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The Patients Association and the Royal College of Physicians (RCP) have published a joint report setting out a bold new vision for reforming outpatient services in the NHS over the next decade. Outpatient care (planned specialist care delivered without an overnight hospital stay) is one of the most commonly used NHS services, with over 135 million appointments in 2023/24 alone. Yet for many patients, the experience is marked by long waits, fragmented communication, and a lack of coordination between services. Drawing on extensive engagement with patients, clinicians and NHS England, Prescription for outpatients: reimagining planned specialist care outlines five key ambitions to reshape the outpatient model: provide timely care by the right person, in the right setting, empower patients through personalised care and self-management, improve communication across professionals and with patients, use innovative models of care to avoid unnecessary appointments, harness data and technology to reduce inequalities and prioritise need. The report also proposes eight transformational shifts to how care is delivered, supported by five key enablers including digital infrastructure, workforce investment, and improved commissioning models. Collectively, these changes aim to ensure outpatient services are more efficient, equitable and centred around patients' needs.

Although most healthcare is delivered in outpatient settings, knowledge about outpatient adverse events (AEs) and harm remains limited. The SafeCare Study aimed to assess the frequency of adverse events in both inpatients and outpatients across several healthcare systems in Massachusetts, USA. This paper in the Annals of Internal Medicine presents the results of the SafeCare Study which relate to adverse events in outpatients. The results showed that outpatient harm was relatively common and often serious. Adverse medication events were most frequent adverse event and rates of harm were higher among older adults. Key findings 7% of patients experienced at least one adverse event 17.4% of adverse events identified were considered serious in nature. 2.1% were life-threatening and none were fatal 10.4% of Black or African American patients and 13.1% of patients over the age of 85 experienced an adverse event 64% of adverse events identified were medication-related Variation in adverse event rates across the 11 study sites ranged from 1.8% to 23.6% of patients who received care The study is likely to have undercounted the true number of adverse events

The Patients Association has been working with NHS England and the Royal College of Physicians on the development of an outpatient strategy for the past year. In this series of three blogs, they discuss what they have heard from patients about the state of outpatient care and what patients would like to see change. What patients want from an outpatient strategy Kindness, reasonable adjustments and consistency needed across outpatients Personalising care and offering patients choice

Working in partnership to improve patients' experiences of outpatients was chaired by Sarah Tilsed, Head of Patient Partnership at the Patients Association. Joining her were: Dr Fiona McKevitt, Clinical Director for Outpatient Recovery and Transformation, NHS England Dr Theresa Barnes, Clinical Lead for Outpatients, Royal College of Physicians Irene Poku, Representative Patient and Public Involvement and Engagement with experience of using outpatient services. In a wide ranging discussion, the panel talk about collaboration, equity of access and group consultations.  This webinar was part of Patient Partnership Week 2023. 

