This guidance is endorsed by the British Orthopaedic Association.

1. Introduction

Patient initiated follow-up (PIFU) is key to personalising outpatient care, and by enabling patients to have more control over when they receive care, can reduce unnecessary follow-up appointments and make best use of clinical time. The NHS Long Term Plan recognises that the current model of outpatient delivery is outdated and the experience of outpatient visits could be improved for many (Royal College of Physicians 2018).

This guide provides specialty-specific PIFU guidance, tools and resources as a supplement to the generic implementing PIFU guidance for local health and care systems. It supports systems and providers, both those with well-established PIFU processes and those in the early stages of implementing PIFU, to deliver best practice models that are personalised, robust, safe and sustainable, and tailor PIFU services to the needs of their local population.

It was developed by the Outpatient Recovery and Transformation Programme (OPRT) and BestMSKHealth Collaborative, with the involvement of key stakeholders (including patients, clinicians, implementation managers, relevant professional bodies such as the British Orthopaedic Association (BOA) and Getting It Right First Time (GIRFT)), and organisations representing the views and interests of people with lived experience (including Day One Trauma, Arthritis and Musculoskeletal Alliance (ARMA), Versus Arthritis and NHS England’s national lived experience group).

2. National context

Trauma and orthopaedic referrals to secondary care providers have been increasing by 7–8% a year (GIRFT March 2015). Of the 7.4 million trauma and orthopaedic outpatient appointments in 2019/20, 4.6 million were follow-up appointments, with an average 1.8 follow-up attendances for each first attendance. Almost a third of patients were discharged after their first attendance (NHS Digital, Hospital outpatient activity 2019-20).

Furthermore, the musculoskeletal (MSK) demography is shifting. An estimated 20.3 million people across the UK have an MSK condition such as arthritis and back pain. MSK conditions account for 21% of UK years lived with disability. The population is ageing, living longer with complex MSK conditions and co-morbidities, and the demand on NHS health and social care services is increasing (Versus Arthritis 2021).

The scale of those with MSK conditions potentially requiring access to trauma and orthopaedic secondary care services is clear, and higher than the above pre-pandemic data suggests because of the need to recover services and tackle the backlog that built during the COVID-19 pandemic. Innovative and new ways of working are required.

3. Why use PIFU in trauma and orthopaedics?

PIFU is not a new concept across trauma and orthopaedic secondary care pathways, but follow-up models vary across sub-specialties; for example, virtual fracture clinics, open access follow-up, patient-led follow-up, patient triggered follow-up, patient-initiated appointments, supported self-management, see on symptom, direct access or patient activated care, as well as the stratified follow-up required by the GIRFT pathways for orthopaedics. The principle, however, is the same: individuals are discharged without the need for a consultation after an agreed length of time during which they have not contacted the service.

PIFU truly personalises care, enabling patients to access support when they need it but not attend routine follow-up appointments when they are well. Regular unnecessary visits to hospital can be especially difficult for people with transport challenges and those who require support from family to attend a consultation.

In general, trauma and orthopaedic patients will have expected functional milestones for their recovery, dependent on their condition or the surgery they have undergone. PIFU can particularly benefit those who may not be reaching these milestones. It is not suitable or beneficial for all trauma and orthopaedic patients, and should not be used as an alternative to appropriate clinical discharge or to allow patients to re-access services after a treatment episode is considered complete. It is also not a process for discharge to a GP pathway.

The implementation of PIFU can help to reduce unnecessary outpatient follow-up appointments, a key priority outlined in the 2023/24 priorities and operational planning guidance which aligns with the priorities of the OPRT Programme and BestMSKHealth Collaborative Programme High Impact Strategy. Used alongside clinical waiting list reviews, remote consultations, eg virtual fracture clinics and a ‘digital enablement’ approach, it is an important intervention as part of trauma and orthopaedic recovery (Delivery plan for tackling the COVID-19 backlog of elective care) and transformation.

