What’s in a name? A PIFU pathway by any other name would smell as sweet.

Imagine a way that you could get to see the clinical team who know you already, without going through the pain and hassle and automated messages telling you that “you are number 5 in the queue.”?

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Well, this was the plan when NHS England set the target of reducing outpatient activity by 25%. This was undoubtedly a hugely ambitious target, but rather than focussing on the art of setting stretch goals – lets instead focus on how this could be achieved.?

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Clearly this was never going to be easy, but one of the tactics in this war on outpatients was the acronym - #PIFU – or Patient Initiated Follow-Up.?

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This is not all that new. It has come and gone in different guises previously, and NHS England themselves list a few of these including

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- ? ? ? ? ? open access follow-up?

- ? ? ? ? ? patient led follow-up

- ? ? ? ? ? patient triggered follow-up

- ? ? ? ? ? patient initiated appointments

- ? ? ? ? ? supported self-managed follow-up

- ? ? ? ? ? self-managed follow-up

- ? ? ? ? ? see on symptom

- ? ? ? ? ? open appointments

- ? ? ? ? ? open self-referral appointments

- ? ? ? ? ? patient-activated care

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I don’t know about you, but that is a lot of jargon and an impressive amount of re-branding.

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The original target was to move or discharge 5% of all outpatient attendances to PIFU pathways. And to do this a variety of resources and strategies were utilised, including forums, webinars, case studies, financial incentives and a whole host of other bits and bobs too. This is not a criticism. Actually doing this can free up teams capacity to see those focussed on clinical need, and not on arbitrary time points. But administering this and implementing this can be tricker than it sounds.?

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But before we dive in too deep, let's rewind and think about what PIFU is. In the olden days, people would call up the doctors’ secretary if they ran into trouble with a problem, and the patient would have an appointment made, and before long get seen. The doctor would know the patient, and hey presto, the problem would be sorted. Obviously it wasn’t quite as easy as that and there were all kinds of problems, but the premise was there.

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Then, this became slightly more formalised. People would be given an open appointment. “Give my secretary a ring if you run into any problems”. And this is what PIFU is. At its most basic level, it is an open appointment.?

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But then things got a bit out of control. Healthcare has all kinds of problems, and one of these is a well established supply and demand problem. One has rapidly become bigger than the other. And as central oversight was sought, keeping tabs on all these open appointments rapidly became completely unmanageable. And this mattered because of payment for the Trusts as well as workload and ensuring sustainable high-quality patient care, which absolutely should not be overlooked. This really is what should be at the core of all health systems.?

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But rather than focussing on payments and flow through the system, there are other requirements for a solution in this space. And as someone whom has sworn to do no harm, patient safety has to sit top of the list.?

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The systems used have to be robust. Which means a lot of things – but it has to work despite strains, surges in demand and unforeseen challenges.?

It needs to be scale-able.?

It needs to actually work.

It needs to be trusted. And to do this amongst other things, it needs to be trustworthy.?

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When I first joined DrDoctor , I spent a lot of time thinking and learning. And one of the things that really intrigued me was the messaging about PIFU. Not from DrDoctor, but amongst the healthcare profession. There were pockets of passionate advocates. There were a handful of zealots. There were people seconded to roles with NHS England. And inevitably there were those who scorned from the side-lines.

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And there were the targets. Keen NHS target-watchers won’t be surprised, but collectively the NHS missed it’s target. By the end of the 2nd quarter of 2023-24, the average PIFU rate was 2.9%. Not to be sniffed at, but not quite hitting it out the park.?

And last month, the The Rt. Hon. Wes Streeting MP and Amanda Pritchard reiterated the plan to “significantly increase the uptake of PIFU to at least 5% of all outpatient appointments”.?

Targets are good. But this more than a target, and in order to realise this, we need to think about what PIFU - or frankly whatever acronym you want to use, could and should be.

In a land where “First, do no harm” rules, and where the threat of personally and professionally damaging medicolegal threat lurks, doing things safely is key. One lovely phrase banded around is “safety netting”. This is when a clinician wants to discharge you, but wants to do it safely.?

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“Go home from the Emergency Department, but take this leaflet with Head Injury advice and come back if you start vomiting”.?

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If you have kids like mine, you’ve probably got a few of these lying around.?

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In Outpatients, it is saying,?

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“I am pretty sure I don’t need to see you again, but if you do run into trouble…”

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There is nothing wrong with this at all. It is reassuring the patient and the treating team. We all know the challenge of getting a GP appointment in the UK – and why should we have to bother them to see the team who know us already.?

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Really, PIFU is what it stands for – a patient initiating a follow-up. Recognising that the patient knows their own body and disease much better than an arbitrary quantity of time. That might well be based on evidence – but is based on population averages rather than any one individual patient. Normal curves are great, but let us not ignore the fact that almost every single person in that cohort sits outside the mean.?

