Introduction: generating greater value for patients from outpatient care

This improvement guide supports clinical and operational teams to improve the outpatient care provided to patients. In 2023 the NHS worked with the Royal College of Physicians and the Patients Association to engage with people with lived experience to understand what mattered to them. In addition to the clear expectation of high quality safe care, delivered as rapidly as possible, people told us they want:

• care to be co-ordinated better, particularly for people with co-occurring conditions which bring them into contact with multiple clinical teams
• improved communication, both between healthcare professionals, and between healthcare professionals and their patients
• a more holistic approach to care – treating the whole person, focusing not just on physical but also psychosocial care needs
• greater control and choice – not just choice of hospital but of their whole end-to-end experience (including information about treatment choices; control over timing and format of appointments; more options for post treatment care)
• greater join up between services and organisations – avoiding suboptimal hand-offs of care between parts of the system, which are inefficient and clinically risky

This guide sets out the current evidence-based practice and provides a range of change ideas that can deliver improved care for patients. We encourage teams, organisations and systems to test and adapt these for their local context.

We want to understand how this guide works for you and your teams, and how we can further develop and improve it to make it as useful as possible to support local improvement programmes. Therefore, this is an interim guide – our intention is it will be refined, developed and updated as we learn what works through your teams. Please share your thoughts on the guide and your ideas to include in it – details on how to do this are at the end of this guide.

Alongside this guide, improvement analytics can be used to diagnose issues and identify opportunities to improve care and track improvement over time. The improvement metrics will evolve as data collected nationally better reflects new care models. Alone they do not give the complete picture for flow and the opportunities to improve patient outcomes across the whole cycle of care. For this, clinical and operational teams need to work together to join up local insight and intelligence to better understand and address opportunities to improve outcomes for the patient, particularly at the interface of specialties and services. Teams are encouraged to supplement the nationally available measures with locally collected insight on patient experience and pathway-related outcomes.

Overarching ambition

This diagram sets out the ideas that can lead to improved outpatient services.

Figure 1: outpatient driver diagram

Right place

Improve outcomes for patients and maximise the value of patients’ and clinicians’ time by ensuring people are cared for in the right place

Optimising referrals

Ensure faster access for those people who will benefit from specialist elective care

There are several ways in which clinicians can work together at the interface between services to ensure people access the right specialist care as rapidly as possible. Key to success is consistent and constructive engagement between primary care and secondary care.

Many systems have agreed guidelines that advise primary care clinicians on the criteria and thresholds for referral to specialist care. The GIRFT programme is publishing referral and specialist advice guidance for several higher volume pathways later this year. Straight to test pathways are also now expanding beyond cancer pathways, streamlining access for patients and avoiding unnecessary appointments.

Systems are also going further and establishing walk-in and pre-appointment health hubs that bring together primary, community and secondary care to improve access to care currently delivered in hospital outpatients and to bring it closer to home.

Specialist advice (both pre and post-referral) is now a cornerstone of referral optimisation. Enabled by the e-Referral Service (e-RS), this approach helps ensure patients are managed in the most appropriate setting.

Technology is also transforming how referrals are managed. Telehealth solutions (for example, teledermatology) are enabling a step-change in the speed with which referrals can be safely reviewed by specialists, cutting waiting times for patients.

How to optimise your referrals

Value opportunity

If every system increased the impact of Advice and Guidance (A&G) by 15% in 2024/25, this would free up 60,000 first appointments across the country (even accounting for the time spent supporting the A&G process). If this increase in A&G impact were achieved equally across the country, the averaged sized acute hospital would be processing 48 additional A&G requests every week.

Tracking indicators

In addition to local process measures linked to your change ideas, A&G process measures are available in the Model Health System, including utilisation, turnaround time and diversion rate.

Change ideas

1. Work in partnership with general practice to establish or optimise existing pre-referral specialist advice services. There is guidance on commissioning these services; support on medico-legal issues; benchmarking information on expansion opportunities; a specialist advice toolkit and a specialist advice comms toolkit, and GIRFT standardised A&G templates (FutureNHS is a member platform that requires a log in).
2. Streamline and reduce variation in post-referral A&G and triage, supported by the NHS e-Referral Service (e-RS) toolkit. Optimise user interfaces to improve clinical productivity. Also consider using your patient portal to collect pre-consultation questionnaires from patients to support clinicians to enhance this post-referral assessment process.
3. Work as a system to review current practice for consultant-to-consultant referrals.
4. Adopt GIRFT ‘further faster’ specialty-level standards.
5. Explore the use of straight to test pathways.
6. Review the opportunity to improve adherence to nationally published evidence-based interventions.
   

