A year ago, the NHS Long term plan highlighted the dramatic rise in outpatient appointments, and pledged to save £1bn a year by stemming the growth in hospital visits. Key to this was a commitment to allow patients to choose virtual appointments, with a 5-year ambition to avoid up to 30 million outpatient visits a year.
Virtual consultations offer important benefits, notably greater convenience for patients, which can improve access and reduce NHS-related travel – important in light of the climate crisis. But by themselves virtual consultations don't necessarily reduce the number of appointments, they merely shift the mode of delivery.
Reducing appointment volumes may instead require a solution to one of the fundamental problems driving inefficiencies in outpatient care: most patients are unable to schedule follow-up when they need it. This may explain the growing interest in patient-initiated follow up (PIFU), which involves patients scheduling appointments when they need them. The Royal College of Physicians has identified this as a priority for outpatient reform and NHS England and Improvement is studying it closely. Here we explore this potential solution and what might be required to make it work in practice, drawing on the insights of the Q Community, a UK-wide network of 3,500 people with expertise in health care improvement.
The case for change
Outpatient hospital appointments have nearly doubled since 2007/08 to 120 million a year, with follow-ups accounting for two-thirds of all appointments. While the number of appointments has increased, so too has the proportion of unattended appointments, which now stands at 22%. This has led to some clinics overbooking outpatient appointments, exacerbating the problem of wait times and poor patient experience.
The reasons underlying missed appointments are varied, but a key driver is that they are often scheduled at times when patients feel they are not needed and unlikely to result in any meaningful changes to care. The CQC Outpatient Satisfaction survey and NHS Improvement indicate this is one of the most commonly reported reasons for missed appointments (DNAs). Patients are typically called back for outpatient appointments every 6, 9 or 12 months, the timing for which is often not decided by clinical need or when a patient needs extra support. Conversely, when a patient’s symptoms or circumstances do change, it can be difficult to get an appointment as capacity has been devoted to routine follow up.
Unsurprisingly then, there’s significant interest in how to reduce unnecessary appointments. In a poll of the Q Community, two-thirds of respondents named reducing unnecessary appointments as the greatest opportunity for improving outpatient care.
Giving patients more control
PIFU is one way of making appointments more responsive to patient need, thereby minimising the risk of DNAs. NHS England and NHS Improvement are exploring this as a solution as part of their implementation of the NHS Long term plan. Meanwhile, the Royal College of Physicians (RCP), in their report Outpatients: The future – adding value through sustainability, advocated for patient-initiated appointments and patient involvement in scheduling. Some studies have shown that PIFU in outpatient care achieves similar health outcomes to standard care across a diverse range of conditions, and generally reduces total number of appointments over time. It also improves patient and clinician satisfaction compared to regular scheduling.
Despite this, PIFU seems to be rare in outpatient care, explained partly by the complexities surrounding its implementation. To be effective, it may require other components of pathway redesign, such as virtual appointments to increase flexibility for patients, patient registries and improved appointment booking systems. And given that PIFU shifts more responsibility to patients and GPs, it must be implemented in a way that strengthens trust between clinicians, patients and the broader system.
Getting PIFU right
In a session with Q members at their recent annual event, working alongside RCP, we discussed some of the risks involved in PIFU, and what needs to be considered for effective implementation.
First, while many patients – particularly the 15 million people in England living with long-term conditions – effectively self-manage their condition on a daily basis and are the experts in their own health care, there is a risk that some patients might not be sufficiently empowered or informed to recognise triggers or changes in their condition, or be able to access the necessary services when they require support. PIFU requires supporting patients to self-manage, giving them confidence to act on changes in their symptoms.
For this reason, PIFU often relies on various ways to access advice such as patient guidebooks, remote monitoring, advice hotlines or dedicated nurse specialists to help track changes and develop personalised self-management plans. Agreed escalation points between patients and professionals can also help to facilitate this trust and support. PIFU may not be appropriate for all, including patients with less stability, low health literacy or conditions that have less visible symptoms. Deciding which patient groups should be targeted, and where fixed appointments remain the best option, is a critical first step.
Second, changing the way patients schedule outpatient appointments also calls into question their very purpose. There is a risk that if an appointment is created by the patient only in response to a problem, clinicians will miss opportunities to discuss other changes that may impact the patient’s health or ability to manage their condition. Regular appointments also often serve as useful check-ins. PIFU pathways should account for this by incorporating other ‘touch points’ to engage patients in broader conversations about their circumstances and care, ensuring they receive the best support for them.
There is also a risk with PIFU that some patients get ‘lost’ in the system and important changes are missed over time. Patients not seen within a certain window may need to be automatically contacted to ensure nothing critical goes unnoticed. This may be especially important for those living in poverty or facing multiple disadvantage to ensure these vulnerable groups are not missed. To maintain this contact over the long term, a short questionnaire or phone call might be sufficient for those patients who don’t need to be seen in person. A key part of PIFU pathways will be thoughtful use of technology including co-produced questionnaires with patients and clinicians, professional initiated data-led recall, and patient and clinician access to information.
PIFU’s advocates argue it offers a potential solution to a fundamental problem we have in outpatient care. Reducing unnecessary appointments by making them more responsive to patient need is certainly important. But as with any complex change, much will depend on how it’s designed and implemented. While studies have shown the potential of PIFU, more testing and evaluation will be needed to better understand why this approach has succeeded in some places while failing to take hold in others, and what is needed to make it work in practice.