Purpose of the PSP and background
The purpose of this protocol is to clearly set out the aims, objectives and commitments of the Outpatient Service Delivery Priority Setting Partnership (PSP) in line with James Lind Alliance (JLA) principles. The Protocol is a JLA requirement and will be published on the PSP’s page of the JLA website. The Steering Group will review the Protocol regularly and any updated version will be sent to the JLA.
The JLA is a non-profit making initiative, established in 2004. It brings patients, carers and clinicians together in PSPs. These PSPs identify and prioritise the evidence uncertainties, or ‘unanswered questions’, that they agree are the most important for research in their topic area. Traditionally PSPs have focused on uncertainties about the effects of treatments, but some PSPs have chosen to broaden their scope beyond that. The aim of a PSP is to help ensure that those who fund health research are aware of what really matters to patients, carers and clinicians. The National Institute for Health Research (NIHR) coordinates the infrastructure of the JLA to oversee the processes for PSPs, based at the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC), University of Southampton.
The NHS Long Term plan published before the start of the COVID pandemic outlined plans over the next 5 years to offer patients online ‘digital’ GP consultations with integrated local primary care pathways, remote monitoring of chronic conditions and a redesign of hospital support to avoid up to a third of outpatient appointments. These changes were estimated to save the NHS over £1 billion per year.
The current COVID-19 pandemic has driven a rapid change in how the NHS delivers services to patients with support for proven digital solutions that reduce unnecessary waits and attendances to healthcare services. Whilst patients wait to be seen by a doctor or physiotherapist, ‘self management’ has been promoted to provide them with information and help them manage their condition. Patients can have long waits for an outpatient appointment and often try to access their GP or emergency department if their symptoms do not improve leading to poor patient satisfaction. The information and advice is often standardised and may not suit all patients from all backgrounds.
The NHS digital strategy also provided a vision of transformed outpatient services with patients able to access their data through portals, book their appointments, access information and contact clinicians. This vision aligns with the Wachter review that concluded that the NHS must modernise and transform in order to provide a high level of healthcare at an affordable cost.
There is therefore a need for research into outpatient service delivery to determine what patients prefer and how technology can be integrated into the care pathway to reduce waiting times, monitor patients effectively in an outpatient setting and allow patients access to their information and results. The aim of the PSP is to identify the areas of uncertainty in outpatient service delivery from patient, clinical and managerial perspectives and to prioritise those that patients and clinicians agree are the most important.
Aims, objectives and scope of the PSP
The aim of the Outpatient Service Delivery (OSD) PSP is to identify the unanswered questions about how best to deliver outpatient care from patient, carer and clinical perspectives and then prioritise those that patients, carers, service managers and clinicians agree are the most important for research to address. The PSP will focus on adults and children in England attending outpatients in primary and secondary care. The OSD PSP will focus on service delivery and not on management of conditions which would be outside of the scope of the PSP. The PSP will focus on outpatient appointments from the initial GP referral through to follow up appointments in primary or secondary care. The PSP will focus on the outpatient appointment delivery or episode.
The objectives of the PSP are to:
- work with patients, carers, clinicians and managers to identify uncertainties about face to face versus remote clinics, use of digital enablers and location of clinics and care
- to agree by consensus a prioritised list of those uncertainties, for research
- to publicise the results of the PSP and process
- to take the results to research commissioning bodies to be considered for funding.
The scope of the OSD PSP is defined as NHS outpatient services for adults and children in England and includes:
- Referral management systems from first referral by primary care (triage services)
- Choose and book services (NHS and NHS hosted in Private sector)
- Advice and guidance to primary care
- Mode of communication before appointment (apps, portals, text messages)
- Questionnaires before appointment
- Information (patient leaflets, letters, text messages, emails)
- Environment of delivery (location, facilities and space)
- Sign posting
- Virtual versus face to face
- Digital appointment booking
- Digital checking in
- Experience of booking systems (booking appointment, loss to follow up and continuity of outpatient care)
- Information after appointment (including self management)
- Patient Initiated Follow Up (PIFU)
- Both primary and secondary care appointments
- Support services (such as pharmacy, phlebotomy, physiotherapy, community based appointments including pain clinic appointments)
- Local delivery of appointments or care in prisons and care homes
- Intra-operability of digital systems (communication between different digital management systems)
- Definition of procedures (standard operating procedures [SOPs], service level agreements [SLAs])
The PSP will exclude from its scope questions about:
- Scotland/Wales/Northern Ireland NHS Service delivery
- Non-UK service delivery
- Private healthcare delivery
- Interventional procedures such as Day case procedures in Hospital trusts
- Clinical management of conditions
- Pharmacy services in the community
- Excluding community nursing (previous PSP 2021)
The Steering Group is responsible for discussing what implications the scope of the PSP will have for the evidence-checking stage of the process. Resources and expertise will be put in place to do this evidence checking.
