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.
A number of projects were undertaken to evaluate PIC further:
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.
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.
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.