The complete slide deck from the Nuffield Trust and NHS Improvement's joint 'Transforming outpatient services' event on the 21st November 2017.

4. Referral Management:
Candace Imison, Director of Policy
What does the evidence tell us

5. A growing imperative to manage referrals

6. What’s the evidence?

7. Ten fold variation in rate of GP referral
Source: Imison & Naylor, 2010

8. Source: Imison & Naylor, 2010

9. A variety of approaches to GP referral
management
Source: Imison & Naylor, 2010

10. Management – tackles a variety of factors
Source: Imison & Naylor, 2010

11. Questionable Value for Money
• Referral management centres carry a large overhead cost that is
likely to outweigh savings from any reductions in referrals.
• BMJ FOI request to CCGs - only 10/72 CCGs able to demonstrate
any savings from referral management schemes.
• Any strategy to reduce over-referral may also expose under-referral.
• Reductions in referrals from one source can be negated by rises
from other sources, so any demand management strategy needs to
consider all referral routes and not just target one.
Source: Imison & Naylor, 2010

12. Source: Imison & Naylor, 2010

13. Impact of secondary care referral assessment
service
Wolverhampton Gastroenterology Services
• Secondary care clinicians (gastroenterology) assessed referrals for
appropriateness
• Used electronic proforma
• Systematised pathways of care for most common patients
Impact
• 32% patients discharged to primary care with letter of advice
• 60% patients offered outpatient appoints – 23% had bloods
arranged in advance
• 5.2% directed to other specialists
• DNA rates fell – 14% -> 8.5%
Source: Pelitari et al, 2017 GUT - BMJ
http://gut.bmj.com/content/66/Suppl_2/A8.1

14. Any referral management system requires strong
governance
• Strong governance needed to manage clinic risks and potential
conflicts of interest
Clinical risks
• Ensure appropriate referrals are not being diverted => late or
missed diagnoses and treatment.
Conflict of Interests
• General Practice
• Referral to alternative GP led or delivered services in which
GP has financial interest.
• Secondary Care
• Holding on inappropriately to activity for which the
provider will be paid.

18. CONNECTING CARE FOR CHILDREN
DR BOB KLABER
Imperial College Healthcare NHS Trust
@bobklaber @CC4CLondon
Transforming outpatients services

19. CC4C Logic Model - Adapted August 2017 from CC4C/CLAHRC Early Years 2014 A:E
diagram
Mando.Watson@nhs.net M.Blair@imperial.ac.uk bob.klaber@nhs.net
THE LOGIC BEHIND OUR MODEL OF CARE:
GLOBAL
AIMS
PRIMARY
DRIVERS
Some examples of
SECONDARY
DRIVERSIncrease shared knowledge
about services
Focus on connections and
relationships
Increase parents and
professionals capability in
child health issues
Include whole population
to drive prevention &
improve equity
Focus on outcomes that
really matter to patients
Better quality of care
Better population
health
Reduced per capita cost
Better staff experience
Inter-professional support
= OPEN ACCESS
Professional education
packages = SPECIALIST
OUTREACH
Patient support &
education = PATIENT &
PUBLIC ENGAGEMENT

20. • 3-5 GP practices within
existing locality
• ~20,000 practice population,
(~4,000 children)
CHILD HEALTH GP HUB
• 3 core elements
• Centred in primary care
• Built around monthly
MDT and clinic

21. DEMONSTRATING VALUE AND BENEFITS
Improved
patient
experience of
care
Reduced per-
capita cost
Improved
staff
experience &
learning
Improved
population
health

22. Reference: Montgomery-Taylor, S., Watson, M., & Klaber, R. (2016). Child health general
practice hubs: a service evaluation. Archives of disease in childhood, 101(4), 333-337.
USE OF HOSPITAL SERVICES

23. NEW CARE MODELS IN CHILDREN –
DESIGN PRINCIPLES
1. Focus on connections and relationships; NHS services can be minimally
changed, while their capability and capacity are maximised
2. Harness existing strengths: put GP practices at the heart of new care models
- specialist services are drawn out of the hospital to provide support & to help
connect services across all of health, social care and education
3. Include the whole population, (using segmentation to create bundles of care)
to drive prevention and improve equity
4. Health seeking behaviours improve through peer-to-peer support
5. New approaches to care to be co-designed with children, young people,
parents, carers and communities
6. Focus on outcomes that really matter to patients
7. Use education and development, for the whole multi-professional team, as a
key way to build relationships and finding new ways to work together

