The modern outpatient: a collaborative approach 2017-2020

3. Introduction

3.1 'The Modern Outpatient Programme' has enormous ambition: we want to transform our concept of both what an 'outpatient' is and what 'outpatient services' are. We want the default position to be that The Modern Outpatient is safely managed at home, or close to home - either by managing their own health or being supported by a member of the wider primary care team, and not just those based in GP practices; we want to revolutionise the way patients' needs are addressed by hospital-based, but not necessarily hospital-delivered, services if and when required; and we want to ensure that every return appointment is timely, appropriate and effective.

3.2 The initial outpatient appointment has always been critical to the patient and their journey through care; it allows for diagnosis, reassurance and definitive decisions on treatment - sometimes including treatment itself. In addition, we want to influence the way in which return outpatient appointments are managed and to influence a positive shift in the way that this is done.

3.3 New outpatient appointments are a key element of the whole patient pathway standard, assuring 18 weeks from referral to treatment; they are also an important stage on the way to delivering the Treatment Time Guarantee of 12 weeks from decision to treat to the start of treatment; they are a critical point in the pathway to diagnosing cancer early - or providing reassurance that there is nothing to worry about. This is therefore a time when patients need to be seen without delay. For example, there is significant evidence of the importance of early diagnosis and treatment for certain patients, particularly those with urological, head and neck or skin cancers. Doing things differently, often in a different setting, will help speed the flow of patients through the whole system to ensure that they can access the right level of care, in the right setting at the right time.

3.4 Custom and practice has meant that the outpatient appointment has become a fixed item delivered in secondary care. Patients expect to be referred by a GP to a hospital-based consultant in a specialty, see that consultant and remain under their personal care until treatment is complete, follow-up has happened and/or we are discharged. We have designed and developed services that fit this model.

3.5 This is not sustainable or patient centred. The pressures on all parts of NHSScotland of an increasing older population, the welcome improvements in the availability of treatments for many conditions and the ambition to deliver better care, faster, are putting a strain on outpatient services and may impact negatively on patients' experience of those services. Therefore we need to transform the way in which we understand, diagnose and manage care and also risk. This is not just about a transformation in secondary care but about transformation across the whole of the local health and social care system; expectations of general practice and other community-based professionals are changing too. Fostering a co-production culture, whereby patients are engaged more effectively and consistently in determining the right care for them will be fundamental to managing expectation and new ways of managing rising demand.

3.6 NHSScotland is already developing innovative and ambitious approaches to outpatient services. Many illustrations of the potential transformation these can bring are set out in this document. In short, this programme aims to enable clinicians from all professions to work with patients to:

• bring together all of the existing good practice and ensure it is spread as widely as possible;
• encourage the wider 'skilling up' of staff to deliver the most appropriate care from the most appropriate person;
• support the introduction of further evidence-informed approaches;
• develop and test more innovative ideas;
• provide outpatient services as close to home as practical; and
• use technology to enable clinicians to deliver these modern patient-focused services.

3.7 The clear intention of the Programme is to shift our focus from an outpatient appointment in a hospital to The Modern Outpatient themselves, empowering them to manage their own health and wellbeing but able to access the appropriate support quickly, as and when it is required. This however, is not about adding to the burden on services or moving bottlenecks to a different part of the care continuum. We recognise the significant pressure that GPs and other community-based professionals are facing. So this is not about a transfer of workload but is about working together across the primary/secondary care interface to provide the best care in the most appropriate setting for each patient at the point of need.

3.8 This is not a 'one size fits all' approach, in that some of the new ways of delivering outpatient care may not always be suitable for all patients. Some patients may be vulnerable, have comorbidities or be unable to access services in these ways. Not all patients are equipped to self-manage, nor empowered to access the care systems in 'modern' ways.

3.9 To measure success in a complex programme such as this is not straightforward; it will require qualitative feedback from those delivering and receiving care in the new ways set out by the Programme. However, by supporting the aim of increasing care in primary/community areas and self-management, we aim to reduce the number of hospital-delivered outpatient appointments by up to 400,000 by 2020, including reversing the year-on-year increase. More detail of how we aim to do this is illustrated throughout this document. We know, for example, we can reduce the number of avoidable referrals and appointments by doing things differently, to the benefit of our patients.

3.10 These improvements will free up real resources that will be re-invested in community-based services or in parts of the healthcare system requiring greater capacity. We will build these opportunities in each specialty, determining achievable improvement aims by the end of the first year of the Programme.

3.11 The Programme is therefore designed to inspire a new model which reduces the need for routine face-to-face appointments by predicting risk, providing support only when intervention is necessary, whilst maximising the role of all clinicians across the healthcare system and delivering care in the community or in the patient's home whenever safe and practical to do so.

3.12 The dramatic increase in referrals to secondary care in a number of specialties is driven by increased disease prevalence, increased patient expectation and an increased range of treatments. A large number of referrals, however, do not result in any diagnosis being made (up to 30% in some specialties). Not all referrals are made for diagnostic purposes, and not all referrals result in changes to care and treatment as a whole.

3.13 We need to do more to support clinicians to manage risk appropriately and confidently, especially in the face of multi-morbidity. 'Realistic Medicine' can deliver change by reducing population 'health anxiety' and by fostering a culture which supports clinicians to have more informed conversation and decision making with patients.

3.14 The Programme will support clinicians and other health and social care staff to develop robust approaches to deliver improvements in outpatient services to achieve the aims of the Programme. Working towards the transformational changes that are required will necessitate local clinical leadership and ownership. A number of healthcare systems worldwide have developed approaches that will be shared in order to support the Programme across Scotland. NHS Lothian has been approaching quality and transformation by harnessing key learning from Intermountain Healthcare based in the USA.

Development of The Modern Outpatient model, which avoids the need for routine planned care by predicting risk, enabling self-management, providing support and intervention only when necessary, while maximising the role of all clinicians across the healthcare system.