November 2013

Our plans for spring!

It is tough to escape an emphasis on winter in the NHS right now.  Rightly so after last year.  All our bay doors are on at Sandwell so we should be better able to limit infection.  We are over 3000 staff flu-vaccinated and we are keeping at it!  Waits to be transferred from an ambulance into A&E are down – City is the top performer in Birmingham much of the time.  Though we really have decisively slashed very long waits, we still are not always able to beat four hours for nineteen out of twenty patients.  I cannot see anything but immense effort from everyone on our teams and some days and some nights it works well.  If you read my blog, I always seem to come back to the same idea:  We need to do more routinely what we do sometimes.  The best of what we do becomes the norm.

But, incredibly important though 200,000 attendances at our emergency departments, including eye casualty, are – I want to focus this blog on the part of what we do that sees far more patients than any other.  Outpatient services:  Whether in our hospitals, or your GP surgery, or a school – in total we work from over 150 locations and most of the 1.5 million face to face appointments we undertake are “classified” as outpatient care.

If we look to our long term plan, to our commissioners’ plans, and most importantly to what patients and their GPs tell us they want, we are trying to change the outpatient “offer”.  There are examples right now of how we do that – in BMEC you can check in automatically and electronically when you arrive, in diabetic medicine we are trailing all sorts of ideas to see patients via camera technologies, alongside GPs in their practices, and in groups to develop expert patients.  Given the diversity of those we serve and the diversity of the types of care we provide, in fact we need lots of ways to do outpatient type work – ways that suit patients and their lives and ways that make better use of precious resources (by which I do mean money, but I was also thinking of time).  So building on our award winning breast service, but also on great practice from inside and outside SWBH, we are marshalling some changes to consult with our Board, with Healthwatch, with our staff and others.

We are beginning to think about 2014 as ‘The Year of Outpatients’, where we make a focused whole Trust effort to see through changes.  Of course altering something as traditional as the UK outpatient model is not an easy task, and there will be some trial and error, but I wanted to be open about some ideas for what might change as well as explaining why it matters and why it matters now.

We already have some common standards we would always want to deliver.  In particular the pace and quality of communication matter.  Joining up the NHS is always important and we want to get letters to patients and their GPs smartly and quickly after consultations.  Hopefully when the Birmingham Central Care record proceeds that will give us a great backstop.  But we also want to make sure, by audit and reflective practice, that what is discussed between a clinician and a patient or their family is actually understood – and understood in the same way by all involved.  If you have not heard it – I have not said it, is a pretty obvious rule of thumb.

One of the major changes we need to make is to get right the sequence of care.  In our Trust, like most hospitals in the NHS, the pattern is for referral, attendance at clinic, test ordering, return to clinic, etc.  But for a significant minority of patients, the test (or some tests) can precede the clinic.  In other cases the tests and clinic can be on the same day.  And in others, we would want you to leave clinic knowing the date and time of the test and having agreed it, is convenient to you.  Returning to clinic may be the right step, but in some cases we can discuss results of tests with you by telephone or other media.  And we need to make sure that the repeat attendance at a clinic is truly needed and is not a habit on our part, because we are unsure of help you could get elsewhere, or we are concerned that if you did not have a further appointment you would be “lost” from our care.  We need to make sure that the discharge rates from clinic reflect good clinical practice among both consultant and more junior medics and nurses.

As with diabetes in my example above, the area where we foresee the greatest change is for patients with long term conditions (sometimes called chronic diseases).  Because they can be lifelong, it makes sense we think to try and deliver far more of that type of care in town centres, GP practices, community hubs and at home.  And because we may have that very long term relationship with you, this is also where we see technology – be it remote or self-monitoring or video formats – offering real help.  Without reducing the quality of care we offer, we think that over time less consultant time will be spent in outpatient medicine.  That matters because those specialists will increasingly spend time on inpatient care, as we move towards beds being reserved for the very sickest patients and where it matters most that senior doctors are immediately involved in someone’s care, seven days a week.  To make that happen, we need to change outpatients – and that explains our sense of pace about getting on and doing so, SWBH wide.

Of course, there is a lot to think about, consult and evaluate as we make changes next year.  But I really hope you would agree that though we have lots of great outpatient practices and staff, we can do better with our processes, our communication, and our pace – as well as the environment, the IT, and the experience of care we offer in clinics.  Quality of care, safety of practice, and your experience of the service are the three dimensions we use to assess quality – and we think that if we could improve outpatient services, we help the anxiety that comes with delay and help local people to manage long term conditions better – especially if someone has more than one.

So, after the dark nights of winter are done, expect us to be beginning to talk and listen and adapt our outpatient services at the Trust.  Let us know what you think – either on our website or through NHS Choices. Or email me direct at  I am also now on twitter at @TobyLewis_SWBH. Join me for my monthly Toby Twitter Talk (#SWBH_TTT) – my first one is on Monday 11th November at 8.30am, thereafter I’ll be live from 8.30 –  9am on the second Monday of the month.

Finally, I would urge you to please get your own flu jab if your doctor, nurse or pharmacist recommends one.  Winter for all of us using the NHS will be better if you do choose well.

Toby Lewis

Chief Executive