Recovering services from the covid crisis is the big task for NHS leaders for the foreseeable future. The Recovery Watch newsletter tracks prospects and progress.

NHS England’s latest strategy to deliver much-needed reform of the service’s outdated outpatient model is due in December. But there are already significant concerns trusts will simply not have the bandwidth to deliver the huge transformation required.

One thing we can all agree on

There is widespread consensus that the NHS’s antiquated outpatient system, still all too often reminiscent of LS Lowry’s 1952 painting, The Outpatients’ Hall, needs huge reform.

Desire for reform has only been increased by the fact between 70 to 80 per cent of the NHS’s unprecedented waiting list will end their journey in an outpatient or diagnostic setting. So, tackling outpatient reform is viewed as an integral part of getting the waiting list back to a manageable level.

But while health policy experts have long bemoaned the outpatient system as a 20th century model being used to try to deliver 21st century care, system leaders’ preoccupation with meaningful reform is still relatively new.

The NHS Five Year Forward View, published less than ten years ago in 2014, makes just one solitary mention of outpatients.

“These practices would shift the majority of outpatient consultations and ambulatory care out of hospital settings,” the strategy says in passing on how multispecialty community providers would deliver that long-chased Holy Grail of policy makers: pushing care out of the acute setting and into the community.

Fast forward to NHS long-term plan 2019 and the issue had shot up the agenda, with a whole chapter titled: “Digitally-enabled primary and outpatient care will go mainstream across the NHS”.

And, certainly, significant strides have been made in using technology to deliver all manner of digital outpatient consultations and facilitating messaging between clinicians and clinicians and patients. One of the few upsides of the pandemic was that it acted as a catalyst for a lot of this work.

But, while these advances are all well and good, outpatient reform is about far more than virtual consultations and digital messaging services.

System leaders believe, for example, that there needs to be fundamental re-wiring of the entire commissioning and financial structures which underpin how and when patients are referred from primary into secondary care, with a significant increase of the so-called “advice and guidance” model deemed necessary (more on this below).

There is also a belief among senior policy leaders that there needs to be significant cultural shift, not least around how clinical risk is viewed, if the service is indeed going to deliver more care away from hospitals and into the community.

So, it’s good news that NHSE and the Royal College of Physicians are currently working on a strategy to try and tackle some of these issues and have set out a plan for the next five to ten years.

As we revealed this morning, one idea national leaders are looking at is greatly reducing the number of direct hospital referrals made by GPs, by insisting that they first discuss cases with hospital consultants.

The approach, known as “advice and guidance”, which has already been voluntarily adopted by some health systems, involves GPs sending a patient’s details to a consultant who specialises in their condition before making a referral. The consultant then advises on the best course of action.

The idea has sparked a lively discussion in our comment thread below the story which you can read here.

Trusts will struggle to find ‘leadership bandwidth’ to deliver reforms

But despite the doubtless necessity of outpatient reform, trust bosses have raised fundamental concerns about where they find the “leadership bandwidth” to deliver meaningful reform.

There’s never an easy time to deliver genuine transformation but this period of unprecedented challenge in the post-covid world, exacerbated by seemingly endless industrial action, certainly provides mitigating circumstances.

NHS Providers director of policy and strategy Miriam Deakin told Recovery Watch that trust leaders supported the review’s “direction of travel”.

But she added: “These changes will require leadership and managerial headroom to implement effectively, in partnership with clinicians and patients as part of trusts’ broader efforts to reduce waiting times and bear down on the elective care backlog.

“The rate of progress we see on this important strategy however, seems to reflect in part how challenging it is to find that leadership bandwidth in the midst of strikes and unprecedented operational pressures.”

Ms Deakin was not the only senior provider source to have expressed these concerns to RW.

So, the message to NHSE appears to be this: what incentives can system leaders provide to ensure that this critical agenda does manage to get a share of trust bosses’ available bandwidth, despite competition from elective recovery, winter planning, industrial action and all the other on-going challenges?

While there is widespread agreement outpatient reform is much-needed, it feels like delivery in such a challenging environment, and with so many other competing agendas, will need carrot as well as stick from system leaders.