The Picker Institute Europe coordinated the national outpatients survey for the Care Quality Commission in 2009. This is a summary of the key findings.
It is rare for the NHS to bury a good news story, but the 2009 national survey of outpatients’ experiences in England was published without fanfare by the Care Quality Commission in late February.
This was a shame. Outpatient visits are a key part of healthcare for patients, especially those with continuing or long term conditions. In the year to November 2009 there were 65 million appointments attended by patients. The mantra that patient experience is central to quality must apply here, too.
This the first national survey picture for five years; it showed significant, at times huge, improvements in outpatient experience over time; and it furnishes us with a contemporary dataset to examine what is most important to patients.
All of which allows us to point the way to some key quality improvements that acute trusts could be making.
The survey results make clear that many trusts have worked hard to get better at welcoming, informing, treating and supporting outpatients: on 25 indicators patients had a better experience in 2009 than in 2004, and a worse one on only five.
On access, for example, it is now vastly quicker to get an appointment: 73% of patients reported waiting less than six weeks in 2009, compared to 57% in 2004.
More patients say outpatient departments are clean: 61% rated them ‘very clean’ in 2009, compared to 53% in 2004.
Patients are getting more time with the doctors, and greatly improved explanations of why they need tests, how to find out the results and what those results mean.
A couple of lessons arise from work that the Picker Institute Europe has done with individual trusts to learn from their outpatient results.
One is to look closely at what patients are reporting about different specialties. Even within a well performing trust, some categories of patient are having poorer experiences than others.
Table 1 shows how, at a sample of client trusts, ear, nose and throat and urology patients received much poorer communication from doctors than cancer patients, making these specialty areas the potential focus for improvement.
Having identified this kind of problem, some trusts are putting in place specific small initiatives, such as supporting patients before their consultation to draft three key questions to ask the doctor.
Whipps Cross University Hospital NHS Trust responded to their results by employing an Outpatient Customer Care manager to oversee a range of such actions – see Box 1.
Further improvement: information around discharge
But there are bigger improvements required, too, particularly in supporting vulnerable patients with continuing care and treatment needs.
In a forthcoming paper, Picker Institute Europe will analyse which ‘core domains’ of outpatient experience have the closest relationship to patient satisfaction.
These will include cleanliness, time with the doctors, and information about tests, where, as noted above, gains have been made.
But one core domain where experience could be much better is ‘information around discharge’. This consists of three indicators, showing whether a member of staff told the patient about:
- medication side effects to watch for
- danger signals to watch for
- who to contact if they became worried later on about their condition or treatment
We suggest the results here mean that trusts should switch some of the focus they have been putting on access, reception and waiting to the events that happpen before patients depart.
Medication side effects
Just over a quarter of the survey respondents (28%) were prescribed a new medicine. Of these, only 45% said staff had completely explained about possible side effects. Although this is up 2% since 2004, it still leaves more than half of these patients with too little information about their treatment.
This represents a significant failure to fulfil the rights of patients as stated in the NHS Constitution, and the duties of doctors as specified in ‘Good Medical Practice’.
Chart 1 shows how the proportion of patients answering ‘yes’ varied by 56 points — from 82% at the best performing trust to 26% at the lowest.
Asked whether staff had told them about danger signals to watch out for, only 46% of patients said ‘yes completely’. This was up 5 percentage points since 2004 but remains too low.
Another 22% of patients said ‘yes, to some extent’. So that leaves one third of patients who were not told, and others with partial information.
Chart 2 again shows huge variation, from 71% answering ‘yes, completely’ at the top performing trust, to just 40% at the lowest.
Who to contact
Patients with continuing health problems need to know clearly who they should contact if they subsequently have concerns about their condition or treatment. In 2009, 66% of outpatients said they were told. This has improved from 62% in 2004 but still leaves one third of patients without this significant information.
Chart 3 shows the scores ranged from 87% saying ‘yes’ at the top trust, to barely half, 57%, at the bottom.
