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Redesigning outpatients through inclusive participatory co-design.

Starting from a position that quality and value are only ever viewed through the lens of the customer we will use participatory co-design to redesign and improve our outpatient follow-up offer.

Read comments 21 Project updates 1
  • Winning idea
  • 2019

Meet the team


  • David Crompton
  • Chris Edworthy
  • NHS England/Improvement colleagues
  • Voluntary and community sector representatives
  • Primary Care Clinical Directors

What is the challenge your project is going to address and how does it connect to your chosen theme?

We are experiencing increasing demands on our services, with an aging population often presenting with complex co-morbidities and the impact from the wider determinants of health. One third of our population are living in the 20% most deprived areas in the country.

Challenges for Outpatient services across the whole life journey are:

Increasing first appointment to follow-up rates. Delay = reduced outcomes and poor experience.

Challenges achieving the 18/52 week ‘Referral to Treatment’ times

Workforce burn-out, evidenced by increased sickness/absence, challenges in recruiting into some specialities. Increasing locum and agency spend to address the unavailability of our own workforce capacity to support the required out-patient clinics

Limited space to hold traditional clinics

Financial challenges to deliver safe and effective services

Added to these pressures NHS England’s Long Term Plan states an expectation that face to face out-patient follow-up is reduced by a third in the next five years

What does your project aim to achieve?

We aim to co-design and reimagine our outpatient offer: exploiting and combining opportunities identified through literature and patient/clinical experience, making our service fit for the needs of our population, tailored to their level of complexity and activation, adding value, reducing inefficiencies and helping us achieve the required reduction in face to face out-patient follow-up appointments.

Hold a participatory co-design event with up to 200 patients and 25 practitioners where all perspectives and ideas will be shared and the future offer co-designed.

Next, each clinical service will redesign their outpatient offer as co-designed at the event. This will include High-tech Low Touch for highly activated people, using non-traditional outpatient follow-up and High Touch, Low Tech, including community led resources for those who need support to improve their outcomes. Measured via activity and reported experience.

The co-design event will shape the eventual re-design per speciality.

How will the project be delivered?

Patients and their carers are our biggest and frequently untapped resource when it comes to designing services. We will work with both highly activated and less activated patients and their specialist clinical teams to identify and understand what a tailored out-patient offer would look like in terms of quality and value.

We will be using Quality Improvement methodology throughout.

In our project team we have patients and their carers, specialist programme managers, clinicians, Q members, data and performance specialists, library services (for academic research evidence), multi-disciplinary therapists including primary care working across an integrated secondary and community system.

NHS England/Improvement are very interested in this work and are working alongside us, with a view to spread and sale across England, should it be successful.

Risk management will be monitored discussed and actioned in collaboration with all of the above. Using Prince 2 methodology to maintain the risk log.

What and how is your project going to share learning throughout?

Learning will be iterative and potentially different for each speciality.

Sharing the methodology and learning developed – warts and all!

Using podcasts, video & written feedback capturing and sharing the experience and learning of participants (Patients and ‘NHS Workforce’).

Blogging about our journey in an interactive, interesting and appealing manner, inviting comment and conversation from all who are interested to engage with us – after all “It takes a village to raise a child” or in our case “The Q Community”.

Develop and report on projects templated per speciality and progress made.

Report progress and present outcomes on a regular basis local governance structures.

Development of case-studies, shared via Academic posters, webinars, in-person presentations at appropriate events. We also intend to write this up for publication and wider dissemination.

Spreading via the Billions Institute model for large scale change

How you can contribute

  • Critique
  • Support
  • Information
  • New perspectives
  • Ideas!
  • Collaboration
  • YOUR VOTES Please!

