Recovery Watch: New data lays bare outpatient transformation failings

Outpatients performance in 2022-23 by numbers

Trusts have fallen well short of a target to cut outpatient follow-ups by 25 per cent, NHS Digital data published this month reveals, with the numbers remaining broadly the same as pre-pandemic levels.

The NHSD provisional data on outpatient activity shows there were around 124.2 million outpatient appointments in 2022-23 – almost spookily similar to the 124.4 million in 2019-20 and the 123.4 million the year before that.

Most outpatient appointments are follow-ups, and it was this category which NHS England set a target to cut by “a minimum of 25 per cent” against 2019-20 activity levels in the 2022-23 planning guidance.

But the hospital episode statistics data reveals for the first time that not only have trusts failed to shift the dial on the overall volume of outpatients but that follow-ups remain broadly flat too.

There were around 65.1 million follow-ups in 2022-23, or 5.4 million per month, compared to 65.4 million in 2019-20 and 66 million in 2018-19 (see graph).

One of the main benefits of driving down follow-ups would, of course, be that trusts would have more capacity for first appointments – but the number of first appointments has also flatlined.

It was 30.5 million in 2023, which is around 2.5 million per month, compared to 31 million in 2019-20 and 30.4 million in 2018-19 (see graph).

The difference between the c.95 million first appointments and follow-ups and the overall total of around 124 million outpatient appointments is accounted for by various other categories, such as did not attends or various other re-arranged categories.

The fact the NHS is behind the curve is of no surprise, with trusts operating in an unprecedented and challenging environment.

But the fact the system has failed to shift the dial at all, despite the ambitious target setting and new programmes (such as the greater use of patient initiated follow-ups, which I’ll come onto later) is disappointing. Recovery Watch understands ministers have been demanding explanations for this.

New national outpatient strategy must tackle widespread variation

But as NHS Providers’ policy and strategy director Miriam Deakin told me, the “amount of available ‘headroom’ trust leaders have which they need for complex transformation projects of this nature” has been decimated by high demand and the planning required for months of industrial action.

Ms Deakin explained that while some trusts had made considerable progress, there was significant variation, so NHSP “welcomed NHS England’s plan for developing a national outpatient strategy to drive forward the agenda across the whole system”.

She cautioned, however, that the new outpatient strategy, due later this year, must dovetail with the elective recovery programme and that projects like PIFU must not impact equity of access.

“Transforming the outpatients system needs a tailored approach by speciality and a focus on how to roll out [PIFU] appointments as well as other aspects such as reducing the number of missed appointments,” Ms Deakin added.

King’s Fund senior analyst Danielle Jefferies also warned the complexities buried beneath the high level numbers and the wide variation in what was possible in terms of reducing follow-ups between different specialties made outpatients especially challenging.

She said: “Changing pathways and processes will require a lot of time, effort and staff. This is not only clinical staff, but also administrative staff.

“Admin staff are under a lot of pressure to just get as many appointments booked in as possible, and it can be challenging when patients ask for and expect follow-ups. Changing how things are done requires a lot of capacity and at present this is a significant challenge for the service.”

A major cornerstone of NHSE’s outpatient aspirations to date has been PIFU, with a target set out in the 2022-23 planning guidance for trusts to have expanded PIFU to all major outpatient specialties and 5 per cent of outpatient attendances to have been moved or discharged to PIFU pathways by March 2023.

While the 25 per cent reduction in follow-ups was always widely viewed as over-ambitious for the timescale demanded, the PIFU target was seen as more realistic. Conservative even.

Performance data for PIFU is not yet public, but many trusts are understood to be struggling against this target too.

Nuffield Trust senior fellow Sarah Reed, who is working on a National Institute for Health and Care Research rapid evaluation of PIFU in partnership with UCL, said progress “feels like an uphill battle for trusts at present”.

Ms Reed also raised concerns about the lack of headroom trusts had to oversee the service transformation required amid the aforementioned pressures on the system.

She added: “There are also significant logistical challenges. PIFU, for example, can require a lot of re-jigging and reconfiguring IT systems and approaches and the different ways of communicating information. These are common challenges in any transformation programme but it’s certainly playing out in outpatients at the moment.”

Ms Reed also questioned whether “the targets are the right targets or whether they’re overly crude. For example, if you want to reduce follow-ups, then which ones, as follow-up appointments have different purposes. The potential for reducing follow-ups also varies significantly across different specialties.

“Outpatients is such a broad category, so having a broad target across all specialties is quite difficult and there’s a lot of questions which still feel unanswered.”

NHSE said in a statement that the follow-ups reduction target had now been moved to March 2024. A spokeswoman said: “Our ambition is to reduce outpatient follow-ups by a quarter by March 2024, alongside working to bring down [elective] waits of more than 65 weeks which have already fallen by more than 40 per cent since October.

“Earlier this month, NHSE wrote to trusts about our elective priorities for 2023-24 which set out how we expect them to deliver the reduction, including by expanding patient-initiated follow-ups across all specialties, validating patients on waiting lists and reducing missed appointments.”