Dr Theresa Barnes: Reflections from outpatients summits 2 and 3

The outpatient summits hosted by the Royal College of Physicians (RCP), NHS England and the Patients Association have continued over the summer. We have now completed summits two and three. In summit two we concentrated on access to planned specialty care and in summit three we examined new models of delivering care and personalised medicine.

It was quite gratifying to experience the level of agreement, cohesion and collaboration at these events. There is a sense that we are all ‘on the same page’ when it comes to the direction of travel. To quote Eddie Kinsella from the RCP Patient and Carer Network, I believe that we witnessed a great deal of ‘evidence-based optimism’ in the room.

We have evolved to examine outpatient transformation through a lens of:

• optimising what is already in place that is good
• identifying and spreading good practice
• imagining new models of care for the future.

Some common themes have emerged from the summits, including:

Communication

The need to improve communication between health professionals and with patients. This has included a discussion about a desire for digital tools that will enable seamless communication between professionals. This will allow true collaboration in patient care and improved integration of care between all parts of the health system and beyond, including social care, community care and public health. The aspiration to have appropriate visibility of patient records across the system was repeatedly heard.

In addition, we touched upon digital tools to improve communication, engagement, support and access to patients. This would include patient engagement portals. While these were recognised as being a potential game changer for most patients, there was a universal recognition that there cannot be a ‘one size fits all’ approach and that individual patients have different needs; therefore, a plurality of communication and engagement mechanisms needs to exist and be developed to support patients.

Personalised care

The need to provide care to meet an individual patient’s needs. This includes taking into account the multiple health conditions of a patient, their individual health needs, but also their individual circumstances and preferences for interacting with health services. A change from ‘what’s the matter?’ to ‘what matters?’.

We covered practical solutions such as patient passports, which lay out a patient’s individual preferences and needs. This information would be valuable to collect as a matter of routine ahead of a first contact with any service, so that personalised care can be delivered from the start. We also discussed the importance of providing flexibility in appointment times, venues and delivery mechanisms to provide choice where possible for the patient.

Treating the whole patient provides significant benefits for patients. Understanding how medical problems impact on a patient’s life, but also on the lives of those around them including family and carers, and taking measures to support these needs is important. We acknowledged the value of community resources in addressing these needs. Charitable organisations and social prescribers play an important role in providing peer support and education. We recognised the importance of patient navigators in managing access to these important resources.

Promoting patient activation is extremely important in improving patient and system outcomes and measures should be promoted that increase patient activation, including the removal of paternalistic/maternalistic attitudes to delivering care.

Integration

It was recognised that better integration between all parts of health and social care is likely to produce more efficient and streamlined pathways of care for patients and staff and likely to improve patient outcomes and experience. Examples of good practice include pathways for condition management that are developed in collaboration between primary care, secondary care and patients, with well-defined roles for each part of the system. These pathways are often improved by employing practitioners who work across multiple parts of the system, hence developing a working understanding of the relative strengths of all providers within the pathway.

However, integration relates not only to the primary/secondary care interface, but also across specialties for patients with multiple health conditions or multi-system conditions and also across the secondary/tertiary care interface.

Finally, pathways that integrate well with multidisciplinary team members, social care, peer support and the third sector to provide holistic care were thought to represent examples of excellent practice, especially when they afford the flexibility to provide personalised, person -centric care.

Workforce and wellbeing

We discussed the importance of looking after staff and making them feel valued. We used the analogy of putting on your own oxygen mask before helping others with theirs, a familiar refrain for any flyers, acknowledging that it is hard to be consistently empathetic and caring if staff feel burnt out and devalued. One of our delegates even quoted Aristotle, ‘pleasure in the job puts perfection in the work’.

During the summits we have repeatedly referred to the critical role that our administrative staff play in providing good care to our patients. Concerns were frequently discussed that they may feel undervalued and their input into redesign not sought. However, they are often the first point of contact and their training and skills in dealing with patients and healthcare professionals, as well as their ability to navigate the system empathetically and compassionately, is frequently at the heart of what makes a good patient experience.

Great value was given to working in teams, especially diverse multidisciplinary teams that benefit from a plurality of skills, including soft skills, and the importance of giving the right task to the right professional individual, valuing what each individual brings to the team and maximising their skills and expertise. This would include not expecting highly skilled and trained members of the team to carry out tasks that could be done by others – maximising their ability to do the things that only they could do.

It was acknowledged that while broadening the skill mix and encouraging staff to work to the top of their license were important principles to make workforces more sustainable, fundamentally, an investment in increasing workforce was necessary for the future.

Incentivisation and driving good care

There has been significant concordance that clinical coding in outpatients, including coding depth to allow estimates of complexity to be applied, will be an essential driver for the development of good outpatient care in the future. It will be important to have accurate, diagnosis-specific data going forward, to plan, implement and evaluate changes made to improve services.

However, it is recognised that activity or target-driven care can sometimes drive perverse and counterproductive behaviours and that measuring patient outcomes and experience should be given primacy as drivers of care.

There is a need to drive out unwarranted variation in productivity, but this should be balanced with an accurate assessment of case load complexity.

Spreading good care

We continue to collect examples of good and innovative practice related to planned, specialty care and we will be sharing these via Medical Care – driving change. We would encourage clinicians to share and review information here to gain inspiration for transformative practice that may benefit their patients.

Education and training

Finally, the delegates appreciated that there will be a need to provide education and training to support the implementation of new and innovative practices. We have all adapted to virtual consultations, by necessity and mostly without support or training. The skills needed to deliver a successful virtual consultation, group appointment or asynchronous interaction are different to the traditional consultation skills that we learnt at medical school. We must develop, deliver and support changes in education for our medical students, junior doctors and team members to ensure that these skills are honed. We need to be able to develop in our training grades the ability to perform well in delivering advice and guidance and triage, so that they feel enabled to deliver this when they become consultants for the first time. We also need to keep one step ahead and ensure that new models of care are rapidly adopted into curricula to enable their optimal delivery.