Specialist outreach clinics in general practiceBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6936.1083 (Published 23 April 1994) Cite this as: BMJ 1994;308:1083
- J J Bailey, Dr,
- M E Black,
- D Wilkin
- Centre for Primary Care Research, Department of General Practice, University of Manchester, Rusholme Health Centre, Manchester M14 5NP20
- Correspondence to: Dr Bailey.
- Accepted 3 March 1994
Objectives : To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists' and general practitioners' views on outreach clinics.
Design : Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners.
Setting : 50 hospitals in Englands and Wales.
Subjects : 50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires.
Main outcome measures : Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems.
Results : 28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times.
Conclusions : Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interation between general practitioners and specialists.
Provision of specialist outpatient services in primary care has been increasing
In this study over half of all provider units had established outreach clinics in a wide range of specialties
Developments in outreach clinics since 1990 have been concentrated in fundholding practices
Care is mainly provided by specialists with little interaction between specialists and general practitioners
Cost effectiveness, patient satisfaction, and outcome need to be evaluated in outreach clinics
The traditional patterns of delivering specialist outpatient services in the NHS are increasingly being questioned. This reflects a desire for closer integration between primary and secondary care, the effects of competition in the internal market in the NHS, and attempts to respond to the wishes of patients. New models of provision include community based specialists, shared care schemes, walk in centres, and outpatient clinics held in primary care settings.1, 2
Outreach clinics, in which the hospital based specialist team provides an outpatient diagnostic or treatment service in primary care rather than in a hospital have become increasingly common. Most of the early initiatives were in psychiatry,3 ranging from “shifted outpatient” clinics, where specialists simply provide the same service in different settings, to “liaison attachment” schemes, where the specialties, meet with the primary care team and see patients with general practitioners.4 More recently, other specialties, including obstetrics,5 orthopaedics,6 dermatology,7 ophthalmology,8 and paediatrics,9, 10 have begun to develop outreach clinics.
The growth of outreach clinics has caused some controversy. Fundholding practices have used their purchasing power to secure a better service for their patients, and this has led to fears of a two tier service.11 In response to growing demands by fundholders for outreach clinics in dermatology, the British Association of Dermatologists has expressed strong reservations and issued guidelines for its members.12 Jones argued that good outpatient care requires a range of hospital based diagnostic services and close liaison with other hospital departments, neither of which is available in general practice.13 General practitioners have countered that most patients referred do not need sophisticated hospital facilities14 and that they should have open access to these facilities.15
The lack of systematic information about cost effectiveness and whether these clinics help overcome the barriers between primary and secondary care or contribute towards a two tier service is an obstacle to informed debate and rational decision making. We obtained descriptive information on the current pattern of outreach clinics in England and Wales.
We selected a random sample of 50 hospitals (22 district general hospitals and 28 NHS trust hospitals) from the 372 provider units in England and Wales (excluding community units). The research was conducted in four stages between February and June 1993.
We conducted telephone interviews with hospital managers (chief executives, unit general managers, and contracts managers) in each of the 50 hospitals to identify outreach clinics (defined as clinics in which hospital specialists see patients in health centres or general practitioner surgeries). We excluded clinics provided in community hospitals and those provided by staff other than clinical specialists.
We sent a postal questionnaire to all consultants providing outreach clinics. The questions included type of clinic, organisation, types of patients seen, reasons for establishing the clinic, and the specialists' opinions. We also sent a questionnaire to up to three general practitioners using each clinic, covering details of the clinic and general practitioners' opinions. A similar postal questionnaire was sent to a separate random sample of 122 lead partners from fundholding practices within the same districts as the 50 hospitals. This survey was done to capture any private and out of district arrangements made by fundholders.
For all surveys, three reminders, two postal and one telephone, were used to follow up non-responders. Analyses focused on comparisons between clinics in different specialties (grouped into psychiatric, medical, and surgical specialties) and between clinics held in fundholding and non- fundholding practices.
We interviewed managers in all of the 50 hospitals. Completed postal questionnaires were received from 69 (72%) of the 96 specialists known to be providing outreach clinics. These specialists identified 88 general practitioners, of whom 46 responded to a postal questionnaire; 28 were in non-fundholding practices and 18 in fundholding practices. We received completed questionnaires from 72 (59%) of the 122 general practitioner fundholders.