PIFU also helps the NHS reduce its carbon footprint, as it gives patients the flexibility to be seen in the right place, by the right person when they need care, and not when their condition is stable.

4. Which patients could benefit?

Non-condition specific criteria for selecting patients for PIFU are given in the national PIFU guidance.

People with trauma and orthopaedic conditions who are most likely to be suitable for and benefit from dedicated PIFU pathways are those:

• whose recovery is progressing but not fast enough to meet the expected milestones
• needing a routine arthroplasty follow-up after an appropriate time (ie one, three, five years); these patients will typically be on a blended pathway, combining scheduled follow-up with the option of contacting the service in between should they have a clinical need to do so
• with minor injuries or fractures that are likely to heal without needing regular follow-up.

People with trauma and orthopaedic conditions who should not be considered for PIFU are those:

• with life or limb-threatening emergencies
• for whom the healthcare professional has safeguarding, consent, capacity or health literacy concerns
• with low levels of knowledge, skills or confidence in self-managing their condition and who cannot initiate a follow-up; it is recommended that people with low health confidence are signposted to health coaches and social prescribers within their primary care network
• with red flag symptoms or symptoms requiring urgent and emergency management
• with co-morbidities that may require close monitoring
• for whom the healthcare professional has ongoing concerns about the nature of their condition, or potential for changing circumstances or deterioration
• for whom there are clinical requirements to be seen on a fixed timescale (timed follow-ups).

PIFU is not an urgent or emergency service. People with red flag symptoms or symptoms requiring urgent and emergency management should be managed through existing local urgent and emergency pathways.

5. Designing a PIFU model for trauma and orthopaedic services

PIFU should not be used as a waiting list management tool or a substitute for discharging patients when clinically appropriate to do so.

Appropriate resourcing should be considered to ensure available clinical and administrative time is adequate to fully support the pathway.

We recommend that organisations adopt a consistent approach for PIFU, but one that can be tailored to the needs of each specialty (and sub-specialty where appropriate), local population and service’s casemix. The virtual fracture service model is an example in trauma services; it incorporates PIFU and can be varied to meet clinical need. Alternatively, for orthopaedics pathways, such as young adult hip pain, the PIFU design may need to be adapted to provide longer term follow-up than the typical 3, 6 and 12 months reflecting the expected time of an exacerbation or need for support in different conditions.

Innovation in supporting the delivery of PIFU, eg using videos to inform patients about the service (Dorset Health and Care Video Library, Rheumatology Direct Access Service Plymouth Hospitals NHS Trust), is encouraged by co-designing services with people with lived experience and by understanding how digital enablement can support service delivery.

The trauma and orthopaedic clinical team should have overall responsibility for the development of all documents relating to the implementation and delivery of PIFU within their service.

Three principles should underpin a PIFU service in trauma and orthopaedics:

1. Clinicians should engage all patients and/or carers in shared decision-making conversations about PIFU, explaining to them what it is and giving them the opportunity to ask questions and raise concerns. If they do not understand how or when to trigger an appointment, PIFU should not be used.
2. A standard operating procedure (SOP) that includes patient safety nets should be in place.
3. All patients moved to a PIFU pathway should be logged and tracked on the organisation’s IT system, and the service able to report on key metrics, including number of patients on a PIFU pathway.

In addition, we recommend the following:

• Robust safety nets ensure individuals have the appropriate knowledge, skills and confidence to know when to initiate a follow-up appointment and are not lost to follow-up. (It can be useful for those delivering the local primary and community MSK provision to be aware of those on a PIFU pathway.)
• PIFU does not lead to inequity in service delivery or inequality in outcomes.
• Services are co-designed with patients/family members/carers and people with lived experience.
• All staff delivering PIFU understand the process and benefits to patients/carers and staff.
• To prevent a ‘PIFU follow-up’ waiting list developing, an agreed and equitable way for patients to re-access the service is in place so that those on a PIFU pathway are not disadvantaged when initiating an appointment.
• Services use a blended model for consultation, including telephone, video and face-to-face, to avoid inequality of access to care and give individuals choice.
• Services are provided using a multidisciplinary model so that individuals can see the most appropriate member of the team: consultant, specialist nurse, advanced practitioner, physiotherapist or other relevant healthcare professional.
• Patient records can be promptly accessed; this is essential for patient safety and continuity of care.
• Services build in the relevant processes for robust data collection, reporting and service evaluation.

