Nelson Advisors The End of the Outpatient Appointment in the NHS?
The End of the Outpatient Appointment in the NHS? What Do The ‘Get On With It" Messages Mean for Primary Care, Hospitals and Healthcare Technology suppliers?
Every year, the NHS in England delivers roughly 120 million outpatient appointments. Two thirds of them are follow-ups. And, according to the chair of NHS England, almost nobody in the system believes this is a sensible way to spend clinical time, patient time or public money.
Speaking at the King's Fund last week, one year on from the publication of the 10 Year Health Plan, Penny Dash made a remark that will resonate with anyone who has spent time in health policy circles. At pretty much every conference she has attended in twenty years, she said, someone has stood up and declared that outpatients is an outdated model and that the NHS should get rid of it. And yet the volume keeps growing. Her conclusion was blunt: the time for saying it is over, and the time for doing it has arrived.
That framing matters. It is not a new diagnosis, but it is a new tone. The chair of NHS England is no longer describing outpatient reform as an aspiration to be worked towards over a decade. She is describing it as a change that the system has already agreed on, and is now simply failing to execute. This post looks at what she actually said, why the outpatient model has proved so stubbornly resistant to reform, what the neighbourhood health and NHS Online agendas are designed to do about it, and what all of this is likely to mean for general practice, for patients and for the digital health companies that will be asked to build the new model.
The scale of the problem
The 120 million figure deserves a moment's reflection. Outpatient activity is by some distance the largest single category of planned hospital contact in England, dwarfing inpatient admissions and day cases. It has grown steadily for decades, faster than population growth, faster than the growth in GP consultations, and far faster than the growth in hospital capacity to deliver it.
The reason two thirds of those appointments are follow-ups is structural rather than clinical. Once a patient enters a specialist pathway, the default is for the specialist to see them again. Follow-up intervals are set by habit and by risk aversion as much as by evidence. A consultant who discharges a patient back to their GP takes on a small reputational risk if something goes wrong; a consultant who books a six-month review takes on none. Multiply that asymmetry across every clinic in every trust and you arrive at a system in which tens of millions of appointments happen largely because the previous appointment happened.
Dash's point was that this is not a good use of anyone's time. It is not a good use of the patient's time, who may take a half-day off work and travel across a city for a ten-minute conversation that could have happened by message or not at all. It is not a good use of clinical time, because the consultant reviewing a stable patient is not seeing a new patient on the waiting list. And it is a poor use of estate, because outpatient departments are among the most expensive real estate in the country to run for the value they generate.
None of this is contested. The remarkable thing about the outpatient debate is how little disagreement there is on the diagnosis and how little progress has been made on the cure. Patient-initiated follow-up, advice and guidance, virtual clinics and remote monitoring have all been piloted, published and praised. Each has nibbled at the edges. None has bent the curve.
Why the model has proved so hard to shift
There are several reasons why an obviously inefficient model has survived twenty years of conference speeches calling for its abolition.
The first is that the outpatient appointment is the unit of currency in which the hospital system counts, plans and is paid. Activity is commissioned in appointments. Waiting lists are measured in first appointments. Consultant job plans are built around clinic sessions. When the whole architecture of a system is denominated in a particular unit, it is extremely difficult to reduce the number of those units without appearing to reduce the amount of care being delivered.
The second is that outpatients is where the boundary between primary and secondary care is negotiated, and that boundary is contested territory. From the hospital's point of view, a follow-up appointment is a way of keeping a patient under specialist supervision. From the GP's point of view, discharge back to primary care often means absorbing work without the resource to do it. The system has never resolved this tension, and so both sides have an incentive to keep the patient in the outpatient loop.
The third reason, and the one Dash dwelt on most, is that the alternative to outpatients does not yet exist at scale. If the answer to "who looks after the patient with stable heart failure who no longer needs a cardiologist" is "a well-resourced, multidisciplinary community team with access to the patient's full record and a shared care plan", then that team has to be built first. In most of England it has not been. And this is where her comments on primary care come in.
"Small, fragmented GP practices working in isolation"
The most pointed passage of the speech was not about hospitals at all. It was about general practice.
Dash reiterated a claim she has made before, that primary care has roughly twice the space it needs, and she went further in describing the current organisational model as unfit for the job the 10 Year Plan asks of it. Small, fragmented GP practices working in isolation, she said, are not a way to deliver a transformed emergency care pathway. They are not a way to deliver a transformed elective care pathway. And they are certainly not a way to deliver improvements in cardiovascular disease, other long-term conditions, or frailty and old age.
Her use of the word "subscale" is worth noting. It is a term from corporate strategy rather than clinical practice, and it signals how NHS England's leadership now thinks about the sector. A subscale unit is one that is too small to achieve the efficiencies, the specialisation and the resilience that the market or the system demands. The implication is that the historic model of the independent contractor practice, serving a list of a few thousand patients from a converted house, is being described by the chair of NHS England as a structural problem to be solved rather than a tradition to be protected.
The solution she set out is scale. GP practices need to be brought together with community services, mental health services and specialist services, working as integrated neighbourhood teams rather than as separate organisations passing patients between them. Everyone should have a care plan. Everyone should have a single patient record. Multidisciplinary working should be the norm rather than the exception.
