The modern outpatient: a collaborative approach 2017-2020

7. Building on Existing Success

7.1 The Programme will also build on work which has already demonstrated a positive impact on patient experience and outcome, or has the potential to do so.

7.2 Increasing uptake of advice only referral and e-advice feedback is important with regard to providing more timely access to treatment for the patient. Whilst advice only referral options are available, they are not universally used.

Redesign in action: Advice and triage

NHS Lanarkshire successfully trialled the use of advice only referrals and electronic feedback for patients with neurological conditions. An 'advice only' option was added to the existing referral system, enabling primary care clinicians to request advice from secondary care clinicians and ensure the advice given is recorded as part of the patient record.

In addition, some referrals requesting an appointment were converted to advice only providing more timely access to treatment/management from the patient's perspective. The use of advice only referrals in neurology has the potential to reduce the number of new outpatient appointments by 5,000 in Year 1 of the Programme.

7.3 Access to digital imaging software, virtual mediums and diagnostics is considered essential to enhancing referral quality and primary care/secondary care dialogue for patients with dermatological conditions. Similarly, once the report is available, GPs would benefit from having access to the radiology images which in turn can be shown to the patient and support the GP to manage the patient in the longer term.

Redesign in action: Maximising consultant time

The National Dermatology Collaboration recently launched a Small Business Research Initiative ( SBRI) with Innovate UK. The Dermatology Challenge is 'Optimisation of a four hour clinic session' where the aim is to identify new technological solutions that can permit more diagnosis and ongoing management of skin conditions to be achieved outwith the conventional clinic setting, in order to then provide sufficient consultation time for patients who do require a personal consultation with a dermatologist.

The work is being led by NHS Forth Valley in partnership with NHS Greater Glasgow and Clyde and NHS Tayside. We have over 300,000 dermatology appointments a year. By reducing the number of patients who need to be seen and managing return patients in different ways, we can release around 30,000 appointments in Year 1 and 2 of the Programme.

7.4 Existing programmes have developed a range of condition-specific pathways which triage the patient to the right clinician first time and reduce unnecessary delays. Example pathways include Inflammatory Bowel Disease, Irritable Bowel Syndrome, Coeliac Disease, Abnormal Liver Disease, MSK and Ophthalmology pathways.

Redesign in action: The right clinician first time

The National Gastroenterology Collaboration has developed a National Pathway for patients with coeliac disease ( CD). Currently, once diagnosed, patients are followed up in secondary care, for ongoing review, annual bloods and bone health status. The new pathway will triage patients to community-based dietetic services post positive CD diagnosis with subsequent annual review being undertaken by pharmacists as part of the existing Gluten-Free Food Scheme. The new pathway will be implemented in January 2017 in NHS Greater Glasgow and NHS Lothian. There are over 160,000 attendances a year. This work, once spread across Scotland, has the potential to divert 3,000 patients to more appropriate clinicians.

Redesign in action: Virtual clinics

Fracture Pathway Redesign (Initiated at Glasgow Royal Infirmary)

Clinical pathways have been redesigned for patients presenting with non-operative fractures in Emergency Department ( ED). A standardised process is set up in ED for management, discharge or referral of all non-operative fractures patients. A proportion (38%) are discharged directly and do not need any further attendance. The remaining 62% of patients are then reviewed within 24 hours (seven days per week) at a virtual clinic led by a consultant surgeon and nurse and a management plan is developed, recorded electronically and discussed with each patient by telephone. A further 20% of patients are discharged with no planned follow-up. Only 42% of patients are required to attend an outpatient face-to-face clinic with a management plan in place to see the right subspecialist. This standardisation of the management plan continues and reduces the number of subsequent appointments required. Virtual Fracture Clinics have shown a clear benefit in reducing variation and improving patient flow. This process has been widely adopted across Scotland and although the proportion of patients discharged at each stage differs between sites, the general reduction in outpatient attendances has improved flow for the whole department.

Importantly an open door policy is available for patients to return if they wish at any point.

The virtual review principles are now being used within elective new patient referrals, thus reducing the need for face-to-face appointments and freeing up resources to deal with demand in other areas.

Redesign in action: Patient self-management

MSK redesign

NHSInform plays an important role in providing patients with evidence-based information to allow them to manage their own musculoskeletal condition. It includes links to an app which provides exercise videos, exercise logging and reminder options.

Redesign in action: Advice and triage

Musculoskeletal Advice and Triage Service ( MATS) is operated by NHS24 (operational in nine Boards, covering 70% of the population). Patients with MSK pain are taken through risk stratification questions to determine their clinical need for: self-management advice ( e.g. exercises, footwear); supported self-management ( e.g. for patients less able to self-manage); an Allied Health Professional call back ( e.g. a physiotherapy or podiatrist); AHP referral for assessment; secondary care referral e.g. to Trauma and Orthopaedics and occasionally immediate A&E attendance. This leads to higher quality and a reduced number of referrals to Orthopaedics with patients on the right pathway or an optimal outcome (Exhibit 2).

Potential financial savings of £2m per annum from patients being seen by community AHPs rather than Orthopaedic services. (Based on 20,000 referrals routed to community MSK services directly rather than via Orthopaedics.)

Redesign in action: Treating back pain in the community

The NHS Lanarkshire Back Pain Pathway achieved a 75% reduction in back pain referrals to Orthopaedics and a significant reduction in MRIs through use of a standardised protocol.

Exhibit 2 'Front-end' Musculoskeletal Redesign

7.5 A major focus for the Programme will be to reduce return appointments by ensuring only patients with a clinical need are seen at the right clinical interval by the right clinician. Redesigning the approach to accessing appointments and the planned return list provides a mechanism for seeing patients with a clinical need, proactively aligning capacity with demand and an approach to ensuring patients are seen at intervals specified by the clinician. Speedier triage and treatment reduces demand on community services and enhances the work experience for clinicians in outpatients.

7.6 Clinicians across Scotland have been frustrated by the lack of subspeciality data available to them and are keen to ensure the data they require to inform subsequent redesign opportunities is collected systematically.

Redesign in action: Using iTriage to manage return demand

At least 27,700 return appointments per annum could be saved by reducing the need for postsurgery Trauma and Orthopaedic appointments. Patients can be sent a questionnaire on their outcome ( e.g. range of movement in their new joint replacement) at intervals following their initial six week and one year review. Their response to the questions determines if an X-ray and/or an appointment is required.

Redesign in action: Using data to enable service redesign

The National Gastroenterology Collaboration has developed a minimum data set and extended data set for patients with inflammatory bowel. Robust clinical data is critical to understanding what patients groups are being seen in secondary care and determining how many patients could be managed more effectively elsewhere.

NHS Grampian has developed subspecialty diagnostic codes and will test the collection of the Inflammatory Bowel Disease ( IBD) data and subspecialty codes within the existing Patient Management System. Once tested, these data collection fields will be available to all NHS Boards.