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It can also be about patients who “DNA” – i.e. do not attend their appointment. What do you do with them? Most get a letter sent, telling them that they have missed an appointment. For Trust management, this is a wasted clinic slot. For the clinician, it is sometimes a chance to pause for breath – or even go to the toilet if very lucky. But despite the empty bladder or fresh cup of tea, there is also the fact that the patient who didn’t turn up, might really need to be seen. Their taxi might not have turned up, or they never received the letter, or they are unwell. There are a whole myriad of valid reasons. In these cases, you could discharge them back to their GP, and let them start the miserable waiting process again. You could wait for them to phone the secretary. Or you could onboard them to “PIFU”, and say you missed your appointment, but if you still need one, here is a simple way to let us know. And direct them to book again. Neat, huh?! The fact is, it is not PIFU. But it is a way to let a patient take ownership of their health journey, rather than have another appointment blindly sent out.

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Some clinical teams use PIFU but not-PIFU to monitor patients in an arms-length fashion. If you have coeliac disease, why shouldn’t you be offered a chance to have input from the dietetics team looking after you? You should be. It’s a national recommendation but one rarely achieved. But one that Cristian and colleagues have done – and in doing so, check if their patients need their input. You might not – but the really important thing is that you might. And if you do, this is making your life easy in getting the help that you need.?

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It can also be used to manage lists of patient who different needs. It isn’t PIFU – let’s face it, but what is? In the cancer world, it is referred to as Personalised Stratified Follow-Up or PFSU.?

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In this context, it means that patients can inform their treating teams of symptoms or certain predetermined parameters that are relevant, and rapidly provide the help that they need. It means they can have arms-length surveillance and help keep anxiety at a minimum – whilst making sure the patient is being kept an eye on. If you have had prostate cancer, a PSA test in primary care above 2 might be an appropriate trigger for a clinical review if you have had radiotherapy. If you have had a prostatectomy, 0.2 might be the threshold. This is a huge difference, and so configurability is key. Here the word personalised comes into its own.

But why should personalised care be limited to those recovering from cancer?

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PIFU can be used as the basis to redesign pathways and transform care. If you have a long-term disease that can suffer flares and relapses, you don’t want to be seen just because 6 months has passed by. You want to be seen because you actually need to be seen. Because you are sick, or you have a question, or something has changed. Time is a terrible metric of disease activity, so it is interesting that this is what we base most of our clinical review cycles on.

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Last year, the Nuffield Trust published some analysis looking at PIFU outcomes. If you are a PIFU-nerd like me, take a look.?

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They found 15 specialities that reduced their outpatient activity as a result of PIFU, and 7 that actually increased their outpatient activity. Does this mean that in 7 it is a failure? Absolutely not. In fact, I would argue it means it is a booming success.?

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And this is why – because, in these 7 specialities the patients who needed help got it. And this is the point of PIFU, PFSU, see-on-symptoms, self-managed follow-up or whatever jargon is thrown about. Healthcare is about getting people to see the people they need to see.?

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There are also some fascinating insights to consider into the barriers. Given that most patients like it, management love it, NHS England are clearly big fans – there was sadly but perhaps not surprisingly evidence of resistance from staff.?

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These include?

- ? ? ? Concern patients will get ‘lost’ in the system?

- ? ? ? Anxiety that using PIFU would lead to an increased number of GP referrals/ more complex interactions where appointments do occur (impact of workload still felt to be unknown)?

- ? ? ? Contradictory clinical guidelines or targets (e.g. oncology or surgery)?

- ? ? ? Limited understanding of aims of PIFU and how it is different to previous approaches?

- ? ? ? Differing values amongst healthcare team

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My 2 pennies on this are as follows. As the clinician treating the patient in front of you, you take ultimate responsibility. So if something goes wrong, you have to carry the can. So whilst you might be aware of targets, and the impact that PIFU can have, and the fact that most patients like it – sitting there in clinic requires you to be confident in?

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What is it? What it can be. Potential lost in the targets. Targets are powerful drivers for change – but?

Healthcare is about getting people to see the people they need to see. It isn’t just about reducing numbers coming through – although for these 15 specialities it absolutely can be game-changing.?

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Missed the target. Who cares? Technology and tools can be leveraged to do cool things. And whether you call it PIFU, PAFU, potato or tomato does it matter??

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Let us not focus on the meaningless target, let’s focus on the potential.

James Illman Gui Tran Outpatient Recovery & Transformation Norfolk and Norwich University Hospitals NHS Foundation Trust Dr Annabelle Painter Chetan Trivedi Aziz Yuldashev Andrew Bennett Jovita D'silva

#nnuh #hybridhealthcare #healthtech #nhs #patientempowerment #digitalhealth

Originally published at https://www.cleatlearning.co.uk/blog-1