With the number of outpatient appointments in 2018-19 at 123 million – an increase of 63 per cent in the last decade – there are calls for a radical rethink about how the system works. Although GPs have been successful at constraining the growth of new outpatient visits, a report by the Royal College of Physicians suggests the traditional model of outpatient care is no longer fit for purpose and that the time has come to re-evaluate.
Earlier this year, Health Secretary Matt Hancock also called for an overhaul of the system after a report revealed nine million outpatient appointments a year are being cancelled. Cancellations and delay mean greater anxiety and distress for patients along with an increased clinical risk and worse health outcomes which, in turn, lead to higher system costs.
Hancock said: “The outdated model of outpatient services needs a fundamental overhaul. Smarter use of technology, including digital appointments and online booking systems, will help save patients time and inconvenience while freeing up staff and resources where out-patient clinics remain the preferred or most suitable option.”
Why outpatients has become a frustration
There are three main reasons for an outpatient visit: diagnosis, follow-up after a hospital procedure, and ongoing, usually specialist, input for longer-term conditions. These outpatient appointments should follow defined procedures and processes that are well documented, yet often, for a variety of reasons, appointments do not run according to plan.
Frustrations with outpatient care are frequent for patients and healthcare professionals. For the patient there are waiting times to consider (both to receive the appointment and after arrival in the clinic), appointment letters that are often uninformative and confusing, the journey times and other physical difficulties around getting to the appointment, as well as wasted journeys if appointments fail because, for example, test results are not available.
Clinicians too, including GPs, nurses, physiotherapists and other healthcare professionals are frustrated by the outpatient system. They are often fatigued by the pressures of high workloads combined with staff shortages and ever-growing demand. The outpatients concept was initially developed as a way to help clinicians, but working in outpatients can now be extremely stressful.
The NHS Long Term Plan commits to redesigning services with the aim of reducing up to a third of outpatient visits through a digital-first approach. While technology is in no way the only answer to such improvements, it needs to be a key element of a redesign process.
How technology can help to improve outcomes
Technology, such as video consultation, can provide alternative ways of providing patients with advice after a diagnosis, a follow-up review after a hospital procedure and ongoing specialist input. Some appointments do require face-to-face physical interaction, but many do not. By providing alternative ways to access advice, technology can help to reduce the number of outpatient appointments.
According to the Royal College of Physicians, 25 per cent of doctors say 10-20 per cent of their patients do not really need an outpatient appointment. Greater communication between services and a more integrated approach at the beginning of the pathway can avoid patients having to enter the outpatient system at all.
At Newham University Hospital, web-based consultations were used for patients with diabetes attending an outpatient clinic, with the aim of exploring whether web-based consultations could provide more accessible and cost-effective care, using already available technology. This web-based approach led to a drop in the number of patients who failed to attend their appointment, from 33-50 per cent (depending on age) for standard clinic appointments to 16 per cent. There was also an indication that Accident and Emergency attendances reduced over time. The patients involved in the study said that they preferred web-based appointments as they were more convenient and saved them time, while the quality of care was at least as good as that provided face to face.
The World Health Organisation has also suggested exploring the use of mHealth – healthcare facilitated by the use of mobile phones and tablets – to communicate with new mothers and their babies who may be physically hard to reach. Technology alone, however, can only take us so far. What we need to see happen is the redesign of the end-to-end patient pathway, including the embedding of useful technology and the removal of process and procedures that have been shown not to work well.
Investment decisions are needed now
For technology to reach its potential in an overhauled system, the NHS must decide to invest to enable remote consultations via telephone or online (including the Internet of Medical Things). This approach not only makes more productive use of clinician time, but will also facilitate greater clinician wellbeing, removing some of the pressures that they currently face.
In addition, this approach would release more appointment capacity and be more convenient for patients by avoiding the need to travel to the clinic, resulting in less cost and time. By removing some of the dependencies on stretched physical facilities, outpatient clinics can be scheduled more easily. One example of this is University College London Hospitals NHS Trust using artificial intelligence to identify people most likely to not to attend appointments and allowing intervention to prevent that.
Integrating systems can ensure better integration
Technology can also play a part in smoothing the interface between primary care and outpatients, resulting in a better patient experience. There is an opportunity for transformation across the system by sharing data between providers to improve the overall patient experience, as well as health outcomes.
Transformation must be undertaken sensitively, ensuring that it does not jeopardise equality of access to services and in turn does not lead to increased isolation of vulnerable patients. We should also accept that NHS staff are working hard to make the current system work, but there has to be change to progress.
While technology can help to create a more efficient system, it is vital that access to services remains easy and open to all. A system that is digitised must not mean that vulnerable patients who do not have access to computers or smartphones do not have the same access to the system as those who do. It is the outpatient concept that needs to change with technology as a key component in that system-wide evolution.
Charles Young is Chief Medical Officer, Capita Healthcare Decisions and Stuart Bailey is Product Director, Capita Healthcare Decisions