Traditionally, many long-term conditions that require secondary care specialist reviews follow-up patients on a regular basis, e.g. every three to six months. One of the problems with this approach is that resources are used inefficiently and ineffectively both for patients and for the NHS. For example, when attending routine appointments patients may feel well and therefore don’t need to see a consultant. At other times, when their condition deteriorates or changes, they may be unable to see the clinical team at short notice.
Evidence shows that patient-initiated clinics (PIC) are a safe and cost-effective alternative approach to accessing hospital follow-up appointments. Patients have access to a telephone support line and initiate appointments only when they need them. Initially, we undertook two systematic reviews that indicate PIC can result in improved quality of life, increase patient and clinician satisfaction, and reduce healthcare resource use.
More recently we have conducted a Cochrane review of patient-initiated appointment systems and their impact on patient outcomes. Learn more about our systematic review of patient-initiated appointment systems (PIAS) in secondary care for people with chronic disease here.
Watch this video to find out how PIC can benefit patients and hospital staff:
A number of projects were undertaken to evaluate PIC further:
1. PIC for patients with rheumatoid arthritis – an implementation study
Approximately 400,000 people in the UK suffer with rheumatoid arthritis (RA), with around 12,000 people developing the condition each year. Although RA can be treated and managed effectively, it is a painful condition that has a huge impact on the lives of its sufferers. The economic costs of RA are estimated to be approximately £3.8 – £4.8 billion per year. This is made up of NHS costs and indirect costs, such as the effects of lower work productivity and the personal impact of the disease. Approximately one third of people have to stop working within two years of the onset of RA.
In most cases, patient follow-up appointments for sufferers of RA are initiated by physicians. There are often delays in follow-up, meaning patients are sometimes seen when they are well and little action is required. The introduction of a PIC to Derriford Hospital in Plymouth has resulted in the majority of people in the area with RA having rapid access to secondary care when they or their GP feel it is required.
The team behind the project won the Health Service Journal (HSJ) Value in Healthcare Awards, in May 2016. The award recognises and rewards outstanding efficiency and improvement by the NHS, as well as the excellent use of resources. The project was also named runner up for Best Practice at the British Society for Rheumatology (BSR) and Musculoskeletal Health Awards 2016.
2. Building a DIY toolkit for implementing PIC
PenCLAHRC worked in collaboration with the South West Academic Health Science Network (SW AHSN) and University Hospitals Plymouth NHS Trust (UHPT), to design and test a template for implementing PIC across various specialities at Derriford Hospital in Plymouth. The intention was to make a template that could be easily adapted to other specialties and organisations by leaving room for context-demanded flexibility (speciality, individual patients, specific hospital etc). Instructions on how to implement PIC within a speciality would be provided and monitoring of its success on a day-to-day basis was planned. The aim was to contribute to the straightforward implementation of PIC not only across the south west peninsula but elsewhere in the UK.
Two departments, nephrology and gastroenterology, were identified by UHPT as having appointment delays and the potential to benefit from PIC. Rheumatology were also keen to expand PIC from patients with rheumatoid arthritis to a wider group, e.g. those with psoriatic arthritis and ankylosing spondylitis.
Although a number of focus groups were carried out with patients, along with reviews of their follow-up services and a selection of patient records, a number of issues were encountered with the roll-out of PIC across nephrology and gastroenterology. However, as of November 2015, over 900 patients with RA were signed up to PIC, with the number increasing on a weekly basis as more education sessions are undertaken, including those with psoriatic arthritis and ankylosing spondylitis. The sessions are now delivered by a Band 4 Healthcare assistant rather than Band 7 specialist nurse, thus making better use of resources.
3. Cochrane Review of PIC
PenARC’s Evidence Synthesis Team have conducted a Cochrane Systematic Review of patient-initiated appointment systems (PIAS). The objective of this was to systematically review the evidence for a PIAS system in secondary care for patients with chronic or recurrent conditions. In particular the review was interested in whether these clinics can effectively manage conditions without causing clinical harm to patients and whether resource use can be reduced in comparison to usual care.
The PIC protocol entitled ‘Evaluation of a patient-initiated review system in rheumatoid arthritis: an implementation trial protocol’ was published in the BMC Musculoskeletal Disorder journal in July 2012. A copy of the protocol can be viewed and downloaded from the BioMed Central website.
The qualitative study results were presented at the Exeter Health and Medical Showcase event on 27th June 2014 in a poster; ‘Implementing a patient-initiated clinic for people with rheumatoid arthritis: a qualitative evaluation.’
PIC in the news
The project was featured on both BBC Radio Cornwall and BBC Spotlight in September 2015:
The project was also included as a case study in the 2014/15 PenCLAHRC Annual Report to the National Institute for Health Research. A copy of this report can be downloaded via the link in the right-hand sidebar at the top of this page under ‘Downloads’.
- Read a BITE sized summary of this project.
- Find out more and watch a video about patient-initiated clinics.
- Review 1: The Clinical Effectiveness of Patient Initiated Clinics for Patients with Chronic or Recurrent Conditions Managed in Secondary Care: A Systematic Review
- Review 2: Patient initiated clinics for patients with chronic or recurrent conditions managed in secondary care: a systematic review of patient reported outcomes and patient and clinician satisfaction
- Review 3: Patient‐initiated appointment systems for adults with chronic conditions in secondary care
- Child S, Goodwin V, Perry M, Gericke C, Byng R. Implementing a patient-initiated review system in rheumatoid arthritis: a qualitative evaluation. BMC Health Services Research. 2015; 15: 157.
- Goodwin V, Paudyal P, Perry M, Day N, Hawton A, Gericke C, Ukoumunne O, Byng R. Implementing a patient-initiated review system for people with rheumatoid arthritis: a prospective, comparative service evaluation. Journal of Evaluation in Clinical Practice 2016; 22(3): 439-445
- Eline Kieft, Jo Day, Richard Byng, Paul McArdle and Vicki Goodwin ‘Bridging the second gap in translation: a case study of barriers and facilitators to implementing Patient-initiated Clinics into secondary care’ European Journal for Person Centred Healthcare
- A poster about the process of building a PIC Toolkit was presented at the Health Services Research Network Conference on 1-2 July 2015.