Resources

• advice and guidance services
• e-RS dashboard
• Model Health System data

Help and support: england.outpatient-transformation@nhs.net

Optimising post-treatment care

Transform how people access ongoing specialist care

There are significant opportunities to improve the experience and outcomes for elective patients following diagnosis and at the start of their treatment, particularly for those people with co-occurring conditions whose care can lack co-ordination and be difficult to navigate.

How to optimise post-treatment care

Value opportunity

If every hospital were to increase its patient initiated follow up (PIFU) utilisation rate by 1 percentage point compared to the 2023/24 baseline through the second half of 2024/25, nationally 400,000 more patients could be seen in outpatients this financial year. For an average sized hospital this would mean 60 more patients on a PIFU pathway every week.

Tracking indicators

In addition to local process measures linked to your change ideas, 2 process measures feature in the improvement analytics:

• PIFU utilisation
• proportion of all outpatient attendances that are for first appointments or follow-up appointments attracting a procedure tariff

Change ideas

1. Expand the use of PIFU; there is national guidance, GIRFT specialty-level guidance and the trust-specific PIFU opportunity packs to support you. While PIFU will be appropriate for many children and young people, there are specific considerations to take into account, including the availability of alternative support for children and whether the primary care workforce is currently best placed to support children.
2. Develop Care Coordination to better support all patients, but particularly the most vulnerable or those who are on complex co-occurring condition pathways.
3. Develop remote monitoring protocols for patients on long-term condition pathways who require regular and routine review, leveraging patient engagement portals. Where possible automate this remote monitoring to reduce the administrative burden on staff; see Supporting care with remote monitoring. Consider using freed up clinic administrative staff to support patients to use new digital channels.
4. Consider using personalised videos to inform, reassure and equip patients with the information they require to manage their care following surgery, reducing the need for follow-up appointments.
5. Use forms and questionnaires delivered through your patient portal to triage post-surgical patients to determine if they require follow up care. Artificial intelligence can augment this approach, collecting, collating and presenting information to clinicians to enable them to discharge without follow-up.
6. Learning from primary care models, use digitally-enabled group appointments (particularly for long term condition pathways) to increase the number of patients accessing advice and support per clinician.

Resources

• improvement analytics
• specialty level guidance
• case studies

Help and support: england.outpatient-transformation@nhs.net

Right process

Tackling waste and reducing variation

Increasing clinic throughput

As described above, referral initiatives can release capacity for quicker first and procedure follow-up appointments, but unwarranted variation in clinic throughput should also be addressed. The number of patients scheduled to be seen in clinic templates varies widely even within the same specialty and hospital.

In many cases, this variation is appropriate as it relates to the mix and complexity of patients, but in some it will be down to practical constraints or historical practices that would benefit from review – to deliver greater value from our existing services.

We encourage systems to focus on identifying, understanding and addressing variation in clinic throughput in 2024/25

How to increase clinic throughput

Case study: Devon Health System

Supported by GIRFT, Devon ran a pan-system improvement programme across a range of specialties including spinal. The Devon Spinal clinical lead led work to harmonise clinical pathways, standardise clinic templates and improve operational processes. This increased clinic slots within existing job plans by about 50%, providing over 1,100 additional slots per annum and delivering a significant reduction in long (65+-week) waiters.

 

Value opportunity

If every clinical team sees at least 1 more patient in every outpatient clinic held in the second half of 2024/25, nationally an additional 3.5 to 4.5 million more patients could be seen by the end of the financial year.

Tracking indicators

In addition to local process measures linked to your change ideas, the relevant indicator in the improvement analytics is:

• All outpatient attendances per consultant whole time equivalent.

Change ideas

1. Review your current operational processes against the GIRFT best practice guidance*
2. Increase your use of remote consultation and telehealth (including teledermatology) to help increase your clinic throughput. Remember children and young people have specific needs in relation to remote consultation*
3. Increase the transparency of clinic throughput within and between specialties. You can benchmark your specialty throughput against the ‘further faster’ sites using GIRFT data. We are developing specialty-specific clinic templates that set minimum throughput ambitions with Royal Colleges, and these will be available later in 2024/25*
4. Review clinic processes to identify where technology (for example, robotic process automation) might address operational constraints and/or where technology might be creating delays.
5. Review the alignment between consultant outpatient activity and consultant job plans with a view to increasing job plan compliance – using the national job planning toolkits on the FutureNHS NHS IMPACT platform.*
6. Deploy the NHS Federated Data Platform outpatient care co-ordination solution.
7. Use your learning network/improvement collaboratives to identify variation in specialty or condition level clinic throughput, and develop collective improvement plans to reduce variation across the system.

