The modern outpatient: a collaborative approach 2017-2020

Advice only referral options are available but are not used as often as they could be. When used appropriately, they have made a significant impact on reducing the time patients wait to get onto the most appropriate treatment or management plan.

GPs currently seek and receive advice on care, using a range of communications, such as email or telephone, but it is not always recorded in the patient's record.

GPs will continue to manage the patient and offer advice on self-management. They may wish to ask a secondary care specialist for advice about the patient's care using 'Advice only' referral options.

If the specialist feels they do want to see the patient, the advice referral will be converted to an outpatient appointment.

The advice and decision will be recorded in the patient's record.

Patients have a GP appointment and are often referred on to secondary care.

Public awareness of self-management, advice and triage options will be increased (such as NHSInform and NHS24). Self-referral and GP referral to community-based assessment and treatment options (such as physiotherapy) will be increased.

Patients experience multiple appointments for multiple purposes and undergo a plethora of diagnostic investigations often resulting in over medicalisation of their care.

We will work together to ensure a more integrated approach to managing patients more holistically rather by disease group and condition.

Ordering certain diagnostic tests is often restricted to clinicians in an appointment-based secondary care setting resulting in patients waiting for this appointment before any tests can be organised.

The results of these tests may indicate that an appointment in secondary care was not needed and has introduced delays to the patient seeing the right clinician first time.

To support the referral process, access to certain diagnostic tests, which have been approved as part of collaborative pathway redesign, will be available to primary care clinicians. This will help determine if a referral is needed and to which service the referral should be made.

Extended Scope Practitioners and specialist nurses currently review some referrals to ensure the patient is seen by the most appropriate clinician. This practice is not as widespread as it could be.

The referral once received in secondary care will be sent on to the most appropriate clinician. This may not always be a Consultant.

We have been extending the roles of nurses and other professions such as physiotherapist. It may be one of these clinicians will assess referrals and decide on the best course of action.

Referral guidelines and management pathways are useful tools designed to assist clinicians in making referral decisions. To make this more effective, we will need to combine peer review and specialist feedback whereby GPs work together to look at referral patterns both within their own practice and neighbouring practices.

Most consultations take place in a hospital environment and are in person.

This can result in inconvenience to the patient, both in travel costs and time and may result in unnecessary travel costs for the referring NHS Board and patient.

We already use some technologies to help patients self-manage or which help monitor their health remotely. However, these technologies are not extensively used.

If patients need to be seen in secondary care, following the first appointment there are several outcomes:

• they may be discharged with no follow up;
• they may be given further follow up appointments but not necessarily with a consultant. It will be with a consultant or another hospital clinician if their on-going care needs are complex and are required to be managed closely;
• any follow up care needed may take place in the comfort of the patient's home or in another community setting; and
• patients may be discharged but with supported self-management as they still need to be kept informed.

We will extend the range of technologies we use to support patients at home or provide remote monitoring services where clinically appropriate.

If the patients' needs change and the supported self-management is not working they will be able to initiate their own review.

Routine return appointing is the predominant means of bringing patients back for a review. High demand for return appointments means that patients do not always get seen when the clinician has requested them to come back.

Routine appointments may also be seen as a means of only ensuring patients are doing well. This may be of no benefit to the patient or the clinician with regard to the assessment of their health care needs.

A large number of return appointments are made to give patients results and may result in unnecessary anxiety.

We will avoid unnecessary return appointments routinely (unless ongoing care needs require it). We will provide patients with the means to book an appointment if they feel they need it.

When a GP receives results it is likely they will contact patients to advise on them and discuss next steps. This is more convenient to patients. This is often not common practice in consultant-led care. We will work to encourage consultants to work in this way.

To ensure that patients are seen or given advice by the right clinician, a mechanism of self-assessment will be included in the booking system.