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Delivering a better NHS hospital outpatient service

Emeritus Professor Angus Wallace, a leading figure in British orthopaedic surgery, academic research and former chair of the National Osteoporosis Society, looks at how technology can be used to improve outpatient services.

Managing hospital outpatient clinics has always been a challenge for both hospital managers and the clinical staff delivering an outpatient service. 

Unfortunately, many NHS clinics are still being managed using systems developed 20 years ago, but there are new opportunities to move forwards and to provide a better and more efficient service. This discussion focuses on how we can do things better. 

Step 1: Define your outpatients – New outpatients, follow-up patients or a mixture. 

Step 2: Why are they attending the outpatient clinic and what does the doctor need when they see the patient? 

For new patients, the medical team will require: 

1. Case records – hard copy or electronic – it is no longer professionally or medico-legally acceptable to see patients without these, so providing case records efficiently for clinics is vital
2. The Referral letter – usually from a GP
3. Possibly X-rays – particularly if attending an orthopaedic or rheumatology clinic
4. Often a completed assessment form i.e. an Aberdeen Varicose Veins Questionnaire (AVVQ) if the patient has varicose veins; an Oxford Hip Score or an Oxford Knee Score if the patient has been referred with hip or knee pain; the Baseline assessment tool for NICE guideline on Gallstone disease (CG188) if the patient has suspected gall bladder disease 

Step two depends on making a provisional diagnosis on the patient before assessment by reading the referral letter and then providing a system, so that the doctor or extended care practitioners can make a detailed assessment, an early diagnosis and decide if treatment is required. This step is best planned with the consultant so that his/her particular needs for their outpatient clinic are defined in advance – such meetings rarely take place in the NHS. 

Step 3 – How do you ensure the booking procedure is time efficient? and Step 4 – How do you ensure the patient pathway in outpatients is smooth? have been addressed much better by the independent Treatment Centres than by the NHS trusts. 

Mark Howells, who is a member of the Circle Team in Nottingham, highlights the organisation's approach to these steps. 

Step 3: How do you ensure the booking procedure is time efficient? 

At the centre, all clinical areas define their own booking rules in agreement with the clinician. This ensures patients are booked in a way that maximises clinic time. We also try to offer patients any further appointments, or ensure they know the likely timeframe before their next appointment before they leave the building. 

Working as a ‘whole’ Treatment Centre, rather than in clinical silos, also means we can plan activity to optimise our work. An example being theatre schedulers from different specialties working together to ensure sharing of resources is maximised to accommodate everyone’s needs, compared with one scheduler planning their own theatre schedules in isolation, which can result in theatres not being used efficiently. 

Step 4: How do you ensure the patient pathway in outpatients is smooth?                                   

Ensuring smooth pathways requires an overarching approach to patient care. From the first impressions upon entering the Treatment Centre, where patients are welcomed by our front of house team, through to friendly reception staff at each gateway, we endeavour to make the patients journey simple and stress-free. To enable this, we ensure we have enough staff available to deal with the volumes of patients and all staff are trained to greet patients and deal with them in a friendly and courteous manner – first impressions count. 

Our environment is designed to support this approach, with all gateways anonymously described by a letter rather than a specialty. This means patients can wait in the Atrium without concern that anyone near them will know what they are being seen for when called to a gateway.

An added benefit of the central Atirum is that patients can use the café facilities. This is encouraged by giving patients a buzzer to allow them to move away from the gateway reception desk, comfortable in the knowledge they will be called when their time is approaching. 

Pathways are also designed wherever possible to minimise the need for a patient to revisit the Treatment Centre. An example being that a patient could attend for an initial consultation, then be sent straight to another gateway for surgical pre-assessment. This reduces the need for patients to attend twice. 

Step 5: How do you ensure the patient feels they are well looked after?          

We take an extremely proactive approach to ensure that the individual feels well looked after. This can present a unique challenge, given the high volume of patients that we encounter. Our aim is to ensure the patient experience is above and beyond anything they are used to from the traditional NHS. 

