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Targets to reduce outpatient numbers ‘risk’ exacerbating GP pressure, NHS England admits

NHS England has admitted that its policy to reduce outpatient appointments risks putting ‘added pressure on primary care’.

Under national targets for 2022/23, trusts have been asked to reduce outpatient follow-ups and expand the uptake of patient initiated follow-up (PIFU) – where patients are given appointments when they request them rather than at routine intervals – in all major outpatient specialties. 

But recent NHS England guidance on implementing PIFU said one of the policy’s ‘risks to quality of care’ is putting ‘added pressure on primary care’.

It said: ‘Patients may forget when and how to get in touch during the time they are on PIFU or they may not want to “bother” services, leading to worse outcomes or added pressure on primary care.’

It added that ‘mitigation measures’ could include sending patients ‘reminders’ and developing patient information leaflets and videos.

The risk could also be mitigated by keeping patients’ GPs ‘informed so they can signpost the patient to the service if required and so that they understand when they should inform secondary care about risks, eg if a patient is diagnosed with a new condition such as dementia’, it said.

The guidance added that if patients are ‘unable to book their [follow-up] appointments directly’, their GP practice administrative staff ‘may be able to help’.

A template standard operating procedure published alongside the guidance said that the patient’s GP will be contacted with ‘guidance on the symptoms and how and when the patient should request a follow-up’ and notified when the patient is discharged from the programme.

Patients who request an appointment after their PIFU timescales have expired will need a new referral through their GP, it added.

National targets to reduce outpatient appointments

NHS England operational planning guidance for 2022/23 asked providers to reduce outpatient follow-ups by a ‘minimum’ 25% against 2019/20 activity levels by March 2023 but ‘going further where possible’.

It also said they should expand the uptake of patient initiated follow-up (PIFU) in all major outpatient specialties, with 5% of outpatient attendances to be moved or discharged to PIFU pathways by March 2023. 

Meanwhile, separate NHS England guidance published at the same time on delivering a ‘personalised’ outpatient model said that reducing outpatient appointments will not transfer follow-up to ‘capacity-constrained’ general practice without a ‘coherent’ plan.

It said: ‘Through this more personalised approach to outpatient follow-up appointments, patients can expect their care needs to be dealt with faster and closer to home where appropriate. This will be done in a way that improves overall efficiency, while not transferring follow-up to capacity-constrained services in the community and general practice without a coherent system plan.’

It remains unclear what such a plan would entail, but the guidance added that preparation for the new model should ‘include understanding of core concerns’ from primary care.

It added that adopting a personalised outpatient approach has the ‘potential to reduce pressures on primary and community care’ if system working is ‘embedded from the onset’ and ‘sufficient information and patient access is provided’.

The guidance reiterated that clinical time gained by reducing outpatient follow-up activity could be ‘repurposed’ for an increase in ‘primary care support/interface’ such as advice and guidance (A&G).

It said: ‘Trusts should consider how released capacity from outpatient follow-ups could be repurposed to activities that support primary care or are commissioned from primary care, for example through the increased provision of specialist advice and guidance.’

However, it added: ‘At one pilot trust, initial discussions around increased specialist advice implementation revealed the need to build further communication channels and educational tools with primary care to support the programme.’

A&G involves GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.

Final NHS England elective recovery planning guidance last month confirmed plans for this year’s 10% increased elective activity target to be predominantly achieved through increased GP advice and guidance (A&G).

The plans were first revealed in draft guidance seen by Pulse in March, which set out that GP A&G ‘could contribute an estimated six percentage points’ towards the target of ‘over 10% more’ activity.

The Government’s long-awaited elective recovery plan – published in February – also stressed that GPs’ role in tackling the NHS hospital backlog will focus on the use of A&G to try to avoid ‘unnecessary’ referrals to secondary care.

But Government auditors have warned against ‘overloading’ GPs in clearing the elective backlog and the Public Accounts Committee has said even if the NHS meets its targets for elective care, one million more patients will be on the waiting list posing a ‘huge risk’ to primary care.

It comes as NHS England has said that pandemic recovery for general practice should have the ‘same focus as elective care’.

READERS' COMMENTS [5]

David Church 27 May, 2022 10:35 am

Instead of putting so much secondary care professionals’ effort and time into managing new administrative ways to make OP loads LOOK smaller, if they actually allowed the same amount of clinical effort and time to go into secondary care professionals doing clinical stuff that improved patients’ health and made them less reliant on healthcare at either location, this would help much more.
If GP’s questions at referral are answered speedily, they can often return to GP instead of having any kind of follow-up at secondary care; but on the other hand, patients that need monitoring of condition or medication BY the specialist, DO NEED to have that review done at regular intervals, and not thrown at pot luck for if the patient remembers and also manages to get past the obstructuve secondary care appointment booking system.
These patients probably do not have access to computers to manage on-line booking, but even if they did it often does not work. More likely they will not even have the skills to do it, or be unable to communicate with the system because of their problem.
When things go wrong in this way is when it puts disproportionately more burden on the system for less and less benefit, and reduces access to others.

Andrea Barrow 27 May, 2022 1:20 pm

There is 100% risk that GP workload would increase.
If a follow up is needed on the basis of clinical need, it is needed and should be booked, If there is no clinical need then discharge. Those that are booked should have a process where they can contact the hospital directly if they feel their appointment should be earlier. The appointment can then be changed according to clinical need.
Appointments need to be allocated on clinical need not patient wants. This is the only way the NHS could possibly survive and even on this basis, I wonder about survival.
To do anything other than this will not only increase GP workload but will increase health inequalities.
Covid has dramatically increased the number of patients presenting with “on my goodness- why didn’t you come earlier” – “well doctor I know you are so busy and others need you more than me”…. My impression is these are often those who have significant need, but don’t want to bother the system.

Unless there is a clinical need driving the NHS, it will not survive. Unless that is the underlying objective?

Patrufini Duffy 27 May, 2022 1:28 pm

Rule 1 of the NHS – patient is always right ; not you. And no one is coming to save you.

Therefore act accordingly and don’t change course.
GP should keep referring, if anything increase the referral rates, as that is what Sajid wanted = he said “come forward” and like ping pong, you deflect the wave where it belongs, towards the hospital managers, not your own managers. And as long as there is a Good Medical Practice code, your complaints policy on the wall and a questionable GMC lurking with rafts of American apps, law firms and other providers dumping on primary care’s shores, keep the hospital busy and patient busy too.

Darren Tymens 27 May, 2022 1:31 pm

‘NHSE admits making GPs do most of everyone else’s work as well as doing their own work might increase GP workload.’
Would NHSE like to comment on the religious inclinications of the Pope, or the nocturnal toilet habits of bears? Or have they not formulated opinions yet?

Patrufini Duffy 30 May, 2022 2:41 pm

Refer directly to the place that gets funded and protected.