Long-term follow-up in outpatient clinics. 2: The view from the specialist clinic

Most of the patients seen in outpatient clinics are in follow-up. Waiting times for patients requiring first appointments would be shorter if more patients were discharged to the care of their GPs.

To identify opportunities and barriers to discharge of patients from follow-up in medical outpatient clinics and describe the use of discharge criteria to facilitate discharge.

General medical clinics held by five consultants in a district general hospital in Manchester were observed by the research team. Discussion groups were held with specialists to explore their views on barriers to and opportunities for discharge from outpatient care. Data from the hospital information system were used to compare discharge rates before, during and after the introduction of discharge criteria.

Discharge consultations were inconsistently handled, and patients were not always aware that they had been discharged. Specialists were ambivalent about discharging patients, and uncertain about the care these patients would receive in general practice. Use of structured discharge criteria appeared to improve the quality of discharge consultations, and may have increased the proportion of patients discharged. Specialists were concerned about the work involved in giving detailed feedback to patients and GPs about patients' management needs after discharge.

There are a number of issues arising from the findings of our study concerning the discharge of patients from long-term outpatient follow-up which purchasers of outpatient services may wish to consider. Referral letters should spell out clearly reasons for referral and the expectations of the GP. Discharge consultations should be accorded higher priority, and allocated sufficient time. It may sometimes be appropriate to prepare a patient for discharge at the previous visit. The reason for discharge should be made clear to patients. All discharges should be accompanied by a management plan for the GP, including arrangements for gaining further access to specialist care when needed in the future. Providing written information for patients in lay language would improve the process of discharge, and would allow patients to share the responsibility for their on-going care.