically brings together three or four GP practices covering a population of 20,000, with about 4,000 registered children. They are built around monthly multidisciplinary team meetings attended by hospital consultants to discuss paediatric cases. The consultants also hold outreach clinics with a hub GP.

The response has been positive, with patients feeling better supported and health practitioners also benefiting. GPs talk about learning from the joint clinics and meetings and being able to apply that learning in general consultations. They also have more confidence in talking to and contacting paediatricians.

With this collaborative approach, there has also been a reduction in traditional hospital activity. In one hub – comprising three GP practices – 39% of new patient appointments were avoided through the multidisciplinary team and improved care co-ordination. A further 42% of appointments were relocated from hospital to GP practices. There was also a 19% drop in subspecialty new patient appointments, with paediatric admissions down 17% and A&E attendees down 10%.

Imperial’s consultant paediatrician, Mando Watson, says the changes – part of a Connecting care for children programme – represent more of an adjustment to existing practice than a revolution. With a first hub in place five years ago, Imperial now supports seven hubs across its patch, covering a third of its resident population. Further hubs have been established across North West London and some areas outside London are in the early stages of establishing similar arrangements.

But while she is keen to expand the model further – within child health across the Imperial patch and beyond and more broadly where the model is relevant to other services – Dr Watson says a revised payment system would help. The current tariff system, with payments for first and follow-up outpatient attendances, does not fit well with the new community-based model.

A capitation model would be more appropriate, she says, admitting to frustration at the slow pace of change in payment reform nationally. ‘I’d love this to be scaled up quickly,’ she says. ‘In a cash-strapped NHS, when you have something that delivers this type of efficiency, we have a moral obligation to do it.’

Another key principle is to concentrate consultants’ time – the service’s most expensive resource – where it is most needed. In some examples, this has involved consultants supporting other practitioners in assessing or reviewing general patients, leaving consultants to see the most complex cases.

A new musculoskeletal service in Nottinghamshire relies on a consultant-supported but physiotherapy-led triage service.

This is not a referral management centre – simply reviewing GP referrals – but recognises that nearly half of first outpatient appointments had resulted in no treatment or a referral for physiotherapy. For many patients it means faster treatment, while the most complex cases are still handled directly by consultants.

In Sheffield, redesign of geriatric care has been based around the delivery of value overall, with changes leading to faster assessment of patients in a new dedicated elderly frailty unit (see box).

Follow-up appointments are another key area, with many scheduled routinely regardless of need or risk. Ms Castle-Clarke highlights an orthopaedic surgery service at Central Manchester NHS Foundation Trust that uses patient reported outcome measures (PROMs) to help indicate whether a follow-up appointment is needed.

Glaucoma focus

A glaucoma service at the Manchester Royal Eye Hospital also takes a risk-based approach to the use of consultant-led clinics. Glaucoma is a chronic condition and all patients are assessed in optometric-led clinics. Lowest risk patients are then supported using virtual clinics, while moderate risk patients are offered follow-ups with the same clinics. Consultant clinics are then reserved for complex/high-risk patients or those requiring surgery.

Ms Castle-Clarke stresses that there is no one-size fits all for outpatient services. ‘It’s not one thing, it is so complex, even within a single specialty. For example, just because you redesign glaucoma clinics in a certain way doesn’t mean you can use the same model for all ophthalmology clinics.’

There are lots of factors. What is the type of problem trying to be addressed? Is it progressive? Does it follow a predictable course? Is it acute or time sensitive? All of these issues could demand a different approach, with changes clinically-led.

This means outpatient transformation cannot be a single project – a point recognised by the Berkshire West Integrated Care System (see box), where outpatient modernisation is spread across 20 workstreams and a diverse range of specialties.

Ms Castle-Clarke adds that technology has a role to play. ‘But just focusing on moving to remote consultations is the wrong starting point,’ she says. ‘The aims have to be to use consultants’ time appropriately and not to keep patients waiting.’ Where technology can help meet these aims, it should be used.

Transformation of services in general is a long-term project and is likely to see a blurring of boundaries between primary/community services and hospital services. As the interface between the two, outpatient services are fundamental to this overall reform.

And with system leaders now making outpatient reform a clear priority, the rapid spreading of effective new models and sharing of best practice will be vital.

Single visit approach