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NHS outpatient model is no longer fit for purpose, says RCP

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4759 (Published 09 November 2018) Cite this as: BMJ 2018;363:k4759
  1. Gareth Iacobucci
  1. The BMJ

The current model of outpatient care in the NHS requires wholesale redesign to meet growing demand and patient need, the Royal College of Physicians has argued.

A new report1 from the college says the traditional model of outpatient care, based on specialty opinion, diagnosis, and disease monitoring is “no longer fit for purpose,” and places “unnecessary financial and time costs on patients, clinicians, the NHS, and the public purse.”

The college calls for a new approach that takes into account all the costs related to an intervention, including loss of income for patients attending appointments and the impact of transport on public health.

Solutions could involve making better use of telephone and video consultations and remote monitoring to promote self care for some patients, it says.

The report highlights that in England, outpatient appointments have doubled over the past decade to 118 million per year, with demand outstripping the growth of the UK population.

It highlights the inefficiency of the current system, with one in five potential outpatient appointments cancelled or reported as “did not attend,” and most cancellations instigated by the hospital.

An accompanying survey of nearly 1389 doctors reported that 57% of outpatient clinics finish late at least once a week, with some running late every time.

A quarter of doctors (25%) who responded to the poll felt that up to 10-20% of their new patients didn’t need to come to outpatients at all, while 28% said that 10-20% of their follow-up patients could have been seen using an alternative to face-to-face consultation.

The report says that patients are frustrated by poor communication and long waiting times, as well as having to spend time and money on things like childcare and travel when attending appointments. It also highlighted the impact on the environment and public health of transport to and from outpatient clinics.

Current barriers to innovative practice—including discrepancies in payment tariffs associated with the different types of consultation, and current job plans not recognising alternative consultations as clinical activity—need to be tackled.

Stephen Powis, NHS England medical director, backed the RCP’s recommendations. In a foreword for the report, he said that the antiquated processes in outpatient clinics were equally frustrating for patients and doctors.

“The outpatient system is older than the NHS and the time has come to grasp the nettle and use tech and other innovations to improve patients’ experience and care,” he said. “It’s right we look at ways to cut unnecessary appointments, save thousands of journeys, reduce traffic and pollution, and make the NHS more efficient.”

Toby Hillman, co-author of the report, clinical lead for the RCP Sustainability Programme, and a consultant respiratory physician, said, “We must recognise the public as individuals with varying health needs, personal pressures, and ability to manage their own treatment, and give them more control over when and how they receive care.”

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