The following account has been shared with Patient Safety Learning anonymously. We’d like to thank the patient for to sharing their experience to help raise awareness of the patient safety issues surrounding outpatient hysteroscopy care. I recently had a hysteroscopy. I was put onto the urgent 2-week wait for gynaecology after some suspicious pelvic and trans-vaginal scans. I am 53, peri-menopausal, and had one vaginal childbirth aged 23. I received no information on the procedure beforehand, just a brief phone call from the clinic to say it would be similar to a smear test, followed by the appointment letter. I researched the procedure myself using the NHS website and took the advised paracetamol/ibuprofen before arrival. On the day I wasn't asked to sign any consent form or the like. I just had to give a urine sample on arrival. After a long wait in reception I was called into a small anteroom with a strange cut-out tilting chair with a bucket underneath. I know I was anxious, but in my high alert state it seemed a very alarming set up. After explaining that I have panic attacks, and worried that this environment could be a trigger, my husband came into the room with me (otherwise I think I'd have ran back out again). They gave me a sheet to wrap around my naked bottom half, no gown with a fastening was available. I did not receive any pain relief or anaesthesia. I was really frightened as I saw the hysteroscope and thought how on earth is that going to get through my cervix and into my uterus! I like to think that I've a good pain threshold; but this was like nothing I've ever experienced. I felt the hysteroscope break through my cervix (this made me cry out in pain), and then saline was pumped into my uterus and that was extremely unpleasant. I was deep breathing to try to control myself but I couldn't stop crying and shaking with the shock of it all. I felt such distress that I couldn't speak. It was a terrible deep searing/dragging pain. The nurses were lovely and held my hand while my husband held the other, but I have to say that it was the most frightening experience I've ever been through. I looked up at my husband who was comforting me and I could see tears in his eyes too. The doctor said that all appeared ok, but took some biopsies just to double check. That cutting into my womb hurt a great deal. They then put in a Mirena coil which I had agreed to just before the procedure started, as the doctor said it would help alleviate my heavy periods and thickened womb lining. No one said that I may experience such intense pain during the hysteroscopy, just likely some period type pain. This comparison is not accurate at all. After the procedure I was asked to get dressed. My husband helped me out of the room and I sat down in the reception area trying to hide my distress from the other people waiting in there. I eventually felt able to walk back to the car and my husband drove me home. I have to say that I've been left feeling horrible after all this and I can’t stop thinking about it. I will never undergo a hysteroscopy procedure in this way again. I’m also already very frightened about when the Mirena coil will need to be removed… and that’s 4 or 5 years in the future. The fear of any future internal procedures is now very real, and I find this sad as I’ve never had any concerns about undergoing these in the past This hysteroscopy is such a brutal outpatient procedure and I can't believe that there was no pain relief or anaesthesia offered. I’m still cramping and bleeding and I feel a bit of a wreck. I felt I needed to get my hysteroscopy experience written down to try help me make sense of it, whilst wondering if this is the norm? I’m so confused if it is. I felt embarrassed by my crying and shaking… but it was shockingly painful. It's also left me feeling upset that this may be happening to other women who are already worried about their health and need to know if there’s anything wrong internally; and, like me, believe that there’s no option other than having to go through this ordeal. This is just my personal experience and I do appreciate that there may be other women who have had a different experience to mine. Even so, regardless of any data collected about this procedure, I find it unacceptable for any woman to be expected to bear this terrible pain and trauma. Further reading on the hub: Hysteroscopy: 6 calls for action to prevent avoidable harm The normalisation of women’s pain What is your experience of hysteroscopy? Share and read other accounts in our Painful hysteroscopy community thread.

In 2019 the Royal College of Surgeons of Edinburgh (RCSEd) carried out a survey which evidenced the extent of non-consultant hospital doctors’ concerns about different aspects of their ability to deliver out of hours care. Respondents were also asked to give examples or aspirations of best practice. This report uses this survey data and examples of best practice to provide a proactive guideline to support trainee surgeons. The survey found that there were five key areas requiring improvement for nonconsultant hospital doctors when working OOH, specifically: a) electronic systems; b) supervision; c) training; d) staffing; e) facilities. This document considers the results of the survey to make recommendations on best practice that will support non-consultant hospital doctors and protect patients out of hours.

The Healthcare Safety Investigation Branch (HSIB) have identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay. If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment. The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made. HSIB recommendations HSIB recommends that NHS England and NHS Improvement develops standards and an operating framework that describes the assurance required for all outpatient appointment booking processes, including after an inpatient stay. The assurance should include feedback mechanisms which provide safeguards that intended outpatient appointments are booked. Ideally, solutions will use technology and automation to create resilience and efficiency so that there is less reliance on staff vigilance. HSIB recommends that NHSX’s What Good Looks Like programme includes a requirement for organisations to be responsive to HSIB reports and recommendations within the ‘Safe Practice’ section of its guidance.

Active surveillance (AS) is an option in the management of men with low-stage, low-risk prostate cancer. These patients, who often require prolonged follow-up, can put a strain on outpatient resources. Nurses are ideally placed to develop advanced roles to help meet this increased demand—a model Martin et al. have utilised since 2014. The authors set about to comprehensively evaluate their nurse-led AS (NLAS) programme. The study found that nurse-led active surveillance is safe and effective. Patients and stakeholders alike held positive views of the programme.

Leeds Hospital NHS Trust has developed a range of patient leaflets. These leaflets inform patients and relatives about the changes to their care and different processes during the pandemic.

Primary care services provide an entry point into the health system which directly impact's people well-being and their use of other healthcare resources. Patient safety has been recognised as an issue of global importance for the past 10 years. Unsafe primary and ambulatory care results in greater morbidity, higher healthcare usage and economic costs. According to data from World Health Organization (WHO), the risk of a patient dying from preventable medical accident while receiving health care is 1 in 300, which is much higher than risk of dying while travelling in an airplane. Unsafe medication practices and inaccurate and delayed diagnosis are the most common causes of patient harm which affects millions of patients globally. However, the majority of the work has been focused on hospital care and there is very less understanding of what can be done to improve patient safety in primary care. Provision of safe primary care is priority as every day millions of people use primary care services across the world. The paper from Kuriakose et al., published in the Journal of Family Medicine and Primary Care, focuses on various aspects of patient safety, especially in the primary care settings and also provides some potential solutions in order to reduce patient harm as much as possible. Some important challenges regarding patient safety in India are also highlighted.

