Outpatient care is stuck in the 1950's

NHS England recently wrote to all NHS Trusts asking Boards to revisit plans on outpatient productivity, reductions in follow-ups and to identify more “opportunities for transformation”.

In the letter, Sir Jim Mackey wrote: “We are now asking trusts to provide assurance against a set of activities that will drive outpatient recovery at pace. This process will require a review of current annual plans, detailing the progress that can be made on outpatients’ transformation.

“As part of the above priorities, we are asking each provider to ensure that this work is discussed and challenged appropriately at board, undertake a board self-certification process and have it signed off by trust chairs and chief executives by 30 September 2023.”

This all comes off the back of the national RTT waiting lists now being made up of 2/3rds non-admitted (an NHS term for outpatient or diagnostic) waits.

We’ve written extensively on the topic of outpatients, but today we will look in more detail at what the main challenges are to increasing outpatient productivity as well as the key emerging trends that any new outpatient recovery taskforce should be looking at.

Why we are seeing less outpatient activity and less productivity

The Unreported list

With the reported list now standing at 7.6m patients and growing (June 2023) focus has understandably been on these patients. However, those in the service know there is an avalanche of patients who do not sit on the reported list. Patients with chronic conditions or post-surgical follow ups don’t appear in the reported figures nor do patients who have had cancer treatment in the past and need regular monitoring. Arguably these groups of patients are now at more risk than the reported ones as pressure increases politically to get the reported figures down, thus lowering capacity to see the unreported ones.

Administrative & Management reductions

Often the first area the NHS cuts when money becomes tight. Couple this with the the relentless stupidity of politicians and their crusade to “add front line staff” and you have a perfect storm. Front line staff without administrative and managerial support simply means front line staff have to do more and more administrative and managerial tasks. The place front line staff encounter this problem most is outpatients.

The fastest step to improving efficiency in outpatients in to manage and administer clinics properly.

EPR rollout

The administrative and managerial reductions are then further exacerbated by the central push for all hospitals to implement “modern” EPR systems. Often, there is nothing modern about these systems at all. Most EPR systems currently being rolled out in the NHS are nearly 20 years old now - certainly the biggest two. Technology has again moved on and these systems are now clunky to use. Anyone who thinks EPIC is cutting edge needs to get some new knives. Add to this that we are hopeless at training staff generally and you have recipe for chaos.

Infrastructure

How many times will we hear “my computer took 25 minutes to boot up this morning”? Expecting anyone to record anything on something tied together with elastic and hope is a fools errand. And it’s not just the machines. Often outpatient areas are cramped, hot and generally unpleasant places to be. Estate infrastructure is a major impediment to more productivity.

Loss of goodwill

Add this all together and then think of the wider context. Most of the NHS has been on strike in 2023. It’s workforce clearly do not feel valued. Pre-covid, a significant proportion of activity was based on goodwill - that is now gone and clinicians are very reluctant to do more than what they feel they are already underpaid for doing.

Reluctance to see new patients  

All of this is most acutely felt in the reduction of patients being seen for a first appointment. Why? Well, clinicians feel a sense of responsibility for the patients they have already seen and are treating. In the current environment, seeing a new patient adds to that sense of responsibility more and more. In a situation where you already have too many patients wanting to see you, it is perhaps not surprising that you don’t want to take on anymore.

What can be done to tackle outpatient productivity?

Given the issues identified above, you’d be forgiven for thinking that this is an intractable problem to solve. However, our experience of this area tells us that it is ripe for reform and now is the perfect time to address it.

With the announcement of a new outpatient taskforce, we’ve done some of the heavy lifting on areas they should be focussed on. Our experience in this area has identified the top 10 priorities:

Top 10 opportunities to improve outpatient care and productivity

Improving Data Quality

Technology is only ever as good as the data it is being fed. With lots of new technologies appearing on the market it’s promise is clear to see. However, unless the data underpinning technology is of the highest quality, none of this fancy technology will be of use. Incorrect decisions made on inaccurate data poses an even greater challenge in the future.

Aspirations of making appointment scheduling seamless, care coordination, advanced analytics, artificial intelligence etc all rely on accurate data. Not enough focus has been placed on this area within healthcare.

Enhancing Care Coordination

Fragmented, episodic care is a major pitfall in outpatient settings. Patients, especially those with multiple chronic conditions, need proactive coordination across providers, settings, and services. Health systems should invest in care management teams, tools to facilitate referrals and follow-up, and better information sharing between sites and specialists. Studies show this can reduce hospitalisations by 11%.

Streamlining Appointment Scheduling

Missed appointments and scheduling hassles frustrate patients and reduce efficiency. Patients need expanded self-scheduling options, appointment reminders, and clinics should overbook strategically. Open access scheduling should allow for same-day appointments. Technology is simply better in almost every other industry at doing just that (however every other industry has better data quality).

Incentivising Group visits 

Seeing patients with similar conditions in a group setting provides peer support and more time with providers. This approach could be particularly valuable when dealing with patients with chronic conditions.

Engaging Primary Care

Not enough thought has gone into the link between the unreported follow up list and primary care. Patients not being seen for their follow ups inevitably end up back in primary care and this has led to a large increase in demand. New models of care working closely with primary care colleagues are required to work out the most appropriate setting for managing patients and this is highly likely to be outside rather than inside hospitals.

Deploying Advanced Analytics

Powerful data analytics can identify at-risk patients, customise interventions, and provide population health insights. Building analytics capabilities through patient data, risk stratification models, and AI should be a priority.

Natural Language Processing applications can extract key information from unstructured physician notes and patient reports to provide more complete health profiles and medical histories. This additional context assists faster diagnosis & treatment. LUNA is making huge strides in this area.

Artificial Intelligence and Machine Learning tools can analyse large datasets from patient medical records, lab tests, imaging studies, etc. to uncover patterns and aid clinical decision-making. This can help reduce diagnostic errors.

Addressing Social Determinants

Screening patients for social determinants of health like food and housing insecurity can facilitate referrals to community resources that address needs. Identifying at-risk cohorts of patients and managing them differently through enhanced care coordination can yield significant benefits.

Strengthened Patient Education

Improving patients' knowledge and self-management skills leads to better health outcomes. Clinics must integrate patient education into visits via teach-back methods, videos, discharge instructions, classes, and more. Patients and referrers should have access to waiting times, what their role is in the process and what their rights are. My Waiting Time is a prime example of this approach.

Point-of-Care Diagnostics

Devices like portable ultrasounds and rapid diagnostic tests allow obtaining lab-quality results at the clinic should be heavily rolled-out. A focus on One-Stop appointment and diagnosis should be a central aim of any outpatient improvement. This facilitates faster and more accurate diagnosis.

Mobile Health Applications 

Health apps on smartphones and wearables allow patients to track symptoms, share data with providers, and receive reminders for health events. This generates more longitudinal data for diagnosis, and allows both patient and clinician to know when things have gone wrong and they need to be seen.

And finally….

Be optimistic. At present, large numbers of patients are at risk but this can be fixed. There are people who have the knowledge and experience to help.