What will it take to transform outpatient care?

Lessons from the Q community for delivering the NHS Long Term Plan

10 July 2019

The NHS Long Term Plan set the formidable aim of reducing face-to-face outpatient appointments in England by a third over the next 5 years by making better use of technology and virtual consultations. This makes sense given that patients and staff have long recognised the need to cut down on unnecessary appointments and give patients greater flexibility and control over how they receive care.

But even when policymakers know the changes needed to improve health care, it can be hard to know how best to support those on the front line to make change happen. What precise combination of rule changes, new structures, support programmes, carrots and sticks will help the NHS get from A to B?

NHS England and NHS Improvement are currently faced with exactly this question as they work to develop the Outpatients Transformation Programme recently announced in the Long Term Plan implementation framework. If this programme is to deliver, it must clearly address the issues faced by those directly responsible for implementing reforms to outpatient care.

One source of insight that can help policymakers comes in the shape of the Q community. Q is an initiative jointly funded by NHS Improvement and the Health Foundation, helping thousands of people with improvement expertise across the UK to learn, share and collaborate. This network is also a vast source of people with knowledge and experience of what it really takes to improve and transform care on the front line – including ideas for improving outpatient care that will be tested in this year’s Q Exchange participatory funding programme. The Health Foundation is currently working with the Q Community to help capture this insight and share it to inform policy and practice.

We recently surveyed Q members from across the UK (87% of whom were from England) to ask what their biggest priorities are for improving outpatient care services, and what it would take to make virtual consultations a reality. While transforming outpatients care is an explicit pledge in the NHS Long Term Plan for England, it is also a key focus for the whole of the UK. We received 427 responses, with over half of respondents (52%) having direct experience of improving outpatient care, and other respondents bringing different lenses to the problem such as data analytics, academia, and patient experience. Here’s what they said, and what it might mean for implementing the NHS Long Term Plan.

Priorities for improving outpatient care

The survey results confirm that Q members think that reforming outpatient care is a key system priority: 89% of respondents rated it as ‘extremely important’ or ‘very important’. Encouragingly, 64% of respondents expressed ‘a great deal of confidence’ or ‘moderate confidence’ that the scale of improvement needed in outpatient care in their area will be achieved over the next decade. This is despite just over half of respondents (51%) feeling that there had been little or no progress made to improve outpatient care in the previous decade.

In terms of the greatest opportunities for improving outpatient care, Q members’ views largely align with the vision set out in the NHS Long Term Plan. 59% of respondents selected improving referral and triage to reduce unnecessary appointments as the greatest opportunity for improving outpatient care, and 50% selected using online or mobile technology to improve patient access and reduce demand for in-person consultations.

Q members’ top five choices for the greatest opportunities to improve outpatient care

  • 59%: improving referral and triage processes so patients are seen by the right person at the right time and unnecessary appointments are avoided
  • 50%: using online/mobile technology to improve patient access and reduce demand for face-to-face consultations
  • 40%: improving support for self-management
  • 31%: shifting clinics out of hospital and into primary care/community settings
  • 29%: improving the way patients are stratified by risk to help prioritise patients with greatest need and ensure unnecessary follow-up appointments are avoided

Barriers and enablers for delivering virtual outpatient consultations

When asked what is needed to make virtual consultations a reality, one of the key barriers highlighted by Q members was getting buy-in from NHS staff for this agenda. This was the second most highly ranked barrier to change overall and, importantly, it was the most highly ranked barrier among those with previous involvement of outpatient reform, cited by 63% of this group. This suggests it is essential that policymakers think about how these changes can be rolled out in a way that will command the support of those needed to deliver them and will help local system leaders to make the case for new care models.

One potentially worrying finding from our survey is that, even with broad support for shifting more care virtually, basic infrastructure is still an issue. Access to reliable technology was cited by nearly two thirds of Q members as a barrier to delivering virtual consultations (the most highly ranked barrier to change amongst all Q members). This may not be surprising, given that capital spending in the NHS currently lags behind comparable countries, with only a very small proportion of overall spending being on IT. If front-line teams are to meet the vision for a digitally-enhanced service in the next 5 years, investing in capital and infrastructure is imperative.

Q members’ top five barriers to significantly increasing virtual outpatient consultations

 

All Q members

Those with direct experience of outpatient reform

Access to and reliability of new technologies

64%

61%

Staff buy-in / acceptance

59%

63%

Patient buy-in / acceptance

45%

39%

Information governance / compliance with privacy and data protections

39%

40%

Lack of tariff / reimbursement for delivering care virtually

39%

49%

In terms of potential enablers, Q members’ biggest ask (chosen by 57% of respondents) was for more time to support designing, testing and iterating new ways of working. This was closely followed by additional funding for setting up and testing new services (55% of respondents), and the chance to learn from others implementing similar changes (46% of respondents). It will clearly be a challenge for NHS England and NHS Improvement to balance the desire to roll out virtual consultations quickly with the iterative and sometimes experimental approach that is often needed to successfully implement change of this kind.

Q members’ top five enablers for delivering virtual outpatient consultations

 

All Q members

Those with direct experience of outpatient reform

More time for designing, testing and iterating new ways of working

57%

56%

Additional funding for setting up and testing new services

55%

59%

The chance to learn from others implementing similar changes

46%

42%

Training for staff in the use of new technologies

36%

35%

Toolkits of standard service models and advice to support implementation

34%

37%

The NHS Long Term Plan and the Outpatients Transformation Programme create an opportunity for NHS England and NHS Improvement to develop a support offer that enables faster progress on key system challenges like outpatient reform. But as the Q survey results make clear, even if front-line teams support the end goals for outpatient care set out in the NHS Long Term Plan, effective delivery will require arming teams with the time, resources, skills and capacity to deliver change on the ground.

Sarah Reed (@sjanereed) is an Improvement Fellow at the Health Foundation.

Further information

  • You can see what Q members are proposing for changing outpatient care as part of Q Exchange and add your comments. Over the coming months we will be sharing more about what the Q community are learning and doing in this area – to find out more, please contact QExchange@health.org.uk

Further reading

Collection

The NHS Long Term Plan

The latest news and opinion from the Health Foundation on the NHS Long Term Plan.

Partnership

The Q Improvement Lab

We bring people and organisations together to explore, develop and test ideas to make progress on health and care challenges.

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