Intended for healthcare professionals

Views And Reviews Provocations

Bring outpatients into the 21st century

BMJ 2018; 361 doi: (Published 06 June 2018) Cite this as: BMJ 2018;361:k2472
  1. Tessa Richards, senior editor/patient partnership
  1. The BMJ
  1. trichards{at}

And give patients a say in the design of new services

I owe my life to the NHS, so it seems churlish to criticise it. But when it comes to outpatient clinics I can’t restrain myself. In a digital age that provides a range of options for consultation other than face to face in hospital clinics there is surely little justification to perpetuate an inflexible old model.

Living with long term conditions, and being a carer of close family members with their fair share, has given me plenty of time to observe how little things have changed since I did outpatient clinics over 35 years ago. Back then, to my shame, I was barely aware of the toll on patient and carers, the expense and logistical hurdles they faced, let alone the stress.1 Now with the boot on the other foot I seethe with impatience about a system that frustrates patients and doctors alike. T S Eliot’s Prufrock had it easy. A life “measured out in coffee spoons”2 was a snip compared with one meted out in outpatient clinics.

The one I attend on a Friday afternoon routinely runs over an hour late and sometimes closer to two. You queue like a supplicant to tell the administrative staff you have arrived and search for a spare seat in the overheated, overcrowded room. Time passes. How long will all this take? Who will I see? I scrunch up the piece of paper with my prepared questions and tell myself to cool it; evening plans can be rearranged. The important thing is not to be sidetracked by the clinician’s agenda. And to perch on the edge of the couch, not in the chair provided, and stand up when the retinue comes in. I greatly dislike standing doctors looking down on me as they conduct the consultation.

There is wifi access now, but it’s hard to concentrate. I sit and watch staff and patients struggle through the afternoon. It’s an emotionally draining spectator sport—and that’s before you get into the consulting room.

A handful of what to me have felt like very poor face-to-face consultations, largely with clinicians who have not had time to process my full history and know nothing of my priorities and preferences, have left me disillusioned. I dread outpatient visits and resent the time and expense when an email exchange or phone call would have sufficed. “Off the record” online, Skype, and phone call exchanges with clinicians I have got to know have been fruitful and made attending the clinic unnecessary.

Occasionally I resort to deception. I phone the hospital, ask to be put through to a registrar, say that regrettably I can’t make the clinic and might they kindly be able to give me my test results? I have even pretended to be my GP to get them. I do this, for I find that “processing” results at home and thinking things through in my own time helps me steer a calmer, more collaborative course through subsequent consultations.

The idea that patients should determine or at least have a say on when they are seen, where, and how they get (and use) tests results is not new, of course. A systematic review of patient initiated versus consultant initiated clinics in secondary care showed the potential for cost saving in time and resources.3 And there are plenty of innovative examples of co-designed clinics, particularly for people with chronic conditions, that take advantage of new technologies and patients’ preferences, including ParkinsonsNet, which has also delivered cost savings.4 A Dutch model for teenagers with inflammatory bowel disease (not the most reliable clinic attenders) has shown home telemonitoring to be a safe and cost saving alternative to conventional follow-up.5 There are many UK models too where patients take the lead in managing their own conditions, including renal patients.6

Giving patients full access to their health records and allowing exchange with clinicians through patient portals reaps dividends and holds potential to further empower people to self manage conditions.78 Working with patients to design new systems rather than imposing them has to be the way forward. But technology will not provide all the answers. Good relationships, good communication, and continuity of care—which is still not prioritised in the NHS—will always be hugely important.9 In some places the future is already here. It’s time it was evenly distributed.



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