Implementing patient initiated follow-up

Patient initiated follow-up (PIFU) is designed to give patients and carers greater flexibility to arrange follow-up appointments for their ongoing care when and if needed. NHS England is promoting it as a way for services to reduce unnecessary outpatient appointments to improve access for people who need them most.

Implementing PIFU has its challenges, but as part of organisational strategies it can help address backlogs and access to care. It can alleviate service pressures by prompting auditing and validation of existing lists; ensuring staff better understand the scale of waiting lists, and helping patients avoid being ​‘lost to follow up’ because of how their records are coded. 

Longer term, services can identify new patients who could benefit from PIFU through indicators such as missed appointments rates and developing clinically-led and service- specific inclusion criteria. This can help services prioritise patients most in need.

Adam Binnie is Planned Care Project Manager at NHS Surrey Heartlands Clinical Commissioning Group (CCG). He spoke with Q Insight Manager Jo Scott about implementing PIFU across the Royal Surrey NHS Foundation Trust.

“We’ve been finding a lot of support for its potential to improve quality and experience of  services” Adam says. ​“We have clinical buy-in from both primary and secondary care. The clinicians I have worked with see the benefits, and patients equally love it… Nobody likes to waste people’s time… That’s why it works.”

“PIFU is not a new concept. Similar models of care have existed for years” says Adam. So while some clinicians already manage their patients in this way, for others it requires a change in behaviour and service redesign. They may worry that it is not clinically appropriate or it will increase problematic demand if patients request follow ups that can’t be met due to capacity. 

To overcome this in Royal Surrey, ​“the trust have created a strategic objective to support implementation and we have a clinical lead assigned to the project. This has helped to engage clinicians and to ensure we take a clinically-led approach.” 

A checklist guides services through the process of creating their own standard operating procedures, and ensuring there are plans in place for people on the PIFU pathway who need to be seen. While there are targets for implementing PIFU, this element needs to be carefully managed, so – as Adam says – staff don’t ​“run a mile”. Good stakeholder engagement is key. ​“It’s important that clinicians lead on the setting up of PIFU and localise processes to best meet the needs of their patients.”

“We assume that patients know who to contact when they need to speak to someone, but this is not always the case” says Adam. In Surrey, implementing PIFU has prompted services to update and improve communications to patients including websites, leaflets and working with patient-facing organisations and primary care to ensure patients know how to get in touch. 

This should reduce variation across and within services. But PIFU may not be appropriate everywhere, particularly where community services and other self-management support is not available.

“In one of our pilots, around 85% of patients who were put onto a PIFU pathway did not contact the service again. They’ve discharged around 70–80 patients so far who would otherwise still be on their waiting list.” 

In helping clinicians better understand who is on their waiting lists, the benefits of PIFU can be immediate. However, as with other longer-term initiatives to address health service utilisation, further analysis using linked, patient identifiable data is needed to understand if PIFU is improving access or simply displacing demand.

Royal Surrey NHS Foundation Trust was one of NHS England’s rapid adopter sites for PIFU, and its implementation is one of the Trust’s high-level strategic objectives. While Surrey’s strategic context for its PIFU roll-out may differ from elsewhere, this highlights important learning: PIFU needs senior operational and clinical buy-in and resource. 

The checklist Surrey developed provides implementation guidance for clinical teams and ensures inclusion and exclusion criteria are clinically led (and clinically challenged, if there is disagreement about what is clinically appropriate).

It is likely that a large proportion of people on current outpatient lists are already on this pathway by another name. Auditing and ​‘recoding’ to PIFU pathways could be a quick win helping services better understand how to prioritise resources; implementing this across the organisation is a way to reduce variation across and within specialties. 

In the longer term, more service redesign, evaluation and partnership working are needed to ensure PIFU is used to improve quality and experience for all, and not merely displace demand.