“It has been great working as a partner with the East Midlands AHSN and this collaboration made the project possible. Their initial funding for the demonstrator helped us generate evidence for our business case, which they also supported with, and their continual project support including their coordination of the production and sharing of clinical questionnaires has been essential to the success of the project.”
Lisa Lawrence, Head of Digital Products at NUH
Overview

East Midlands AHSN have worked with Nottingham University Hospitals NHS Trust (NUH) on a demonstrator digital outpatient programme to increase efficiencies and improve patient experience by reducing unnecessary follow up outpatient appointments.

The demonstrator came about following an East Midlands Innovation Exchange with local health and care partners focused on long-term conditions. Reducing outpatient appointments was highlighted as a priority and an area that holds potential for improving patient care and creating efficiencies.

NUH initially trialled technology provided by DrDoctor (patient communication and digital care solutions) in two clinical specialties (oncology and breast services) to understand the potential impacts that the service could have to reduce unnecessary follow up appointments and supplement physical appointments with alternatives. NUH introduced bespoke digital questionnaires, designed by clinicians, for each patient group within the clinical specialties to establish the necessity of outpatient appointments. Patients who are suitable for a digital pathway are able to complete the questionnaire at home, allowing the clinical team to establish whether they need to see the patient.

As an example, within the Oncology clinical specialty (for patients undergoing treatment for cancer) patients are normally required to attend hospital several times for each round of treatment. In one treatment pathway, 97% of patients on the digital pathway were able to avoid their next appointment.

East Midlands AHSN provided initial funding for the demonstrator, ongoing support and advice as part of the project board and resource to develop a business case and modelling tool to support sustainability and spread within the Trust and to other organisations.

Challenge / problem identified

The NHS Long Term Plan sets out the ambition to reduce face-to-face outpatient appointments by a third using digital technology to provide convenient ways for patients to access advice and care.

In the East Midlands local commissioners had set an equivalent target of 30% reduction in outpatient activity, with the majority of this concentrated on follow up activity.

Reducing unnecessary follow up outpatient appointments using digital technology works to:

Improve patient experience

  • The average cost of attending an outpatient appointment for a patient is £50 or more (based on the HMRC’s research paper ‘costing customer time’)
  • Decreasing the number of hospital visits reduces the risk of infection to immunocompromised patients
  • Introducing digital options provides patients with more control and flexibility over their care
  • Reducing stress and anxiety related to hospital appointments.

Reduce waiting lists and increase efficiencies

  • By determining if appointments are necessary (from the perspective of both the patient and the clinician) and removing unnecessary follow up appointments, clinicians are able to see more patients therefore reducing waiting lists
  • Allows more frequent interactions with patients without increasing costs. It is anticipated that there can be a positive impact on the wider health community with a reduction in GP and Emergency Department attendances.

Create financial efficiencies

  • Reduction of wasted appointments when patients do not attend (DNAs)
  • Ability to take advantage of the Digital Outpatient tariff to offset loss of income from decreasing outpatient appointments and concentrate efforts and activities elsewhere.

COVID-19 response

The reduction of unnecessary outpatient appointments also became a pertinent issue during the COVID-19 pandemic. Using digital technology was recognised as an imperative way of reducing patient risk of contracting the disease, particularly those who are more vulnerable.

Actions taken

Following a long-term conditions Innovation Exchange, East Midlands AHSN have worked with Nottingham University Hospital NHS Trust (NUH) and supplier DrDoctor on a demonstrator project to determine and showcase the impacts that the introduction of digital pathways can have to reduce unnecessary follow up outpatient appointments.

NUH initially introduced bespoke digital questionnaires, designed by clinicians, for two clinical specialties (oncology and breast services) to establish the necessity of outpatient appointments.

Patients who are suitable for a digital pathway are able to complete the questionnaire at home, allowing the clinical team to establish whether they need to see the patient. Questionnaires are uploaded to the DrDoctor platform which allows an automated approach, enabling clinicians to review completed questionnaires from patients.