25. Transforming Outpatients:
Was Not Brought
(not DNAs)
Jenny Handforth
November 2017

26. Was not Brought rather then DNA
• ‘WAS NOT BROUGHT’
• CHANGING THE MIND-SET OF:
• the admin teams
• the clinicians
• JUNIOR DOCTOR INDUCTION
• ADMIN INDUCTION
• YOU TUBE CLIP; RETHINKING ‘DID NOT ATTEND’-
NOTTINGHAM SAFEGUARDING TEAM

27. 27
What did we do?
PDSA
• Designated OPD transformation team-clinicians/Admin/AHP
• Review of patient journey
• Identification of red flag areas
• Patient experience
• Data analysis of trends/hot spots
• Brainstorming of ideas for next steps
• Lean modelling of pathways
• Allocation of projects
• Analysis of data again
• Revision and further tweaking

28. 28
Key aspects
• Admin
• Communication
• Letters
• Dr Dr
• Telephone reminders
• Clarity re Contact number for families
• SARD use
• Outcomes/PIMS timeliness/accuracy
• Lean work-shadowing admin team
• Clinical
• SARD-universal for all leave-no exceptions
• Trust cancellation policy enforced
• Red flag escalation policy
• Trend analysis
• Lean work around clinic cancellations
• Risk register
• Outcomes
• Multiple DNAs
• Waiting list back log impact awareness
• Clinician scorecards

29. 29
Ongoing
Monthly OPD Transformation team meetings
• Trends and Patterns
• RCA and Insights
• Actions set and progress to date reviewed
Monthly Report
• Historic backlog to SM and HoS
Weekly Reports
• Completion data to SM and HoS
• Error report for reception team to action
• Multiple DNAs/cancellations from previous week sent to clinicians for active plan
Weekly
• Admin/nursing/OPD staff engagement with clinicians-re outcomes and DNAs
• Benchmarking against other clinical areas
Evelina Access policy in draft

30. WNB/DNA Trends
WNB/DNA Rates
remain low at around
8-9%

31. Scorecard
Children's Medical Services

32. Scorecard
Children's Surgical Services

33. What else is going well?
• % missing notes remains
consistently low below 5%
• Clinic room utilisation consistently
high since new consultants
commenced posts in Q4 16/17.
• Reduction in number of short
notice avoidable cancellations
following stricter approach from
DMTs, red flag system, letter
from OP clinical lead.
• 96% parental FFT
recommendation

34. What is going less well?
No improvement in:
• reducing follow up backlog
• reducing delay to start of appt
• increasing outcome
completion

35. Any Questions?

37. Value based design of Geriatric Care
Tom Downes
Clinical Lead for Quality Improvement, Sheffield Teaching Hospitals
21st November 2017

38. Gastroenterology Service
Ryhov Hospital, Jönköping, Sweden

39. The Big Room
(Obeya)

40. PDSA cycle 1
One patient, one day
• Current system takes ~3 months from seeing GP to
receiving a management plan
• Prediction: shorten this to under 8 hours in a single visit
• Completed in 3hrs 10mins
• Patient and daughter left with written management plan
in hand

42. Sheffield Frailty Assessment Unit
Opens 4th December 2017

43. Sheffield
Frailty
Assessment
Unit

44. www.sheffieldmca.org.uk/flow

45. FCA Sheffield
FCA Bath
Flow Coaching Academy Programme
FCA Imperial
FCA Northumbria
FCA Northern Ireland
FCA Birmingham
FCA Exeter

47. Transforming outpatient Services
Bibhas Roy
Consultant Orthopaedic Surgeon (Shoulder & Elbow)
Central Manchester Foundation Trust
Health Service Journal Top Innovator 2013
MIMIT, Manchester Interdisciplinary Biocentre
www.proms2.org

49. OUTPATIENT CLINICS; THE NUMBERS (DEC 2016)
o 113.3 Million outpatient appointments in
2015-16
o 89.4 (78.9%) Million were attended
• first attendances 31%(27.3 million out of
89.4 million)
o Hence 69% of outpatients appointments are
follow-ups
o Patients aged 65 to 69 had the highest
number of attendances
http://content.digital.nhs.uk/catalogue/PUB22596/hosp-epis-stat-outp-summ-repo-2015-16-rep.pdf

51. SPECIALTIES

52. VIRTUAL CLINIC
• Virtual clinic is a contact between the clinical team and the patient to plan
clinical care without direct face-to-face meeting.
• However, there is a lack of standard definition in the context of virtual clinics in
their descriptions, technologies used, services offered etc.
• The term has been used to indicate very different set of services

