Performance watch: A new outpatients target?

A bold ambition on outpatients is set to be a cornerstone of the long-term plan, HSJ understands, as system leaders finally appear to be grasping the nettle on an area singled out for reform.

As exclusively revealed by HSJ, NHS bosses have already identified £700m of potential savings in outpatient services as part of a major programme to radically overhaul the nearly £10bn worth of non-emergency services.

The news follows NHS England chief Simon Stevens branding the outpatients system as an “obsolescent mode” of care delivery in June.

I’m told by multiple sources that senior NHS England figures pushed for a challenging overarching target to be included in the long-term plan on radically cutting expenditure and the number of outpatient appointments. Senior figures apparently pushed for a pledge to cut expenditure by a third, or even more.

The final text however remains a closely guarded secret. But the programme is set to rightly propel the issue – which has been bubbling along under the surface for some time – into the spotlight.

I understand that, in addition to the NHSI work, NHSE’s elective care transformation programme – led by director Linda Charles-Ozuzu, who may well end up a pivotal player in the debate – is already working on projects to advance the agenda (more information is in a recent blog Dr Charles-Ozuzu posted on the NHSE website).

The arguments for the need to reform outpatient services on cost, clinical outcomes and patient experience grounds are well rehearsed and convincing. Outpatient appointments have nearly doubled from 60.6 million to 118.6 million since 2005-06, a faster growth rate than any other aspect of hospital activity. 

Nuffield Trust chief Nigel Edwards eloquently sets out the need for change here, and a recent report by the Royal College of Physicians also calls for change, asserting that many of the principles underpinning the outpatient system were introduced in the 18^th century.

But the “how” aspect is far less clear.. 

The desire for a headline catching overarching target from system leaders is understandable: a quantifiable way to concentrate and prioritise efforts within the service and easy to explain to patients, politicians and the media.

The pushback from trust leaders and clinicians is equally understandable. Targets drive unintended consequences and the complexity of the diverse bundle of services included under the “outpatient” banner means a one-size-fits-all approach will simply not work.

NHS Providers chief Chris Hopson agreed a “bold ambition” was needed. But he warned: “We need to be very careful about treating outpatients as a single, all-encompassing form of clinical treatment to which a blanket tariff, volume or time reduction target can be applied.

“All the evidence suggests different sets of patients with different conditions in different specialties have different needs and that moving to different models of care can therefore be complicated and time consuming.”

Senior clinical leaders also agreed with the need for reform, but viewed an overall target as too blunt a tool.

Academy of Medical Royal Colleges chair Carrie MacEwen cautioned a better understanding of the capacity available and demand pressures was needed before even considering development of a new standard.

Professor MacEwen said she had not been involved in the official long-term plan discussion around outpatients. But she warned: “We can only develop a standard if we fully understand what and where the problems are. At the moment we don’t. So, a piece of auditing work would be required to address this.

“We also do not want to introduce unintended consequences and push the system into discharging patients into community services which may not exist or be unable to adequately deal with the patient’s needs.”

She also proposed other available levers rather than new targets, such as using the tariff to incentivise trusts to send patients to virtual or non face-to-face appointments, which are financially disincentivised under the current rules.

Giving the system a push to further develop community and digital alternatives to the orthodox outpatients pathway is clearly a Good Thing. Big ambitions not only make great headlines but also give the system a standard to coalesce around. 

But, as with much of the debate around the long-term plan, the aims must be tempered with realism about the pace of delivery and the frontloaded resource required to deliver meaningful change.