Impacts have been positive across each pathway within the two specialties and NUH have used these results to develop a business case (supported by EMAHSN) to secure Trust board support to roll-out the approach across other clinical specialties. Initially NUH plan to introduce digital pathways to a further seven specialties. Following this, the next phase will be to introduce pathways in the Trust’s 10 specialities that have the highest proportion of outpatient activity including cardiology, diabetic medicine and respiratory medicine, along with other clinical areas.

Impacts / outcomes

Results of the project are at early stages and differ between different clinical specialties, however the Trust has seen impressive results, including:

  • 29% reduction in face-to-face follow appointments in the Immunotherapy pathway within Oncology
  • In one Oncology pathway, taking this approach reduced follow up appointments for patients on the digital pathway by 97%
  • 47% reduction of follow up appointments is expected in Breast Services based on the outcome of the feasibility study
  • A 99% completion rate of questionnaires
  • Significant capacity released. Digital reviews take on average two minutes per patient, opposed to up to 15 minutes for a face-to-face appointment
  • In 2019, the project was shortlisted in the Digitising Patient Services Initiative category at the HSJ Awards and was a Finalist in the Patient Experience National Awards in March 2020
  • A multitude of other trusts across the country have sought advice from NUH, sharing best practice and learnings outside of the region
  • Continuation of the service within the Trust and planned roll out to a further 17 clinical specialties, helped by data from the demonstrator to build a strong business case for continuation
  • Improved patient feedback evidenced by the excellent feedback and comments received – as a result of the project patients have been able to avoid costs of attending unnecessary outpatient appointments and associated risks of infection and have had more control and flexibility over their care.

The digital outpatients programme was also recognised by the Trust as an important service during the COVID-19 pandemic as it:

  • Helped to keep vulnerable/shielding patients out of hospital
  • Enabled clinicians who were shielding/self-isolating to complete reviews from home.

The digital outpatients programme forms a key part of the Trust’s restoration and recovery strategy and will be used to support the reduction of the backlog following the pandemic.

Patient involvement

NUH had initial concerns of how patients would react to such a significant change in the way that outpatient activity is delivered at the Trust.

They engaged with patients using focus groups to determine the appetite for the project and to understand any potential implications. Feedback was extremely positive with 90% of patients asked stating that they would like to use a digital follow up service moving forward.

The digital pathways are also ‘opt in’ so patients ultimately have the choice.

The project team are continually working with patients to improve the service and attain feedback. For example, in the Breast Services pathway they are seeking feedback from patients who still want face-to-face appointments to understand if the questionnaire or process could be made more accessible to encourage their uptake.

Sustainability and plans for the future

NUH are continuing to refine the service and are introducing it to more clinical specialties. This was made possible by the demonstrator project which provided valuable data for their internal business case.

East Midlands AHSN has also facilitated a digital outpatient sharing event bringing together trusts from across the region to share their experiences and discuss options and opportunities as well as share clinical questionnaires to reduce unnecessary duplication of efforts.

The AHSN are now working with other partners in the region, including University Hospitals of Derby and Burton NHS Foundation Trust to further test this approach using another digital platform and applying the approach to further clinical specialities.

The AHSN will also provide resource for further and broader evaluation to support adoption and spread.

Which national clinical or policy priorities does this example address?
  • Care and Quality
  • Funding and Efficiency
  • Health and Wellbeing.
Where did the innovation originate from?

The NHS.

Which AHSN Priorities does this example cover?
  • Long term conditions
  • Digital health
  • NHS Innovation Accelerator
  • Workforce development.
Start and end dates:

May 2018 – ongoing.

Contacts

Project contact

Suzanne Horobin

Head of Innovation Exchange, East Midlands AHSN

Suzanne.Horobin@nottingham.ac.uk

AHSN communications team contact

Jayne Holgate, Communications Manager, East Midlands AHSN

Jayne.holgate1@nottingham.ac.uk

0797 367 4164