Authors' objectives: Within outpatient services, a broad range of innovations are being pursued to better manage care and reduce unnecessary appointments. One of the least-studied innovations is Patient-Initiated Follow-Up, which allows patients to book appointments if and when they need them, rather than follow a standard schedule. To use routine national hospital data to identify innovations in outpatient services implemented, in recent years, within the National Health Service in England. To carry out a rapid mixed-methods evaluation of the implementation and impact of Patient-Initiated Follow-Up. The number of outpatient attendances in the UK has increased in recent years, outstripping population growth and unmatched by comparable increases in workforce or capacity. Improving the value of outpatient care has therefore become a key priority for the NHS in England, which aimed to reduce follow-up outpatient attendances by 25% from 2019 to 2020 levels by March 2024. Across the outpatient care pathway, a broad range of innovations are being pursued to better manage outpatient care and reduce unnecessary appointments. The NHS also aims to link such innovations to a more patient-centred service by making better use of primary, secondary, and community services and helping people to manage their own health. However, there is limited understanding of which interventions are effective and what factors contribute to their success. We aimed to devise a methodology for using data to identify potentially successful innovations in outpatient services and to select up to two for more in-depth evaluation. The innovation we chose was Patient-Initiated Follow-Up (PIFU) because it was not well studied, was becoming widely implemented across the NHS and NHS England were interested in it being evaluated, with findings informing the evolving outpatient transformation policy. With PIFU, patients can make their own follow-up appointments when they need them rather than be called back at pre-planned times (e.g. every 6 months). The intention is that follow-up appointments become more clinically valuable by increasing the chances that patients are seen at the right time. However, when we began the evaluation, it was little known what impact PIFU would have on patient outcomes, service resources, and patient and staff experience. This study aimed to identify innovations in outpatient services implemented in recent years in the English NHS and to carry out a rapid evaluation of PIFU. The study was divided into four sequential workstreams with the following aims: To understand the scope and breadth of interventions being pursued to improve efficiency in outpatient service delivery, and to understand key evidence gaps and research needs. To identify trusts and/or specialties where there is quantitative evidence of a positive change to outpatient activity, for example, a reduction in the numbers of attendances or a substitution between different modes of attendance (e.g. from face-to-face consultation to teleconsultation). To undertake interviews of selected trusts and specialties identified in workstream 2. To investigate whether changes in their outpatient activity were the result of specific innovations in care management. To conduct a mixed-methods evaluation of PIFU, considering its implementation, impact, and the experiences of patients and staff.

Authors' results and conclusions: Using indicator saturation, we identified nine services with notable changes in follow-up to first attendance ratios. Of three sites interviewed, two queried the data findings and one attributed the change to a clinical assessment service. Models of Patient-Initiated Follow-Up varied widely between hospital and clinical specialty, with a significant degree of variation in the approach to patient selection, patient monitoring and discharge. The success of implementation was dependent on several factors, for example, clinical condition, staff capacity and information technology systems. From the analysis of national data, we found evidence of an association between greater use of Patient-Initiated Follow-Up and a lower frequency of outpatient attendance within 15 out of 29 specialties and higher frequency of outpatient attendance within 7 specialties. Four specialties had less frequent emergency department visits associated with increasing Patient-Initiated Follow-Up rates. Patient-Initiated Follow-Up was viewed by staff and the few patients we interviewed as a positive intervention, although there was varied impact on individual staff roles and workload. It is important that sites and services undertake their own evaluations of Patient-Initiated Follow-Up. To this end we have developed an evaluation guide to support trusts with data collection and methods. The study provides useful insights into the evolving national outpatient transformation policy and for local practice. Patient-Initiated Follow-Up is often perceived as a positive intervention for staff and patients, but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain. Scoping review of innovations The scoping review found a variety of innovations in outpatient care that have been evaluated within different health systems. Some of these include changing how appointments are delivered (e.g. teleconsultations), new administration and support systems, specialised support for primary care and personalised follow-up. The purposes of these innovations were grouped into three main areas, for making booking systems more efficient, for optimising use of resources and for improving the clinical value of follow-up appointments. Virtual appointments and administration and scheduling systems are the most evaluated innovations, and only a few studies investigated personalised follow-up. With many initiatives being undertaken in NHS hospitals and for different clinical conditions, distinguishing those that provide benefits for outpatient care can be a formidable task. We have found that the implementation of PIFU is associated with significant reductions in the frequency of outpatient attendances and DNAs in some specialties and significant increases in a smaller number of others. However, we do not know if these relationships are all due to PIFU and, because of the available data, have not been able to measure impacts on those specific individuals who are put onto PIFU pathways. Many of the findings have implications for the organisation of outpatient services at a national and local level. These include ensuring PIFU guidance is tailored to specialties or conditions and ensuring communication about PIFU, and its purpose is clear, consistent and accessible to both staff and patients. PIFU is generally perceived as a positive intervention for staff and patients but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain.