53. ATTRIBUTES OF VIRTUAL CARE DELIVERY
• What is it?
• Hi-Tech 
• Tele-something 
• Asynchronous 
• Outsourced 
• Anonymous 

54. VIRTUAL CARE DELIVERY
Real Patient Virtual Patient
Real Provider Traditional clinics
Patient accesses information before
exercising choice
Virtual Provider
Remote monitoring from the clinical
service team
Support groups, patients forums etc
Proc AMIA Symp. 2001 : 244–248. PMCID: PMC2243512
Virtual healthcare delivery: defined, modelled, and predictive barriers to implementation identified.
V M Harrop, MIT, USA.

55. PATIENT-REPORTED OUTCOME
MEASURES: AN ON-LINE SYSTEM
EMPOWERING PATIENT CHOICE
• Virtual clinic F/U - planned surgery
• ASAD
• Pre and post treatment data can be gathered for audit,
research, service improvement
• The focus is on reducing unnecessary follow up
appointments
• Uses PROMs to guide F/U 55

56. E-MAIL TO PATIENT

57. REGULATORY FRAMEWORK
• Data protection Act – 1998 (DPD -1995)
• General Data Protection Regulation - EU
• January 2012, the European Commission proposed a
comprehensive reform of data protection rules in the EU
• 14th April 2016 – adopted by European parliament
• 24th May 2016 enter into force
• 6th May 2018 applies as law to all of EU
http://eur-lex.europa.eu/legalcontent/EN/TXT/PDF/?uri=CELEX:32016R0679&from=BG

58. Consent also has to be a positive indication of
agreement to personal data being processed – it cannot
be inferred from silence, pre-ticked boxes or inactivity

59. VIRTUAL CLINICS AND DATA SECURITY
• New patient – clinician relationship
• Define roles and responsibilities
• Contracts and Consents (patients
are not employees, are
consumers)
• Patient information documents
and informed consents
• Security has to extend to patients

61. Developing a service based on
clinical risk for patients in
glaucoma
Fiona Spencer
Manchester Royal Eye Hospital

62. Managing Glaucoma in Manchester :
Capacity vs Demand
• Chronic condition, treatment, not cure
• Increasing aging population
• Increased case finding from optometry
• Success in keeping patients sighted
increases workload
• High risk/post-op patients means
frequent visits
• Less medical staff in SAS posts
• Manchester 13,500 glaucoma patients, 3
consultants in 2015
2010
4.9 million
>75 years
1.4 million
>85 year
2035
8.9 million
>75 years
3.5 million
>85 years

63. Engaging the wider workforce
• Developed team with visual scientist, lead optometrist
• Engaged with Local Optical Committee & Commissioners
• Trained optometrists in community in referral refinement:
GERS
• Trained optometrists in HES in glaucoma assessment &
management: OLGA
• Trained nurse practitioners in patient education: ‘Get a
Grip on Glaucoma’
• Trained ophthalmic science practitioners : Virtual Clinic
• Ensured new consultants were engaged and responsible
for area of development
• Developed post CCT fellowships: Consultant complex
clinics

64. Service based on clinical risk
• Referral refinement to triage new patients; reduce 40% false
positives
• New Optometric Led Glaucoma Assessment (OLGA) Clinics
• New patients invited to Education: ‘Get a Grip on Glaucoma’
• GEC Virtual Clinics for lowest risk patients (OHT/suspect)
• OLGA follow up clinics for moderate risk: also in community
• Consultant clinics for complex/high risk and surgical patients
• Interim GEC Virtual clinics for backlog/long waiters

65. Lessons Learned
• We have developed a ‘consultant light’ and ‘resource light’ service
• Developing the team was key: training and accreditation of roles
• Engaging with stakeholders/commissioners vital to share vision
• Audits/publications/patient satisfaction surveys to demonstrate
outcomes
• Ensuring new consultants have ownership strengthened service
• Takes time to develop the service!

