Millions of people use hospital services as an outpatient, with numbers of appointments rising rapidly over recent years. As a relatively new initiative in England the NHS has been rolling out patient-initiated follow-up ('PIFU' for short) for appropriate patients and conditions – with the idea that this may suit people's needs better while reducing unnecessary appointments at the same time. The NIHR RSET team was asked to conduct a mixed-methods evaluation to understand how it's working in different contexts, whether it's having an impact on re-appointment rates and workload, how the professionals and patients involved feel about it, and whether there are any unintended consequences.
These slide sets bring together the full results from the large-scale mixed methods evaluation that took place from 2022 to 2023. The analysis included a literature review, interviews with national stakeholders, staff and patients, and detailed analysis of national and local datasets to understand impact.
How is PIFU being used?
- In the NHS, PIFU is most commonly being used in short-term pathways (e.g. physiotherapy or following surgery) although there are several examples where it is being used for people with long-term conditions.
- Models of PIFU vary widely between trusts and clinical areas in the approach to patient selection, monitoring and discharge. The nature of the condition was a key influence on how PIFU was implemented.
Enablers and barriers to successful implementation
- Where PIFU had been implemented successfully, enablers included conditions where symptoms and deterioration were easy to identify, clinical engagement, supporting guidance, champions, dedicated staff capacity and flexible recording systems.
- Barriers to successful implementation included patients not being aware they were on PIFU, perceptions of challenges accessing care, staff resistance, competing priorities and limited capacity to dedicate to PIFU, a lack of engagement with primary care and challenges updating Electronic Patient Record (EPR) systems to record PIFU activity.
Impact on outpatient attendance and missed appointments
- Increasing PIFU rates appear to be associated with less frequent outpatient attendance and rates of missed appointments, particularly within certain clinical specialties. However, in some specialties increased PIFU rates seem to be associated with more frequent visits.
- This complements findings from interviews with staff and our workshop in that the variety of ways PIFU is implemented can lead to different impacts.
Impact on visits to the emergency department
- We found no practically significant association between PIFU rates and frequency of ED visits overall (results were statistically significant but of negligible effect size), but a small number of specialties appeared to have less frequent ED visits associated with higher PIFU rates.
It should be noted that the existing data is not currently able to capture wider consequences such as the impact on primary care - and staff noted its limitations for monitoring changes in clinical outcomes.
- There is currently limited understanding of the impact of PIFU on different patient groups and it is recognised as needing more investigation.
- Digital exclusion, demographic characteristics, socio-economic status and patient characteristics were all thought to be relevant to how patients engage with or are impacted by PIFU.
- Local evaluation of outcomes and inequalities is difficult in many trusts due to the problems of reporting PIFU activity on the local electronic patient administration system. Data from one site reported differences between children and adults with 17% of children put on to PIFU pathways having a return visit within one year, compared to 11% of adults.
Staff experiences depend on how PIFU is being used
- The specific characteristics of the model of PIFU being used in a service, as well as the extent to which it is a departure from previous practice, significantly affects how it is experienced by staff.
- The extent to which staff are confident that their service can implement PIFU as intended affects their levels of satisfaction.
- Staff feel strongly that PIFU should act primarily to benefit patients, and their attitudes are often shaped by the extent to which they believe adoption is being driven by this, versus an attempt to meet organisational targets.
Impact on staff roles and workload
- PIFU can entail significant changes to the roles of clinical staff including taking on new responsibilities and the creation of new, PIFU-specific roles.
- While PIFU has the potential to reduce outpatient attendances, it could increase staff workload in other ways (for example, additional administrative tasks and by interactions which do occur becoming more complex).
Do patients like being on a PIFU pathway?
Anecdotally patients were positive about PIFU as an approach and the support they had received.
We were only able to speak four patients as part of our evaluation. But those we spoke to were positive about their experiences and liked the option of contacting a specialist when they needed to.
Why do some patients decline and what are the barriers?
- Reasons for declining PIFU included preference for regular interaction, desire to stick to their routine and concerns about getting appointments.
- Staff were unclear if patients were always contacting the services when they needed to. But, when they did, they did not all require a face-to-face appointment with a consultant.
- Enablers to patient engagement include clear routes to support, communication and ensuring patients don’t feel abandoned.
- Barriers to patient engagement included lack of awareness and understanding about PIFU, wider context on access to services and condition-specific factors.
Implications for policy and practice
Realising the impact of PIFU
- Due to existing pressures on the NHS it may be some years before any impact of PIFU on overall capacity is realised. Also, although the number of patients on PIFU is broadly in line with what the NHS have expected, it is currently small in comparison to all outpatient activity.
- Varied implementation: Although it is desirable to ensure that PIFU is implemented in a way that is appropriate to individual specialties and organisations, this has implications for understanding how it is being used and for assessing its impact.
- Clear, consistent and accessible information on PIFU and its purpose, to both staff and patients, is key to successful implementation. This includes clarity (for patients and staff) on the difference between PIFU and discharge.
Impact on staff and workload
This largely depends on how PIFU is adopted within services, the numbers of people contacting these services and how clinics are configured. Compared to routine follow-up appointments, clinical interactions could be more complex and time-consuming. There may be greater activity for some roles, for example, nurse specialists having telephone calls with patients.
Capacity and demand
If the numbers of patients placed on PIFU continues to increase it could be that more or alternative capacity will be required – for example to review or monitor patients on PIFU, respond to requests or conduct/ manage clinics. What this looks like will depend on the characteristics of individual services.