Table 1.

Key recommendations and actions to improve outpatient efficiency

Change/recommendation	Notes on actions, benefits and examples	GIRFT report where change mentioned most often/examples given
Reorganise NHS hospitals to meet population need	Identify inefficient configurations Work with local populations to explain opportunity	Multiple reports
Link secondary care networks to primary care networks	Multiagency joined-up care Rapid response to crises	Cardiology¹ Rheumatology² Urology³ Endocrinology⁴ Children's and young people's mental health services⁵
Address workforce shortages to reduce geographic variations	Reduce variation in waiting times across country	Rheumatology²
Develop MDT	Increased efficiency and quality Develop specialist nurses, pharmacists, physiotherapists and others	Urology³ Cardiology¹ Ear, nose and throat surgery⁶ Dermatology⁷
Train specialty doctors locally to meet local needs	Develop CESR training programmes	Dermatology⁷
Develop superclinics to see very large referral numbers	Use MDT	Dermatology⁷
Manage patient expectations of what NHS can provide	Carry out communications, including social media, to show realistically what NHS can do Focus resources on highest priorities	Multiple reports
Reduce referrals due to fear of litigation	Provide better communication, training and information on litigation and risk	Multiple reports
Introduce threshold policies to avoid inappropriate referrals	Work with integrated care systems (ICSs), GPs and specialists to introduce specialty criteria Agreement at ICS/national level will help avoid postcode differences	Dermatology⁷
Encourage patient self-management	Engage with charities to provide education Provide web resources	Gastroenterology⁸
Develop whole system care models (will avoid destructive primary care/ secondary care behaviours)	Community assessment hubs Crisis response hubs MDT working Primary care education	Geriatric medicine⁹
Avoid targets which disadvantage some in greatest need	Avoid suspending non-cancer services to meet cancer targets	Rheumatology² Endocrinology⁴
Working with patients	Make joint decision making central to improve adherence and outcomes	Gastroenterology⁸
Avoid wastage on high-cost locums	Avoid short-term gains which lead to long term worsening of workforce problems, due to staff leaving NHS	Dermatology⁷
Use pre-referral advice and guidance telemedicine wisely	NHS e-RS service can offer GPs and patients immediate advice and prevent the need for a hospital appointment Ensure that the increased provision does not increase overall demand on a fixed secondary care resource or telemedicine can lengthen waits Change cancer referral rules so that suspected cancer can be discharged without a consultation (just a letter) if appropriate and safe	Neurology¹⁰ Dermatology⁷
Develop effective community services	Effective diabetes services can reduce referrals for amputation	Diabetes¹¹
Direct triage by telemedicine to services	For some surgery, dietician or pharmacist led clinics	Gastroenterology⁸ Dermatology⁷
Avoid duplication of secondary care services	Ensure elderly with frailty do not attend multiple clinics for same problem	Geriatric medicine⁹
Most efficient use of hospital facilities	Develop evening and weekend services	Gastroenterology⁸
Link services to produce synergistic shorter pathways	Dermatology and plastics or gastroenterology and surgery for cancer services	Dermatology⁷ Gastroenterology⁸
Efficient transition from paediatric to adult services	Transition clinics improve quality	Diabetes¹¹
Develop one-stop services	Appropriate for some investigations and procedures	Multiple reports
Innovative clinic settings	Eg in shopping centres Not suitable for all services	Ophthalmology¹²
Reduce clinic DNAs	Target those who have waited a long time Ensure that communication works for non-English speakers and those with vision disability or poor reading to avoid disadvantaging minorities	Respiratory¹³ Neurology¹⁰ Dermatology⁷
Reduce follow ups by discharge or when appropriate by open appointments	Use patient-initiated follow-up (PIFU) or personalised stratified follow-up (PSFU) Aim for discharge at first appointment (one stop)	Breast surgery¹⁴ Multiple reports
Avoid losing follow up patients with disabilities	Ensure elderly with retinal disease and glaucoma not lost to follow up	Ophthalmology¹²
Efficient use of high-cost drugs	Ensure high-cost outpatient drug use follows best and most efficient practice Identify outliers of hospital outpatient prescribing Pharmacists embedded in outpatient teams	Rheumatology² Dermatology⁷ Gastroenterology⁸