68. Delivering a digital appointment service
Guy’s and St Thomas’ and DrDoctor
Emma McLachlan
Programme Director, Digital Patient Journey

69. What we set out to achieve
Provide a quality digital service for patients to enable appointment booking and management with
additional content (location & preparation information) to support each appointment
Patient
experience
A&C timeDNAs

70. The majority of our outpatients (and inpatients) receive
timely confirmations and reminders via SMS
You have an appointment
booked: Mon 3rd July at
1.30pm at Guy’s and St
Thomas’ Trust
- Text CHANGE for
alternatives, CANCEL if
you don't want to be seen
- View more info and
manage this appointment
online by visiting
https://nhs.my/demo
- For any queries please
call 0207 188 7188

71. Content available via the web to help patients prepare for
and locate appointments
71
You have an
appointment booked:
Mon 3rd July at 1.30pm
at Guy’s and St
Thomas’ Trust
- Text CHANGE for
alternatives, CANCEL if
you don't want to be
seen
- View more info and
manage this
appointment online by
visiting
https://nhs.my/demo
- For any queries please
call 0207 188 7188
You have an
appointment booked:
Mon 3rd July at 1.30pm
at Guy’s and St
Thomas’ Trust
- Text CHANGE for
alternatives, CANCEL if
you don't want to be
seen
- View more info and
manage this
appointment online by
visiting
https://nhs.my/demo
- For any queries please
call 0207 188 7188
You have an
appointment booked:
Mon 3rd July at 1.30pm
at Guy’s and St
Thomas’ Trust
- Text CHANGE for
alternatives, CANCEL if
you don't want to be
seen
- View more info and
manage this
appointment online by
visiting
https://nhs.my/demo
- For any queries please
call 0207 188 7188

72. We have achieved a 2.4% reduction in DNA rates
A&C timePatient experienceDNAs
• 91% of patients would
recommend or highly
recommend the service
(poll of ~1000 patients in
2016)
• Patients have the choice to
manage their appointments
through convenient digital
channels – reducing their
need to rely on telephone
contact
2016/17
• Contributed to a 2.4%
reduction in DNA rate within
outpatients which led to
£2,600,000 increase in
revenue through
attendance of 14,316 more
appointments
• No time saving for A&C
staff from confirmation and
reminder service
• Limited time saving on self-
serve booking as manual
process still required to
input patient details into
PAS on receipt of referral
(NB – ERS will reduce
demand by 40% for new
appointments)
• Patients mostly still calling
the hospital to change
appointments with < 3%
using SMS/web
change/cancel service

73. 73
Lessons learned

74. Lessons learned
1. Implementation requires focussed resource – critical to have overarching ‘super users’ to
support service managers in addition to focus from central ops to ensure standardisation and
troubleshoot. Staff at SM level have a high churn and therefore central management is key
2. We are adding – not removing – process – administrative teams must now deal with parallel
processes to manage appointment changes – attending to inbox as well as manning phones.
This does not reduce time unless the service is fully automated
3. Limitations of existing PAS – full automation is hard to achieve with legacy systems that have
no/limited logic around scheduling and appointment types e.g. linked appointments, order of
appointments
4. One size doesn’t fit all – not all services have seen DNAs reduce. We need to look harder at
the reasons why people DNA – motivation, fear, lack of preparation and find other ways to
counteract those
5. The role of content… we want to look at trigger based communications that lead people to
targeted content relevant to each patient e.g. timely reminder to ensure you’ve prepared the food
you need to bring in for Paeds Allergy clinic or video from surgeon sent 36 hours prior to
operation to assure patient and request they contact us with any concerns

75. 75
Thank you.
Emma McLachlan
Programme Director, Digital Patient Journey
emma.mclachlan@gstt.nhs.uk

77. Inform and Transform – Outpatient
Services
Steve Ryan, EPR Programme Manager
Katie Squire, Informatics and myhealth Programme Manager

78. Facts and Figures
• Over 9000 staff
• 1213 beds, 100 critical care beds, 32 theatres,
• Circa 762,000 outpatients, 135,000 inpatients;
115,000 ED attendances
• UHBfT and Heart of England working together,
potentially a single organisation serving a diverse
population of 3.2 million
• Global Digital Exemplar committed to acceleration of
EPR programme utilising in-house IT development and
Informatics

79. Patients - “No decision about me without me”
• Patients want to be part of their health care
• Give patients more control, they will take more responsibility
• Patients will contribute to improving the efficiency of the service

80. “My Grandfather was a doctor 50 years ago and he
used to run his OP clinic in the same way that I do.
A change is overdue”
James Ferguson
Consultant Hepatologist & UHB Clinical Lead for the MyHealth Patient
Portal
Clinicians – ‘Grandfather to Grandson, what’s changed?’

81. Transforming outpatients at UHB
Paper notes
Separate,
spread out
OPD
locations.
Electronic
systems for
clinicians
Centralised
OPD location.
Electronic
systems for
patients and
clinicians
Centralised
and virtual
locations.
2011 2017

82. 2011 – removed paper notes from OPD
Prescribing, clinical notes and GP letters created in PICS pulling in patient details
and medicines information into predefined templates to standardising letter
layouts.

