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In outpatient clinics, consultation times are often eroded by extraneous activities. We measured the components of each outpatient episode in 167 patients attending a general urology follow-up clinic. 41% of time in the clinic was spent away from the patient—administration 17%, disturbances 15%, finding results 9%. The inefficiencies had changed little since a study in the same setting thirteen years earlier. Since then, parallel nurse-practitioner-run clinics have been introduced in the hope of giving consultants longer with the patient; however, time with each patient is now 4.8 min compared with a previous 7.6 min. The most easily addressed inefficiencies are those relating to missing information, such as radiology reports.
The efficiency of the NHS is under intense scrutiny. The media regularly highlight the length of waiting times for outpatient consultations. There is continued pressure from the Government to ensure certain patients are seen within a particular time period. Are the structure and resources of the outpatient clinic adequate to cope with these demands? The efficient working of the clinic depends upon a multiskilled team of support staff, as well as dependable means of transferring information between healthcare professionals.
We examined the time-efficiency of a general urology outpatient clinic which had been studied thirteen years earlier1.
We examined the components of consultations in 167 men and women with a general case mix attending a urology outpatient clinic for follow-up. Patients were given the opportunity to refuse observation before entering the consulting room. Two consultant urologists (MSN, RAM) saw all follow-up patients over a period of six weeks in 2001. The ten clinics were monitored by independent observers (CL, TB, JB, DZ) who recorded the time spent for each consultation, with a breakdown in seconds of where delays occurred. The consultant, supporting staff and patients were all blinded to these measurements. For every consultation, the assessors recorded times for: discussion; examination; reading notes (before, during or after consultation); administration (including form-filling, dictation, note-taking); finding missing results; disturbances. They also noted numbers of patients who did not keep their appointment, numbers for whom medical records were incomplete or missing and numbers for whom results of investigations were missing (specifying the department concerned). Data interpretation was by reviewers independent of the study (HRHP, LKM).
The mean time for each consultation was 8.2 min, of which 4.8 min was spent with the patient. Table 1 shows how the remaining 3.4 min (41%) was occupied.
Regarding missing results, the main culprit was the radiology department, accounting for 71% of this component; also commonly missing were records on transrectal prostate imaging, urodynamic studies and flexible cystoscopy. An item of some kind was missing in 25% of patients.
Disturbances (Figure 1) were about equally attributable to the telephone, nurses, junior doctors, and others (including students and fellow consultants).
Much of the administrative work consisted of requesting investigations and writing up the notes. Over the ten clinics, 62 patients (27%) did not attend.
Over 40% of outpatient time was lost in administration and inefficiency. Some of the administrative tasks might be eased by a computerized information system, with data input by well-trained staff; however, the most conspicuous waste of time is in hunting for missing notes or results. In 1988, the radiology department accounted for only 13% of missing data, in 2001 71%. The reason, apparently, is that the department's workload has increased vastly without a corresponding increase in secretarial assistance; thus written reports fall into arrears. Whereas digital image acquisition is the standard for equipment used in ultrasonography and CT, MRI and radionuclide scanning, most radiological images are still recorded on film2. Although digital radiology allows immediate access to images, it is not yet trouble-free: a computer crash due to overload can be hugely disruptive. Also, of course, the information still has to be processed.
The most disappointing finding in this survey was that time with the patient decreased substantially, from 7.6 min to 4.8 min, between 1988 and 2001. This was despite efforts, in line with Royal College guidelines, to increase the time spent consulting. The strategy in our clinic was to introduce parallel one-stop clinics (e.g. for prostate symptoms, erectile dysfunction) run by nurse-practitioners. However, the ‘nurse’ component in Figure 1 is largely due to the need for consultant supervision and advice in certain aspects of this work. So these clinics tend to dilute the consultant time available in the main clinic. Telephone disturbances were mainly attributable to general practitioners, who know that this is the only time when consultants are readily accessible.
The main message of our study is that patients lost out on consultation time between 1988 and 2001. If the inefficiencies in these clinics could be cut by half, each patient could be given much more time or the throughput could be increased by one-third. The best approach is probably to introduce an electronic system for accessing and recording information on patients3. This will need to be backed by investment in staff and training to maintain the quality of the system4.