01 Demand
Outpatient demand may be difficult to measure as it encompasses all requests for a service. This will include new patient referrals from GPs, tertiary referrals and return appointments.
NHSScotland does not currently record demand for services. Information Services Division ( ISD) collect and collate the numbers of new referrals to consultants, however, this does not reflect the full extent of demand for services (as defined above) nor describe the nature of the demand. As it is believed that the nature and volume of demand is changing with the ageing population, understanding demand is even more important.
Actively measuring, analysing and managing demand for consultant services facilitates planning of services and evidence for resource allocation and utilisation.
NHS Boards bid for funding for projects that would allow them to better manage demand. Projects attempted to identify and direct demand or provide alternative pathways for previously identified patient groups, thus changing demand to consultants.
Some projects changed demand on consultant time by providing alternatives to consultant return appointments. This changes the new to return ratio, that is, more new patients can be seen providing quicker access for those requiring diagnosis.
Illustrations
In NHS Tayside, referral management was introduced alongside community outpatient services in orthopaedics. Over the course of the project 71% of referrals were directed to primary care-based services with only 1.2% requiring a consultant opinion.
NHS Greater Glasgow and Clyde (formerly NHS Argyll and Clyde) introduced physiotherapy-led low-back pain clinics in seven community sites. Patients can access this service through their GP or direct through self referral. Referrals to the service have increased from 55 in July 2005 to 250 in November 2005. In the first four months of the service only one patient was referred on for consultant opinion.
NHS Lanarkshire introduced a community-based vascular service. A multidisciplinary team see approximately 500 patients per year and the onward referral rate to consultants is only 16%. The average clinic wait is five weeks. This has contributed to a reduction in the waiting time to see a vascular consultant from 73 weeks to 15 weeks.
In NHS Borders, a multidisciplinary team has been set up to treat orthopaedic patients. The service has only referred on 15% of all patients seen, saving a total of 264 consultant patient appointments. The waiting time to see the multidisciplinary team has been consistently 13 weeks shorter than the consultant waiting time.
NHS Grampian has been running a dermatology telephone helpline for patients since March 2005. Over the nine months the telephone line has been running they have received 124 calls from patients; 60% received telephone advice, 30% were referred to a nurse, 5% were referred to a doctor (5% were wrong numbers). Not only has this service saved outpatient appointments, it has enabled patients to access specialist care immediately.
NHS Tayside has established a digital referral service for skin cancer patients in 34 GP practices. An image of the lesion is taken at the GP practice and is electronically sent through to consultant plastic surgeons at Ninewells. The images are vetted by the consultants and either management advice for primary care or an appointment for the patient is given to the GP. Over the life of the project, 300 electronic referrals were made to the plastic surgery department at Ninewells. Of the 300 patients audited, only 57 required an outpatient appointment, releasing 243 consultant plastic surgeon outpatient appointments. The waiting times for this service, from referral to vetting, has also reduced from 10.5 days to two days over the life of the project.
Local Learning Points
"Changing historical referral patterns takes time to achieve. Being aware of this, being patient and providing ongoing support and communication to GP practices is time well spent."
"Onward referral to other specialities when indicated has received a mixed reception. Some consultants made it very clear they would not accept referrals from an ESP even on the recommendation of the orthopaedic consultant. This impacts on what should be a seamless service resulting in patient delays."
"Consider effects of change on other parts of the system, and plan for these effects ( e.g. seeing more outpatients will generally mean more patients listed for surgery)."
"Depending on medical staff for referrals failed to maximise referrals for nurse/ AHP-led clinics resulting in an irregular referral pattern."
" MRI access has been hugely beneficial. Positive MRI findings which require an orthopaedic opinion arrive at their consultation with all relevant information. Conversely, results which do not need orthopaedic management are no longer automatically given a consultant appointment. These patients are extended scope practitioner managed."
"Establish and maintain communication links with GPs. Face-to-face encouragement to use the protocols as they see many protocols from different sources with regularity. Once a personal connection is made GPs use the service more appropriately and feel free to telephone and speak to someone they have met."
Programme Action
As well as providing resource for projects such as those described above, the Outpatient Programme:
- Produced 80 patient pathways in 12 specialties for local adaptation and adoption;
- Provided training and raised awareness on measuring demand;
- Described alternative pathways for demand with presentations on best practice throughout the UK;
- Collated and presented demand information for local projects where provided.
- Measurement can be difficult for local systems;
- Many services plan only on the average GP referral rate leading to shortages in capacity because at least 50% of the time demand will be higher than capacity provided;
- Referral Management and community-based services together can help reduce waits in under two years more effectively than referral information services alone;
- Alternative referral options are key to changing demand for consultants;
- Referral management services have a knock-on effect upon other services, e.g. Physio, Podiatry;
- Having a single referral point simplifies clinic coordination;
- Consideration of impact of changes on staff;
- No one size fits all, but learning is transferable.