The visibility of our staff is of paramount importance. Patients should not have to struggle to locate help if there is a problem. 

All gateways offer free tea and coffee to patients while they wait to see their clinician. If patients bring young children with them, reception teams have packs of colouring pencils and books that can be given to keep them occupied during their wait.  

On those occasions where the patient is experiencing an unexpectedly long delay, gateway staff can offer them a number of remunerations, such as cancelled parking fees or free vouchers to be redeemed at the Atrium café. Staff at each gateway are empowered to the point where they can make this judgement call for themselves, rather than having to follow the chain of command. In addition to these extra offerings we provide things that one would expect such as a chaperone service to those patients that need it. 

Why is the NHS lagging behind the independent health providers? 

In relation to NHS systems, there are many “legacy systems” in place that the NHS has not shaken off and many have failed to move into modern processes. NHS hospital staff are genuinely dedicated to providing a first-class service, but the facilities they are provided with are often poor and the equipment can be archaic. 

Often a holistic approach to outpatients has never taken place, and one reason for this is the way the hospital is managed through the inherited NHS administrative structure. It is no wonder that NHS hospitals find it difficult or impossible to run efficient services when there is no single leader. 

Introducing modern technology 

NHS hospitals are now, at last, taking on new technology. Check-in kiosks for outpatients (extensively utilised by the airline industry) are now appearing within the NHS. However, when these are introduced they should be introduced in pairs, not standalone. 

One hospital has reported that their check-in kiosk worked for three months, then broke down and was non-functional for nine months. This occurred because the procurement process did not include IT support for breakdowns! Ensuring patients are reminded about their appointments using smartphone messaging is now being widely used to good effect. Modern technology should now also embrace better workflow in outpatients. 

For instance, Jim Gray, an orthopaedic surgeon from Luton and Dunstable University Hospital, is working on an e-referral project and is designing a system (see box out) which ensures that the digital acceptance of a referral encompasses the definition of a clinic pathway (X-ray followed by consultation, for instance). 

All too often the acceptance of paper referrals permits scheduling only, and of course the flow of the patients through multi-episode clinic steps (plaster room, X-ray, consult and possibly back again) can cause havoc to flow and capacity. Unfortunately, there is a wide diversity, and highly complex requirements for healthcare queuing and digital strategies will be pivotal in providing efficiency in this sector in the future. However, impressive solutions are being developed at present.  

Conclusion 

At present the independent healthcare companies seem to have out-played and side-lined our NHS hospitals in the outpatient delivery of care arena, and our NHS trusts now need to urgently address their shortcomings. Some are stepping up to the mark, but more need to focus on this in order to deliver a more efficient service.

The Luton & Dunstable Queue Management Module

Problem

• Patients are frustrated in healthcare clinics, spending time waiting because the queues are complex and need to be personalised
• Clinicians are frustrated, spending more time on poorly designed desktop software systems that require training, deterring staff
• Managers are frustrated, struggling for capacity, overrun clinics and ineffective coding, losing revenue
• Paper forms are abundant and often used to communicate process, carried by the patients themselves in an unfamiliar environment
• This needs revolutionising and there is no comprehensive solution on the market, no software companies have appreciated this clinical problem coupled with the disparity between clinical language and clinical coding language

 The Luton & Dunstable Solution

• We’ve designed an easy and unique intuitive mobile app to manage healthcare clinics 
• It controls patient flow without paper and encompasses note-taking, requests and performs smart clinical coding, making it faster for clinicians, easier for patients, less onerous on nursing staff and gathers vital data including coding for large revenue gains
• Whilst due for beta testing in an NHS orthopaedic centre soon, managing patient flow with requests and coding for orthopaedic procedures (casting, splinting, dressings), it is scalable for use in any healthcare clinic
• It will give clinical staff more time to care, and improves patient/clinician/manager satisfaction 

FOR MORE INFORMATION

To learn more about the Luton & Dunstable solution visit:

W: www.dashclinic.co.uk

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