What is it with outpatients?

by Rob Findlay

Recently I visited a highly-capable senior manager who has been doing a lot of work on outpatient clinics. I will spare blushes by not naming names, but this is in a major acute hospital. Here is a flavour of current practices (which the manager in question is trying to sort out):

  • Patients are booked into clinics, not to individual doctors. When the day of the clinic comes around, the doctors turn up and look around as if to say, “Oh look, we have three doctors in the clinic today. What are we going to do with ourselves?”. Then they divide the patients up between themselves, with regard to the training needs of the juniors, but without regard to appointment times. Unsurprisingly, this means that some of the doctors are not always very busy.
  • No clinic time is held back for urgent patients. When urgent referrals inevitably arrive, they are force-booked onto the clinic. If there is no time to fit them in, follow-up patients are cancelled (to avoid delaying routine patients who are subject to the 18-week target). The displaced follow-up patients then have to be rebooked urgently, because they must be seen within a specific time window, and so the whole problem repeats itself.
  • Another reason that follow-ups are being displaced is that they are not regarded as high priority. Yet no assessment has been made of whether all these patients need to be followed-up in the first place.
  • The hospital has a good procedure for approving annual leave several weeks in advance. When a doctor’s leave is agreed, it is immediately notified by email to the booking staff, so that they can block out that doctor’s clinic time. But they don’t do this right away. Instead they wait until a few weeks before the clinic, when of course patients have already been booked in and must now be cancelled.

There is more, but I think you get the general idea. You may also recognise that this is not the only hospital in Britain where this kind of thing carries on.

(deep breath)

At this point I would like to appeal to the sense of professionalism that, thank goodness, remains strong across the NHS’s medical staff.

The above tales come from a surgical clinic and, according to the Royal College of Surgeons’ guidance on revalidation (p.18), all surgeons must provide, as core information: “Audits of practice: This includes your non-operative work and audits about the process of care”. An audit implies that there is some standard against which the process of care is being compared, and it is difficult to imagine our featured clinic doing very well under any conceivable comparison.

So what to do?

First there is a question of will. The doctors in this clinic are responding to proposals for change with a stance of passive resistance. I can understand why; years of experience have taught many doctors that passive resistance is a rational response to impositions from above, because the NHS is prone to fads that go away if you wait long enough. However I would question the rationality of that response in this case. This is a very local issue. It is causing many problems that affect all parties: patients (who are messed around and delayed), doctors (whose time is wasted), and the hospital (which fails to meet its waiting time targets and is wasting resources). It surely makes no sense to perpetuate this when the solution is within the doctors’ own grasp?

Now to the practicalities, and here are the things the doctors could do:

  1. Book patients to each doctor separately, not to the clinic as a whole.
  2. Ensure that when referrals are triaged (on paper) for urgency, an indication is made about which doctors could and could not see that patient, so that booking staff can allocate the patient to the right doctor.
  3. Review the practice of issuing follow-up appointments. Are there alternatives that might work better for some patients (such as a patient information leaflet, GP follow-up, or alternating a follow-up by a junior doctor with review by a senior doctor)?
  4. Reserve the right number* of slots in each doctor’s clinic for a) follow-ups and other time-constrained patients such as ward discharges; and b) urgent patients who are referred at short notice.
  5. Use good booking tactics* when booking new outpatients.
  6. Work out the capacity needed* to achieve the hospital’s waiting time targets, and take the necessary action if it falls short.

Finally, should these changes be made gradually, or all at once? I would suggest doing them all at once, with the possible exception of reviewing follow-ups which could be done separately. They are all parts of a whole.

* These items are big subjects in themselves. See SimTrainer and the Booking Rules calculator for reserving urgent slots, SimTrainer for the best booking tactics, and the Booking Rules Calculator and Planner for working out capacity.
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