Outpatients have probably been a feature of hospitals for as long as they have existed, but the current structures seem to have started in the seventeenth century, when the Royal College of Physicians started their clinic in 16961. Little has changed since. Patients take time from work and travel to genuflect and allow the expert to demonstrate their superiority and importance. A more paternalistic system would be hard to design.
An anachronism! In other areas of the NHS there are complaints that innovations take 10 years to reach the front-line. In outpatients the clinicians have still not learnt to use the telephone, invented in 1876 - a mere 142 years ago, and apparently still too complex for routine use in the NHS.
In outpatients, little changes:-
- Waiting for letters that arrive after the appointment was due.
- Having to see the GP again for another referral.
- Waiting for the specialist as the sessions starts late.
- 10 minutes in to see a junior doctor and ‘we’ll see you again in 6 months’….
- And a copy of a letter written half in Latin and the other half barely recognisable as the description given to the doctor.
One change that has developed are full and expensive carparks (well I guess they weren’t common in 1696!). This seems to be the major change; hospitals in England were estimated to earn £120,000,000 in 2016 – up 5% from the previous year.
The other change is volume – outpatient attendances continue to grow rapidly.
Referrals and attendances for outpatient admissions, England,
Q1 2008/09 to Q2 2017/183
GP referrals rose by less than 1% year on year, but other referrals rose much more rapidly at 5.6% and follow-ups also increased faster than GP referrals. Commissioning groups have intervened with referral management systems and a variety of bans on consultant to consultant referrals. Evidence that these efforts are effective is mixed at best4, but often increase work for GPs, confusion for patients and can increase risk 5.
This activity is expensive. Over 90 million attendances in England last year and accounted for 17% of NHS spend. This compares with 8% spend on general practice and 350 million appointments6. Twice the spend and It locks doctors and patients in the corridors of unproductivity.
Perhaps the fact that 8% of patients fail to attend new or follow-up appointments, despite phone calls and text reminders, indicates that a large proportion are unhappy with the system?
Despite this pessimism, there are many shoots of new thinking and provision. London Clinical Senate Forum held a workshop in October ‘17 and more recently Nuffield Trust with NHS Improvement held an event7 with exemplars of clinicians trying to address the many issue, working with patients in co-design.
Some of these remove the need to travel – with use of telephone (especially for follow-up) or Skype video-consultation – but these examples still depend on a referral process and synchronous availability of specialist and patient. Digital technology enables clinical note sharing, request for advice and asynchronous efficient care8; reactive systems don’t see routine follow-ups for conditions that are prone to uncommon exacerbations – but don’t discharge patients who may need rapid support if inflammatory bowel disease flares.
However, a common complaint from innovators and implementers alike is that current funding systems do not easily identify the costs of the new service – or work out how providers afford the legacy overheads that get stranded. NHS England promise action to address this and suggest some ways forward.
Let’s hope that these innovations take less than 10 years to hit the front-line.
Dr Mark Spencer
1 BMJ 1:6118;974-977
Imison C, Naylor C. Referral management: lessons for success. King’s Fund. 2010
5 Referral management schemes: good for whom?
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.i6856
6 Understanding the Pressure on General Practice. Kingsfund 2016