Our focus needs to be on working with our patients to ensure their needs are met
Three years ago, we had the privilege to take the retro-spectoscope to one of the most ubiquitous encounters in any patient’s dealings with secondary care services—the outpatient appointment.
The RCP report, Outpatients: the future—adding value through sustainability, was broadly welcomed. [1] Some of the surrounding press was obsessed by the ambition to shift a significant proportion of patient contacts from face to face to virtual. The aim though was to reduce waste, improve efficiency, and enhance convenience.
What we did not imagine was the global pandemic of 2020. Nor could we have predicted the vast changes in clinical practice introduced as covid measures enforced a wholesale switch to virtual consultations. Professionals and public alike have had to live more of their lives online, both at work and at home. The pendulum has swung away from the traditional doctors visit replacing one “one size fits all” approach for another. In the process, some professionals have been left behind and certain groups of patients have been left wanting.
There are undoubtedly elements of the therapeutic relationship which are hard to replicate by telephone or video call. The nuances of body language, tone of voice, and even the observed walk from the waiting room are lacking in these exchanges. These deficiencies have been pounced on, and currently there are campaigns to return to the “good old days” of the face-to-face appointment. But, before we all jump on board the pendulum as it swings back—propelled by headline-friendly soundbites from populist politicians, we need to pause. Consider the pitfalls of yearning for the time before covid where we perceive life was simpler, and people knew what to expect of their visits to hospital and GP surgeries.
The starting point of our investigation into outpatient services was the vast amount of waste we had seen personally and that had been reported by RCP Members and Fellows. There was a desire to examine this hotspot of resource use, to see if leveraging new models of working could solve some of the structural problems inherent in the outpatient system. These included discordance in demand and capacity, limited responsiveness to individual and community needs, and overwhelming waste and inefficiency.
Waste was bound up in the number of journeys made by the NHS, estimated to be 5% of all UK road journeys. Journeys were made by an endless stream of patients attending hospital departments to receive news that could have been communicated in other ways. Waste was also in the funding settlements that encouraged a “bums on seats” production line to ensure adequate income streams for secondary providers, and the merry-go-round of referral ping-pong for patients with complex or interacting multi-morbidity that for some patients is like a full time job. Indirect costs were also clear—carers who had to take time off work to take older patients to appointments, after which many older patients felt worse, from the stress of attending and enduring long days on the road. Our report outlined several principles for outpatient care that could enhance the quality and reduce waste.
As the popular press points the finger again at primary care providers who are struggling to balance the needs and wants of patients, while continuing to try and protect them during in the ongoing pandemic, the medical profession must not throw the baby out with the bathwater. Multiple secondary care specialties have published on improved patient satisfaction, more timely reviews, reduced waiting times and non-attendances, and heightened cost effectiveness across a spectrum of surgical and medical specialties, including geriatrics. [2-9]
Before the pandemic, outpatient care pathways were broken, and not fit for purpose—a one size fits all model does not work for a diverse population with diverse medical problems. The pandemic, and wholesale switch to virtual consultations has simply strengthened this assertion—it does not matter which model is employed, a one size fits all mode of working will never work.
Instead of reverting to a rose-tinted vision of lines of patients waiting on rows of seats in calm clinical spaces, we need to learn the lessons of the pandemic. We need to rely on evidence, not rumour; be agile and adaptable; be led by patient need, not practitioner preference; and accept that working virtually continues to be valuable clinical work. Our focus needs to be on working with our patients to ensure their needs are met. Our leaders need to recognise that populism has never made good policy. We should persist in efforts to reduce waste in the NHS and again use the retro-spectoscope. But this time focus on reforms in the last three years and address the infrastructure, training, and expectation deficits that we lacked the time to address, the first-time round.
Jen Isherwood is an Oncoplastic Breast Surgeon who undertook a National Medical Director’s fellowship working in Strategy, Communications and Policy at the Royal College of Physicians. During this time she led on their work looking at Healthcare Sustainability and authored a seminal report looking at outpatient care in the NHS. Twitter @jen_isherwood
Toby Hillman is a Consultant Respiratory Physician who worked as the National Clinical Lead for the RCP on Healthcare Sustainability, and co-authored the RCP report on Outpatients. He continues to advise the College on Sustainability issues, and is attending COP26 as a delegate of the Royal College of Physicians. Twitter @tobyhillman
Competing interests: none declared.
References:
1 Royal College of Physicians. Outpatients: the future – adding value through sustainability. 2018
2 Murphy, R, Dennehy, K,Costello, M, Murphy, EP, Judge, CS, O’Donnell, MJ, et al. Virtual geriatric clinics and the COVID-19 catalyst: a rapid review. Age Ageing. 2020;1–8.
3 Gilbert,AW, Billany, JC, Adam, R, Martin, L, Tobin, R, Bagdai, S, et al. Rapid implementation of virtual clinics due to COVID-19: report and early evaluation of a quality improvement initiative. BMJ Open Qual. 2020;9:e000985).
4 Quinn, L, Davies, M, Hadjiconstantinou, M. Virtual consultations and the role of technology during the COVID-19 pandemic for people with type 2 diabetes: the UK perspective. J Med Internet Res. 2020; 22:e21609.
5 Leung, M, Lin, S, Chow, J, Harky, A. COVID-19 and oncology: service transformation during pandemic. Cancer Med. 2020;9:7161–71.
6 Hwa, K, Wren, S. Telehealth follow-up in lieu of postoperative clinic visit for ambulatory surgery: results of a pilot program. JAMA Surg. 2013;148:823–7.
7 Healy,P, McCrone, L, Tully, R, Flannery, E, Flynn, A, Cahir, C, et al. Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: a randomised controlled trial. BMJ Qual Saf. 2019;28:24–31.
8 Byravan, S. and Sunmboye, K., 2021. The Impact of the Coronavirus (COVID-19) Pandemic on Outpatient Services—An Analysis of Patient Feedback of Virtual Outpatient Clinics in a Tertiary Teaching Center With a Focus on Musculoskeletal and Rheumatology Services. Journal of Patient Experience, 8, p.23743735211008284.
9 Gray, R, Sut, M, Badger, SA, Harvey, CF. Post-operative telephone review is cost-effective and acceptable to patients. Ulster Med J. 2010;79:76–9.