1. Reducing outpatient activity Charlie Tomson (NO ‘H’!!!) Southmead Hospital, Bristol

2. Caveats We should be interested in saving money across the NHS, not just balancing the books in secondary care….. Seeing patients in outpatients attracts a tariff; avoiding seeing them by designing a lean pathway doesn’t. Doing a phone clinic can attract a tariff (1/10 of a visit), but only if you can work out how to charge for it

3. Applying ‘lean’ to OP care Define ‘value’ from the customer’s (patient’s) perspective Remove muda (waste) from the system –Any activity that absorbs resources but does not create value Identify the value stream – the parts of the process that add value Improve flow –Avoid batching, let the patient ‘pull’ value

4. Adding value from nephrology referrals..these guidelines were….developed to promote the optimal management of patients within the NHS, including the identification of those who would benefit from referral to specialist services..we have addressed this as much as possible from the patient’s perspective…analysis, based on UK practice, of what interventions and treatments require specialist training, and on when these interventions and treatments are necessary

5. Added value from nephrology outpatient visits Making a diagnosis that cannot be made in primary care –Skilled history taking, examination, specialised investigation Making/implementing a management plan that cannot be made/implemented in primary care Building trust for future decisions e.g. RRT

6. Trust in OP medical care 417 patients attending new patient OPA with cardiologist, neurologist, nephrologist, gastroenterologist, rheumatologist Keating NL. Arch Intern Med 2004; 164: 1015-1020

7. Keating NL. J Gen Intern Med 2002; 27:29-39

8. May C. We need minimally disruptive medicine. BMJ 2009;339;b2803

9. Low-added value OPAs?? Any CKD patient who does not meet the NICE referral criteria Stable stage 3B CKD Stable stage 4 CKD without anaemia/HPT Most transplant clinic visits Most dialysis review clinic visits Any clinic where the blood test results are only available once the patient has gone home and are likely to prompt recall

10. Alternatives Discharging patients who are just being ‘monitored’ Specifying a precise treatment plan (if/then statements) for patients with CKD, CCF, etc, and being available to advise on implementation in primary care Empowering patients to implement treatment plans Telephone follow-up with tests done locally, in advance of the scheduled phone call

11. People I saw yesterday Tp: purpura on sunlight, pulled muscles Potential kidney donor (lives S Africa) DM2, Ileostomy, hypotension, CKD4, massive oedema, OSA Cystinuria (not on chelation Rx); annual review. ? Screen offspring? Reflux nephropathy, recurrent UTI, son has Alports; benefit from 12/12 antibiotic prophylaxis: discharged Recent diagnosed ANCA-neg vasculitis; arrange iv Cyclophosphamide Steroid-responsive MCGN; reduce Pred to 5/0, GP blood tests in 2, 4, 6/52 (+phone to ensure I see them), see 8/52 Hyperkalaemia with eGFR 60 ? Gordon’s, ? Membrane transport defect. Stop thiazide and repeat in vitro tests; isotope GFR; US 90% RAS following surgery for paraganglioma: ?for angioplasty? CKD4, cystinuria, persistent UTI; full-dose Nitrofurantoin; arrange lung function tests.

12. Summary Many patients seen in OPD may not gain added value Systems often designed around our convenience rather than the patient’s Pathway for those patients who do gain value contains significant muda PbR (better termed payment for activity) presents a major perverse incentive not to reduce overall NHS cost

13. Thank you