Plan timeline

1 Jun 2019 Continue Patient Stratification for the 5 specialities
24 Jun 2019 Continue Academic Literature Searches
10 Sep 2019 Participatory Co-design Event
15 Sep 2019 Develop Test of Change for each specility
1 Nov 2019 Run test of change - 3 months
28 Feb 2020 Measure the impact
20 Apr 2020 Hold video sharing event
25 Jun 2020 Hold second co-design event for cohort 2

Project updates

  • 20 May 2020

    We ran a co-design event with 4 secondary care specialties (Rheumatology, Neurology, Diabetes and Respiratory) and 135 patients (some accompanied by their informal carers).  The day was split into 2 halves, stratified by the patient activation levels (identified through using the Patient Activation Measure).

    In the morning the work of participatory co-design was with people who had scored a level 3 or 4 using the PAM and their primary condition, secondary care team.  In the afternoon the work was repeated however this time the patient group were those who scored 1 or 2 on the PAM. Interestingly several of the participant could have joined  any one of the 4 specialty tables, due to living with all 4 co-morbidities; this discovery was made my chance and not design, but emphasises the relevance of the activity and the transferability of the learning.

    Prior to the event we had prepared ‘possibility’ prompt cards that were created/developed either from the specialty specific literature reviews that we undertook to identify the most effective supported self-management interventions and behaviours for those conditions and from a McKinsey & Company Consultation carried out in the Summer of 2019 to identify potential opportunity’s to transform our outpatient delivery model.

    These prompt cards were a combination of condition specific and generic and were available on the tables to support conversation where needed.

    There was fascinating learning generated about the different mindsets, perceived challenges and opportunities throughout the day.  In particular the stark and palpable differences felt in the atmosphere in the room between the morning and the afternoon groups of patients.  The clinical teams in attendance, in the main, stayed for the whole day( the change in participants was in the patient population).  A significant number of clinical attendees remarked about how impactful it was to see for themselves the huge difference there is between levels of activation and that the experience had demonstrated how essential it was to appropriately tailor support and intervention for people.

    Many people who attended on the day offered to continue to work with their teams to re-design the offer.

    An out-put of the day was a keen interest and willingness to try video consultation as an outpatient offer, this was particularly of interest to those individuals who were more highly activated (levels 3 and 4).  It was our aim to host and support specialty specific co-design teams of clinicians and patients to design how this would best work; however, Covid-19 got in the way and the video consultation roll out across the country happened at a much greater pace than originally anticipated, using the Attend Anywhere platform supported and funded by NHSEI.  This has impacted on our ability to genuinely codesign the process, offer and experience, however once covid calms down we will have an opportunity to revisit this and improve the offer using QI methodology.

    One of the possibility prompt card suggested volunteer peer health coaches with lived experience (possibility identified via the literature review in support of self-management): A number of participants from the morning session stated that they would be very interested in becoming volunteer peer health coaches and a significant number of the afternoon participants exclaimed that they would find this extremely useful.  We are planning on developing this support offer and are currently building appropriate training, volunteer recruitment, ongoing supervision and quality assurance.  This proposed offer has already generated support from across the system, Primary Care, Secondary Care, Community Care and Social care.  This work will support the transformation of outpatients by supporting individual’s self-management capabilities, thereby reducing individual health crisis, reducing the likelihood of developing further health conditions and optimise the opportunity of Patient Initiated Follow-Up (PIFU) pathways while also focussing on improving the health and outcomes of individuals.


  1. Congratulations on being short listed

    I like the generic approach rather than diagnosis related, as this can develop ideas which are widely transferrable. I would be delighted to support your work

    Best wishes


  2. I think this sounds a brilliant piece of work and am really keen to see how this evolves.  We have very similar issues and would be keen to learn from you.

    Be helpful to have a conversation.

    1. Hi Kate,

      We'd love lo share our learning  with you and learn from you too - great brains and ideas collaborating together will give us all greater opportunities to transform our services and ways of working.

      Happy to have a conversation either via phone or email, whichever works best for you.


  3. Great idea and fully support your work.  I am a keen advocate for participatory co-design where service users and staff work together to develop services, enhance care practices and improve experiences. I would be interested to receive updates in due course, e.g.key findings from the recent co-design event and how these will be used to influence learning and improvement.  Good luck with the project.