Trusts whose scores are low on the ‘information around discharge’ domain, could gather useful lessons for improvement from the practice of other trusts in their region.
For Table 2 we ranked the performance of all trusts across three of the core domains that have strong effects on patient satisfaction:
- Whether the issue for which they went to outpatients was dealt with
- Interaction with doctors
- Information around discharge
The table reports one general acute trust for each of the non-London regions, that has scored well on these three indicators.
Specialist hospitals were excluded as they typically cater to a unique and specialised patient population and are difficult to compare with general hospital trusts, so any lessons may not be transferable. However, in London, where patient experience scores are often low, specialist hospitals may have to be used as the exemplars.
Outpatients’ experience of care and treatment is a success story, with great improvements since 2004.
Acute trusts that want to improve further should consider:
- Targeting the less improved specialties
- Specific support to outpatients, as at Whipps Cross
- Learning from good performers in their region, and
- Focusing less on access, and more on information-sharing before discharge
These results have relevance to the whole local health economy. As the NHS in England attempts to deliver more integrated care, closer to home, it is vital that patients are given the information and support they need to make seamless transitions across care settings.
Table 1: variation in outpatient experience by main specialty, in a sample of client trusts
Doctor did not always give clear answers to questions, or the patient did not have an opportunity to ask
Top 10 specialties by number of respondents
|3=||Trauma & Orthopaedics||29%|
Box 1: Whipps Cross
· The customer care manager and lead nurse for outpatients are available in the department throughout the day to deal with concerns or complaints on the spot. This increased visibility helps clinics run smoothly.
· Reception guidelines and scripts for receptionists
· A service desk call centre for receptionists allows them to deal with queries for all clinic areas
· Some clinics open in the evening with staff available to signpost patients.
· If appointments are delayed more than 45 minutes a tea trolley is taken to the waiting area offering refreshments
· Patients delayed for more than 2 hours can claim a car parking charge refund
· A running board welcomes people to the hospital and provides information on current clinic waiting times
· A visual information board highlights issues including the importance of returning clinic outcome forms
· Colouring books provided for all children to help occupy them whilst waiting with their family
· “Just a minute” comment cards gather ongoing feedback
Chart 1: information about side effects of new medication, variation across trusts
Chart 2: whether staff gave full information about danger signals, variation across trusts
Chart 3: whether staff gave clear contact information, variation across trusts
Table 2: by region, examples of hospitals performing well on three core domains of outpatient experience
|North West||Countess Of Chester Hospital NHS Foundation Trust|
|North East||Northumbria Healthcare NHS Foundation Trust|
|Yorkshire & Humberside||Harrogate and District NHS Foundation Trust|
|East Midlands||Nottingham University Hospitals NHS Trust|
|West Midlands||Sandwell and West Birmingham Hospitals NHS Trust|
|East of England||Hinchingbrooke Health Care NHS Trust|
|South West||Salisbury NHS Foundation Trust|
|South Central||Winchester and Eastleigh Healthcare NHS Trust|
|South East Coastal and Kent||Frimley Park Hospital NHS Foundation Trust|
Don Redding, associate; Jason Boyd, former research associate; and Danielle Swaiin, quality improvement manager, at Picker Institute Europe.
- Acute care
- Care Quality Commission (CQC)
- COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
- FRIMLEY HEALTH NHS FOUNDATION TRUST
- GP practice management
- HARROGATE AND DISTRICT NHS FOUNDATION TRUST
- HINCHINGBROOKE HEALTH CARE NHS TRUST
- Long-term conditions
- NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST
- NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
- Patient experience
- Picker Institute
- Public and patient involvement
- SALISBURY NHS FOUNDATION TRUST
- SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST
- WHIPPS CROSS UNIVERSITY HOSP NHS TRUST
- WINCHESTER AND EASTLEIGH HEALTHCARE NHS TRUST