I have recently been working with an outpatient service. This service provides a number of clinics each day of the week, from a simple outpatient clinic which patients attend to receive a diagnostic test followed by a consultant appointment, to complex clinics where a select group of patients will see up to four different people, including two different clinicians.
In addition to providing these clinics, the staff also allow patients to call in if they are having any problems.
Permitting patients to attend unplanned has a series of unintended consequences, including:
- creating large delays for patients attending planned slots;
- all clinics failing to run to time;
- overcrowded waiting rooms;
- no system being in place to deal with urgent patients;
- frustrated clinicians;
- overbooking and underutilisation;
- long delays between diagnostic test and consultant appointment;
- patients must make individual appointments for diagnostics and outpatient consultations, leading to them only making the diagnostic appointment and having to be fitted in as urgent appointments in the clinic.
In spite of these issues, patients are happy with the quality of care that they receive (although they may not be happy with the waits). Patients from outside the organisation's catchment area even choose to attend the clinics.
This could in part be because of their ability to access the service when they feel there are no other options available to them or because the quality of care they receive is exemplary.
However, negative aspects such as delays, waits and overbooking are a consequence of the service failing to manage patients appropriately.
It is impossible to manage a planned elective service and then allow anyone to attend and 'fit them in'.
The reason this situation has arisen is in part due to the conscientious nature of the staff, who allow anyone to attend any time they feel there is a problem, but also a result of patients being made to feel the hospital is the most appropriate resource for them to use.
These unplanned patients are attending at the hospital for a variety of reasons, including:
- they cannot access the community service;
- they do not know how to access the community service;
- they do not want to access the community service;
- they know that if they call the hospital they will be seen the same day.
This situation is approaching breaking point. More and more patients are attending as unplanned urgent cases, demand within the clinics is increasing year on year and the ability to run to plan is deteriorating.
The solutions to this sort of problem are multi-faceted but would involve some combination of the following actions:
- Separate the planned and unplanned attendances. If they are to continue seeing the urgent cases and it is deemed that the hospital is the most appropriate place to do so, they should be seen by the consultant on call, even if they have to wait longer, rather than by a consultant attempting to see patients in a planned clinic. In a true emergency, an outpatient clinic is not the appropriate place for them to attend.
- Attempt to move some of the urgent patients back in to primary care. Some of the attendances are inappropriate and the patients attend the hospital not because it offers a service that is not available in the community but because they prefer the service provided.
- Put in place a system that does not require patients to make multiple appointments for a single visit but one appointment that co-ordinates the diagnostic test with the consultation
The issues presented in this clinic are not unusual, and overbooking, delays, over-running, underutilisation and inappropriate attendances are not uncommon.
To tackle these issues, a fundamental understanding of the demands placed on the system is required. This would require data, an understanding of the process in place and some examinations of the root causes that have led to the current state. Once that has been completed it would be possible to start to look at implementing solutions.