The clinical decision to transfer a patient onto a trauma and orthopaedic PIFU pathway remains with the clinician responsible for that individual following a shared decision-making conversation.

5.1 Design considerations

Triage

The information provided by the individual making contact to initiate a follow-up appointment should be clinically reviewed before they are booked into a PIFU appointment. A consultant may choose to review the patient’s last clinic letter as part of this review.

Appropriate job planning and resourcing to support the triage process needs to be factored into service redesign.

Target response times

When an individual initiates a follow-up appointment through the agreed process, they should receive an initial response in line with the trust’s guidance on response times.

There should be adequate capacity planning for PIFU appointments, and clinic templates changed to accommodate more complex interventions. Early evaluation of trauma and orthopaedic PIFU suggests one or two slots should be ringfenced in each outpatient clinic, with the option to use these for other patients if not required for PIFU. For orthopaedic PIFU, the booking period is typically 3–8 weeks for upper limb and 2–6 weeks for lower limb, but shorter for more urgent/traumatic conditions, and 1 week for trauma PIFU.

An escalation process needs to be in place to support any capacity issues.

PIFU timescales and action at the end of these

When a patient/carer and clinician jointly agree a PIFU pathway is appropriate, this will be valid for the predefined timescale agreed through local protocols, but timescales must be clinically relevant and personalised to the individual.

The trauma and orthopaedic team should agree how to end each patient’s pathway safely, to minimise the risk they get lost in the system. Concluded pathways should be documented in patient medical records and on the trust Patient Administration System.

Patients/carers, through shared decision-making conversations, should understand the PIFU timescale and process that ends the pathway, and feel they have the skills and confidence to make an informed choice about how their pathway will end.

Primary care teams also need to be fully aware when a patient’s pathway is ending, so they know that a new referral may be required if the patient’s condition changes significantly.

The following table suggests timescales for trauma and orthopaedic pathways.

5.2 Workforce planning

Workforce planning, to consider the effect on staff, including their capacity, confidence and morale, is essential for the delivery of a successful PIFU service, along with supporting expectations through a change process.

6. Implementing PIFU in trauma and orthopaedics

We recommend first implementing PIFU for a few specific conditions, and then rolling it out to all appropriate trauma and orthopaedic pathways.

Generic guidance on implementing PIFU is provided on the PIFU pages of the OPRT FutureNHS workspace.

NHS England regional teams may be able to connect you to organisations who have implemented PIFU in trauma and orthopaedic specialties.

Suggested steps to support implementation include:

• invite key stakeholders to a project initiation meeting, eg clinical and administrative team, primary care and people with lived experience
• undertake a governance review to support development of an implementation guide, process map, risk stratification protocols, inclusion and exclusion criteria, SOP, specialty clinical protocols and decision support aids, and GP letter
• clinic modelling to allow for follow-up capacity
• agree the ‘go live’ date and communicate the plan for going live, eg patient leaflets, website, adding PIFU to staff computer screen savers
• implement PIFU recording requirements, eg EPR system, Elective Recovery Outpatient Collection (EROC)
• ensure IT access for all users of PIFU
• implement training requirements for all users of PIFU, eg e-learning and training guides on how to use the EPR system to record PIFU
• use the plan, do, study, act cycle improvement methodology to drive improvement.

6.1 Technology

Some providers use patient portals for follow-up management and scheduling. These enable individuals to activate their follow-ups remotely and be seen when they need to be.

