Outpatient improvements must be clinically led

Its report, Rethinking outpatient services, draws on a workshop held with NHS Improvement at the end of last year and highlights successful outpatient redesigns from around the country.

It comes amid an increasing focus on modernising outpatient services. NHS England chief executive Simon Stevens recently described the current model as ‘an obsolescent mode of specialty long-term support’ and an outpatients review has recently been added to the Getting it right first time programme.

A number of sustainability and transformation plans have also outlined ambitious proposals to cut costs by reducing outpatient activity

The Nuffield Trust said it was important that redesign work was led by the ‘clinicians who are delivering it’. It also warned that administrative referral management models – applying rules to check referrals – did not appear cost-effective, introducing a non-value-adding step and delay into the pathway.

Instead, the thinktank highlighted the transformation of relationships between consultants and GPs and their wider teams as the foundation of some impressive outpatient redesigns. Two-way conversations had the ‘potential to treat more patients in the community and support clinicians in their decision-making’, the report said – a change that could reduce referrals.

Child health GP hubs, pioneered by Imperial College Healthcare NHS Trust, have led to big improvements in patient experience and a reduction in hospital activity. In one hub, 39% of new patient hospital appointments were avoided altogether and a further 42% of appointments were relocated from hospitals to GP practices.

Other successful redesigns had introduced virtual clinics and questionnaire-based risk assessment approaches to determine where follow-up appointments were needed.

The report also highlighted the need to change payment systems. The national tariff does not currently have national prices for advice, guidance and remote consultations, though there is ongoing work to develop these. The authors said local prices should be negotiated that took account of overall outcomes and total cost. A price set higher than the tariff for a single professional face-to-face follow-up appointment could actually deliver better value when wider benefits were factored in.

However, the report also warned that there was no one-size-fits-all solution to outpatients redesign. Even within a particular specialty, each clinic was likely to respond differently to interventions and each service would need to experiment with different delivery models.

Workshop attendees emphasised the importance of looking at the patient journey from start to finish and ensuring each member of staff was adding the most value possible.

Sophie Castle-Clarke, a senior fellow in health policy and digital programme lead at the Nuffield Trust, said that with more than 110 million scheduled appointments in England a year and activity on the increase, it was time to rethink outpatient services.

‘The good news is that with this significant challenge comes great opportunity to do things differently,’ she said.

‘A clear thread running through successful changes to outpatient services was allowing clinicians to orchestrate these changes and build strong and productive working relationships. Clinicians and hospital managers should not underestimate the time it takes to achieve this.’