TransformingOutpatient Services

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Simon StevensNHS Confederation – HSJ June 2018• “an obsolescent mode of specialty long term support”

• “When we are talking about redesigning care…From the point of view of the person with Parkinson’s, the periodic [trip] along to the outpatients for the five minutes with the consultants is probably not the best way of staying in touch with the health system [or report symptoms and get the information needed]

• “Likewise, across a lot of other specialties, the fact that we’re spending nearly £10bn on outpatients which is an obsolescent mode of specialty long term support…Think of it from the patients’ point of view, think of it from the clinical teams. Have the conversation of what re-design looks like there, and, in a way, everything else follows from that.”

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Outpatient “performance”

• DNA rates 9% per annum exceeded by cancellations 20% appointments cancelled or DNA

• RCP - 25% docs say that 10-20% of all new patients did not need to come to clinic

• RCP - 20% of pensioners reporting feeling worse after visit to clinic

• 5% of road traffic attributed to NHS. Consider in terms on carbon footprint and effects on atmosphere - 753 deaths from air pollution, £650m NHS expenditure

• Cost to patients @ £17/hour

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NHS Outpatients 2006 - 2017

• 118.6 million appointments

• 93.9 million attended by patients (79.2% attendance)

• 29.1 million first attendances (31% attendances)

• Demand growing 6% per annum

• £18 billion spent onoutpatients

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2016 – 2017 Attendances

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Growth in Outpatients Appointments

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2016 – 2017 Referral by source

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Cancellations 06/07 to 16/17

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Number of people waiting to start treatment on the referral to treatment pathway

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CQC – NHS Acute Hospital Core Service Ratings 2018

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Secondary Care Outpatients – purpose

• Advice and diagnosis for patient and GP

• Follow up review after procedure

• Ongoing specialist input into chronic conditions

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Aim of outpatients : To deliver a specialist opinion to support the diagnosis and management of conditions, or oversee management in more complex patients, preventing admissions.

OUTPATIENTS: WHAT IS IT?

• Diagnosis and management plan• LTC Follow up• Multimorbidity

• Referral and booking management• Facilities management• Payment systems• Records systems• Skills of staff

Outpatients activity

GP practices and hospital outpatients currently provide 400 million face to face appointments each year

What does good look like in outpatients?

• Limited data available on outpatient activity

• Difficulty in assessing patients experience

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Patient view

• Local television presenter and fitness trainer

• As a baby she was badly burned and as a result has required on-going treatment throughout her life

• Feeling safe and welcome as a patient is so important to her

• “As a patient, just being looked at and being listened to makes all the difference”

Institute for Health Improvement

Quality:

• Safe

• Effective

• Person-centred

• Timely

• Efficient

• Equitable

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Picker Institute – patient satisfaction

• Organisation of the dept

• Being treated with respect and dignity

• Having the reason for attendance addressed

• Interaction with the doctor

• Cleanliness

• Information they receive

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Royal College of Physicians• Capacity to meet demand

• Interventions to reduce demand apply to all referral sources

• Pool generic referrals

• Minimise disruption to patients and carers

• Flexible clinic templates to accommodate patients requirements

• Patient involvement in selecting date and time for OPD

• Clinical information available to patient and clinician prior to appointment

• Patients informed of what to expect and waiting times prior to OPD

• Alternatives to face to face should be available

• Support for patient self management and shared decision making

• Patients and community staff should be able to communicate with secondary care

• Flexible access to follow up

• Care pathways to optimize skill mix

• Letters to patients with copy to community health team

• Supportive environment for training

• Promotion of well being for staff and patients

Government directives

• Five year forward view 2014o Make it easier for patients to access urgent care online

o Enable 111 to resolve more problems for patients without telling them to go to A&E or their GP

o Simplify and improve the online appointment booking process for hospitals

o Make patients’ medical information available to the right clinicians wherever they are

o Increase the use of apps to help people manage their own health

• Long term plano Community based care

o Reduction in face to face consultations

Outpatient Transformation Model

Encompassing ongoing efficiency opportunities:• N:R• DNAs• Discretionary

spend• Clinic utilisation

Supporting:• Quality e.g. holding list

reduction• Performance e.g. RTT• Workforce e.g. workforce

transformation• Finance e.g. SRCP plans

F2F Consultant

F2F SAS & ST3+

F2F Specialist Nurse (AHP /

HCA)

Group consultations

Virtual clinics (SpN, ANP, AHP, Consultant)

Telephone F/U (Nurse & AHP led)

Self-Care Apps

Patient Triggers Reviews

Advice & Guidance

NHSi - Deloittes Diagnostic

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GIRFT

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Getting It Right First Time is a national programme designed to improve the quality of care within the NHS by reducing unwarranted variations

By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.

Clinician to clinician process

Unwarranted variation

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The NHS serves a million patients every 36 hours, spending over £120bn annually. While the NHS benefits from some of the best local and organisational leadership and innovation, there is also widespread unwarranted variation which affects patient outcomes, service costs and overall productivity

In February 2016, Lord Carter’s report on unwarranted variation in acute NHS trusts was published. It highlighted the opportunity to save up to £5bn if unwarranted variation can be tackled and all providers’ cost bases were at the median level

GIRFT Process

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GIRFT National Reports

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GIRFT Regional Hubs • The 7 GIRFT Regional Hubs, formed last autumn, have all gone live

• This means that they are now in a position to start providing systematic support for each trust in the region to deliver the priorities agreed with the GIRFT clinical lead for each specialty.

• They are collaborating with NHSI/E and Op Prod regional teams in a ‘one team’ operating model.

• They are starting to deliver joined up support at STP level alongside RightCare and NHSE programmes as set out under collaboration MOUs signed in February.

Regional Hub Hub Director Contact Go Live Date

London Graham Lomax graham.lomax@nhs.net March 2018

South East Michael Dixon michael.dixon4@nhs.net June 2018

South West Eiri Jones eiri.jones@nhs.net June 2018

West Midlands Ian Donnelly ian.donnelly1@nhs.net April 2018

East Midlands Karen Hansed karen.hansed@nhs.net April 2018

North West Ruth Tyrrell ruth.tyrrell@nhs.net March 2018

N. East, N. Cumbria & Yorkshire

Liz Lingard liz.lingard@nhs.net April 2018

The Model Hospital

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Institute for Health Improvement –Triple Aim

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Systems Approach

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Systems approach -ordered and iterative set of activities targeted to answer questions relating to• People• Systems• Design• Risk• General Process of

Improvement

Surrey Heartlands – The Nine Planned Care Principles

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Surrey Heartlands – Good Practice Planned Care Pathway

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Governance

• Long term plan – face to face reduction by 30%

• Improved metrics and coding

• Workforce planning

• Measurement of success – patient satisfaction

• Reduction of perverse incentives

• Patient vs community experience

• Environmental impact