Research Paper - (2003) Volume 11, Issue 2
Senior House Officer
Lydia Chang FRCOphth
Specialist Registrar
Department of Ophthalmology, Hillingdon Hospital NHS Trust, Middlesex, UK
Nicholas Lee FRCOphth*
Consultant Ophthalmologist, Department of Ophthalmology, Hillingdon Hospital NHS Trust, Middlesex, and Western Eye Hospital, St Mary‘s NHS Trust, London, UK
Background The partial booking (PB) outpatient appointment system was introduced by the Department of Health in 1999 into NHS trusts with outpatient waiting times of over 13 weeks. With PB, patients have the opportunity to choose a convenient outpatient appointment date. Failure to do so results in automatic removal from the PB system, with no appointment issued.Aims Since the implementation of PB, 10% of all new outpatient referrals to a single ophthalmic department have failed to result in an appointment. We conducted a study to analyse if ophthalmic referrals have been inappropriately removed from the PB system.Method Randomised telephone survey of outpatient referrals that failed to result in an appointment.Setting Ophthalmology outpatient department in a district general hospital.Results Seventy patients were recruited into our study, of whom 35% were referred for possible cataract or glaucoma. Forty-nine patients were contactable by telephone. Twenty-four percent of these were not aware that they had been referred for a specialist opinion. Fifty-three percent felt that the symptoms that prompted the original referral were still present. Thirty-nine percent did notrecall receiving any letters from the hospital inviting them to choose an appointment date. Eighteen (37%) of the contactable patients felt that they still required another appointment.Conclusions A signiŽ cant number of patients still required an outpatient appointment despite being removed from the partial booking system. We believe there are ? aws in the partial booking system, principally due to the manner in which it is implemented by the individual NHS trusts.
DNA rates, outpatient waiting times,partial booking
The NHS provides approximately 11 million new outpatient appointments per year.[1] As part of a government commitment to reduce outpatient wait-ing times, the Department of Health National Patients’ Access Team (NPAT) has recommended the implementation of the partial booking (PB) system in trusts with a waiting time of over 13 weeks for routine outpatient appointments.[1] This replaces the traditional fi xed appointment system, where patients are given outpatient appointments upon receipt of the referral letter (see Figure 1). With the Department of Health recommended PB system, upon receipt of a referral, patients are sent an initial letter indicating the approximate waiting time for an outpatient appointment.[2] A second letter is subse-quently sent to the patient four weeks prior to the appointment, inviting them to phone to agree a mutually convenient date and time. If the patient does not respond, they are sent a reminder letter and contacted by telephone. Failing this, the patient is removed from the outpatient appointment waiting list and the referring general practitioner (GP) is informed (see Figure 2).
Figure 1: Fixed appointment system: routine patients
Figure 2: Department of Health recommended partial booking system
The aim of the PB system is to ensure that patients have the opportunity to choose a convenient date within a short time of the outpatient appointment, thereby reducing both ‘did not attend’ (DNA) rates and patient cancellations. This was felt, in the NPAT report, to be the key to improving outpatient efficiency and reducing waiting times.[1] Following successful implementation of the PB system in two pilot Trusts in 1999 (Chesterfi eld and North Derbyshire Royal Hospitals NHS Trust and Basildon and Thurrock NHS Trust), it has since been introduced in over 60 trusts across the UK.[2]
PB was implemented in the ophthalmology out-patient department of the Hillingdon Hospital NHSrust in October 2000. In the following 18 months, approximately 300 referrals were removed from the outpatient waiting list and were described as ‘have not responded’ to hospital letters. This represented almost 10% of all new routine patients seen annually in our department.
