Improving the Outpatient experience
Workshop Objective
Healthwatch in Sussex (a collaboration between Healthwatch Brighton and Hove, Healthwatch East Sussex, and Healthwatch West Sussex) was commissioned by the Outpatient Transformation Team, at NHS Sussex to run workshops with the purpose of gaining participant views on new initiatives being explored to improve the Outpatient experience. Healthwatch Brighton and Hove led the project, supported by colleagues in East and West Sussex. 31 participants attended from across Sussex, representing people who had attended an outpatient appointment and those people on the outpatient waiting list. Participants represented a diverse profile in age, ethnicity, sexuality, and health needs.
“We wanted to understand what matters to patients and how we need to adapt our programme accordingly. The discussions and points raised by all participants were of huge value to our programme plan going forward. Overall, the workshops and deliberative engagement process exceeded our expectations and we are incredibly grateful to everyone involved.” - Outpatient Transformation Team.
“Patients should not be passive recipients of healthcare. But rather active users who are prepared to give their opinion and ensure they influence the service they receive.”
Outpatient transformation - four initiatives
The purpose of the workshops was to review four proposed initiatives to transform the
outpatient experience, as part of NHS England’s Outpatient Recovery and Transformation Programme, namely:
- Advice and Guidance (A&G)
- Utilising system capacity inclusive of Patient Choice (Patient Choice)
- Patient initiated follow-up (PIFU)
- Reducing ‘Did not attends’ (DNAs)
For further information on these initiatives, please see "Additional Information" at the bottom of this article.
Methodology used
Workshops followed a deliberative engagement methodology which focused on increasing participant knowledge of the outpatient system and enabling them to make an informed judgement of the transformation options proposed. Participants were encouraged to view the transformation from others’ perspectives as well as their own, by being provided with scenarios and encouraged to listen to other perspectives in their discussion groups. The majority of workshop time was given to participant discussion and feedback.
To view the workshop information shared with participants, please see Additional Information at the end of this article.
“This process demonstrated willingness to learn from participants. The time for more active discussions and listening gave people the space to learn from each other.”
Views expressed across the discussion groups:
- Participants thought Advice & Guidance made good sense in theory but were concerned that some conditions and some individuals were not suitable for this system.
- Participants felt that Utilising System Capacity (Patient Choice) could help respond to local demand pressures. However, if the offer is further away than the patient’s local hospital, this may exclude some patient groups.
- Participants felt Patient Initiated Follow-up (PIFU) was a good example of giving patients some control over their own healthcare journey. However, some patients would need additional support and for other patients, PIFU may not be suitable.
- Participants disagreed with one another about patient responsibility around reducing Did Not Attends. Some participants felt that DNAs should go to the bottom of the waiting list. Other patients suggested that financial and deprivation reasons caused patients to DNA.
For further details on the above and to read about other findings, please see the full report in the downloads at the end of this article.
Recommendations
Based on the findings above, Healthwatch in Sussex recommends the following to the Outpatient Transformation Team, at NHS Sussex:
1. Involve patients in their care.
Participants felt this was key to all initiatives, from involving the patient when making a diagnosis and planning treatment to finding out a patient’s preferred form of appointment and communication.
Participants were shown several samples of NHS patient information, and similar observations were raised across all the examples. Information was often lengthy and unclear; some practical information was not included, and not enough emphasis was given to the important facts that patients needed to know. Co-production with patients could benefit development of future patient information and any related communication.
Participants felt publicity for introducing service changes to the outpatient system, should be widespread, in various formats, and local organisations could be helpful in promoting this.
In summary, to ensure the transformation of outpatient services was effective participants felt patients should be kept at the heart of all proposed initiatives.
2. Communicate with the patient throughout their journey.
Participants felt that lack of appropriate communication was one of the biggest frustrations for patients. Patients should be kept updated concerning waiting times for diagnosis, referrals, and appointments. Patients should be kept up to date on where they are in the treatment lifecycle.
3. Ensure GPs are aware of and trained accordingly in all new healthcare initiatives.
Participants stressed the importance of the GP as the first point of contact for healthcare. GPs should be made aware of any new healthcare initiatives and trained accordingly. Where patients need extra support, this should be noted on the GP patient record and maintained throughout the patient journey.
Participants also stressed the importance of including “personal notes” on a patient’s record, which may help identify any flexibility or restrictions on attending appointments, or communicating with the patient.
4. Take patients individual needs into consideration and adapt care, communication, and treatment accordingly.
Participants agreed that some of the transformation initiatives might not work for every patient. Some conditions need to be seen in person and cannot rely on second hand communication via the GP. Patients with additional needs may not be suitable for initiatives that relied on the patient proactively following up. Patient Choice may not be suitable for patients with accessibility challenges
5. Ensure the infrastructure supports the transformation.
Participants agreed that a robust infrastructure was needed to ensure the success of the transformation. for examples of this, please see the report in downloads at the bottom of this article.
