Comment

'NHS outpatient care is a relic of nineteenth century medicine'

Dr David Colin-Thomé, the former National Clinical Director of Primary Care at the Department of Health, now an independent healthcare consultant, makes his case for a reconfiguration of outpatient care.

The above quotation is one of Professor Sir Muir Gray’s many aphorisms with which I wholeheartedly concur. In fact I would go further and suggest the current model of hospital-based care in general would still be too recognisable to practitioners of that century, but I will focus on outpatient care.

It is huge in numbers, rising inexorably and a huge utiliser of resources.

Figures from the Information Centre for 2009/10 with 2005/6 figures in brackets:
• Attended first appointment 20,782,376 (14,918,796)
• Attended subsequent appointment 46,222,116 (35,039,342)

It is of more than interest that total appointments far exceed those figures 84,198,458 (60,608,403), demonstrating a high degree of cancellations and ‘no shows’.

Missed outpatient appointments cost NHS hospitals in the region of £600m a year, data from Dr Foster Health and the NHS Information Centre have revealed. Men in their early 20s are the worst offenders for appointment no-shows, while patients of both sexes aged 70 to 74 years are the most conscientious about keeping an appointment. The total average income of a first outpatient appointment to an NHS hospital is £156, while income generated by second appointments averages out at £76. In 2007/8, 6.5 million appointments were missed in the UK, with hospitals losing around £100 per patient in revenue. Such estimates put the total cost of outpatient care at £6.5bn. Can this be value for money even in times of no austerity?

I took a more detailed interest in hospitalbased care when a first wave fund holder – a key part of the 1991 NHS reform programme. A reform which for the first time offered budgetary influence to general practice, enabling challenge and shaping of the care offered to our registered patients when their care was outwith GP-based care. A registered population confers a responsibility towards your patients even when ‘not in front of you’ – a population approach that should ideally apply to all healthcare provision.

But what about outpatient care? Practice level analysis showed much of that care was unnecessary and often duplicative. With enhanced access to both diagnostics without incurring an outpatient appointment and community-based provision, outpatient contacts fell. For example, access to diagnostics and community based musculo-skeletal physiotherapy coupled with GP clinical leadership led to fewer orthopaedic contacts.

And for patients with long-term conditions there was huge duplication of care as patients were being followed up both in hospital and in general practice. The practice consequently majored on systematic management of long-term conditions, employing managed care techniques, with a significant reduction in hospital usage.

In general, hospital staff were not supportive and with the cessation of fundholding the effort of shifting monies into more productive use became too burdensome.

I revisited the issue in ‘Keeping it Personal; Clinical case for change’ (DH, 2007) and received some complaints from GPs about me adding to their work.

Professor Martin Roland’s work was most helpful. To quote: ‘‘David Colin-Thomé says patients don’t need to go back and see their surgeon after routine operations. And GPs are worried that they will be landed with lots of extra work. Should they really be worried? Our research suggests they shouldn’t.1 The only other similar trial came to the same conclusion.2

“Another of our studies suggests that patients are quite good at deciding when they need to see a specialist for follow up, so they could also be given the clinic number to use if they think they need to be seen.

“Some GPs doubt we’re trained for this work. What we do often lack is really good information about what to expect after particular operations. This could be included in an information sheet to GP and patient after every operation. In fact, why don’t we get this anyway? Surgeons could also include an evaluation form for the patient (or GP) to send back.

“Surgeons, especially those in training, may need to inspect their handiwork – though even this doesn’t work at present, as patients are far from guaranteed to see the surgeon who did the operation.”

This was certainly true when as a fundholder we researched this very topic locally.

Professor Roland concluded: “And will practices want to pay for routine post-surgical follow up in the world of commissioning? I doubt it.’’

There has been related evaluation and policy development. Fundholding, which in turn led to some experiments in total budgets being devolved to GP practices – Total Purchasing Pilots (TPP).3

There was evidence that some 15% to 20% of those groups holding real budgets were able to secure shorter waiting times, achieve lower referral rates and, in the case of TPP, reduce emergency bed-days.

And to increase responsiveness and cut down on the numbers of missed appointments, the NHS launched the Choose and Book initiative in 2006 as part of the Free Choice government policy introduced in April 2008. Technical glitches with the related software however delayed the roll-out and indeed clinician acceptability of the continuing potential of Choose and Book to bring a long overdue responsiveness to elective care.

And there has been much policy development on long-term conditions care, conditions that generate an enormous amount of medical outpatient contact, much of which should be obviated if the NHS systematically implemented the Department of Health’s strongly evidenced-based Long Term Conditions Framework of 2007.

Currently we have the opportunity offered by an even longer overdue systematic involvement of clinicians in commissioning. Commissioning takes place at many levels, by clinicians in the act of referral to other services and by small organisations such as general medical practices.

The responsibility of the commissioner is not to subsume that activity but to support, challenge where necessary, co-ordinate and be the strategic leader for the many levels of commissioning.

Clinically-led commissioning can and must facilitate an improved clinician-led provision so as to align clinical-led activity with budgetary responsibility. It is, after all, clinicians and particularly doctors who spend the money.

Furthermore, unless some budgetary responsibility is devolved to practices themselves, CCGs may not get the systematic clinical involvement that is required for transforming care. Transforming all elective care including unwarranted admissions will of course disproportionately hit hospitals who make a tariff ‘profit’ from elective care to offset frequent urgent care ‘losses’.

The answer must be to also transform urgent care and hospital care in total. And where better and arguably easier to start than with outpatient care, where both referral and especially follow-up appoint- ments can, as described, be lessened significantly?

In fact the future existence of stand-alone large outpatient departments needs to be seriously questioned. Unlike the successful managed care organisations in the USA, we have a comprehensive primary care medical system.

We also need a radical shaping of hospitalbased elective care. Decision support systems for patients and clinicians lessen the need for hospital care.4

The use of electronic communication will lessen the need for face to face contacts. Professor Lord Ara Darzi envisaged an 80/20 split for future planned surgery. ‘Local hospitals will carry out 80% of surgery, mainly as day cases and short stays, with the remaining 20% of planned surgery being carried out at specialised centres, such as those for trauma and cancer. Some of the 80% could be carried out in community hospitals, health centres or even large GP practices.’

And why not direct access to the surgery list?

We can at long last align the incentives of commissioning and provision for cost effective care. The time has come for radical challenges to the complex edifices of the past.

Dr David Colin-Thomé is an independent healthcare consultant, and honorary visiting professor at Manchester Business School, Manchester University and the School of Health, University of Durham. He is a former General Medical Practitioner at Castlefields Health Centre, Runcorn and National Clinical Director of Primary Care. He also sits on NHE’s editorial board. Visit www.dctconsultingltd.co.uk 

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