83. • Patient portal developed in-house by the IT and
Informatics teams
• Approached by long distance, long term care patients
in 2011
• 14 Specialities in 2013  now 40 (Oct 17)
• 2400 active users in 2013  now 9088 (Oct 17)
• 17601 patients signed up (Oct17), 51.7% activation rate
• No age barrier
• Access to letters, medications, results and can
contribute to record
UHB MyHealth Patient Portal

84. Patient feedback
• 92% of patients stated they think myhealth has been beneficial in improving their
involvement in the healthcare they receive.
• 24% of respondents have displayed or reviewed their myhealth record during an
appointment.
• The majority of respondents (94%) use myhealth for less than 1 hour, and for a few times a
month (58%).
• The 3 sections accessed the most are the calendar (22%), letters (29%) and results (30%).
• 56% of respondents informed us that myhealth has saved them from telephoning the
hospital and 12% that it had saved them from making an appointment.
• In addition 24% stated myhealth had prompted a call to the hospital and 8% stated that
myhealth had prompted them to make a hospital appointment.

85. myVirtualClinic
• Accessed through myhealth@QEHB
• Allow follow-up patients to
undertake a video consultation with
their clinician from the comfort of
their own homes
• Commissioners have agreed a face to
face tariff for the pilot only
• Benefits include
– Reduced patient travel times
– Reduced expenses for patients
– Patients can take less time off work for
appointments
– Improved record of consultation
– Patient involved in creating their
health record and plan
– Free up more clinic capacity – arguably

88. myVC Patient feedback
• Saved one patient and a family member the day off work and over £50 in expenses
• Patients keen on alternating virtual appointments as they would like to maintain
face-to-face contact
• “I really got a lot out of it and I think it is a very good solution for people like me”
(Lives in Manchester)
• “Making audio recordings available is a big step towards empowering patients with
greater access to their healthcare records”

89. Data Collector

90. Further discussion and questions

92. VOCALVirtual Online Consultations:
Advantages and Limitations
Joe Wherton
Nuffield Department of Primary Care Health Sciences
University of Oxford

93. Aim
To define good practice and inform its
implementation in relation to clinician-
patient consultations via Skype™ and
similar virtual media.

94. Preliminary experience with remote consulting in Diabetes service –
‘DREAMS’ Study (2011-2014)
• 104 patients opted for Skype
• 480 Skype consultations documented
• popular with both patients and staff
• Associated with increased engagement: lower did not attend rates for
Skype (13%) compared to face-to-face (28%)
• Improvement to glycaemic control (HbA1c)
Background

95. 1. What defines ‘quality’ in virtual consultations and what are the barriers to achieving this?
2. How is a successful virtual consultation achieved in an organization whose processes
and systems are mostly orientated to more traditional consultations?
3. What is the national-level context for the introduction of virtual consultations in NHS
organizations and what measures might incentivize and make these easier?
VOCAL:
Virtual Online Consultations: Advantages and
Limitations
(2015-2017)

96. Study Design
Two clinical settings: Diabetes and Cancer Surgery
MICRO: Interactional dynamics via Skype by generating a multi-modal
dataset (audio, video and computer screen capture).
MESO: Map the administrative and clinical processes that will need to
change to embed online consultations
MACRO: National policymaker and other key stakeholder perspectives

97. Study Design
Two clinical settings: Diabetes and Cancer Surgery
MICRO: Interactional dynamics via Skype by generating a multi-modal
dataset (audio, video and computer screen capture).
MESO: Map the administrative and clinical processes that will need to
change to embed online consultations
MACRO: National policymaker and other key stakeholder perspectives

98. • Trust policy and service agreements
Technical support, Information Governance
• Management and administration
Recording attendance, Appointment scheduling
• Clinical practice
Patient enrollment and setup, Medical documentation, Patient initiated
contact
Organisational change
(meso level)

99. • Guidance and SOP documents
• Inform routine practices
• Facilitate coordination and shared learning (e.g. working group)
Supporting service development

100. What next?
Health Foundation Scale up award
Seek to support spread of virtual consultation services by:
• Creating a virtual consultation unit (VCU) to facilitate local and national roll-out,
and sustained improvements
• Developing a national network, with new sites acting as local hubs for further
spread
• Working with national-level decision makers to jointly develop standardised
policy (e.g. on tariff, quality assurance, staff training)
• Evaluating the work, continually reflecting on mechanisms for change