6. Provide clear, concise patient information.
Participants agreed that patient information should be clear and concise, emphasising the most important information (appointment time, date, medical speciality etc.,). Where relevant, practical information (e.g., transport links to hospital locations) should be separated either on the back of letters or in a separate leaflet.
Participants felt verbal explanation describing the next steps should accompany any written information. Visual aids, such as maps and pictures should be included where possible to increase accessibility.
7. Publicise the transformation widely and in accessible formats.
Participants suggested that communicating the proposed transformation of outpatient services should be widespread, both nationally and locally, and made available in health and non-health related locations. Information should be in a range of formats, digital and traditional. NHS Sussex would benefit from partnering with local organisations to help publicise the changes as well as directly engaging with patients themselves. All staff should be trained and informed in the new initiatives, and GPs should be kept up to date.
“I’d like to think I now have a better insight into the workings, and the challenges, of the outpatients’ system.”
“I did enjoy the deliberative engagement process. It is always better if ordinary service users can have some influence on how services are designed.”
Impact – what difference has been made?
Healthwatch Brighton and Hove presented findings and recommendations from these workshops, on behalf of Healthwatch in Sussex, to NHS Sussex who responded that the views and opinions of workshop participants had already made impact. These are highlighted in the Healthwatch in Sussex report:
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Workshop participants called for:
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NHS Sussex responded: |
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Better patient communication about appointments, including having a clear indication of where a patient is on the waiting list, and the ability to respond to and request an appointment change.
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NHS Sussex is one of three systems in the UK piloting an expanded version of the NHS App. The App will provide patients with appointment notifications & reminders and enable patients to respond and request changes to appointment dates.
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| Greater involvement of GPs in any new changes. |
GPs are helping to inform the proposed changes, by working directly with NHS Sussex.
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Improved training and support for GPs; ensuring that advice shared by consultants was easily accessible by GPs.
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Focus has been given to improving turnaround time of advice provided by consultants to GPs. Through a feedback system, GPs can offer their view on how this system is working for them and directly influence changes.
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Patient notes to be available wherever patients receive care, including outside of their local area. If offered an earlier appointment at a different location to their local hospital, patients need to know there will be consistency of care.
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Patient notes are being shared across all providers within Sussex, so that patients should receive consistent care wherever they receive it.
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Patient records should include notes on a patient’s availability for last-minute appointments and willingness to travel outside the local area.
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The expanded NHS App will also store information on a patient’s willingness to travel and availability for last-minute appointments. |
| Patient written information should be clear and visual aids should be used where possible. |
National communication in the form of a patient-focused video has been shared with all hospitals in Sussex. Maps and links to hospital websites are being included in patient letters, to simplify and provide visual aids.
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Identifying and supporting patient groups who find it particularly challenging to attend appointments.
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Voluntary and community sector organisations across Sussex are helping to identify and support patient groups who find it particularly challenging to access outpatient appointments, and work is taking place with NHS Sussex to find solutions to issues where possible.
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Communication publicising changes to the outpatient system should be available in a range of formats.
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NHS Sussex is working with the hospitals across Sussex to ensure information is available in a range of formats- including overseas languages- and to ensure that information about any changes is provided clearly. NHS Sussex and Healthwatch will work together to ensure that feedback about communication is reviewed and that it shapes the information provided.
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NHS Sussex are also represented at the NHS England “national missed appointments” meeting. Sharing feedback from the Sussex outpatient project is having an impact on the national system.
Additional Information
For further information about the national programme to transform the outpatient system, please visit: NHS England's Outpatient Recovery and Transformation Programme
The four initiatives discussed in these workshops were:
- Advice and Guidance (A&G): This enables GPs to seek advice and guidance from consultants about diagnosis and treatment, with the potential that the patient need not visit the hospital but be treated in the local community.
- Utilising system capacity inclusive of Patient Choice (Patient Choice): This is where an alternative referral location could be offered to patients, which may enable them to see a consultant quicker. However, the provider offered may be in a variety of locations, sometimes outside of the local area.
A note about terminology: Utilising System Capacity was the term used throughout the workshops and one with which all participants became familiar. However, following the workshops NHS Sussex advised that the term Patient Choice was a more familiar term used within the NHS and therefore both terms have been used in this report.
- Patient initiated follow-up (PIFU): After the initial consultant appointment, usually a patient would be given a follow-up appointment on a set date and time. Instead, PIFU gives the responsibility of follow-up to the patient, where they decide if and when they need an appointment. They are then expected to proactively telephone (using a number provided in advance) and make their own booking for a follow up appointment.
- Reducing ‘Did not attends’ (DNAs): DNAs are the name given to patients who do not turn up to appointments, costing the NHS time and money. NHS Sussex were interested in participants’ views about why this might happen and how to prevent this happening.
Please note: at the time of the workshops, it was estimated by NHS Sussex, that 75,000 patients DNA their appointment each year, costing the NHS £160 per appointment.
