I first started speaking to trusts about their outpatient transformation plans in March 2020. I still remember one of my earliest discovery calls with the CCIO of a trust about their outpatient department, who showed me a slide of a Victorian-era waiting room at a train station as an example of their current outpatient experience. Whilst intended as tongue-in-cheek, the reality was that very little had changed for them in the way outpatient care was delivered. This is despite the way we deliver care evolving, the needs and expectations of our patient population evolving, and the digital tools available to deliver care evolving.
Since then, I’ve had many more conversations with trusts, and nationally the picture sadly remains the same. They are overwhelmed with demand, struggling to find the resourcing and capacity to meet it, and are investing in single-point solutions that fail to deliver value for patients and staff or look at pathways of care holistically.
In this piece, I want to examine where there is room for improvement.
Waste and inefficiency
There is abundant waste and inefficiency in our current outpatient model, with high repetition and duplication of effort. This leads to a loss of staff productivity due to wasted time, and patient confusion in navigating their care. Have you ever tried to cancel a hospital appointment and rebook it? Or tried to review and manage a patient in the complete absence of information about why they’ve been referred? Or seen a patient face-to-face only to tell them it would be more beneficial to see them after they have had the investigation that was initially advised? These are just a couple of small examples, but when you map these instances out across every other aspect of a patient’s journey it builds a picture of huge waste and loss of productivity across the system.
Good communication leads to good care
If we are to transform outpatient care and bring it into the 21st century, we should start with something as simple as fixing our communication (and I don’t mean refreshing those communication skills we are taught in medical school!). Communication is the common thread running through outpatient care (and in fact all models of care), and yet we do it so poorly.
If you take a typical patient journey of a patient referred for elective surgery: the patient contacts their GP; the GP asks about their symptoms; the GP refers the patient to secondary care; the patient is given information about the status of their referral; the clinician reviews the patient; the patient is consented for surgery, their conditions are managed and optimised by the GP whilst they wait; the patient is informed how to prep for surgery, the patient is followed-up and reviewed after surgery. Every single one of these steps involves communication.
And yet, we currently do much of this activity in siloes. This has a hidden but great cost to operational productivity in hospitals. A patient who is not optimised for surgery leads to an on the day cancellation, which leads to poor optimisation of surgical resources and theatre utilisation, and wasted slots for patients waiting for care. A patient who does not have visibility over their referral status ends up calling the GP, who contacts the surgical admin to ask where they are on the waiting list, wasting valuable clinical time and creating a poor patient experience. A patient who receives a letter about their appointment at a time they can’t attend ends up DNA’ing because they can’t get through to the hospital to rearrange it.
To reimagine outpatients, we need to examine communication across entire pathways and end-to-end, to understand what we can change for the better. Lots of the improvements we can make today require little change management and do not need to become operational headaches to manage. It is not rocket science but it does take teams wanting to make changes in the way they work. I often ask Consultants ‘do you want to be running the same model for outpatients as you are now, next year?’ I have never received a ‘yes’ to that question. Staff are crying out for change and looking at ways to make their jobs and the care they deliver more sustainable.
A really impactful but more accessible place to start is with communication, and by examining the whole pathway and not in isolated parts of the outpatient journey, such as referrals or follow-up, for example. Why? Because if you improve part of the referral pathway but leave the rest of the experience untouched and delivered in the same way as it was before, there will be a very small productivity gain but the full potential and impact won’t be unlocked across the rest of the pathway. When we talk about outpatient transformation, we must talk about true, end-to-end, foundational transformation.
The vision
Our vision for outpatient transformation is that every patient gets the most appropriate care and intervention at the time they need it, which isn’t delivered by routine booked face-to-face appointments as the default model for secondary care. We must stop treating every single patient in the same way, and start asking some basic questions:
- Who genuinely needs face-to-face care and who doesn’t?
- Who could be moved to a patient-initiated pathway at first referral because their symptoms have resolved but you want to keep an eye on them?
- Where can a digital questionnaire be sent to a patient so you can triage and direct them straight to imaging or investigations ahead of a face-to-face or virtual appointment, so more value is unlocked in that interaction?
- How can we ensure all referrals are made and triaged against agreed criteria?
- How do we support patient messaging when we need a response back from the patient?
- How do we manage entire patient pathways asynchronously for low risk and stable conditions, only defaulting to an appointment when there is a clinical need for a face-to-face interaction?
It is about whole scale transformation through improved communication. This will create a service that is more personalised to patients, and more sustainable for healthcare professionals and the system as a whole.
What does this look like, for patients, staff and the system?
For patients, we want to work with outpatient services to break down silos in their care provision, to ensure personalised clinical care that feels integrated across the NHS.
For staff, it’s about increasing efficiency and improving productivity, as well as creating more capacity or flex within the system. For example, staff at University Hospitals of Leicester are using Accurx’s rectal bleeding questionnaire to direct patients referred for rectal bleeding straight to a diagnostic test, bypassing an unnecessary initial clinic appointment. Patients who are referred now receive the questionnaire via SMS asking about their symptoms. A clinician then reviews the responses and triages the referrals appropriately, sending 64% of patients straight to a diagnostic colonoscopy and bypassing the need for the initial clinic appointment. This is saving clinician time, reducing waiting times for patients and creating more capacity.
Through these changes in ways of working, we want to make staff the agents of change in outpatient transformation. Often, the initial mindset is “this is how we’ve always done it”, but through our work with our partner acute trusts we’ve seen that if you give staff the right digital tools and new ways of working, they become the agents of change to start working in far more sustainable ways that deliver excellent clinical care.
At a system-level, you’ve only got to imagine the impact if this transformation was achieved across every single outpatient department in the country. The value unlocked would be astronomical. It would not only improve operational measures like reducing RTT waiting lists and DNA rates, but the system would also experience huge productivity gains. Imagine a clinician who is now not spending hours seeing patients who don’t need to be seen, but seeing those with the highest critical need. The administrative savings would also be significant - the volume of phone calls avoided, the removal of back and forth phone calls to patients who have tried to cancel their appointment and more.
How will it happen?
How is this type of transformation going to be created? We’re currently developing and implementing a series of transformation blueprints with our partner acute trusts, starting with outpatients. They map and identify all of the opportunities that digital communication and new ways of working can improve an end-to-end patient journey. They give healthcare professionals a platform to transform on - one that is generic enough in its broad functionality, but specific enough to each service through the content (such as specific digital questionnaires of high relevance to other functions). On top of this, we’re also providing full transformational support to help outpatient service staff effectively shift their ways of working, so they can become the agents of change. We hope this work will bring outpatients into the 21st century, one service at a time.