SECOND OPINION


Dr David Colin-Thomé, the former National Clinical Director of Primary Care at the Department of Health, now an independent healthcare consultant, makes his case for a reconfiguration of outpatient care.


T


he above quotation is one of Professor Sir Muir Gray’s many aphorisms with


which I wholeheartedly concur. In fact I would go further and suggest the current model of hospital-based care in general would still be too recognisable to practi- tioners of that century, but I will focus on outpatient care.


It is huge in numbers, rising inexorably and a huge utiliser of resources.


Figures from the Information Centre for 2009/10 with 2005/6 figures in brackets: • Attended first appointment 20,782,376 (14,918,796)


• Attended subsequent appointment 46,222,116 (35,039,342)


It is of more than interest that total appoint- ments far exceed those figures 84,198,458 (60,608,403), demonstrating a high degree of cancellations and ‘no shows’.


Missed outpatient appointments cost NHS hospitals in the region of £600m a year, data from Dr Foster Health and the NHS Information Centre have revealed. Men in their early 20s are the worst offenders for appointment no-shows, while patients of both sexes aged 70 to 74 years are the most conscientious about keeping an ap- pointment. The total average income of a first outpatient appointment to an NHS hospital is £156, while income generated by second appointments averages out at £76. In 2007/8, 6.5 million appointments were missed in the UK, with hospitals losing around £100 per patient in revenue. Such estimates put the total cost of outpatient care at £6.5bn. Can this be value for money even in times of no austerity?


16 | national health executive Jan/Feb 12


I took a more detailed interest in hospital- based care when a first wave fund holder – a key part of the 1991 NHS reform pro- gramme. A reform which for the first time offered budgetary influence to general practice, enabling challenge and shaping of the care offered to our registered patients when their care was outwith GP-based care. A registered population confers a responsibility towards your patients even when ‘not in front of you’ – a population approach that should ideally apply to all healthcare provision.


But what about outpatient care? Practice level analysis showed much of that care was unnecessary and often duplicative. With enhanced access to both diagnostics without incurring an outpatient appoint- ment and community-based provision, outpatient contacts fell. For example, ac- cess to diagnostics and community based musculo-skeletal physiotherapy coupled with GP clinical leadership led to fewer or- thopaedic contacts.


And for patients with long-term conditions there was huge duplication of care as pa- tients were being followed up both in hos- pital and in general practice. The practice consequently majored on systematic man- agement of long-term conditions, employ- ing managed care techniques, with a sig- nificant reduction in hospital usage.


In general, hospital staff were not support- ive and with the cessation of fundholding the effort of shifting monies into more pro- ductive use became too burdensome.


I revisited the issue in ‘Keeping it Personal; Clinical case for change’ (DH, 2007) and


received some complaints from GPs about me adding to their work.


Professor Martin Roland’s work was most helpful. To quote: ‘‘David Colin-Thomé says patients don’t need to go back and see their surgeon after routine operations. And GPs are worried that they will be landed with lots of extra work. Should they really be worried? Our research suggests they shouldn’t.1


came to the same conclusion.2


“Another of our studies suggests that pa- tients are quite good at deciding when they need to see a specialist for follow up, so they could also be given the clinic number to use if they think they need to be seen.


“Some GPs doubt we’re trained for this work. What we do often lack is really good information about what to expect after par- ticular operations. This could be included in an information sheet to GP and patient after every operation. In fact, why don’t we get this anyway? Surgeons could also in- clude an evaluation form for the patient (or GP) to send back.


“Surgeons, especially those in training, may need to inspect their handiwork – though even this doesn’t work at present, as patients are far from guaranteed to see the surgeon who did the operation.”


This was certainly true when as a fundhold- er we researched this very topic locally.


Professor Roland concluded: “And will practices want to pay for routine post-sur- gical follow up in the world of commission- ing? I doubt it.’’


The only other similar trial


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