The Steering Group
The Steering Group includes membership of (12-15) patients and carers and clinicians , as individuals or representatives from a relevant group.
The OPD PSP will be led and managed by a Steering Group involving the following:
Patient and carer representative/s
Clive Moore Ceaton
Ben Bridgewater Health Innovation London
Caroline Knox Corporate OPD SGH
James Friend Digital Strategy London Region NHS England
Max Carter NHJS North West London CCG
Natasha Curran Health Innovation Network South London
Naz Jivani General Practiice Kingston Borough SWL
Sarbinder Sandhu Kingston Hospital
Simon Clayton Corporate OPD SGH
Toby Smith Patient Groups and AHPs
James Lind Alliance Adviser and Chair of the Steering Group
The Steering Group will agree the resources, including time and expertise that they will be able to contribute to each stage of the process, with input and advice from the JLA.
Organisations and individuals will be invited to be involved with the PSP as partners. Partners are organisations or groups who will commit to supporting the PSP, promoting the process and encouraging their represented groups or members to participate. Organisations which can reach and advocate for these groups will be invited to become involved in the PSP. Partners represent the following groups which will be updated as the PSP progresses:
- Protected characteristics patient groups
- NHS practitioner health
- SCOPE (disabled children)
- British Doctors and Dentists group
- Alzheimer’s association
- Diabetes association
- Sickle cell association
- Royal College of Surgeons
- Royal College of Medicine
- British Pain Society
- Faculty of Pain Medicine
- Royal College of Psychiatrists
- British Psychological Society
- Cancer Research UK
- Versus Arthritis
- British Heart Foundation
- Carers UK
- Patient Participation Groups (allied to primary care networks
- Chartered Society of Physiotherapists
- National Voices
- Royal College of Child Health
- Royal College of Pharmacy
- Paediatrics and Child Health
- How to link in to admin / digital / management
- Diabetes UK
- Paediatrics and Child Health
- Primary Care Support England
- people who have attended outpatients
- carers of people who have attended outpatients
- health and social care professionals - with experience of attending outpatients. Including administrators, digital and management staff.
Some organisations may be judged by the JLA or the Steering Group to have conflicts of interest. These may be perceived to potentially cause unacceptable bias as a member of the Steering Group. As this is likely to affect the ultimate findings of the PSP, those organisations will not be invited to participate. It is possible, however, that interested parties may participate in a purely observational capacity when the Steering Group considers it may be helpful.
The methods the PSP will use
This section describes a schedule of proposed steps through which the PSP aims to meet its objectives. The process is iterative and dependent on the active participation and contribution of different groups. The methods used in any step will be agreed through consultation between the Steering Group members, guided by the PSP’s aims and objectives. More details of the method are in the Guidebook section of the JLA website where examples of the work of other JLA PSPs can be seen.
Step 1: Identification and invitation of potential partners
Potential partner organisations will be identified through a process of peer knowledge and consultation, through the Steering Group members’ networks. Potential partners will be contacted and informed of the establishment and aims of the OSD PSP.
Step 2: Awareness raising
PSPs will need to raise awareness of their proposed activity among their patient, carer and clinician communities, in order to secure support and participation. Depending on budget, this may be done by a face-to-face meeting, or there may be other ways in which the process can be launched, e.g. via social media. It may be carried out as part of steps 1 and/or 3. The Steering Group should advise on when to do this. Awareness raising has several key objectives:
- to present the proposed plan for the PSP
- to generate support for the process
- to encourage participation in the process
- to initiate discussion, answer questions and address concerns.
Step 3: Identifying evidence uncertainties
The OSD PSP will carry out a consultation to gather uncertainties from patients, carers and clinicians. A period of 2 years will be given to complete this exercise (which may be revised by the Steering Group if required).
