Personal views: Have we reached crisis management in outpatient clinics?
Authors: David Sellu
Journal: BMJ (1998)

I have just finished a typical outpatient clinic for patients with general and colorectal disease. I arrived at 8 30 in the morning and did not leave till 1 30 pm—officially the clinic runs from 9 00 am to 12 30 pm—and, with my registrar, saw 46 patients, more than half of them new. In a smaller clinic, which I acquired against considerable competition from other users, we see 18 patients. 

What pressures are there on my clinics? I receive on average 52 new general practitioner and internal referrals each week, a third of them marked urgent. This number is over four times more than five years ago, and continues to rise steeply. I also have hundreds of patients to follow up, including those undergoing tests, those previously treated for cancer, and those requiring outpatient treatment for conditions such as haemorrhoids and complicated inflammatory bowel disease, some in the last category indefinitely. As the genetics of cancer becomes better understood, more people present for screening. I estimate that one in 10 new patients will need to remain in the system for the following five years 

I have six hours a week to do all this work, a time limit imposed by the need to cater for other consultants and by the shortage of nurses. For all new patients I take a history and perform a physical examination, in many I perform proctoscopy and sigmoidoscopy, and, if I find an abnormality, take biopsies. I record my findings on all patients and for some I complete request forms for tests. I discuss my findings and future plans with all patients, answer questions, and dictate a letter to the general practitioner. 

To do all this properly, I need at least half an hour for each patient. Allowance must also be made for delays from lost notes, x ray packets, and laboratory results; answering the telephone; and for teaching, a vital part of my work. Our health authority has limited drastically the number of patients it will pay for, while the patient’s charter demands that 90% of patients arriving in the clinic should be seen within 30 minutes and all patients have an appointment within 13 weeks of referral. 

These pressures have alarming implications while demand for the outpatient clinics far outstrips supply. Simple arithmetic shows that I cannot meet both charter standards simultaneously. I have increased the number of patients in each clinic to reduce the times for those waiting for their first appointments, but this has simply created chaos. Consultations lasting less than 12 minutes with new patients do not provide opportunities for resolution of problems. 

How do you explain to a patient in six minutes that the tumour in his rectum is cancer—what is cancer anyway? During surgery it may be possible to preserve the rectum—do I mention the risk of impotence now? But if this is not feasible the back passage will have to be removed and a colostomy fashioned—what is a colostomy? Depending on what the pathologist says, the patient will be considered for chemotherapy and radiotherapy—what are they, how are they given, where, over how long, and what about side effects? 


When, as often happens, these consultation times are inadequate clinics overrun, and on several occasions I have managed to see only 20% of patients within 30 minutes. I spend more time apologising for delays than getting down to the real business in hand, and occasionally patients are so incensed by delays that the quality of the consultation deteriorates. This is hardly an atmosphere for providing specialist treatment, counselling, and advice on prevention, just some of the many things expected. In any case, seeing more patients in a clinic means doing more work than the health authority will pay for. 


“The final solution must be to allocate more money”



The alternative—the politically preferred option and not surprisingly the cheaper—is to see far fewer patients in each clinic. If this is adopted, and there is growing pressure for it, in a few months new patients will wait for an unacceptable time of over 20 weeks for their first appointments. Some long waiters have serious diseases such as cancer, not predictable from the history and examination but uncovered only after investigation; a third present to the accident and emergency department with complications, such as intestinal obstruction, an inevitable price of delay. 

How have I responded to these conflicting pressures? Sadly, as an individual, there is little at my disposal to solve these problems, although in the eyes of some general practitioners and patients the failure lies firmly at my doorstep. Juggling with the number of patients coming to a clinic is not a solution. I have lobbied for more clinic time, but not only have I been unsuccessful because of lack of facilities, but the trust, faced with market pressures, is understandably reluctant to do work that it will not be paid for. 

I start clinics earlier and finish later than allowed, skipping tea and lunch, but such gestures are scarcely enough. I have reduced to a minimum visits by patients who have been in hospital or had operations, and those with chronic but stable conditions. Controversy continues about the type of follow up required for people who have been treated for cancer, and it is an uncomfortable fact that most recurrences are detected not in the outpatient clinic but between visits, the so called interval cancers. I have discharged as many patients with cancer as is reasonable to, but a substantial number naturally wish to be followed up for several years. 

What about long term solutions? As elsewhere in the health service, demand has risen exponentially. We must either reduce this or increase supply, or do both. Audits of general practitioners’ letters show that some referrals are inappropriate, but general practitioners are also under intolerable pressure to refer patients to hospital. Many consultants are working with general practitioners to produce referral guidelines, but this will take time and there is scepticism about its likely impact. I favour the patient’s charter but not when it raises expectations without providing the means to meet them. 

The final solution must be to allocate more money to provide ample clinic facilities and to employ more nurses to run them. I believe these difficulties are more widespread than is appreciated and will get worse unless a solution is found. So far this week, I have had 45 referrals. Three of my clinics will be cancelled in the next two months because of audit and bank holidays, adding an extra two weeks to an already long wait. Clinics for the next six weeks are severely overbooked, but 15 letters this week demand appointments within two weeks.