NHS England publishes guidance on reducing ‘did not attends’ in outpatient services

  • 22 Feb 2023
  • David Murray, Policy Advisor

NHS England has published guidance detailing how trusts can reduce instances of ‘did not attends’ (DNAs) for outpatient appointments. RCOphth Policy Advisor David Murray summarises what’s in the guidance, how it might affect ophthalmology services and what else is needed to tackle outpatient backlogs in ophthalmology.

What is in the guidance?

NHS England has this month published high-level guidance on Reducing did not attends in outpatient services, aimed at supporting the delivery of their 2022 elective recovery plan. The guidance details a range of steps trusts can take to reduce instances of DNAs, including:

  • Reviewing previous work to reduce DNAs
  • Using the Model Health System to compare against other trusts
  • Sending appointment reminders to patients
  • Improving access to booking, cancellation and rebooking processes
  • Implementing digital portals where appropriate
  • Effectively monitoring and reporting DNAs

The guidance also contains a range of trust-level case studies providing examples of where DNAs have been reduced.

What are the state of ophthalmology outpatient backlogs?

Ophthalmology is the busiest outpatient specialty, with 7.5 million ophthalmology outpatient attendances in England in 2021/22. At the end of 2022, over 600,000 patients were waiting for consultant-led ophthalmology treatment, accounting for 9% of the entire NHS elective backlog.

Of the increase in ophthalmology backlogs, outpatient backlogs have seen a disproportionate increase of 59% from 2019-2022 compared to 14% for surgical backlogs. This rise is reflected in the concerns of eye units too, with 74% growing more concerned about the impact of outpatient backlogs and 26% estimating it will take over three years to clear them according to the RCOphth’s 2022 workforce census.

Ophthalmology has a similar – though very slightly higher – proportion of DNAs compared to other specialties. In 2021/22 the percentage of attendances to DNAs in ophthalmology was 6.9% compared to an average of 6.5% across all other specialties. This has increased by 0.15% in ophthalmology over the previous 12 months, matching the average increase across all specialties.

How will this guidance affect ophthalmology?

Patients on ophthalmology outpatient waiting lists are often at the highest risk of avoidable sight loss, so measures to reduce these backlogs – including through reducing DNAs – are welcome. However, while this high-level guidance demonstrates a welcome focus on outpatient backlogs, ophthalmology units are likely to be undertaking steps to reduce DNAs already, such as the use of remote consultations to reduce hospital visits for urgent eyecare services in Moorfields Eye Hospital.

In 2020, RCOphth published guidance on prioritising outpatient appointments – primarily outlining the need for risk stratification. In 2022, RCOphth also produced a briefing explaining how to implement previous NHS England guidance on reducing outpatient follow-ups. This outlined the ongoing work that would need to continue around delivering diagnostic services outside of the hospital, offering patient initiated follow-up (PIFU) appointments where clinically appropriate, and developing more robust discharge guidelines and referral refinement criteria.

In its priorities and operational planning guidance 2022/23 published at the end of 2021, NHS England outlined its ambition to reduce outpatient follow-ups (OPFU) through an increased use of PIFU. NHS England has also produced guidance on the Eye Care Hub on how to implement PIFU, which the RCOphth will add to shortly with the publication of a best practice ophthalmology PIFU case study. While PIFU is a useful tool to help reduce outpatient follow-up appointments and DNAs, it is just one of a range of tools that should be used to tackle backlogs in the round, as it is only appropriate for certain eyecare pathways.

The focus on PIFU was not repeated in NHS England’s planning guidance for 2023/24, published in January 2023 What it does do is set a target across the system of ‘an appropriate reduction in outpatient follow-up in line with the national ambition to reduce OPFU activity by 25% against the 2019/20 baseline by March 2024’.

Elective recovery funding of £8 billion between 2022-25 has also been issued, including to support outpatient services. It is important that this funding helps to support outpatient backlogs in ophthalmology, including through the inclusion of ophthalmology services in community diagnostic centres.

What additional measures should be taken to tackle ophthalmology outpatient backlogs?

It has been a year since the publication of the elective recovery plan. Over the last 12 months, there has been a great deal of political focus on tackling surgical backlogs, with increases in the number of NHS-funded cataract procedures performed compared to pre-pandemic. But it is important that the same energy is devoted to tackling backlogs for diagnostic and follow-up appointments.

RCOphth believes the following three areas should be prioritised to help address backlogs for ophthalmology services:

Expanding the workforce

There is a significant mismatch between demand and the available workforce. This is further exacerbated by the need to detect disease in the populations at risk. Efforts to reduce DNAs must therefore come alongside an expansion of the medical and non-medical eye care workforce if outpatient backlogs are to be tackled effectively. By investing in training and expanding the multidisciplinary team and allied health professionals, workforce capacity within ophthalmology can be expanded quickly.

However, in the long term we will need more ophthalmologists to lead the delivery of eye care amid ever-rising patient need. This can only be achieved through an increase in both medical school places and ophthalmology specialty training places. We welcome recent increases in medical school places being made available and expect to see a corresponding increase in specialty training places available. In addition, we hope that NHS England’s upcoming Long Term Workforce Plan will provide a strategy toward increase specialty training places in line with medical school places as outlined above.

Developing electronic eyecare referral systems and electronic patient records

A national electronic eyecare referral system (EERS) should be developed allowing optometrists to directly refer patients to ophthalmology. An EERS would facilitate shared imaging standards across primary and secondary care, enabling high volume, efficient patient data sharing that may help reduce instances of DNA. Development of an EERS is already underway in Wales, and provides a useful case study on how such a system can be developed in other nations.

While a national EERS would standardise referral systems between primary and secondary eyecare, an accompanying expansion of electronic patient records would provide ophthalmology units efficient access to patients’ medical records and may facilitate a smoother booking, cancellation, and rebooking process. Development of EPRs would also facilitate the development of easily accessible online portals.

Ensuring ophthalmology units have adequate outpatient and theatre space

Many eye care units do not have appropriate outpatient and theatre space to meet current patient need. If trusts increase the outpatient and theatre space available to ophthalmology units, and ensure it is suitably configured to support high flow ophthalmic pathways, capacity to treat patients may be increased, reducing overall backlogs.

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