6.2 Personalised care

PIFU offers the ability to personalise care based on what matters to people, giving flexibility in how an individual’s needs are managed.

Co-designing services with people with lived experience will ensure their preferences, views and beliefs are embedded in any redesign.

Decisions about whether an individual patient will or will not benefit from being on a PIFU pathway should be jointly agreed through quality shared decision-making conversations, and these supported by using consultation decision support aids. People’s values, beliefs and preferences about the risks, benefits and consequences of the different care management options should be central to these collaborative conversations. Also, assessment and measurement of a person’s health confidence and ability to self-manage will help clinicians tailor the shared decision-making conversation and provide appropriate options.

Individuals need to understand the health information they are given and know that they can decline PIFU if they do not think it will meet their care needs, with reassurance that their decision will not affect their ongoing care.

The following tools and resources support shared decision-making engagement and health literacy:

• NICE Shared decision making implementation guidance
• General Medical Council: Decision making and consent
• Personalised Care Institute training on shared decision making
• NHS England » Decision support tools
• ChoosingWisely UK: BRAN – Make the most of your appointment
• Institute for Healthcare Improvement: Ask Me 3: Good questions for your good health
• Assessment of the readability of materials (SMOG formula)

Good practice includes writing to individuals to confirm they will be transferred to PIFU (to include a summary of what the process involves, the decision that has been made and the associated benefits and harms), with a copy of the letter sent to their GP.

6.3 Implementation risks specific to trauma and orthopaedics

PIFU must be implemented carefully as there is a risk that people could become ‘lost’ in the system. Ensuring high quality of care when using PIFU provides detailed information around mitigating risks.

Risks for trauma and orthopaedic services and actions to mitigate them are:

• Potential for variation in the PIFU models used (discharged or moved to PIFU) across trauma and orthopaedic sub-specialties, depending on whether an individual requires a longer-term follow-up pathway, eg osteoarthritis, arthroplasty.
  
  Losing to follow-up or discharging in error patients who require scheduled follow-ups in line with post-surgery clinical guidance.
  
  Actions:
  • careful selection for PIFU and clinically relevant setting of timescales
  • having quality shared decision-making conversations with the use of in-consultation decision support aids embedded in practice
  • co-producing patient education and information about relevant conditions and self-management strategies so the individual has the knowledge, skills and confidence to recognise when they may need to seek specialist help
  • measurement of patient ‘activation’ and awareness of their signs and symptoms
  • co-producing guidance and information that people can understand on when and how to contact the service
  • communication with both the individual and their GP about the PIFU process, any associated benefits and harms, how a follow-up appointment can be initiated, and any decision made about being on a PIFU pathway.
    
    
• Potential for inappropriate overuse of initiated follow-ups, reducing the capacity for those with greater clinical need and increasing pressure on clinics and staff.

  Actions:

  • careful selection for PIFU
  • having quality shared decision-making conversations with the use of in-consultation decision support aids embedded in practice
  • co-designing the service with people with lived experience
  • co-producing patient education and information self-management strategies tailored to their condition, to provide a lived experience perspective on being on the PIFU pathway and ensure individuals have the knowledge, skills and confidence to recognise when they may need to seek specialist help
  • measurement of patient ‘activation’ and awareness of their signs and symptoms
  • co-producing guidance and information that people can understand on when and how to contact the service
  • signposting people to relevant available support in the local community, voluntary and charitable sector. Consider referral to health coaching and social prescribing link workers, if available
  • understanding and learning, through evaluation of the service and shared decision-making conversations, why people have initiated follow-up appointments; some may need to be removed from a PIFU pathway and followed up more conventionally
  • ensure agreed access times are kept to avoid individuals booking unnecessary appointments ‘just in case’.
    
    
• Potential for clinician burnout because the patients who come to clinic will have more complex problems that need resolving, and clinicians may not have adequate time to do so this effectively.

