LAUSR

‘Evening dermatology clinics were introduced in our hospital by necessity as there was no room for more daytime clinics. No one asked the patients for their views.’ This dermatologist was struck by the change in atmosphere between evening clinics and daytime clinics. It was the same patients and the same staff in the same clinic rooms, but at a different time; so why the change in atmosphere? The answer was obvious: parking, work and a calm environment. The hospital car parks empty rapidly after five; evening appointments seldom require time off work; there were no competing clinics, so the outpatient department was quiet. Why does this matter? Because having unstressed patients attending at a time that suits them usually results in improved interactions with the clinic staff. Doctoring becomes more enjoyable if the patients are relaxed and have had a chance to prepare themselves mentally for the forthcoming interaction. If patients ask the right questions and are listened to, they have reached first base, improving the chance of creating a shared agenda with their dermatologist. This in turn improves the chance of better patient outcomes and greater patient adherence; everyone is a winner. This is just one example, and highlights an imperative: as clinicians we have a duty to bring our outpatient interactions with patients into the 21st century. Outpatient hospital clinics are dynamic systems. For a system to be viable, it must be able to cope with the complexity of its environment. What has this got to do with hospital outpatient clinics? According to the Royal College of Physicians (RCP) report on outpatient services, outpatient clinics have not changed in decades and are no longer fit for purpose. In plain language, the complexity of patients’ lives and of medical care means that hospital outpatient clinics are doomed to fail unless they can create a variety of options for outpatient care; thus, only complexity absorbs complexity. Imagine the difficulty a dermatologist has in trying to manage an elderly patient with mucous membrane pemphigoid, ensuring understanding and treatment compliance, interacting with ophthalmology and oral medicine specialists, while trying to boost the morale of the patient and her relatives. A conventional outpatient clinic slot is clearly not the ideal environment for reconciling the competing demands of such a complex clinical situation. With this in mind, the scale of the failure of current outpatient clinics in the U.K. might not be a surprise: nearly eight million DNAs (did not attends) and a further eight million cancelled appointments in 2016/2017. Innovation is now needed, recognizing that attending hospital is inconvenient, time consuming and costly for most of our patients. What changes does the RCP report recommend? In essence, major reform of outpatient services underpinned by better use of the technology that is already available. The report includes 16 principles for good outpatient care (Table 1). The only principle missing from this list is the importance of continuity of care. The RCP report also includes seven exemplar projects from around the U.K., although none relates to dermatology (a missed opportunity, as dermatology is so clearly ahead of most other disciplines in the way we operate outpatient services). How have other disciplines responded to the need to deliver excellent services, with limited resources, in a fiscally challenging environment? In short, they have responded with imagination, creativity and innovation. Incremental innovation with tiny improvements to the existing system occurring year on year has been the norm in the National Health Service (NHS) in recent decades. However, the RCP report acknowledges that healthcare in the U.K. has now reached the stage where this is no longer sufficient; something more radical is needed. Common themes are apparent from these seven projects: additional funding was relatively small or was not required; a greater focus on improving the patient experience; technology was often used to underpin the changes; and collaboration and integration of services between primary and secondary care. Most NHS dermatology services in the U.K. will already have adopted some of these RCP principles; few if any will have embraced all 16. There are multiple examples from dermatology in offering alternatives to face-to-face consultations, thereby increasing capacity, and freeing up outpatient clinic slots for those patients needing clinic interaction. These alternatives include teledermatology clinics, triage of e-referrals to ensure the correct option for each patient, virtual clinics utilizing e-mail or telephone, nurse-led Skype clinics, and even patient-initiated consultations. Additionally, there is now growing insight into the nuances of clinician and patient perspectives on outpatient discharge decisions. While some dermatologists are restrained by their antiquated NHS clinic appointment systems, many are not and