Outpatients: First Outpatient Appointment
Outpatients is another hugely important area for the majority of patient pathways. It is usually the step in the patient’s pathway where the majority of different pathways intersect, diagnostic tests are reviewed and the decision to treat (or request additional testing) is made.
Most patient referrals from primary care that initiate an 18 week clock start will find themselves in outpatients. This high volume area can benefit greatly from some of the basic service improvement tools and techniques – some of which are simply about understanding the process and administrative bottlenecks.
Most trust activity data is captured for outpatients. It is only when you try to wholly understand the outcome of an individual patient consultation that the current systems fail to inform, particularly if a patient is referred onto another centre for treatment. Records of this are often patchy and ad-hoc, as are dates when decisions are made to treat or not treat the patient. For the purposes of 18 weeks recording, it will be imperative to capture these additional dates in order to measure and calculate patient journey times accurately.
Demand for outpatient consultations remains high and has increased over the previous year nationally. Frequently a high demand and stagnant capacity will drive waiting times higher. New ways of working and delivering services are required that differ from the more traditional methods along with regular validation and screening of referrals to manage demand at the source of referral. The outpatient waiting list is dynamic - the number of patients entering and leaving the lists at the various stages will differ between organisations, specialities and individual consultants of the same speciality. Understanding the flows on and off the waiting list forms the basis of waiting list and activity modelling and monitoring.
The Basics (First Outpatient Appointment)
- Access the background reading materials available for service improvement and project management.
- Link to the NHS Improvement System to see if there are similar change ideas, related documents and improvement stories that can be used for your work.
- Process map the service in order to understand the patient flow dynamic and potential bottlenecks.
- Understand the demand and capacity of the service.
- Understand the baseline levels of activity of the service.
- Review the booking process in order to understand the administrative processes involved with these clinics.
- Review the clinic templates and schedules for all staff that hold these clinics.
- Understand the baseline waits that patients experience and the overall variation.
- Understand the did not attend (DNA) rates, new to follow-up ratios and hospital clinic cancellation rates for each clinic and member of staff who hold these clinics.
- Review the referral criteria and guidelines for the clinic in order to understand what patients are currently referred to the service.
- Discuss the service with all related staff – get a feel for how the service is viewed and used and also establish the current issues and challenges of the service.
Further Considerations (First Outpatient Appointment)
- There are often a high proportion of non-cardiac referrals made to the cardiology department. Improved screening of patients in primary care is required, possibly through diagnostics prior to when the decision to refer is made.
- All referrals should be generically addressed unless the referral is for a sub-speciality opinion that only specific consultants can provide.
- A high proportion of patients can be referred for a general cardiology outpatient appointment when their referral meets the criteria for Rapid Access Chest Pain Clinic (RACPC). Improved communication to GPs on the criteria is required in order to maintain the referral process along agreed pathways of care.
- It is clear that a ‘rapid access’ model of care for outpatients has a significant impact on overall pathway times. Trusts need to consider duplicating similar models for other high volume speciality conditions such as heart failure and arrhythmias.
- A review of diagnostic access for outreach clinics should be made (if relevant) to prevent the post-outpatient appointment (OPA) diagnostic scenario. The benefits of a locally accessible service versus overall service efficiency and the potential for reduced waits will need to be balanced. It may be possible to continue these services based on tighter screening of patients requiring little diagnostic intervention.
- The times between referral letter receipt, letter grading and appointment are often too long. While the Choose and Book initiative will alleviate some of these problems, trusts will need to consider the full implications of Choose and Book for the purposes of 18 weeks.
- The vast majority of clinics are currently managed by medical staff and some cardiologists participate on the general medical rota. Trusts need to consider the workforce implications of this decision and allow for new ways of working which include the development of nurse and General Practitioners with a Special Interest (GPwSI) led clinics in primary and secondary care in order to increase overall capacity. Some follow-up clinics such as post myocardial infarction (MI) or post-revascularisation can be wholly nurse-led.
- Some GPs may only require advice from a consultant for the treatment of a patient, but find that the current system only supports direct referrals. New ideas such as advice by telephone or email or the introduction of a web-based cardiology information store to support GPs decision making may prevent a number of referrals. Another option may be a system of GPwSI referral triage in primary care with the benefits of improved grading consistency.
- The development of a detailed pathway of care, agreed across primary and secondary care will help support decision making for a range of clinical conditions.
- Some patients will experience multiple pathways of care at any one time and cross a number of specialist areas. Tighter integration of systems will be required to improve the efficiency of monitoring these patients, but particularly where stand alone data systems are used.
- Improve the utilisation and co-ordination of one-stop clinics (where diagnostics are held on the same day as the outpatient appointment) to maximise diagnostic activity during these sessions and avoid unused diagnostic slots.
- The Department of Health 18 week delivery trajectory will be challenging as maximum outpatient waits will need to reduce over the coming years. A system to identify and reduce backlog will need to be introduced that enables sustainability as opposed to a ‘quick fix’.
- There is often very little to distinguish the difference in average waiting times for urgent and routine outpatient appointments. Multiple slot types add inefficiency and reduce productivity so the trust will need to simplify clinic slot types as overall waits reduce.
- One of the major constraints on the efficiency of outpatients departments is the fixed nature of clinic rules. Consultants and their teams are allocated clinic sessions in much the same way as hospital beds used to be allocated. When a consultant (or member of their team) is not available for a particular clinic, it is then often cancelled (or reduced).
- The number of patients seen by each consultant should be standardised in order to meet existing demand. The practice of over-booking should be reduced by clinic template review and modification which will lead to reduced cancellations.
- The DNA rate is the traditional method of performance measurement and reducing DNA rates remains as a key objective. DNA rates normally increase with length of wait due to patients moving, change in condition etc. Evidence suggests that greater sophistication in measuring DNA rates is required as high level analysis can disguise problems with individual patient groups.
- It is commonly accepted that when clinics are cancelled or reduced by the hospital, patients with clinical priorities retain priority access. An analysis of the clinic rules is essential. This should be coupled with an analysis by waiting time for urgent and soon to be seen patients. The review of clinic rules should ensure they reflect the priority mix of the referrals.
- The majority of outpatient services use a traditional fixed appointment system, where patients are given appointments on receipt of a referral letter. This system has many weaknesses. Patients are appointed well in advance so any changes to the clinic schedule or frequency of clinics will affect the appointments of all the patients waiting. Choose and Book will address some of these issues but close monitoring will still be required.
- Although patients are originally appointed in chronological order, changes to appointments (e.g. as a result of clinic cancellations) lead to widely different waiting times for individual patients when attending clinic. Maintain chronological booking as far as possible for similar patient group types.
- Ongoing work is often required in order to analyse outpatient demand and 18 weeks modelling in order to identify gaps in current delivery.
- Involve commissioners as part of any service transformation work in order to provide a mutual understanding of the service delivered and changes required.
Future Developments (First Outpatient Appointment)
- Health communities should develop the planning concept of matching referrals with planned activity by shaping the demand for care and attempting to manage today’s demand today by adjusting available capacity to match varying demand.
- There is a need for health communities to commission on the basis of need using an Integrated Service Improvement Programme (ISIP) approach and, in line with the health needs of their patient populations, planning their inpatient and outpatient activity within a whole system context.