Managing demand for elective care services

The Director of NHS England’s Elective Care Transformation Programme explains why a second wave of practical handbooks can help the NHS address a steady rise in referrals for hospital treatment while benefitting patients:

There is a real challenge around reducing the demand for elective care services across the country.

That’s why the Elective Care Transformation Programme (ECTP) team is working with commissioners, frontline clinicians and other professionals across the health and care system to develop a range of tools and approaches to review patient pathways and referral processes to ensure that patients are treated in the most appropriate setting.

The ECTP is supporting health and care systems to:

  • Better manage rising demand for elective care services
  • Improve patient experience and access to care
  • Provide more integrated person centred care

In 2017-18, around 1.7 million patients were referred to consultant-led elective care services each month. Since 2005-06, total outpatient appointments have nearly doubled from 60.6 million to 118.6 million. This means patients are waiting longer for hospital appointments when they could be seen in the community by a clinician, such as a clinical nurse specialist or physiotherapist.

We are currently working on developing our second wave of handbooks that outline how local health and care systems can work together to ensure patients are seen by the right person, in the right place, first time.

We focused on three high volume specialties – diabetes, dermatology and ophthalmology – testing new ways of working to support local health and care systems to manage demand.

These new approaches were tested by local clinicians in four health communities over a 100 day period. Each handbook draws on what we have learnt and includes examples of good practice. Now we’re asking the wider NHS to look at how they can adopt them, adapting each intervention to meet local circumstances.

We’ve pulled out some of the key themes from the second wave of our handbooks – in particular how we are ensuring that patients are seen in the right place, by the right person, first time.

So, what does this mean in practice for patients?

One of the areas we focused on during testing was helping patients to manage their own condition through education and support. This can give patients greater control over their own health and means that many are able to manage their condition at home – avoiding hospital visits or lengthy stays.

There are a number of great ways to provide patient education, including face-to-face groups or through webinars. These programmes can include clear advice on both healthy lifestyles and when to seek professional help – for example, if symptoms change.

In Lincolnshire, four patients planned, designed and led an event for patients living with type 2 diabetes to find out more about what support the participants felt they needed. Feedback from the 61 patients who attended included the desire for more patient education, peer support and support for specific issues, such as foot care. As a result, the team planned to continue this engagement around co-designing a patient education offer.

In Norfolk, local clinicians tested the idea of providing a dermatology ‘advice and guidance’ service to GPs. Specialists were able to advise on whether a referral into secondary care was necessary and could provide additional guidance to support patients in the community. Over the course of the trial, advice and guidance requests increased by 25% per month. What’s more, just 3% of advice and guidance requests for dermatology went on to be referred to secondary care.

This meant patients avoided hospital appointments that are often inconvenient, and were diagnosed and treated in the community without waiting to see a consultant. The GP, following the consultant’s advice, diagnosed and treated the problem for some patients; other patients were seen by other health professionals, such as a clinical nurse specialist.

To address long waiting times for patients, we worked with clinicians in Stockport to introduce a one stop clinic with the aim of offering two week wait dermatology patients the option to have their procedure done on the same day as their outpatient appointment. During the trial period, 68 patients had their procedure done on the same day – meaning theatre waiting time for two week patients fell from 15 days to just two. Following their procedure, 90% of one stop patients said they preferred having it done on the same day compared to coming back another time.

These are the sorts of rapid results that make us confident we can work together to make the NHS better for everyone.

If you’d like to find out more about our work and how you can manage the demand for diabetes, dermatology and gastroenterology elective care services in your area, join our Community of Practice – where you’ll be able to access best practice resources and guidance.

To join, please email

You can also view our handbooks from the first wave of the Elective Care Development Collaborative.

We have also produced guidance around consultant to consultant referrals. This guidance has been developed through engagement with key partners and is aligned to the onwards referrals guidance produced by the Academy of Medical Royal Colleges.

To access this guidance, please visit our Community of Practice.

Dr Linda Charles-Ozuzu

Linda Charles-Ozuzu is NHS England’s Director of Commissioning in the North West.

She was previously NHS England’s Director of the Elective Care Transformation Programme, and Assistant Director/Associate Medical Director in NHS England Midlands and East.

Her other senior healthcare management roles include extending the Department of Health’s Improving Access to Psychological Therapies (IAPT) Programme to people with long term conditions, severe mental illness and medically unexplained symptoms.

Linda is a member of the Royal Society for Public Health; a recipient of the NHS Leadership Academy Award in Executive Healthcare Leadership and an alumnus of the Global Health Leadership Forum.

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