* Specialty-specific best practice guidance for these change ideas is in the GIRFT ‘further faster’ handbooks and the Remote Consultation Improvement Toolkit.

Resources

• improvement analytics

Help and support: england.outpatient-transformation@nhs.net

Reducing wasted appointments

Last year patients did not attend nearly 7.5 million of the around 100 million booked outpatient appointments. Less visible, but equally impactful, are the patient cancellations too close to the time of the appointment to allow the hospital to re-use the slot. Both these events, as well as unfilled slots, waste appointments. Such waste is frustrating for patients and staff, inefficient and can contribute to inequalities in access and care.

Some clinics work on the basis that some missed appointments are to be expected and seek to mitigate this waste by overbooking the number of patients they plan to see, but this risks a poor experience for patients, and for clinical and operational teams.

We know that the rate of missed appointments varies within and between hospitals. The national rate is just above 7%, but it is over 9% for a quarter of hospitals and below 6% for another quarter. While the demographics of the population served will impact on the rate of missed appointments, there are evidence-based interventions that can improve the situation.

Understanding and addressing the causes of missed appointments and short notice cancellations is key to delivering locally focused improvement. Some will be within the hospital’s direct control. For example, there is a strong correlation between the number of times a hospital changes a patient’s appointment and the likelihood the patient will miss their appointment. 

Communicating with and giving people control of their appointments reduces the number of missed appointments. The recent roll out of patient portals nationally, accessible through the NHS App, is key to achieve this. Refer to the principles for delivering personalised, patient-centred communications to patients who are waiting for planned care.

We also know there is predictability in the people most likely to miss an appointment. Several organisations have used technology, including artificial intelligence, to predict and mitigate the risk of missed appointments or short notice cancellations to good effect. 

How to reduce wasted appointments

Value opportunity

If every hospital reduces the number of missed appointments by 1 percentage point through the second half of 2024/25, the NHS would be able to see an additional 120,000 patients this financial year. For an average sized hospital a 1 percentage point reduction equates to 7,500 fewer missed appointments a year.

Tracking indicators

In addition to local process measures linked to your change ideas, there are process measures in the improvement analytics for the percentage of missed appointments by specialty, type and relative level of deprivation of the area in which the patient lives.

Change ideas

• Send appointment reminders – and where possible do so using the NHS App to minimise costs. Patients are over twice as likely to cancel appointments ahead of time, rather than miss their appointment, if they receive a For those who cancel, half do so within 2 days of being sent a reminder, so the timing of reminders (>4 days) needs to anticipate when services will learn that a patient wishes to cancel and if they do, give sufficient time to allow the appointment slot to be reused. Keep a list of patients who can attend at short notice to fill last minute cancellations. See guidance on reducing DNAs.
• We know a small percentage of patients (~5%), typically those on multiple concurrent pathways, account for almost a quarter of all missed appointments. Ensure you understand and identify how to make care more co-ordinated and appointments more convenient for patients, including by minimising their number. This might be achieved using remote consultations, remote monitoring and PIFU.
• The causes of and solutions to reducing the number of children not brought to appointments are slightly different. The ’further faster’ guide has more detail on reducing the incidence of ‘was not brought’ for children.
• Ensure national referral to treatment rules are applied if patients miss appointments – do not simply continue to send further appointments to people who miss appointments.
• Increase the number of clinic appointments that patients can manage themselves using a patient portal appointment management functionality. Refer to the guidance on NHS Wayfinder services.
• Review which clinics the hospital regularly cancels.
• Undertake administrative validation for 90% of patients waiting over 12 weeks (and every 3 months thereafter).
• Consider using the nationally procured NHS Federated Data Platform care co-ordination solution (using AI to predict missed appointments and short notice cancellations).

Resources

• improvement analytics
• reducing did not attends (DNAs) in outpatient services guidance
• specialty-level guidance

For help and support: england.outpatient-transformation@nhs.net

Right people

Utilising your workforce more effectively through high quality operational workforce planning and deployment will help improve staff experience and retention, support service improvement and further improve productivity by optimising the skills and capacity of your workforce.

Optimising the valuable skills and capacity of clinical workforces

Good quality workforce planning and deployment is about optimising the valuable skills and capacity of our clinical workforce, by ensuring the right people are in the right place, at the right time to deliver high quality, efficient patient care. It is about supporting the development of staff and services and providing the visibility of clinical capacity required to plan services effectively and match valuable clinical capacity to patient need.

Improvement requires targeted action on workforce planning and transformation, workforce deployment, governance and measurement.

