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Views And Reviews Acute Perspective

David Oliver: Outpatient clinics are ripe for reform

BMJ 2018; 362 doi: (Published 17 July 2018) Cite this as: BMJ 2018;362:k3056


Bring outpatients into the 21st century

  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

Traditional specialist outpatient clinics, on which we spend around 7% of the NHS budget, with over 60 million attendances a year and great cost in time and travel to patients, are a prime example of an area that has been relatively neglected amid calls from politicians and the media to reform services.

Simon Stevens, chief executive of NHS England, believes that the current NHS outpatient model is “obsolescent.” Speaking at the NHS Confederation conference in June, he said, “Think of it from the patients’ point of view, think of it from the clinical teams’ point of view, discuss what a redesign would look like, and everything else follows from that.”1

I’d say that this is a signal of intent, particularly as we expect NHS England to publish a plan in the autumn on how to make the best use of additional money. Additionally, NHS Improvement’s “Getting it Right First Time” programme now has a theme on outpatients,2 and its chief executive, Ian Dalton, commented in June that modernising outpatient services should be a priority. The Health Service Journal reported recently3 that national NHS leaders in England plan to alter tariff payment structures for outpatients to incentivise different behaviour and models and to make the excessive use of clinics less attractive for hospital trusts.

The Royal College of Physicians is due to report, also in the autumn, on redesigning outpatient clinics with environmental and financial sustainability as guiding principles.4 And The BMJ’s Tessa Richards recently wrote about the need to redesign outpatient services.5 A groundswell is apparent.

All of this thinking seems to show a broad consensus that we need to reassess which conditions or consultations really need secondary or tertiary care, as well as delivering more multidisciplinary team assessments and consultations in primary and community care settings. A greater focus on care planning, supported self care, and the use of shared (and patient held) interoperable health records could all reduce demand for face to face consultations. This is especially important for patients with multiple long term conditions who often see multiple specialists, sometimes on multiple sites, and then face follow-on referrals to other practitioners. It can be bewildering, time consuming, and costly, when they generally crave continuity of care.67

Patients need better information on what to expect and where to go: let’s co-design the experience through their eyes

Self referral to specialist clinics when a need is identified, or referral from supporting nurse practitioners, may work better for patients. Self monitoring, supported self management, the use of patient held interoperable clinical records, and remote technology may all help.

Follow-up could be done by email or phone rather than at hospitals. The journey to hospital sites can take hours out of patients’ and families’ days, implying that their time is less valuable than a clinician’s.

When people do attend outpatient services on general hospital sites they need better information on what to expect and where to go: let’s co-design the experience through their eyes. Let’s provide patient centred written, recorded, and electronic information, as even the best verbal communication can be forgotten and impossible to re-access.

The suggestions above may not necessarily be cheaper, and we need to have the right workforce and technology in place to make these changes; but outpatient clinics, which have run on the same basic model for so long, are surely now ripe for reform.


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