    1. Hi Sue,

      Thanks for your support and interest.  We have developed an initial output report, which each of the 4 specialities are currently developing their next stage of their project based on the outputs.  Happy to share whatever would be helpful to you.


  4. Hi Helen,

    I think what you are doing here is fabulous. The insights you gain from having so many people involved in the design process should be amazing. Should we both be successful I wonder would it be possible for us to collaborate so that we can swap learning or use the results of each others work?

    I'm involved in the Outpatients Innovation Collaborative.



    1. Tony and Charlie,

      We are always up for collaboration.  I hope that we are all successful.

    2. I agree - our project likewise is complementary and shared experience/collaboration would be really valuable.

  5. Hi Nicola Thomas, (sorry I cant seem to reply directly to your message so have to type your name out in full)

    I totally agree with the need to have a wide and varied representation.  In our local area we have limited ethnic variation, however we are ensuring that we have representation from the different age groups, genders and areas of living, for instance ensuring equal representation from areas of deprivation and affluence - it's tricky but possible.  Thanks for your advice.

  6. This is a great, detailed proposal.

    I would be interested to hear how you are planning to identify patients for the co-design workshop.  In our area, PPI can be quite challenging and getting engagement from the hard-to-reach (particularly in my specialty of Respiratory Medicine) is an ongoing issue for design of services (for primary and secondary care).

    1. Yes I agree with the comment about how you will achieve meaningful PPI by having representation from a diverse group (age, gender, ethnicity etc). It can be very challenging to achieve this and I wonder if you need to consider these other issues, not just 'activation'

    2. Hi Charlie,

      Sorry for the delay in replying - I hadn't spotted your email before.

      We are using the Patient Activation Score to identify which session individuals need to be attending.

      Get in touch, if you need more info.

  7. This looks really great Helen.  I am very interested on how you are planning to measure the effectiveness of your engagement - something I am chewing over in my piece of work!

    1. Hi Katrina,

      We are working with an experienced co-design facilitator, who will be guiding us on the initial co-design event engagement process. Evaluation of the event where 'Quality and Value seen through the lens of customer' will be essential.  We are considering using creative feedback medium such as video and vox pop etc alongside more traditional feedback forms.

      The bigger issue, I feel is ongoing engagement and the evaluation there of.   The co-design event will be followed by each speciality area reimagining and then redesigning their outpatient follow-up offer (depending on the outputs of the co-design day).  A series of rapid tests of the change using QI methodology will then need to be built in, ensuring that the initial engagement process was not a one off tick box exercise, but a genuine engagement relationship with those who are willing to come of the journey with us.  Being this ambitious is both exciting and scary at the same time, as we don't know where it will lead us and we need to have faith in the process.

  8. Hi Helen, Your idea looks well formed and interesting I would be happy to support you and of course you know you can use QuIPPs to talk to patient groups as well. I look forward to seeing this progress.

    1. Hi Jono,

      I am emailing you now to follow up on your kind offer.

  9. It would be great to get the experience and expertise of colleagues from SW AHSN here following the great work they did for last year's Q Exchange:

    1. Thanks Sarah,

      I have already made contact with Jono Broad, who led that successful project.  Jono has been extremely supportive and informative.  Jono and I work closely together and I hope to involve him further as we progress.

  10. Person-centred to the core!  Great stuff.  I wonder if you have made contact with colleagues outside of the NHS to engage with a wider footprint of citizens in your area and to enable thinking about how changes in outpatients will impact upon other services and sectors?

    1. Thanks Sarah, the system that I work in is an integrated health and care system, so impacts will be monitored and considered widely.  We are also attempting to involve out local Health Watch, Lifestyles teams, Primary Care and the Voluntary sector.  Unfortunately due to the word limitation on the bid, I had to delete many things that I wanted to share.

      Great questions/comments though, keep them coming as they help me refine my thinking.

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