There is a growing problem with outpatient care in acute hospitals.
outpatient hospital visits have nearly doubled over the last decade. One in five
appointments are either cancelled, or patients do not attend. The model can be
inconvenient and inflexible for patients, who may need to arrange time off
work, childcare, and travel. There is also an environmental impact; 5% of all road traffic in England is caused by the NHS alone.
In response, the
NHS Long Term Plan aims to reduce outpatient visits by a
third over the next five years, removing the need for up to 30 million
appointments a year – no mean feat. This will free up time for health
professionals and clerical staff in a staff-short system, free up hospital
outpatient rooms currently required to run clinics and reduce CO2 emissions
through reducing the number of patients traveling to hospital. In London, for
example, this has the potential to avoid up to 50,000,000 miles of journeys, aligning
with the London Vision to reduce motor traffic volumes and
improve the environment we live in.
The Royal College of Physicians have considered how improvements could be made,
concluding that there is a place for
managing referrals more effectively, better planning for more efficient initial
investigations and management, and examining alternative models for monitoring
and managing patients. New models of non face-to-face (virtual) clinics can be
part of the solution across all these stages. We know that nationally, only 3% of outpatient appointments are delivered through non
face-to-face models currently.
lack of practical advice on how to set up a non face-to-face clinics,
UCLPartners has worked with NHS clinicians, managers and patients to develop an
online how-to guide to help embed this approach. A set of
common challenges and opportunities emerged in implementing these models of
One of the key challenges has been high expectation around
the financial savings that non face-to-face clinics would deliver. Often, this
hasn’t yet been realised: simply changing from a face-to-face to a non
face-to-face model doesn’t necessarily produce savings or other immediate
benefits such as reduction in outpatient wait times. It requires system-wide
change to ensure that non face-to-face clinics are part of the solution for
outpatient transformation, to support achieve the NHS long term plan objectives,
with system leadership and collaboration essential enablers.
Furthermore, although there are some good examples of
evidence for non face-to-face models, we are mostly dealing with an emerging
evidence base. In practical terms, this requires an approach that weighs up the
available literature and introduces innovation at a local level, all whilst
contributing to the evidence base. A challenging task, especially when
having to convince commissioners that capital investment may be required
upfront, and that both financial savings and clinical outcomes can be delayed. A
quality improvement approach has worked well in some cases, learning through
small-scale testing before implementing more widely.
While some challenges have emerged, developing non face-to-face
models also presents some clear opportunities in how we engage with patients
and work together as a healthcare system.
Broadly speaking, patients are very positive about these new
models of care. The models offer clear benefits, such as reducing the need to
take time off work, minimising their transport and parking costs, reducing the
need to re-arrange caring commitments and better access into services.
It is important to keep patients informed, but also reassure
and demonstrate that non face-to-face models are safe and effective, and that
they are not just a cost-cutting replacement for traditional models. It’s also
important to consider the impact on patients, ensuring that outpatient services
meet the needs of modern-day living and patient expectations.
Through using primary care data, renal teams in East
London have demonstrated reductions in waiting times to see a
specialist and the number of patients requiring face-to-face appointments in
secondary care. There are opportunities to work together as a system to have an
impact at a population level with other specialities that lend themselves to
the approach of reviewing quantifiable population level data and identifying
high risk patients. There are further opportunities to manage patients with
multiple co-morbidities more effectively through these models.
This should result in managing patients with long-term
conditions more holistically and slowing disease progression, along with
improving patient experiences. Primary care is a key enabler to this, and any
change in how patients will be managed that will affect primary care must be
done in partnership with these clinicians.
As technology evolves and patient expectations change, it is becoming evident that the current model is outdated and unsustainable. Non face-to-face clinics will be one part of the outpatient services of the future. There are always challenges and uncertainties in setting out on a new approach, but the potential benefits for patients and teams are significant. We now need to ensure that teams receive the necessary support and guidance to enable them to implement and deliver these new models of care for the benefit of patients and the system.
This blog originally appeared in the HSJ.