A model for 21st century outpatients, built on communication

Outpatient services are old-fashioned and hugely wasteful. But change that works for patients and staff is within our grasp, writes Satya Raghuvanshi of Accurx

I first started speaking to trusts about their outpatient transformation plans in March 2020. I still remember one of my earliest discovery calls with the CCIO of a trust who showed me a slide of a Victorian-era waiting room at a train station as an example of their current outpatient experience. While intended as tongue-in-cheek, the reality was that very little had changed for them in the way outpatient care was delivered. This is despite the evolution in the way we deliver care, the changing needs and expectations of our patient population, and the digital tools now available to deliver care.

Since then, sadly, the national picture has remained the same. Trusts are overwhelmed with demand, struggling to find the resourcing and capacity to meet it, and are investing in single-point solutions that fail to deliver value for patients and staff or look at pathways of care holistically. But there is room for improvement.

Waste and inefficiency

There is waste and inefficiency in our current outpatient model, with high repetition and duplication of effort. This leads to a loss of staff productivity and patient confusion in navigating their care.

Have you ever tried to cancel a hospital appointment and rebook it? Or review and manage a patient in the complete absence of information about why they’ve been referred? Or seen a patient face-to-face when it would have been better to see them after they had an investigation? When you map these kind of examples across every aspect of a patient’s journey it builds a picture of huge waste and loss of productivity.

Good communication leads to good care

To transform outpatient care and bring it into the 21st century, we should start with something as simple as fixing our communication (and I don’t mean refreshing those communication skills we are taught in medical school). Communication is the common thread running through outpatient care (and in fact all models of care), and yet we do it so poorly.

Consider the typical journey of a patient referred for elective surgery: the patient contacts their GP; the GP asks about their symptoms; the GP refers the patient to secondary care; the patient is given information about the status of their referral; the clinician reviews the patient; the patient is consented for surgery; their conditions are managed and optimised by the GP whilst they wait; the patient is informed how to prep for surgery; the patient is followed-up and reviewed after surgery. Every one of these steps involves communication.

And yet, we currently do much of this activity in siloes. This has a hidden but great cost to operational productivity in hospitals. A patient who is not optimised for surgery leads to an on the day cancellation, which leads to poor use of surgical resources. A patient who does not have visibility over their referral status ends up calling the GP, who contacts the surgical admin to ask where they are on the waiting list, wasting valuable clinical time and creating a poor patient experience. A patient who receives a letter about their appointment at a time they can’t attend ends up DNA-ing because they can’t get through to the hospital to rearrange it.

To reimagine outpatients, we need to examine communication across entire pathways and end-to-end. Lots of the improvements we can make today require little change management and do not need to become operational headaches to manage. It is not rocket science but it does take teams wanting to make changes in the way they work.

I often ask consultants “do you want to be running the same model for outpatients as you are now, next year?” I have never received a “yes” to that question. Staff are crying out for change and looking at ways to make their jobs and the care they deliver more sustainable.

Communication is an impactful and accessible place to start; it means examining the whole pathway, not just isolated parts of the outpatient journey, such as referrals or follow-up. If you improve part of the referral pathway but leave the rest of the experience untouched there will be a very small productivity gain. When we talk about outpatient transformation, we must talk about true, end-to-end, foundational transformation.

A personalised service

Every patient should get the most appropriate care and intervention at the time they need it. We must stop treating every single patient in the same way, and start asking some basic questions:

• Who genuinely needs face-to-face care and who doesn’t?
• Who could be moved to a patient-initiated pathway at first referral because their symptoms have resolved but you want to keep an eye on them?
• Where can a digital questionnaire be sent to a patient so you can triage and direct them straight to imaging or investigations ahead of a face-to-face or virtual appointment?
• How can we ensure all referrals are made and triaged against agreed criteria?
• How do we support patient messaging when we need a response back from the patient?
• How do we manage entire patient pathways asynchronously for low risk and stable conditions, only defaulting to an appointment when there is a clinical need for a face-to-face interaction?

It is about whole scale transformation through improved communication. This will create a service that is more personalised to patients, and more sustainable for healthcare professionals and the system as a whole.

What transformation looks like

For patients, we want to work with outpatient services to break down silos in their care provision, to ensure personalised clinical care that feels integrated across the NHS.

For staff, it’s about increasing efficiency and improving productivity, as well as creating more capacity or flex within the system. For example, staff at University Hospitals of Leicester are using Accurx’s rectal bleeding questionnaire to direct patients referred for rectal bleeding straight to a diagnostic test, bypassing an unnecessary initial clinic appointment. Patients who are referred now receive the questionnaire via SMS asking about their symptoms. A clinician then reviews the responses and triages the referrals appropriately, sending 64% of patients straight to a diagnostic colonoscopy and bypassing the need for the initial clinic appointment. This is saving clinician time, reducing waiting times for patients and creating more capacity.

If you give staff the right digital tools and new ways of working, they become the agents of change to start working in far more sustainable ways that deliver excellent clinical care.

At a system level, imagine the impact if transformation was achieved across every single outpatient department in the country. The value unlocked would be astronomical. It would not only improve operational measures like reducing RTT waiting lists and DNA rates, there would also be huge productivity gains. Imagine a clinician who no longer spends hours seeing patients who don’t need to be seen, but instead sees those with the highest critical need. The administrative savings would also be significant – just think of the the volume of phone calls avoided.

How will it happen?

How is this type of transformation going to be created? We’re currently developing and implementing a series of transformation blueprints with our partner acute trusts, starting with outpatients. They map and identify all the opportunities for digital communication and new ways of working to improve an end-to-end patient journey. They give healthcare professionals a platform to transform on – one that is generic enough in its broad functionality, but specific enough to each service through the content (such as digital questionnaires).

On top of this, we’re also providing full transformational support to help outpatient service staff effectively shift their ways of working, so they can become the agents of change. We hope this work will bring outpatients into the 21st century, one service at a time.

Satya Raghuvanshi is VP of clinical at Accurx