It was brought to our attention that the PB system implemented at our hospital was slightly di¡erent from the Department of Health recommendation (see Figure 3). Of most relevance was the fact that patients were not sent a reminder letter of invitation to call and book an appointment. Also, there was no designated appointments clerk to call patients about their appointment. As mentioned previously (see Figures 2 and 3), patients were placed on a waiting list for an outpatient appointment once the initial referral was received. In our hospital, there was a separate waiting list coordinator who regularly (two to three monthly) updated the waiting list independ-ent of the PB centre. This updating was performed by sending a letter to patients on the waiting list, requesting that they return a pre-paid reply slip by post if they wished to remain on the list. Failure to do so within three weeks resulted in removal of the patient from the waiting list.
Figure 3: Hillingdon Hospital NHS Trust partial booking system
We suspected that there could be • aws in the manner with which the PB system is implemented in individual NHS trusts, which had not so far been identifi ed in the Department of Health reports. We decided to audit the PB system as practised in our hospital by conducting a randomised telephone survey of patients to analyse if they had been appropriately removed from the outpatient waiting list.
A record of all new routine referrals to the department of ophthalmology at the Hillingdon hospital NHS Trust that had been removed from the outpatient waiting list was fi led alphabetically. From this, 70 patients were randomly selected by selecting every fourth referral. There were no exclusion criteria.
Patients’ telephone numbers were obtained from the original referral letter and where these were not available, were obtained from either the GP or national directory enquiries. Patients were subse-quently telephoned and verbal consent was obtained prior to asking six questions (see Table 1). A standardised telephone script was used for all patients surveyed. Responses were recorded as ‘yes’ or ‘no’, except for question 5 where answers were varied and open-ended. Patients who did not recall receiving letters from the hospital had their addresses verifi ed verbally. Where patients no longer lived at the specifi ed number, their details were cross-checked with the GP. A total of up to three attempts were made to contact patients by telephone on di¡erent days and at di¡erent times.
Table 1: List of questions that patients were asked
Patient DNA rates pre- and post-implementation of PB were obtained from the Hillingdon Hospital NHS Trust PB centre. This was compared with previously published results.
A total of 70 patients were randomly recruited to the study. Of these, 49 were contactable by telephone within three attempts (70%). The mean age was 56-years (range 14–92). Patients were referred with a range of ophthalmic conditions (see Table 2).
Table 2: Referring diagnoses
Cataract was the single most common suspected referring diagnosis (27% of all patients). All patients were referred by their GP, although 48 (70%) had initially seen a local optometrist.
Of the 49 contactable patients, 39 (76%) were aware that they had been referred to the hospital for a specialist opinion. However, 10 (24%) patients were not aware of this and therefore, were not expecting any letters from the hospital. When patients were asked if they were still experiencing symptoms for which they were initially referred, 26 (53%) felt that their symptoms were still present, but not necessarily problematic.
Thirty (61%) of the 49 contacted patients recalled receiving a letter from the hospital regarding their outpatient appointment. Patients who did not recall receiving any letters (39%) had their addresses verifi ed verbally against the information provided by the referring source. There were no disparities between true and hospital-recorded addresses. Twenty-seven (55%) of the 49 patients were aware that they would not be getting an appointment in the eye clinic as they had not responded to the letters.
They were several reasons why patients did not respond to the letters despite receiving them. Of the 70 patients recruited to our study six (9%) had been seen privately, six (9%) had moved to another area outside the catchment area of the hospital, four (6%) had been seen at another NHS hospital and one (1%) had died. For patients who were uncontactable by phone, the above information was obtained from another person on the same telephone number or the GP.
In the group of 49 patients who were contactable 14 (29%) felt they no longer required an appoint-ment, 11 (22%) patients were still waiting for an appointment and four (8%) did not respond as they did not understand the letters since they found them confusing. None of them felt the print size was too small or were unable to comprehend the written English language. Eighteen (37%) of the contactable patients felt that they still required another appoint-ment at the time of our study.
Ophthalmic outpatient DNA rates before PB implementation were 15% in the preceding 12 months. In the immediate six months post-implementation there would have been a delay before all appointments made under previous systems (not partially booked) had taken place. It was therefore not valid to use the six months immediately post-PB implementation in a comparison of DNA rates. Taking this into account, post-implementation DNA rates had improved to 7%.
