5.2. Patient pathways

Patient pathways are fairly similar across the United Kingdom. Patients can access care through a variety of first point-of-contact mechanisms, either through their GP, emergency departments, walk-in centres or dentists. From here, they can be referred onwards for more specialized care, either as an outpatient or as an inpatient within hospitals. GPs may also refer patients to a number of community services delivered by allied health professionals such as physiotherapists, occupational therapists, speech and language therapists or community psychiatric nurses. Increasingly, GPs also signpost patients to social support such as charities, helplines, social services, although social prescribers are being introduced into primary care to undertake this purpose and reduce burden on GPs.

There are, however, differences between the United Kingdom’s constituent countries in terms of choice of provider for secondary care services. From the mid-2000s, a series of reforms in England expanded the use of independent sector provision of NHS-funded services. To promote competition in the health care sector, the 2012 Health and Social Care Act formalized the right for patients to seek care in any quality provider, whether they were an NHS or independent sector hospital. The result is that, as of 2018/2019, independent sector providers accounted for 6% of total NHS-funded elective activity (Stoye, 2019), although for some procedures such as hip replacements and inguinal hernia repairs, this proportion was much higher, at 30% and 27% respectively (Stoye, 2019). Similar changes have not occurred in other United Kingdom constituent countries and NHS-funded care remains predominantly in NHS hospitals. Patients that have access to privately funded care, either through supplementary private health insurance or out-of-pocket payments, are still required to access care through their GP.

To consider patient pathways in more detail, it is useful to consider the pathway of a patient in need of a hip replacement (Fig5.1).

Fig5.1

• A patient who is experiencing hip pain visits their GP, who diagnoses them with hip arthritis, either clinically or through imaging. This is typically managed conservatively initially, through physiotherapy and weight loss. If these measures fail, the patient and GP collectively agree that a referral to a hospital orthopaedic department is warranted.
• In England, this patient will be given a choice of local hospitals, both NHS and independent sector providers. The patient is likely to make a choice based on reputation of hospital and waiting times to access care. In Scotland, Wales and Northern Ireland, patients will typically be referred directly to the local NHS hospital.
• At this stage, patients can request that their GP write them a letter to refer them for privately funded treatment. The patient can then approach their independent hospital of choice for treatment, where they will be expected to fund their treatment through either supplementary private health insurance or out-of-pocket payments.
• The patient will then attend an outpatient hospital appointment, where they will be examined by a specialist, and appropriate diagnostic tests will be arranged. Surgical options will be discussed with the patient, and if they agree this is appropriate, the patient will be consented for surgery and added to a waiting list.
• Waiting times are variable between and within United Kingdom constituent countries and within regions. Targets exist and hospitals aim to treat patients within 12 weeks in Scotland, within 18 weeks in England and within 26 weeks in Wales. No similar targets exist in Northern Ireland.
• Once surgery and primary rehabilitation are completed at the hospital, patients are discharged home to the care of their GP, who receives a copy of the discharge summary.
• Depending upon the patient, some patients may receive a follow-up outpatient appointment in the hospital to monitor postoperative recovery.