Trust begins ‘most ambitious’ outpatients project in NHS

Norfolk and Norwich University Hospitals Foundation Trust has categorised around half of its outpatient follow-up list as “possible or probable opportunities” for patient-initiated pathways.

NNUH wants to make PIFU the “default model” for patients who are not on active pathways, and where it is safe to do this.

Its project is being closely watched by national leaders and has already drawn praise from NHS England’s director of elective recovery, Rob Stones, during a webinar last month. It is understood to be more ambitious than NHSE’s official PIFU pilot projects.

NHSE’s elective chief, Sir Jim Mackey, has said he wants to expand PIFU pathways on an “industrial” scale.

But the 2022-23 planning guidance target for trusts is to move or discharge a modest 5 per cent of outpatient attendances to PIFU pathways by March 2023 – a benchmark which NNUH said it hit back in April.

NNUH told HSJ it had analysed its c.500,000 follow ups from 2019-20 and found patients broadly fitted into one of four categories: RTT clock stops; follow-ups which are intrinsic to an active pathway; “possible opportunities” for PIFU; and “probable opportunities” for PIFU.

Chief operating officer Chris Cobb told HSJ around 50 per cent of cases fell into the latter two categories.

However, he was keen to dispel the characterisation of the programme as “PIFU by default” – the description given to the project by NHSE’s Mr Stones during the webinar.

Mr Cobb said: “This is not [about] making every follow-up outpatient a PIFU by default.

“It is only patients who are not on an active RTT pathway who are PIFU by default, unless a clinical exclusion has been identified. There are then a proportion of those who are on an active RTT pathway who are suitable, but not all of them.

“We’re leaving the decision [of whether the patient is suitable for PIFU] in the hands of the clinician, with no pressure to opt for either option. They decide – there’s no top down instruction, it’s in the hands of the clinicians.”

Tech support

The trust is working with two technology providers to deliver the project. They are DrDoctor, which is providing patient engagement service, and Infinity Health, which is providing the task management function platform.

DrDoctor’s co-founder Tom Whicher said the company was working with 13 trusts on PIFU “and the NNUH is the most ambitious project of them all, so far”.

He added: “The project represents a huge shift in mindset for clinicians as well as patients. They’re working to make patient initiated follow ups as the default, when clinically applicable, rather than the clinician initiated follow ups. That’s a huge shift.”

One of the major concerns around PIFU has been that if patients on a PIFU pathway do not fully engage with the process, their condition could deteriorate, and this could widen health inequalities.

Infinity Health said alerts sent by their system to clinicians about patients who have not responded to prompts or questionnaires created a “safety net” to prevent this from happening.

Mr Cobb continued: “There are a lot of patient benefits to PIFU. Patients will of course save time by not coming to unnecessary follow ups while preventing unnecessary appointments creates more clinical time for new patients, so it should shorten overall waiting times.”

Concerns around PIFU

However, patient groups and think tanks have raised concerns about the suitability and potential dangers of PIFU pathways for certain vulnerable cohorts.

Nuffield Trust senior fellow Sarah Reed, who is leading a major review of existing evidence on PIFU to be published next week, said: “There is still a lot we don’t know, and the overall evidence is limited and mixed on the overall benefits or drawbacks of PIFU.

“It is important that services gain a better understanding of why and for whom PIFU works less well as schemes are rolled out so services can be adapted and ensure that there is no unintended impact on inequalities.”