Investigating innovations in outpatient services

Background In England, the number of outpatient appointments has increased by two thirds since 2008/09 to 125 million a year (NHS Digital, 2020), currently accounting for 7 per cent of the NHS budget (NHS England, 2020). This is the largest increase in activity of any hospital service, and yet it has not been matched with a commensurate increase in workforce or system capacity (NHS England, 2019). As a result, long wait times, delayed appointments, and rushed consultations have all become the norm, frustrating patients and staff alike (Castle-Clarke S and Edwards N, 2018). Traditional outpatient service models have relied on face-to-face consultations, which can require repeat hospital visits that prolong uncertainty and waste patient and staff time (Royal College of Physicians, 2018). As the number of appointments has grown, so too has the proportion of unattended appointments. These inefficiencies have made improving the value of outpatient care a key priority for the NHS. In 2018, the Royal College of Physicians declared that the "traditional model of outpatient care is no longer fit for purpose" and that the NHS must change how it commissions and delivers the service if it is to be sustainable over the long-term. As part of its outpatient redesign programme, the NHS Long Term Plan seeks to avoid one third of face-to-face outpatient appointments by 2024 - making the claim that this would save the NHS an estimated £1.1 billion a year (and patients 30 million visits to hospital) by streamlining service delivery through expanded technology at each stage of the pathway. Across the outpatient care pathway, a broad range of innovations have and are being pursued to better manage outpatient care and reduce unnecessary appointments, but there is limited understanding of which interventions are most effective and what factors contribute to their success. The aims of outpatient transformation efforts have been varied, but coalesce around several common themes, including: making better use of clinical space and staff time; increasing patient satisfaction, empowerment and convenience; reducing unnecessary in-person appointments; increasing savings for the NHS and improving cost effectiveness; reducing greenhouse gases and other pollution through reduced travel; and decreasing waiting times for patients. Aims This study aims to identify innovations in outpatient services implemented in the English NHS, with a view to evaluating up to two such innovations. The work will include a review of published literature to understand the breadth of system innovations and their potential impacts. The quantitative work will include a detailed analysis of national outpatient activity data to identify hospital trusts or clinical specialties where notable and recent positive changes in measures of activity exist. Interviews with trusts will be used to determine whether these changes were potentially due to innovative changes to services, and for one or two of the most promising examples, we will carry out an evaluation appropriate to the service type and aims. Design and methods This is a mixed methods study that will involve a review of the literature on outpatient service innovation, a retrospective analysis of outpatient service activity data across all English hospitals, light-touch interviews with a limited number of hospital staff and an evaluation of up to two outpatient services. The study includes the following workstreams: 1. Evidence Review We will conduct a rapid review of the literature to understand what is currently known about innovations and strategies and their relative effectiveness to improve outpatient service delivery. The review will follow a pre-defined protocol, and involve structured searches carried out in at least three databases. To manage scope, we will use existing systematic reviews as a starting point, and limit the review to published studies conducted between 2010 and 2020 in English from comparable health systems to the NHS. We will conduct the review using appropriate appraisal tools and guides available via the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis to assess the quality of the articles, strength of evidence, and potential for bias, making adaptations as necessary (Aromataris, 2020). Included studies will have to have some impact on specialist/secondary care. Outcomes of interest may include, but are not limited to, access, patient experience and outcomes, staff experience and outcomes, and health resource use. 2. Analysis investigating potential impacts of innovations We will apply a method called indicator saturation (Castle and Hendry, 2019) to outpatient activity time series data at the hospital-specialty level with the aim of detecting the existence of change points within the data - that is, periods where significant - and broadly positive - changes in the trend of the time series appear to have occurred. The outpatient service activity measures we will analyse will be determined with the help of the study's advisory group, and, to this end, we will carry out preliminary analyses of changes to activity measures using Hospital Episode Statistics outpatient data in England both before and after the start of the COVID-19 pandemic. The focus will be measures where atypical changes could plausibly reflect the impact of service innovations. Candidate metrics might include total numbers of attendances, numbers of tele-consultations, and follow-up to first appointment ratios. We will include data from January 2013 to December 2019, with the aim of detecting changes from January 2015 (i.e., during the five most recent calendar years). A key part of this workstream will be to prioritise between the numerous changes we are likely to identify over all trusts, specialties and included activity measures; the aim will be to end with a shortlist of up to ten specific changes most likely to be the result of a service change or innovation. To this end, we will create metrics to classify - and so to help prioritise - the change points, and also make use of relevant contextual information. 3. Light touch interviews to identify innovations We will carry out telephone or video semi-structured interviews with two members of staff at each of the ten shortlisted hospital trusts. We will share with the interviewees a single page briefing, outlining the quantitative data analysis relevant to the service of interest. The interview questions will be formulated to seek out any service change or innovation implemented at the time of interest that might plausibly have contributed to the change. Where we are able to identify an innovation, we will request further documentation, which will be reviewed alongside the interviewee responses and the analysed data. Using selection criteria to be developed and agreed with our advisory group, we will select one or two services to take forward for evaluation. 4. Mixed methods evaluation of innovations We will carry out evaluations of the one or two innovations identified in the previous section. The exact form of the evaluations will depend on the nature of the innovations, and their anticipated aims and potential impacts, however they will likely to seek to answer questions about the impacts on patients and staff, the impacts on care outcomes, and economic impacts. Dissemination and outputs Potential outputs will include: • A peer-reviewed paper on changes in outpatient activity during the first wave of the COVID-19 pandemic. • An evidence review of outpatient service innovations. • A peer-reviewed article addressing the benefits and difficulties in adopting this quantitative approach to searching for innovations in services. • A final evaluation report: on the evaluation findings for up to two service innovations, also summarising the study's other published work. • Web-based outputs, for example blogs and/or visualisations of key findings. Study timeline The study will take place over thirteen months (April 2021 to April 2022).