Is it time to think differently about outpatients?

I wasn’t around in Victorian times, but I have a hunch that it was the question “how can we connect people with specialist medical advice?” that led the early hospitals to develop the idea of outpatient departments. As illustrated by this lovely account of outpatients at the Royal London Hospital, overcrowding was a big issue and conditions were “cramped, dark and badly ventilated”.

Fast forward to today, and for many hospitals (admittedly not all) the space and ventilation, and the quality of care too, have improved considerably. But the question around connecting patients with specialist medical advice remains. The problem is that some two centuries later we are greeting the question with the very same answer.

Looking at it another way

My work as a paediatrician in North West London, working with patients, families and colleagues to co-design and then implement the Connecting Care for Children Child Health GP Hubs, has been a fantastic opportunity to learn how to think very differently about this question. And the evidence from our work is that only a small part of the answer is outpatients.

One approach to exploring this is to look through the lens of a specialist’s time. If I review the referral data for a particular group of GP practices I might see that each month, they refer around 20 children to the hospital outpatient department for my specialist opinion. For each of these patients, the GP will write a referral letter (yes, it is now 2017) to me and then some six to 10 weeks later I will see them in my clinic. I will do my best to listen to the child and their family, examine them and then try to make sense of what is worrying them. And then I will write a letter (yes, you guessed it) back to the GP with my plan and any details around follow up.

Let’s say that for each of these patients that takes 30 minutes of my time, each month the group of GP practices are getting a total of 10 hours of my time to support the care of their patients. If, instead of a currency of purely outpatient referrals, the GPs were offered those 10 hours of my time each month to help them to look after their population of children and young people, might they think very differently? Our experience with Connecting Care for Children is that, while outpatients is still valid for a small number of patients, the sorts of activities where many of my GP colleagues want most of my time spent are:

• support to run multidisciplinary team meetings where cases can be discussed
• access to telephone ‘hotlines’ where clinical and signposting advice can be sought
• the ability to quickly and directly email with questions and worries
• data-driven work to improve the preventative care of different cohorts of children (perhaps supporting all of the children in the practice with asthma to have a well-thought-through asthma action plan).

And then there is our patients’ time. I increasingly worry about the families where the parents are taking time off work to come to see me, with their child’s school uniform a glaring reminder of the time they are missing from school to be there. Does the interaction with me add enough value to compensate for their time? I am not always convinced it does. Maybe I should be thinking how my one or two half-hours could really make the best possible impact on the 8,760 hours in that child’s life this year?

Getting in the way of change

So why does the outpatient juggernaut roll on? Well, one barrier to change is the payment system we have in the NHS. Called ‘payment by results’ (although more about activity than results) through a payment to the hospital for every patient seen, this primarily incentivises specialists to sit in outpatients to see ever more patients, and so it significantly gets in the way of the sort of work I have described.

Perhaps the biggest barrier though is our inability to think differently about specialist care and advice. Our infrastructure, our training and our ways of working in primary care and hospitals all perpetuate the habit of outpatients, and so on it goes, letters and all. It is some fresh thinking, and challenging these habits and behaviours, that merits our urgent attention.

*Dr Bob Klaber is a consultant paediatrician. He will be speaking at the Nuffield Trust and NHS Improvement’s joint workshop, Transforming outpatient services, on November 21. We’ll be publishing a long read focusing on successful outpatient redesign in the new year.

Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.