  Actions:

  • ringfence capacity for PIFU appointments
  • ensure the PIFU service is appropriately resourced from the outset
  • start small with a few carefully defined sub-specialties and gradually scale up.
    
    
• Insufficient workforce to safely manage the PIFU triage and booking process in a timely manner (will depend on booking model).

  Actions:

  • ensure the PIFU service is appropriately resourced and job planned from the outset
  • SOP to be in place
  • ensure all those involved in the PIFU pathway (across primary, community and secondary care) understand all its elements/processes, as well as relevant escalation processes.
    
    
• Required additional diagnostic tests, eg X-rays, MRIs, are not completed before a PIFU appointment due to limited diagnostic capacity.

  Actions:

  • undertake PIFU evaluation to ascertain common themes/potential tests required for patient-initiated appointments and plan capacity accordingly
  • monitor which tests are not being completed in a timely manner
  • discuss delays with appropriate departments and the orthopaedic team, and how tests can be prioritised to be completed in time for red flag patient-initiated appointments.
    
    
• Clinical staff experience and training opportunities may be more limited, as traditional ‘routine follow-up’ patients who often used to support training will no longer be coming to clinic.

  Action:

  • discuss any clinical staff training gaps with the trauma and orthopaedic team and training organisations, and develop alternative opportunities for them to gain patient experience.

6.4 Health inequalities and engaging with patients and patient groups

PIFU may not be right for everyone but it needs to be accessible to everyone who can benefit from it. If PIFU is offered as a ‘one size fits all’ approach or not well managed, there are risks that some individuals cannot realise the full benefits and health inequalities are exacerbated. It is important to consider whether particular groups or individuals will miss out on being offered PIFU and how to address this. Careful consideration should be given to how PIFU may need to be adapted to work for vulnerable groups. Guidance for systems and providers to help address health inequalities can be found on the FutureNHS collaborative platform.

The following principles support an equitable approach to redesign:

• understand all groups who are accessing the service, and among these which are most at risk of health inequalities
• use a population health management approach to understand variation in access, experience and outcomes
• co-design the service with people with lived experience and other key stakeholders so it meets the needs of the local population
• co-produce public communication based on literacy levels as part of the redesign.

An important consideration when redesigning PIFU services is that MSK conditions, which are predominately seen by trauma and orthopaedic services, are more common among women than men, and can affect people of all ages but increase in prevalence with age (Versus Arthritis: The State of Musculoskeletal Health 2021).

MSK conditions are also more common in areas of higher deprivation and some ethnic groups, due to associated risk factors, such as physical inactivity, vitamin D deficiency, working in manual occupations and other pre-existing long-term conditions, eg diabetes (Jeraj S, Butt JH; Race Equalities Foundation 2020). In England, people from Gypsy or Irish Traveller, White Irish, White British or Black Caribbean groups are most likely to report a long-term MSK condition (Office for Health Improvement & Disparities Fingertips public health data: Musculoskeletal data). Cultural attitudes and behaviours around pain, illness and drugs, as well as language barriers and unavailability of interpretation and translation services, can contribute to inequality in experience and outcomes for people with MSK conditions (Adebaje et al 2017).

Trusts have a legal responsibility to complete their own equality and health inequalities impact assessment (EHIA) for the PIFU services they offer. This will help them understand any inequalities that could emerge and identify interventions to address these. They should also co-design services with people with lived experience and patient support and engagement groups. Talking to these groups about their experiences of health inequality can support co-production of solutions, and provide an opportunity for questions to be asked to prevent any inadvertent widening of the health inequality gap.

In addition, good practice is to assess if offering PIFU in trauma and orthopaedic services has interdependencies with other service activity, and what the impact of PIFU implementation may be on other services.

Involving people with lived experience in co-designing any local trauma and orthopaedic PIFU service, which may include co-producing guidance, SOPs or patient information, is recommended to ensure the patient/carer voice is present and their values, beliefs and preferences are represented throughout.

