Transforming outpatient care: a case study for success

Overview

The NHS is facing significant challenges, with growing demand, long waiting times, and increasing pressure on elective care services. Like many trusts, Northumbria Healthcare NHS Foundation Trust, found itself with outpatient backlogs and fragmented processes. They made a bold decision to totally redesign their outpatient service, with a focus on simplifying access and strengthening relationships between primary and secondary care. The result? 90% of patients having their first routine outpatient appointment within four weeks in gastroenterology (pilot area), with other specialties following suit.

What the trust was facing

Traditional outpatient models were creating inefficiencies, leading to long waiting times and poor communication between primary and secondary care sectors. Baseline waits for a first routine outpatient appointment were typically four-six months, with growing referral volumes placing further pressure on capacity. While traditional responses, namely waiting list initiatives, offered temporary relief, they did not address the structural inefficiencies, and the response was not sustainable. Driven by an ambition to empower patients and generate pride back in the service, Northumbria Healthcare NHS Foundation Trust implemented a single point of access system. 

What the trust did

The starting point was the creation of a Single Point of Access (SPoA), centralising patient referrals for all outpatient services to reduce delays and ensure that patients are directed quickly to the appropriate specialist. Alongside this, a key development was the expansion of the advice and guidance (A&G) service, which allowed GPs to submit digital queries to consultants before making a formal referral. This enabled specialists to provide clinical advice quickly and, where appropriate, avoid unnecessary outpatient appointments or direct to another area such as diagnostics. They created a philosophy more about ‘discuss with’ than simply 'refer to'. 

This ensured patients entered the right pathway first time. With long waits facing patients who do need to be seen in the outpatient department, specialists were also able to provide interim advice to the GP to support that patient – leading to fewer repeat queries or attendances to the GP or via the emergency department. 

The development of SPoA and expansion of A&G: 

• accelerated clinical decision-making 
• reduced unnecessary referrals
• shortened time to treatment 
• improved dialogue between clinicians across care settings 

The result was a more responsive and efficient system that focused outpatient capacity on patients who truly needed specialist care. 

Key enablers of success

The success of this work was only made possible by focusing on relationships – both internally across clinical/managerial teams and across the primary/secondary care interface. This has to be prioritised when working on change initiatives of this nature.

Primary/secondary care relationships

One of the most powerful enablers was stronger relationships between primary and secondary care clinicians. Simple actions mattered; informal conversations and understanding each other's pressures. A motivated group of secondary care clinicians taking the time to link with their local GPs made all the difference to getting this work off the ground and leading to the results they saw. When working well, A&G had the potential to be truly collaborative and educational, offering a seamless journey for patients. The underlying principle for SPoA that both primary and secondary care agreed on is that it must advance the care of the patient; it should not be a bottleneck. 

Dedicated clinical capacity 

The SPoA was supported by a group of consultants having dedicated time to give to answering primary care queries. The time increased as the service grew, and there are now eight dedicated programmed activities (PAs) for this specialist work. This is not additional funding; it was made available through redirection of resource from outpatients. The service model meant that this small group of clinicians undertaking this task were the highly skilled at providing the service and there was more continuity and consistency, rather than the work being spread across a larger team. 

Getting back to basics

Collaboration across managerial and clinical colleagues was essential for this work and building the foundations of good operational discipline including referral validation, tracking systems, standardised templates and regular open communication.  

Key results and benefits

The impact at Northumbria was substantial. In gastroenterology the waiting times reduced from four-six months to four weeks for 90% of routine patients; achieved without any waiting list initiative sessions or outsourcing. While the referrals through A&G increased, the conversion rate to outpatient appointments fell significantly (only around 30%), demonstrating that through redesigning the system, patients’ care could be advanced more quickly through advice or diagnostics.

There were also many unintended positive consequences of this work: 

• The gastroenterology service reduced its reliance on external providers for services like endoscopy, cutting expenses while improving internal efficiency.
  
  
• Improved collaboration between GPs and consultants supported greater empathy and understanding across the primary/secondary interface and allowed for more collaborative conversations longer term.
  
  
• The success of the new model has allowed Northumbria to have ‘breathing space’ to expand care into the community, further improving healthcare access the system and tackle inequalities in access.
  
  
• Workforce morale – the SPoA model supported more flexible working, particularly helpful for those with caring responsibilities for example.

Advice for executive leadership

Invest in relationships across the system

It is crucial to build relationships and not just pathways. Strong collaboration between primary care and secondary care, and across management and clinical teams is crucial. There should be shared ownership of issues across the system and leaders need to deliberately create trusted spaces for informal clinical interaction, not just relying on formal governance structures. This upfront investment will unlock long term efficiency.

Focus on digital tools to support design

Digital has the potential to radically reduce unnecessary referrals and improve communication across the system where people coordinating different aspects of a patient's care are not co-located. Leaders need to prioritise the digital infrastructure to support clinicians and pathway redesign.

Back clinician-led change 

The initiative succeeded because a small group of committed clinicians were empowered to redesign the system. Executive leaders should protect their time, remove operational barriers and enable experimentation, accepting that they are a crucial link to innovation and change. 

Have courage!

Transformational change often requires moving away from familiar models before all the evidence is visible. Sometimes, leaders must simply take a leap of faith.