The OSD PSP recognises that the following groups may require additional consideration.
- Care home residents
- The homeless / no fixed abode
The Steering Group will use the following methods to reach the target groups
- Social media posts
- On line surveys
- Paper surveys
- Virtual workshops
- Membership emails
- Patient Groups
Existing sources of evidence uncertainties may also be searched. For example, question-answering services for patients and carers and for clinicians; research recommendations in systematic reviews and clinical guidelines; protocols for systematic reviews being prepared and registers of ongoing research.
Step 4: Refining questions and uncertainties
The consultation process will produce ‘raw’ questions and comments indicating patients’, carers’ and clinicians’ areas of uncertainty. These raw questions will be categorised and refined by the steering group into summary questions which are clear, addressable by research, and understandable to all. Similar or duplicate questions will be combined where appropriate. Out-of-scope and ‘answered’ submissions will be compiled separately. The Steering Group will have oversight of this process to ensure that the raw data is being interpreted appropriately and that the summary questions are being worded in a way that is understandable to all audiences. The JLA Adviser will observe to ensure accountability and transparency.
This will result in a long list of in-scope summary questions. These are not research questions and to try and word them as such may make them too technical for a non-research audience. They will be framed as researchable questions that capture the themes and topics that people have suggested.
The summary questions will then be checked against evidence to determine whether they have already been answered by research. This will be done by the steering group. The PSP will complete the JLA Question Verification Form, which clearly describes the process used to verify the uncertainty of the questions, before starting prioritisation. The Question Verification Form includes details of the types and sources of evidence used to check uncertainty. The Question Verification Form should be published on the JLA website as soon as it has been agreed to enable researchers and other stakeholders to understand how the PSP has decided that its questions are unanswered, and any limitations of this.
Questions that are not adequately addressed by previous research will be collated and recorded on a standard JLA template by the steering group. This will show the checking undertaken to make sure that the uncertainties have not already been answered. The data should be submitted to the JLA for publication on its website on completion of the priority setting exercise, taking into account any changes made at the final workshop, in order to ensure that PSP results are publicly available.
The Steering Group will also consider how it will deal with submitted questions that have been answered, and questions that are out of scope.
Step 5: Prioritisation – interim and final stages
The aim of the final stage of the priority setting process is to prioritise through consensus the identified uncertainties about OSD PSP. This will involve input from patients, carers and clinicians. The JLA encourages PSPs to involve as wide a range of people as possible, including those who did and did not contribute to the first consultation. There are usually two stages of prioritisation.
- Interim prioritisation is the stage where the long list of questions is reduced to a shorter list that can be taken to the final priority setting workshop. This is aimed at a wide audience, and is done using similar methods to the first consultation. With the JLA’s guidance, the Steering Group will agree the method and consider how best to reach and engage patients, carers and clinicians in the process. The most highly ranked questions (around 25) will be taken to a final priority setting workshop. Where the interim prioritisation does not produce a clear ranking or cut off point, the Steering Group will decide which questions are taken forwards to the final prioritisation.
- The final priority setting stage is generally a one-day workshop facilitated by the JLA. With guidance from the JLA and input from the Steering Group, up to 30 patients, carers and clinicians will be recruited to participate in a day of discussion and ranking, to determine the top 10 questions for research. All participants will declare their interests. The Steering Group will advise on any adaptations needed to ensure that the process is inclusive and accessible.
Dissemination of results
The Steering Group will identify audiences with which it wants to engage when disseminating the results of the priority setting process, such as researchers, funders and the patient and clinical communities. They will need to determine how best to communicate the results and who will take responsibility for this. Previous PSPs’ outputs have included academic papers, lay reports, infographics, conference presentations and videos for social media.
It should be noted that the priorities are not worded as research questions. The Steering Group should discuss how they will work with researchers and funders to establish how to address the priorities and to work out what the research questions are that will address the issues that people have prioritised. The dissemination of the results of the PSP will be led by the steering group.
The JLA encourages PSPs to report back about any activities that have come about because of the PSP, including funded research. Please send any details to firstname.lastname@example.org.
Agreement of the Steering Group
The OSD PSP Steering Group agreed the content and direction of this Protocol: June 2022.