7. Reporting metrics and evaluating PIFU

All providers of outpatient services are required to submit monthly PIFU data to the Provider Elective Recovery Outpatient Collection (EROC) via the NHS England Data Collection Framework. The Recording and reporting PIFU guidance, Provider EROC recordings and FAQs support providers to do this.

The submitted data will provide robust figures for PIFU activity and allow the indirect measurement of trauma and orthopaedic follow-up appointments that are being avoided through PIFU adoption.

The PIFU pathway should be monitored, audited at regular intervals, and adapted in response to local population and service requirements. Evaluation should be in line with local audit and governance services and follow established precedents for the service evaluation of new processes. Both qualitative and quantitative data should be evaluated to demonstrate the benefits of PIFU to both patients and clinicians and capture their experience.

We recommend that trauma and orthopaedic services consider including the measures outlined in the national PIFU guidance in their evaluation plan.

8. Further resources

• BMC Health Services Research (December 2013) Patient initiated clinics for patients with chronic or recurrent conditions managed in secondary care: a systematic review of patient reported outcomes and patient and clinician satisfaction
• Future NHS collaboration platform specialty resources
• Future NHS collaboration platform national implementation toolkit
• Future NHS collaboration platform EHIA provider template for PIFU
• Future NHS collaboration platform roll out examples from providers/systems
• Future NHS collaboration platform regions’ resources
• General Medical Council (September 2020) Decision making and consent: Guidance on professional standards and ethics for doctors
• NHS England Recording and reporting patient initiated follow-ups
• Thelwall C (2021) A service evaluation after 4 year’s use of the virtual fracture clinic model by a district general hospital in the south west of England. Int J Orthop Trauma Nurs 41: 100798
• US National Library of Medicine National Institutes of Health Search database (October 2013) The clinical effectiveness of patient initiated clinics for patients with chronic or recurrent conditions managed in secondary care: a systematic review
• US National Library of Medicine National Institutes of Health Search database (April 2020) Patient‐initiated appointment systems for adults with chronic conditions in secondary care
• Whear R, Thompson-Coon J, Rogers M, et al (April 2020) Patient-initiated appointments for people with chronic conditions managed in hospital outpatient settings. Cochrane Database Syst Rev
• Whear R, Abdul-Rahman A-K, Thomson-Coon J, et al (2013) Patient initiated clinics for patients with chronic or recurrent conditions managed in secondary care: a systematic review of patient reported outcomes and patient and clinician satisfaction. BMC Health Serv Res 2013; 13: 501

Example standard operating procedures

• The Hillingdon Hospitals NHS Foundation Trust elective care outpatient PIFU SOP
• Royal Surrey NHS Foundation Trust Outpatients PIFU SOP

Example GP letter

• Salisbury NHS Foundation Trust PIFU letter to GPs

Example specialty clinical protocol templates

• Sheffield Teaching Hospitals NHS Foundation Trust PIFU clinical protocol for lower limb arthroplasty unit patients
• Sheffield Teaching Hospitals NHS Foundation Trust PIFU clinical protocol for upper limb orthopaedic surgery

Example PIFU patient and staff experience survey templates

• Barnsley Hospital NHS Foundation Trust_Patient Survey for Patient Initiated Follow-Up Following Initial Consultation – BestMSK Health Collaborative – FutureNHS Collaboration Platform
• Barnsley Hospital NHS Foundation Trust_Patient Survey for Patient Initiated Follow-Up BestMSK Health Collaborative – FutureNHS Collaboration Platform
• Barnsley Hospital NHS Foundation Trust_Staff Survey for Patient Initiated Follow-Up BestMSK Health Collaborative – FutureNHS Collaboration Platform

Example PIFU patient leaflet

• The Dudley Group NHS Foundation Trust Midlands Orthopaedic Centre PIFU patient and carer information leaflet

Publications reference number: PR1108