The Re-Engineered Discharge (Project RED) programme is a nationally recognised best practice centered on delivering a patient-tailored hospital discharge plan demonstrated to reduce all-cause 30-day readmissions and improve safety during care transitions. In this study, Mitchell et al. implemented the RED in 10 hospitals to study the implementation process. Key findings: Wide variability in the fidelity of the RED intervention. Engaged leadership and multidisciplinary implementation teams were keys to success. Common challenges included obtaining timely follow-up appointments, transmitting discharge summaries to outpatient clinicians, and leveraging information technology. Eight out of 10 hospitals reported improvement in 30-day readmission rates after RED implementation. The authors concluded that a supportive hospital culture is essential for successful RED implementation. A flexible implementation strategy can be used to implement RED and reduce readmissions.

Myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS) is characterised by persistent and disabling fatigue, exercise intolerance, cognitive difficulty, and musculoskeletal/joint pain. Post-exertional malaise is a worsening of these symptoms after a physical or mental exertion and is considered a central feature of the illness. Scant observations in the available literature provide qualitative assessments of post-exertional malaise in patients with myalgic encephalomyelitis/chronic fatigue syndrome. To enhance our understanding, Stussman et al. formed focus groups and listened to patients’ experiences to better understand post-extertional malaise. The authors found that the experience of post-exertional malaise in ME/CFS varies greatly between individuals and leads to a diminished quality of life. ME/CFS patients describe post-exertional malaise as all-encompassing with symptoms affecting every part of the body, difficult to predict or manage, and requiring complete bedrest to fully or partially recover. Given the extensive variability in patients, further research identifying subtypes of post-exertional malaise could lead to better targeted therapeutic options. 

This leaflet, produced by the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy, is for individuals who have been offered hysteroscopy as an outpatient. It may also be helpful if you are a partner, relative or friend of someone who has been offered this procedure. Key points: Outpatient hysteroscopy (OPH) is a procedure carried out in the outpatient clinic that involves examination of the inside of your uterus (womb) with a thin telescope. There are many reasons why you may be referred for OPH, such as to investigate and/or treat abnormal bleeding, to remove a polyp seen on a scan or to remove a coil with missing threads. The actual procedure usually takes 10-15 minutes. It can take longer if you are having any additional procedures. You may feel pain or discomfort during OPH. It is recommended that you take pain relief 1-2 hours before the appointment. If it is too painful, it is important to let your healthcare professional know as the procedure can be stopped at any time. You may choose to have the hysteroscopy under general anaesthetic. This will be done in an operating theatre, usually as a day case procedure. Possible risks with hysteroscopy include pain, feeling faint or sick, bleeding, infection and rarely uterine perforation (damage to the wall of the uterus). The risk of uterine perforation is lower during OPH than during hysteroscopy under general anaesthesia. Join the conversation on the hub about hysteroscopies.

Following the inquest into the death of former patient Amy Allan and the subsequent Preventing Future Deaths report given to Great Ormond Street Hospital for Children, Chief Executive Matthew Shaw would like to outline how the hospital is learning from this and what action has been taken to address the concerns that have been raised. Following a review of the events that led up to Amy’s death Great Ormond Street Hospital have already made changes to practice: They have improved the way clinical information is shared between different specialist teams, to make sure staff have as comprehensive a picture as possible when making complex decisions about a patient’s treatment. They now use a single log-in electronic patient record system which means staff can quickly access clinical information about a patient and have the right information at the right time, rather than routinely having to use multiple systems. They have improved consultant availability. This means there is more consultant time for each patient being looked after in our paediatric intensive care unit. They have introduced a new process to make sure the care of patients, like Amy, who have both complex spinal and heart conditions is routinely considered by the hospital’s specialist joint cardiology committee.

This cost-effective programme for personalised stratified follow-up delivers better outcomes for prostate cancer patients and has been shown to free up capacity in the follow-up pathway.  The programme moves follow-up care from outpatient clinics to remote monitoring. Men who are eligible for remote follow up therefore don't need to attend routine appointments unless an issue arises. This web page gives advice, guidance and tools, and examples of hospital trusts that took part in the pilot.