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Targets to reduce outpatient numbers ‘risk’ exacerbating GP pressure, NHS England admits

Targets to reduce outpatient numbers ‘risk’ exacerbating GP pressure, NHS England admits

By Costanza Potter
31 May 2022

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NHS England has admitted that its policy to reduce outpatient appointments risks putting ‘added pressure on primary care’.

Under national targets for 2022/23, trusts have been asked to reduce outpatient follow-ups and expand the uptake of patient initiated follow-up (PIFU) – where patients are given appointments when they request them rather than at routine intervals – in all major outpatient specialties. 

But recent NHS England guidance on implementing PIFU said one of the policy’s ‘risks to quality of care’ is putting ‘added pressure on primary care’.

It said: ‘Patients may forget when and how to get in touch during the time they are on PIFU or they may not want to “bother” services, leading to worse outcomes or added pressure on primary care.’

It added that ‘mitigation measures’ could include sending patients ‘reminders’ and developing patient information leaflets and videos.

The risk could also be mitigated by keeping patients’ GPs ‘informed so they can signpost the patient to the service if required and so that they understand when they should inform secondary care about risks, eg if a patient is diagnosed with a new condition such as dementia’, it said.

The guidance added that if patients are ‘unable to book their [follow-up] appointments directly’, their GP practice administrative staff ‘may be able to help’.

A template standard operating procedure published alongside the guidance said that the patient’s GP will be contacted with ‘guidance on the symptoms and how and when the patient should request a follow-up’ and notified when the patient is discharged from the programme.

Patients who request an appointment after their PIFU timescales have expired will need a new referral through their GP, it added.

National targets to reduce outpatient appointments

NHS England operational planning guidance for 2022/23 asked providers to reduce outpatient follow-ups by a ‘minimum’ 25% against 2019/20 activity levels by March 2023 but ‘going further where possible’.

It also said they should expand the uptake of patient initiated follow-up (PIFU) in all major outpatient specialties, with 5% of outpatient attendances to be moved or discharged to PIFU pathways by March 2023. 

Meanwhile, separate NHS England guidance published at the same time on delivering a ‘personalised’ outpatient model said that reducing outpatient appointments will not transfer follow-up to ‘capacity-constrained’ general practice without a ‘coherent’ plan.

It said: ‘Through this more personalised approach to outpatient follow-up appointments, patients can expect their care needs to be dealt with faster and closer to home where appropriate. This will be done in a way that improves overall efficiency, while not transferring follow-up to capacity-constrained services in the community and general practice without a coherent system plan.’

It remains unclear what such a plan would entail, but the guidance added that preparation for the new model should ‘include understanding of core concerns’ from primary care.

It added that adopting a personalised outpatient approach has the ‘potential to reduce pressures on primary and community care’ if system working is ‘embedded from the onset’ and ‘sufficient information and patient access is provided’.

The guidance reiterated that clinical time gained by reducing outpatient follow-up activity could be ‘repurposed’ for an increase in ‘primary care support/interface’ such as advice and guidance (A&G).

It said: ‘Trusts should consider how released capacity from outpatient follow-ups could be repurposed to activities that support primary care or are commissioned from primary care, for example through the increased provision of specialist advice and guidance.’

However, it added: ‘At one pilot trust, initial discussions around increased specialist advice implementation revealed the need to build further communication channels and educational tools with primary care to support the programme.’

A&G involves GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.

Final NHS England elective recovery planning guidance last month confirmed plans for this year’s 10% increased elective activity target to be predominantly achieved through increased GP advice and guidance (A&G).

The plans were first revealed in draft guidance seen by Pulse in March, which set out that GP A&G ‘could contribute an estimated six percentage points’ towards the target of ‘over 10% more’ activity.

The Government’s long-awaited elective recovery plan – published in February – also stressed that GPs’ role in tackling the NHS hospital backlog will focus on the use of A&G to try to avoid ‘unnecessary’ referrals to secondary care.

But Government auditors have warned against ‘overloading’ GPs in clearing the elective backlog and the Public Accounts Committee has said even if the NHS meets its targets for elective care, one million more patients will be on the waiting list posing a ‘huge risk’ to primary care.

It comes as NHS England has said that pandemic recovery for general practice should have the ‘same focus as elective care’.

This story first appeared on our sister title, Pulse.

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