Authors' recommendations: Data collection should include more meaningful patient outcomes and health inequalities alongside patient experiences and impact on staff workload. More research should be conducted on the views and experiences of patients and staff relating to PIFU, particularly with staff in clinical specialties not covered by our own evaluation. More research is needed to understand how PIFU interacts with other outpatient interventions and the wider health and social care system. National data sets could be better used to scan for exceptional changes in relation to outpatient care, combining this with fieldwork to identify whether these correspond to specific innovations.

Authors' methods: The project was carried out in four sequential workstreams: (1) a rapid scoping review of outpatient innovations; (2) the application of indicator saturation methodology for scanning national patient-level data to identify potentially successful local interventions; (3) interviews with hospitals identified in workstream 2; and (4) a rapid mixed-methods evaluation of Patient-Initiated Follow-Up. The evaluation of Patient-Initiated Follow-Up comprised an evidence review, interviews with 36 clinical and operational staff at 5 National Health Service acute trusts, a workshop with staff from 13 National Health Service acute trusts, interviews with four patients, analysis of national and local data, and development of an evaluation guide. The Patient-Initiated Follow-Up evaluation was affected by a lack of patient-level data showing who is on a Patient-Initiated Follow-Up pathway. Engagement with local services was also challenging, given the pressures facing sites and staff. Patient recruitment was low, which affected the ability to understand experiences of patients directly. The project was supported throughout by an advisory group and patient and public involvement representatives. The approaches we used within each workstream were as follows: Workstream 1: scoping review of innovations We adopted an evidence-mapping approach and a literature search to understand the extent to which different outpatient service innovations have been studied and the potential benefits they evaluated. Data were synthesised narratively by type of intervention and their anticipated benefit using a pre-specified framework. The results of this review would inform the choice of innovation to evaluate in workstream 4. We were unable to develop a reliable methodology to rank time series across multiple outpatient activity measures to identify those most likely to show the impact of a service change. The final selection of changes in performance most likely to be connected to implementation of PIFU required more manual researcher input than anticipated, and the results of a small number of interviews with selected hospitals were variable. Conducting a rapid study of an intervention which was still being rolled out alongside other interventions, where data were limited and when there were significant pressures on NHS staff capacity, introduced considerable challenges. Consequently, the sample sizes for hospital sites, staff and patients were small. Owing to this, the qualitative findings cannot be assumed to be representative of the national picture, although they provide valuable insights into the use of PIFU in outpatient services. Due to the lack of quantitative data on outcomes, we have focused the analyses of the impact of PIFU on changes in outpatient activity and ED attendance and have not been able to use more patient-focused measures.

Authors' identified further research: Further research should include patient-level analysis to determine clinical outcomes for individual patients on Patient-Initiated Follow-Up and health inequalities, and more extensive investigation of patient experiences.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/16/138/17

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/VGQD4611

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: United Kingdom

DOI: 10.3310/VGQD4611

Organisation Name: NIHR Health and Social Care Delivery Program

Contact Name: Rhiannon Miller

Contact Email: rhiannon.m@prepress-projects.co.uk