The PB system had been tested in two pilot trusts, Chesterfi eld and North Derbyshire Royal Hospitals NHS Trust and Basildon and Thurrock NHS Trust. Overall, DNA rates reduced from 10% to 3%, patient cancellation rates fell from 16% to 10%, hospital cancellation rates reduced from 14% to 3%, and overall outpatient attendance increased from 74% to 88%.[2] DNA rates at Hillingdon Hospital NHS Trust have similarly shown reduction. Based on these results, the partial booking system of managing outpatient appointments appears to be a promising one.
The PB system as implemented in our hospital was found to be a slight modifi cation of the Department of Health recommendation (see Figure 3). As far as we are aware, there are no NHS trusts (including the two pilot trusts) that have implemented the PB system according to the full Department of Health recommendation (see Figure 2). The additional procedures of sending patients reminder letters and having an appointment clerk make reminder phone calls are rarely practised. These could be crucial fail-safe mechanisms.
The primary aim of the PB system is to reduce outpatient waiting times. There are several inherent flaws in a system of removing patients from the waiting list by default unless they call to book an appointment. Firstly, it can artifi cially reduce the outpatient waiting times. In our study, a signifi cant number of contactable patients (37%) still wanted appointments, which have since been arranged. Removing patients by default may also be unsafe practice, as patients who are unaware of a potentially serious medical condition (e.g. undiagnosed glau-coma resulting in gradual signifi cant visual loss) may remain unrecognised and untreated until a late stage in the disease. In our study, 24% of contactable patients were not aware that they had been referred by their GP to the ophthalmology department. Communication between healthcare workers and patients may have been somewhat imperfect, and may be the root of the problem of patient DNAs and treatment non-compliance. These patients may have taken it upon themselves to decide that they do not require an outpatient appointment, and thus not responded to the hospital letters. Twenty two percent of contactable patients felt they no longer required an appointment. We feel that an improvement would be a PB system where patients are only removed from the outpatient waiting list upon mutual agreement.
Thirty-nine percent of contacted patients did not recall receiving any letters from the hospital. Some of them would have forgotten receiving letters as we recruited patients referred up to 18 months prior to commencement of our study. Nevertheless, it would be important to evaluate the system of postage to patients from the PB centre in our hospital.
As far as we are aware, the process of patient removal from the PB outpatient waiting list by a waiting list coordinator is common practice in hospitals. This process may further increase the number patients who ‘have not responded’ and thus been removed from the waiting list. This may overestimate the true number of patients removed purely as a result of the failings of the PB system.
In conclusion, the partial booking system success-fully reduces outpatient waiting times.[2] It is safer than the traditional fi xed appointment system where an appointment is sent several months ahead, with no reminders to follow. With a now proven decrease in patient DNA rate, a greater proportion of referrals should arrive and be seen in the outpatient clinic. The Department of Health has thus recommended that this system is extended to follow-up patients.[2] Our study has shown that a signifi cant number of patients may be inappropriately removed from the outpatient appointment waiting list. This may be due to individual trust modifi cations to the PB system. We feel that this may be addressed if NHS trusts implement the partial booking based on the full Department of Health recommendation. This would ensure that the recommended fail-safe mechanisms of patient reminders are in place. Since the comple-tion of this study, partial booking as practised in our hospital has been modifi ed to incorporate all Department of Health recommended fail-safe mechanisms. Patients now receive a reminder letter, followed by a telephone call from an appointments clerk. In addition, the GP, consultant in charge, and optometrist are informed when a patient is removed from the waiting list. It is therefore important that trusts review the way in which partial booking is implemented locally.
All work was performed exclusively at Hillingdon Hospital NHS Trust. The authors would like to thank Inayat Khan, Andrew Needham, Molham Entabi and Susie Sarangapani for their assistance with the survey.
