NHS leaders have called for an ‘industrial’ drive to cut the number of unnecessary outpatient appointments and better prioritise clinical time where it adds the most value – setting the target to reduce outpatient follow-ups by 25% against 2019/20 activity levels by March 2023.
To deliver this, NHS England has set the ambition that 5% of outpatient attendances will be moved to patient-initiated follow-up (PIFU) pathways by March 2023.
Given that one of the most fundamental challenges in outpatient care is the mismatch between patient need and access, PIFU aims to give more flexibility and choice to patients over the timing of their care and allow them to book appointments as and when they need them rather than follow a standardised schedule.
As PIFU gets rolled out at varying speeds in NHS trusts across the country, the NIHR RSET team were commissioned to evaluate the impact of patient-initated follow-up as it develops and to understand some of the potential benefits and drawbacks that can arise with service delivery changes of this nature.
The first full phase of this mixed-methods evaluation is now complete. The key lessons and recommendations are below – read the slide decks for more detail.
Key messages
Implementation of PIFU appears to be associated with a lower frequency of outpatient attendances per patient. But further analysis is required to establish the robustness of this finding – it seems to hold for some individual specialties, but not for all.
At present it is difficult to use national routine data to accurately measure PIFU activity within hospitals, and it is not possible to directly observe the impact on cohorts of patients moved to PIFU pathways. The accuracy of the data and consistency of coding between P-EROC and HES may be affecting ability to evaluate PIFU's effectiveness .
There are broad differences in how sites are implementing PIFU in terms of how patients are selected, triaged, or discharged, and how appointment requests are managed.
An important source of variation is whether patients are on ‘long-’ or ‘short-’ term pathways, with the former often involving greater consideration of clinical risk and therefore more intensive approaches to clinical review and safety netting.
PIFU uptake seems to be higher in specialties where ‘open access’ booking is already the norm (e.g. physiotherapy) and/or where there is extensive clinical experience to draw from (e.g. rheumatology). For some specialties with longer-term pathways and higher risks and complexity in detecting fluctuations or progression in disease (eg, ophthalmology), the scope for PIFU uptake may well be lower.
A key challenge in delivering PIFU has been the degree of adjustment and adaptation required by clinical subspecialty. Adoption has lagged in areas with strong clinical resistance, which stems from fears that evidence is lacking for PIFU in some specialties, that it may not benefit patients with certain conditions, and that PIFU may disrupt workflows or increase clinical admin.
How PIFU might impact inequalities continues to be an important unknown. Limited data is available or being collected to understand how PIFU may affect patient groups differently. Sites also vary in whether or how they are considering a patient’s broader life circumstances and socioeconomic factors when selecting patients for PIFU, triaging appointment requests, and managing risks.
One of the biggest risks to PIFU is that it might undermine patient trust if patients are unable to access care when they need to. So far, study sites seem to be able to manage volumes of patient requests and have developed systems for protecting capacity for PIFU patients.
Recommendations and opportunitites
The quality of P-EROC needs to be reviewed, including the reporting of complete submissions.
Local trusts should capture data at the patient level for their own monitoring and evaluation reporting which can be linked their own Patient Administration System (PAS).
To help achieve adoption by specialties where uptake has lagged, NHS England may consider further and expanded working with clinical societies to develop condition-specific guidance and with NICE to adapt guidelines for PIFU.
While the extent of resources and time needed to set up PIFU will vary depending on each organisation’s context, protecting staff time to develop and adapt PIFU approaches and engage with clinical teams is vital to delivery.
Initial targets have been helpful in accelerating a shift towards PIFU, but there is an opportunity to gain further support if NHS England explained the basis for targets and adapted them for specific conditions or specialties . For some sub-specialties with higher risk (e.g., ophthalmology) the scope for PIFU uptake may be lower.
Collecting more data to understand how PIFU affects patient outcomes and experience should be a priority, both to mitigate inequalities and to support local adoption of PIFU pathways.
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