David Oliver: Outpatient clinics’ role in sustainability

In 2018 the Royal College of Physicians published Outpatients: The Future—Adding Value through Sustainability,1 arguing that the traditional care model for outpatient specialty opinion, diagnosis, and disease monitoring was no longer fit for purpose. This future focused report is worth revisiting as NHS elective services recover and incorporate learning from covid-19 but struggle for staff and facilities.

The RCP authors, whose new article is now in BMJ Opinion,2 argued that outpatient clinics accounted for the highest volume of hospital activity and yet, when compared with pathways and targets for acute care, had received far less national policy attention for reform or improvement. Recommendations to improve value and sustainability included greater use of remote and “one stop” clinics; greater co-design, information signposting, and peer support with patients and charities; and fewer needless “routine follow-up” appointments, with more patient directed follow-up when problems or questions arose. These would also mean less traffic ferrying patients to and from clinics.

Since that report, the Richmond Group of health charities has published a report rich with recommendations based on patients’ personal experiences of multimorbidity.3 This showed starkly the burden and personal cost—in time, inconvenience, worry, and money—to patients with multiple long term conditions who had to make repeated physical visits to different outpatient clinics. And National Voices has repeatedly set out the case from patients’ perspective for more coordinated and person centred care.4

Major surveys of patient experiences and public attitudes have shown that, while respect and gratitude for the NHS and trust in its staff remain high, patients increasingly struggle with access, timeliness, and communication and can feel unsupported.567

The NHS’s Getting it Right First Time programme8 has produced a range of reports and recommendations across a range of outpatient specialties, highlighting major variations in activity, staffing, performance, and value while recommending potential improvement activities and picking out examples of good practice.

The pandemic response has helped to accelerate some innovations recommended by the RCP report.9 Greater use was made of remote consulting, online or by phone.1011 Trusts employed one stop hubs, rapid access ambulatory clinics, or home based support models such as virtual wards.12 Fewer patients attended outpatient services on hospital sites, partly because of infection control measures and emergency service changes and partly through use of phone or online consultations.13 Just like GPs, hospital teams will now have to strike a new balance between remote and face-to-face consulting.

There are some caveats. First, while some patients like the convenience of remote consulting and the lower impact on their day, others still want to see a (hopefully familiar) practitioner in person. We need the flexibility to accommodate this—although we could make more use of community specialty clinics closer to patients’ homes, with reduced travel.14 Another concern is that serious pathology may be missed without physical consultation.

Second, GP leaders have repeatedly expressed dissatisfaction about hospitals transferring uncontracted secondary and tertiary care work back to primary care, which doesn’t have the right funding, staffing, or access to investigations.15 Reducing outpatient activity could worsen this schism and increase pressure on primary care.

Third, the drive to catch up on post-covid backlogs16 might focus minds on using outpatient appointments more wisely and efficiently, but for now it’s likely to drive more activity, not less.

Finally, the financial mechanisms that fund hospitals’ clinical activity will need to reimburse new models of outpatient working adequately, and provision of more one stop assessment and investigation clinics, while cutting down on routine follow-ups with multiple specialty clinics, needs to be incentivised and rewarded.

The RCP report has already influenced the NHS long term plan and operational guidance,17 but, as environmental sustainability and post-covid health service recovery are such defining political issues, we have fresh impetus to revisit its messages.