Follow the resources on clinical workforce productivity on FutureNHS. In particular, we recommend the following resources for each of the 3 pillars of excellence, which are workforce planning and deployment; workforce transformation; and governance and measurement.

Workforce planning and deployment

Workforce planning and deployment resources

• e-job planning and e-rostering for effective planning and deployment of all staff:
• the Advancing levels of attainment handbook and related resources: help organisations establish what their e-rostering and e-job planning levels of attainment are and what is required at each level to progress, based on local need and current position
• the e-job planning toolkit and e-rostering toolkit: provide a step-by-step guide to optimising system usage and embedding effective associated processes and governance
• e-rostering as an enabler to flexible working: provides resources to support team leaders working in clinical areas to develop ways to roster their staff more flexibly, thereby improving work-life balance and experience at work for staff. The case studies showcase the innovative initiatives that are being implemented and their impacts on staff wellbeing and retention
• medical consultant job planning improvement guide
• demand and capacity planning: provides resources to support service and system-level demand and capacity planning, including modelling tools and approaches, case studies, webinars and e-learning
• digital staff passport: enables NHS employees to use their smart phone to share employment, education and training, and occupational health details with hospitals 24/7, to support their moves between those hospitals
• agency toolkit: supports organisations to reduce their agency staff bills and encourage workers back into substantive and bank roles

Retention resources

• improving staff retention guide: supports line managers and employers to consider the key areas that affect workforce retention
• international retention toolkit: actions employers can take, such as mapping skillset and qualifications and setting up pastoral support, to ensure internationally recruited staff will want to stay, thrive and build lasting careers in the NHS
• NHS Emeritus: an initiative that connects recently retired and peri-retired clinicians across England with NHS providers of acute care who need the help only experienced clinicians can offer

Workforce transformation

Workforce transformation resources

• Clinically-Led Workforce and Activity Redesign (CLEAR) programme: supports clinicians and organisations to deliver transformation and workforce redesign projects to enhance patient care, by equipping frontline staff with skills in data analysis, innovation and leadership
• Star: accelerating workforce redesign: a model and workshop for workforce transformation, enabling you to explore workforce challenges, develop bespoke action plans and use resources in the Star online directory
• roles explorer: provides resources for workforce redesign, such as introducing new roles or innovative adaptations to existing roles within a service or system
• Calderdale Framework: an evidence-based workforce transformation tool used in acute and community settings to rapidly identify skill sets required by services and their populations in acute, sub-acute and rehabilitation phases
• workforce transformation case studies: an interactive map of good workforce transformation practice, including examples from diagnostics and outpatients

Governance and measurement

Governance resources

• National Quality Board (NQB): safe sustainable and productive staffing guidance (2016): an improvement resource that builds on the NQB’s 2013 expectations and framework within which organisations and staff should make decisions about staffing that optimise productivity and efficiency while maintaining focus on improving quality
• e-rostering and e-job planning meaningful use standards: support hospitals to implement and use e-job planning and e-rostering software to its full potential, which includes the use of board reporting and metrics for improvement

Measurement resources

• Model Health System: data-driven improvement tool that enables NHS health systems and hospitals to benchmark quality and productivity
• Workforce Productivity Diagnostic Tool: supporting systems and hospitals to understand and benchmark their workforce productivity

Change ideas

• Collect workforce data to understand your workforce capacity:
  • capture and review data for all staff who work in outpatients on a permanent or temporary basis. Include data from/on ESR, temporary spend, recharge, recruitment and retention rates, turnover, sickness absence, age profile and demographics
  • review your consultant-level capacity (including direct clinical care and supporting professional activity time)
• Understand your retrospective and prospective activity:
  • collect activity data and review any service plans that may impact on future activity levels (such as work transferring from location or changes in mode of delivery)
  • this review should include key hours of operation
• Undertake a systematic review of your workforce requirements:
  • map your pathway and consider which staff are required at each stage
  • review the roles, skills and capacity required to meet your expected activity. Consider whether any new roles are required or would improve productivity
  • review your pay spend run rates and compare these to your budget
  • consider recruitment, training and retention needs, including specific equipment/ specialty training requirements
• Review national policy when building your establishment and optimising deployment:
  • Developing workforce safeguards: Supporting providers to deliver high quality care through safe and effective staffing
  • GIRFT guidance
  • appropriate Royal College guidance

Please share your ideas and feedback with us

Thank you for engaging with this guide. While we have collected a wide range of improvement ideas, we want to gather your local improvement ideas for inclusion in an updated version of this guide early in 2025.

Please share your ideas and feedback with us. There are 2 ways you can do this:

• by emailing clinops@nhs.net
• by feeding back through your local Learning and Improvement Network. Details on the networks are on the FutureNHS platform

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