Hospital outpatient department, the great mess

Jordi Varela
Editor

 

Hospital day services don’t stop growing to the detriment of traditional hospitalizations, to the extent that the NHS has estimated that, in England, patient movements to hospitals generate 5% of road traffic throughout the country. Many of these services, such as surgery without admission, chemotherapy, anticoagulants or endoscopies, have been very well outlined since their origin, external consultations in general, on the other hand, are multipurpose devices where each speciality has accumulated outpatient services of very different characteristics until they become overflowing spaces that are difficult to manage, precisely because they have not defined what is expected of each of their activities. To give an example, a rheumatologist told me that it was unfortunate that they were evaluated due to the relationship between first and subsequent visits, when it’s known that his patients are complex forever, and he suggested that it would be convenient to be able to assess their service based on the quality of life their patients get, about the costs of prescribed treatments.

The outpatient experience for patients is dazzling, to say the least, with a multitude of hard-to-understand summons papers, convoluted circuits, and countless delays in waiting rooms. As Stephen Powis, NHS Medical Director, states in "Outpatients: the future - adding value through sustainability": "Outpatient clinics appear to have been designed according to practitioners' designs, rather than interests of patients. Their disorder is so great that it’s also frustrating for doctors. It’s time, then, to rethink the organizational model of services that are used more and more. "

A recipe based on the value of a clinical activity

If you want to improve the efficiency of the facilities, the patient experience and the clinical results, you must follow some recommendations based on the principles of value chains:

1. Group patients by type or by needs.
2. Establish what results are to be obtained and what costs are to be assumed, including the burdens of the patients themselves (sick leave and transportation, for example) and society in general.
3. See how patients can be involved in their processes, through shared decision-making and co-creation methodologies.
4. Profiling who does what and establishing the formats for collaboration between primary care and hospital.
5. Define circuits and referrals, including e-health, remote visits and remote controls.

First visits

For people with typified health problems. Primary and hospital care should establish what the referral criteria should be for each of the most common health problems, as has been done with rapid cancer diagnosis circuits. Take, for example, low back pain that doesn’t subside after six weeks of treatment or a depression resistant to standard therapies. For each of these circumstances, there should be specific circuits, in which all actors have the same information about the procedure to follow and what waiting limits are considered reasonable.

For people with complex health problems. It would be convenient for all specialities, especially internal medicine, to have an open consultation for professionals (face-to-face, telephone or asynchronous remote consultations), to address cases from the same primary care, or the point of reference, and thus avoid unnecessary referrals. When, despite everything, the patient has to go to external consultations, communication between professionals should continue after the visit, to plan a follow-up of the case in a tight and coordinated way.

Process monitoring

For the follow-up of people with long-term clinical processes, the outpatient consultations should be reorganized based on groups of patients, such as multiple sclerosis, glaucoma or type 1 diabetes, which should be attended by multidisciplinary teams that they would prepare each visit collaboratively with the respective programming of all the required services. This individualization of the follow-ups and the team vision should be the foundation to promote shared decisions, self-control and remote visits, to reduce the unnecessary comings and goings of chronic and complex patients to external consultations.

To organize hospital outpatient departments and save unnecessary visits and excessive travel, it’s necessary to group patients, work in a multidisciplinary team (surpassing the focused vision of a specialist), establish agreed circuits with primary care, involve patients in decisions and promote self-care and remote contacts.