Twenty eight hospitals (95% confidence interval 21 to 35) reported having one or more outreach clinics (14 district general hospitals and 14 trusts). These clinics involved a total of 96 specialists. Thirty two (24 to 41) general practitioner fundholders reported 61 outreach clinics in their own practices or to which they could refer their patients. Seventy six of the 157 clinics were in surgical specialties, 38 in medical specialties, and 43 in psychiatry (table I).
The postal questionnaires provided detailed information on 72 clinics from specialists and on 40 clinics from fundholders. General practitioners using the 96 clinics originally identified provided information on 58 clinics in fundholding practices and 28 clinics in non-fundholding practices. Some respondents did not answer all the questions.
Forty five of the clinics (40%, 95% confidence interval 31% to 50%) had been operating before 1990, including most clinics in psychiatry (table II). Fifty four of the clinics that started in 1990 or later were in fundholding practices (81%, 69% to 89%), of which 30 were in surgical specialties (56%, 42% to 69%) but only five in psychiatry (9%, 3% to 20%).
Operation of outreach clinics
Data from the general practitioner questionnaire showed that fundholders had initiated 44 outreach clinics (76%, 64% to 87%), of which 25 were in surgical specialties. However, 15 of 18 clinics in non-fundholding practices had been initiated by a specialist (83%, 59% to 96%). Twelve of these clinics were in psychiatry.
Consultants saw patients in 107 of the 112 outreach clinics but general practitioners attended only six clinics (five in medical specialties and one in general surgery).
Twelve of 55 (22%) outreach clinics held in fundholding practices were open to referral from other practices compared with 14 out of 23 (61%) held in non-fundholding practices (observed difference 39%, 95% confidence interval 17% to 62%). Forty (69%) fundholders referred patients directly to the outreach clinic compared with only eight (29%) non-fundholders (observed difference 40%, 20% to 61%; table III). Non- fundholders more often relied on the specialist to decide where the patient should be seen.
Specialists and fundholders described 61 clinics as having shorter waiting times for first appointments than hospital clinics. This was most marked in surgical specialties, where 33 out of 39 clinics (85%, 70% to 94%) had shorter waiting times. Waiting times for medical specialties were also shorter in 20 out of 26 clinics (77%, 56% to 91%). However, in 15 out of 27 psychiatric clinics (54%, 34% to 73%) waiting times were the same as in hospital clinics. Waiting times were shorter than for hospital appointments in 45 out of 57 (79%) clinics held in fundholding practices compared with 16 out of 35 (46%) clinics held in non-fundholding practices (observed difference 33%, 14% to 53%).
Specialists reported that there were fewer non-attenders at outreach clinics than in hospital outpatient clinics in 13 of 25 psychiatric clinics (52%, 31% to 72%), eight of 14 medical clinics (57%, 29% to 82%), and 18 of 23 surgical clinics (78%, 56% to 93%). Hospital clinics had not had to be cancelled for 48 of 67 outreach clinics (72%, 59% to 82%), although 11 of 25 psychiatry clinics (44%, 24% to 65%) had resulted in cancellation of hospital clinics. Specialists reported that 37 outreach clinics had not affected the waiting times for hospital outpatient appointments.
Twenty nine out of 66 specialists (44%, 32% to 57%) reported plans for further outreach clinics: 15 psychiatrists, nine surgeons, and five medical specialists. Thirty seven out of 57 (65%) fundholders had plans for further outreach clinics compared with three out of 24 (13%) non-fundholders (observed difference 52%, 34% to 71%). Clinics were planned in dermatology (13), rheumatology (four), gynaecology (four), general medicine (three), orthopaedics (three), paediatrics (two), urology (two), geriatrics (one), ear, nose, and throat surgery (one), psychiatry (one), neurology (one), diabetes (one), ophthalmology (one), and obstetrics (one).
Benefits and problems
Tables IV and V summarise the perceived benefits and problems of outreach clinics. Reduced travelling times and more convenience were commonly identified as important benefits to patients. Fundholders placed more emphasis than non-fundholders on shorter waiting times. Nine specialists, of whom seven were surgeons, also referred to shorter waiting times.
Most specialists and a third of general practitioners felt that general practitioners benefited from improved communication with, and access to, specialists. Some specialists felt there were no benefits to them. A medical specialist wrote: “Nil except to keep the chief executive happy.” Seventeen specialists, of whom 15 were surgeons, mentioned attracting referrals and generating income for the hospital.