Can we see more outpatients without more doctors?

A reduction in the number of return patients attending general cardiology clinics, if achievable without harm, would improve access for newly referred patients. Outpatient clinic letters (525) sent to general practitioners over a three-month period were reviewed. Simultaneously, physicians' opinions were collected by questionnaire. A subset of 30 clinic patients who attended three local general practitioners were studied to identify how many were assessed in primary care, and how often, in a six-month period. The hospital records of these patients were reviewed to determine whether information about these visits to the general practitioner was documented in the hospital notes. From the outpatient clinics the discharge rates were only 26% and the reason for further clinic review was often not clear. The fact that many patients had no intervention or treatment change performed at the clinic (42%) indicates that patients are reviewed to assess symptom change rather than to receive further interventions. The use of fixed times for review appointment (six months or 1 year) suggests that the intervals are determined by habit rather than clinical indication. A high proportion of patients (28/30) were reviewed at least once in primary care by general practitioners between hospital clinic visits and 20/30 were seen three or more times. There was poor documentation of these consultations in the hospital case notes, and so hospital physicians may be unaware that symptoms are under regular review in primary care. This study suggests that a substantial proportion of current cardiology return outpatients do not require regular outpatient review. However, alternative management demands good communication and exchange of information between secondary and primary care, development of formal written discharge planning in outpatient letters and other forms of follow-up.