The Scottish Government

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ISBN 0 7559 4880 7

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Introduction

Patient Focussed Booking ( PFB) is a new approach to booking outpatient appointments in NHSScotland. The £2.5m project, funded by the Centre for Change and Innovation ( CCI) Outpatient Programme, was launched in November 2003 and involves 14 Health Boards.

This short booklet has been produced to explain PFB and outlines why it represents an improvement to traditional booking processes. It also illustrates the impact to date and describes how the process could be extended to other parts of the NHS in Scotland.

What is PFB?

Very simply, PFB puts patients at the heart of the booking process by engaging them in dialogue about their appointment. Previously, patients would be sent an appointment letter, with the date and time of their appointment, no matter how far ahead in time that may have been. When the appointment day came, patients may have no longer required the consultation, may have forgotten to turn up or booked clinics may have been cancelled.

With PFB, patients are sent a referral acknowledgment letter, indicating the likely wait for their appointment and explaining that they are on a waiting list (non-routine patients are clinically prioritised to by-pass this process and will always be seen first).

As the patient nears the top of the waiting list, they receive a further letter inviting them to telephone to arrange an appointment. The process is complemented by a policy that prevents a clinic being cancelled with less than six weeks' notice. Therefore, when the patient phones, the appointment options are limited to only those clinics scheduled in the next few weeks.

The call operator offers a choice of dates and times and the patient chooses the most convenient to them. If the patient fails to phone following a reminder, after checking contact details, a further letter is sent to the patient and their GP, explaining that they have been removed from the waiting list.

What patients think . . .

"I cannot see that it could be improved - with telephone booking, hopefully, everyone is happy!"

"For someone travelling from the North it was a lot more convenient being able to make an appointment around work and family commitments and not having to set off too early."

"I appreciate the flexibility of this service."

"I wanted a later date and this was no trouble at all."

"I thought it was better as I could say when it was suitable for me to come without changing work."

"I was told I had to come on a Wednesday morning - why so restrictive?"
- inevitably some clinics occur less frequently and choice may be limited to time of appointment.

"This new system is an improvement on previous system for appointments."

"The initial wait for appointment was excessive"
- PFB improves queue efficiency and reduces cancellation and DNA rates, which will help to achieve the 18-week maximum outpatient wait standard by the end of 2007.

"Phone was engaged for some time but I did phone early so perhaps everyone who had received their letter that morning was ringing"
- flexible staffing, call queuing systems and ring-back facilities can improve the service.

Why use PFB?

1. Patients are listed according to date of referral, so letters are always sent to the longest waiting routine patients, ensuring that they are invited to phone in order (clinically prioritised patients are always seen first);

2. Patients have a choice. With PFB, the patient instigates the dialogue about their appointment and can choose a date and time that is more suited to their lifestyle. Data shows that patients are far more likely to attend as a result;

3. Less administrative staff time is spent cancelling and rearranging appointments;

4. No action is taken to allocate resources to the patient's care until they have contacted the appointment centre to confirm attendance, at which time contact details can also be updated;

5. PFB complies with Scottish Executive Health Department guidance on New Ways of Defining and Measuring Waiting Times.

Patient and staff feedback

In September 2005, patients attending dermatology outpatient clinics across Scotland were asked to feedback on the PFB process. Over 700 responses were returned, revealing that 98% of patients were happy to telephone to arrange their appointment and 97% were happy with the appointment they received. However, 10% of patients had difficulty contacting the hospital and project sites are working to improve this.

A survey of over 150 staff across NHSScotland was also undertaken. Half of the respondents were actively involved in implementing PFB and 43% had experienced a change in their job role. 65% of respondents felt that PFB has had a positive impact on the patient experience of the service. When asked what aspects of the service have been improved by PFB, "patient communication" and "waiting times" were the most common responses.

12 key conditions for making PFB a success

During the lifetime of the project a number of lessons have been learned and are listed below as key conditions for making PFB a success. Whilst each of these is deemed to be important, the list has been prioritised by local PFB project managers, based on their experiences of PFB implementation:

1. Outpatient IT system capable of operating PFB;

2. Senior managerial and clinical leadership and support;

3. Dedicated project management for implementation process;

4. Appropriate on-going staffing of appointment centre/medical records;

5. Effective telephone system providing accessible service to patients;

6. Robust clinic cancellation and patient non attendance policies;

7. Good communication and collaboration with all stakeholders;

8. Clean, validated waiting lists prior to PFB implementation;

9. Clear, informative patient information;

10. Review of clinic profiles;

11. Acknowledging circumstances where PFB may need to be adapted;

12. Centralised booking process.

Circumstances where PFB may require adaptation

There are circumstances where the introduction of PFB, as described above, could complicate the booking process. However, where these exist, consideration should be given to adapting the process to incorporate patient choice and to improve attendance rates. This includes where …

• waiting times are less than 6 weeks;
• patients need to be seen within 6 weeks;
• clinics are arranged with less than 6 weeks' notice;
• very specific appointment dates need to be arranged, e.g. obstetrics;
• multiple appointments with set times need to be arranged.

What staff think . . .

" PFB has undoubtedly led to a reduction in our waiting times below the magic 26 weeks."

"One of the most positive initiatives I have been involved in!"

"Patient feedback has been very positive and I have noticed excellent improvements in DNA rates."

"It has had little impact on my practice as I still see the same number and type of patients as before"
- apart from improving attendance rates, consultants should notice little difference to their clinics. The good work goes on behind the scenes.

"Patients comment that there has been an improvement in communications regarding their appointment."

"One central appointment office would have made it easier"
- centralising the appointments process can provide economies of scale, leading to more efficient waiting lists and increased patient choice.

"Hopefully the service can be expanded for return patients where maximum benefit will be realised."

" PFB has enabled clinics to be better utilised thus reducing wasted consultant time."

What next?

PFB does not end with new outpatient appointments. The generic benefits of decreased DNA and cancellation rates, improved queue management and patient choice are equally valuable when applied to other aspects of planned care. CCI will support the extension of PFB to:

• return outpatients (six NHS Boards have already introduced this);
• inpatients and day cases;
• diagnostic tests;
• patient transport booking (alongside appointment allocation).

"NHSScotland has embraced this new way of booking outpatient appointments and patients are now offered real choice. This, coupled with creating more efficient management of waiting lists, has helped to drive down waiting times.

The Health Department will continue to support the development and roll out of PFB through future programmes of work, to ensure that similar benefits can be realised in other parts of the NHS."

Kevin Woods, Chief Executive, NHSScotland

Further reading

• Scottish Executive Health Department (2005): New ways of defining and measuring waiting times (interim guidance);
• Centre for Change and Innovation (2005): A guide to service improvement - tools and techniques for the delivery of modern healthcare;
• Centre for Change and Innovation (2005): Fundamentals of 21st-century outpatient services - demand, capacity, activity and queue;
• National Leadership and Innovation Agency for Healthcare (2005): A guide to good practice - elective services.

Further information

For more information visit the Centre for Change and Innovation website at www.cci.scot.nhs.uk

The success of PFB in Scotland is attributable to the dedicated staff involved with each local project. In particular, recognition goes to the following local project managers, who can also be contacted should you want to find out more about PFB in your locality:

If you have any other comments or queries about PFB, please contact cci@scotland.gsi.gov.uk

"Patient Focussed Booking is a practical way of offering patients a choice of outpatient appointment and adhering to New Ways guidance"

Dr H Burns, Chief Medical Officer

This document is also available on the CCI website: www.cci.scot.nhs.uk