Theresa Barnes: Managing risk in the modern outpatients and the effects on productivity

Risk is inherent to all clinical care. Most clinical decisions are a matter of weighing up risks versus benefit. We are used to managing treatment related risk and we are familiar with the concept of shared decision making (where these risk benefit analyses are taken in conjunction with the patient).

Some areas of risk management that we are perhaps less adept at managing, which directly affect outpatients, are confidence in making or ruling out a diagnosis, whether to refer for a more specialist opinion, and whether to discharge a patient from follow-up.

Outpatient demand is increasing and services are struggling to keep up. (1) During the development of a national outpatient strategy, the Royal College of Physicians has been having wide ranging conversations with key stakeholders. The subject of risk management has frequently been raised and, in this blog, I would like to consider how this may affect the productivity in outpatient services.

Learning how to manage risk

Traditionally, clinicians have learned to manage risk ‘on the job’. Clinicians have, during their training and continuous development, been supported to take controlled, supervised risk and have therefore learned experientially how to manage risk for themselves. Confidence in taking risk builds over time, and is related to pattern recognition and the breadth and depth of clinical experience.

Changes to training have meant that over time trainees may have less exposure to risk management. Aspects that directly affect this are shortening of clinical training programmes, lack of exposure to outpatient care, and the move to more senior decision making. All changes have been made for good reason and are likely to stay, but an unforeseen consequence is that the chance to develop the breadth of experience that can lead to more confident risk management is reduced. Therefore, I would suggest that it is important that we tackle this in a different way, providing targeted training in risk management.
The Royal College of Occupational Therapists have already embraced this, issuing a guidance document called ‘Embracing risk; enabling choice’ – a blueprint which could be replicated by other colleges to support their practitioners. (2)

It is also important that we give appropriate prioritisation to outpatient clinic exposure for our trainees, as well as exposure to referral management including advice and guidance, and triage during training. Feedback from the RCP Trainees Committee indicates that this continues to be an area of deficiency.

Referrals to secondary care

In recent years, there has been a significant diversification of the clinical workforce, partly to mitigate the workforce crisis in the NHS, but also to deliver the appropriate holistic, personalised, person-centred care that we aspire to. At the RCP, we advocate for multi-disciplinary teams, believing that they add significant value to patient care in terms of their different perspectives and skillsets.

We have heard concerns expressed that primary care advanced nurse practitioners (ANPs) and first contact physios may make more secondary care referrals compared to GPs, due to different risk attitudes, hence increasing demand for outpatient appointments. However, the published evidence would indicate that this is not an issue, with equal referral rates for ANPs and GPs, (3,4,5) and decreased secondary care referrals from first contact physios. (6)

GP referral rates do however vary considerably, and this is largely unexplained in the literature. One study from Norway indicated that difficulties in handling professional uncertainty was a significant influence on referral behaviour in clinicians with higher referral rates. In addition, they noted that increased consumerism in healthcare and the increased patient legal rights influenced referral behaviour. (7) A survey from the Medical Protection Society found that 84% of GPs said that the fear of being sued resulted in them ordering more tests or referrals. (8) A full-time GP can expect to receive two medical negligence claims over their career.

Integration

We have repeatedly heard during our conversations that a lack of integrated pathways, difficulty with access to both primary and secondary care, and poor communication with patients and across the interface is causing risk to patients. In addition, these issues affect the confidence within clinical teams that risk is adequately managed. This leads to duplication of work, inefficiency, and a reluctance to discharge.

Measures to improve pathway integration, access and communication will help to address the risk sharing. These could include better digital communication solutions; the development of integrated pathways across primary, secondary, and tertiary care; shared care protocols; and mapping of safety nets.

Safety netting

There is a perception that, overall, primary care have better developed safety netting systems. Secondary care has traditionally used follow up appointments or primary care as safety nets. Capacity within both primary and secondary care is currently severely pressurised and we need to be very mindful not to move work around an overstretched system. Equally it is important that we don’t use urgent care resource as a safety net as there is no capacity in this system either.

We suggest that benefit can be derived from mapping and sharing safety nets across the local system, with equal access to them for primary and secondary care. Safety nets may include patient support groups, social prescribing practitioners, charitable organisations, and community services. We should train our clinical workforce in risk management and safety netting. Although we think the risk is ours, it ultimately belongs to the patient. We should extend shared decision making to involve decisions around safety nets, follow-up and discharge, and we should optimise education of patients so they can participate in managing their own risk.

In summary

If we can support risk management across the system, it is likely that we can increase productivity in outpatients by reducing unnecessary referrals and improving the rates of discharge from outpatient pathways, while not increasing pressure on any part of the healthcare ecosystem. We can do this by increasing exposure to outpatient pathways including referral management for our trainees, providing training in risk management, integrating pathways, and improving communication. It is important that we develop system strategies to sharing risk and inclusion of patients, including shared safety nets. This is an area that requires further exploration.

References

1. NHS England. Hospital outpatient activity 2022-23. digital.nhs.uk/data-and-information/publications/statistical/hospital-outpatient-activity/2022-23
2. Royal College of Occupational Therapists. Embracing risk; enabling choice. www.rcot.co.uk/sites/default/files/RCOT%20Embracing%20Risk%20FINAL%20WEB_0.pdf
3. Laurant M, van der Biezen M, Wijers N et al. Nurses as substitutes for doctors in primary care. Cochrane Library 2018. www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001271.pub3/references
4. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002. www.bmj.com/content/324/7341/819
5. Kinnersley P, Anderson E, Parry K et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care. BMJ 2000. www.ncbi.nlm.nih.gov/pmc/articles/PMC27347
6. Parliament UK. AGP0004 - Evidence on access to general practice: progress review. committees.parliament.uk/writtenevidence/78360
7. Ringberg U, Fleten N, Forde O. Examining the variation in GPs’ referral practice: a cross-sectional study of GPs’ reasons for referral. British Journal of General Practice 2014. bjgp.org/content/64/624/e426
8. Medical Protection. Fear of legal action impacting on way GPs practise. www.medicalprotection.org/uk/articles/fear-of-legal-action-impacting-on-way-gps-practise