This is the neighbourhood health agenda, and it is the central organising idea of the 10 Year Plan. The plan's three shifts, from hospital to community, from analogue to digital and from sickness to prevention, all depend on there being a community model capable of absorbing the work. The outpatient reforms and the primary care reforms are therefore not two separate policies. They are two halves of the same policy. You cannot dismantle the outpatient follow-up unless there is somewhere for the patient to go, and Dash is arguing that the current shape of general practice is not that place.
General practice will hear this differently. Many GPs would point out that they are already delivering more consultations than ever before, that the funding share of primary care has fallen over the past decade, and that "at scale" has in the past meant mergers and federations that added management cost without adding capacity. The claim about surplus estate has been particularly contentious, with practices arguing that the space is there because clinical rooms have to be available for a workforce that has not been funded. The "twice the space" figure will be interrogated closely, and the sector will want to see the analysis behind it.
But the direction is unmistakable. The centre of NHS England has decided that the neighbourhood model requires organisational consolidation, and it is now saying so in public with increasing directness.
NHS Online and the end of the referral
If the neighbourhood reforms deal with the community end of the pathway, NHS Online deals with the hospital end.
The new NHS "online hospital", due to launch in 2027, was described by Dash as a service that will move away from the concept of referrals and outpatients entirely. Instead, it will provide people with the advice they want and need very quickly. The initial scope is deliberately narrow. GPs will be able to refer patients, via the NHS App, to specialist clinicians anywhere in the country for a defined set of conditions. Those named so far include women's health symptoms pointing towards endometriosis and fibroids, and men's health presentations including prostate enlargement and raised PSA levels.
The choice of conditions is telling. These are high-volume, often long-wait pathways in which the initial specialist input is largely a matter of history-taking, interpretation of results and decision-making about next steps rather than physical examination. They are the kind of clinical conversations that can happen asynchronously, at a distance, with a clinician who has spare capacity in Newcastle seeing a patient who would otherwise wait months in Norfolk.
The deeper significance of NHS Online lies in three design choices. The first is that it is national. It decouples specialist capacity from geography, which is a direct challenge to the trust-based model in which each hospital serves its own catchment. The second is that it runs through the NHS App, which places the patient-facing front door of secondary care inside a platform that NHS England controls directly. The third, and the one Dash emphasised, is that it is framed as advice rather than as a referral. The patient is not being handed over to a specialist to be managed. They are getting a specialist opinion that flows back to the person who asked for it.
There is a certain irony here that GPs will not have missed. The announcement of NHS Online, which will let GPs refer to specialists across the country, arrives at a moment when many GPs report increasing resistance to their referral activity from local systems. NHS England denies that GPs' ability to refer has changed, but the perception on the ground is of tighter triage, more referrals being bounced back, and more pressure to manage within primary care. Whether NHS Online opens a new door or merely reroutes patients away from local hospitals will depend entirely on how it is commissioned and how its capacity is funded.
Data, records and the plumbing of reform
Underneath all of this sits a simple technical precondition that Dash stated plainly: single patient records for everybody.
It is impossible to run a neighbourhood team, dismantle follow-up appointments or deliver a national online specialist service if the clinician at each point in the pathway cannot see what happened at the previous point. The reason outpatient follow-ups persist is partly that the consultant does not trust that anyone else will see the patient's results. The reason GPs are wary of discharge is partly that they do not have visibility of the specialist's plan. The single patient record is the mechanism that is supposed to make trust possible.
The NHS has been promising a single record for as long as it has been promising to abolish outpatients, and with a similar track record of delivery. But there are grounds for thinking this time is different. The NHS App has become a genuine mass-market platform. The federated data platform, whatever one thinks of its procurement, exists and is being adopted. The political commitment to the single patient record has been restated at the highest level, and the 10 Year Plan ties it explicitly to the care plan concept Dash described. If everyone is to have a care plan, then the plan has to live somewhere that everyone can see it.
For the digital health sector, this is the layer where the commercial opportunity is most concrete. The neighbourhood model needs population health tooling to identify who needs a care plan. It needs shared care planning software that works across organisational boundaries. It needs remote monitoring to replace the follow-up appointment with continuous data. It needs triage and clinical decision support to make NHS Online safe at scale. And it needs integration, because the single patient record will in practice be assembled from many systems rather than replaced by one.
Predictions: where this goes next
The speech was a statement of intent rather than a policy announcement, but the intent was clear enough to support some reasonable predictions about the next three to five years.
Outpatient follow-up volumes will finally start to fall, but slowly and unevenly. The combination of patient-initiated follow-up targets, remote monitoring and a shift in the payment model away from activity will begin to reduce the two-thirds follow-up share. The first movers will be the specialties where the follow-up is most obviously administrative, such as stable long-term conditions with a clear biomarker. The specialties where the clinician's physical presence adds real value will be the last to change. Expect the headline 120 million figure to be revisited as a benchmark in every future speech on the subject, and expect the first year in which it drops to be treated as a major milestone.
General practice will consolidate, whether or not it wants to. The language of "subscale" is not accidental. The neighbourhood contracts, the estates review and the funding model will all be designed to favour practices that operate as part of larger integrated units. Some of this will happen through mergers, some through the growth of at-scale providers, and some through the migration of GPs into salaried roles within neighbourhood organisations. The independent contractor model will survive in name, but its share of the workforce and the population will shrink. Expect this to be one of the most contested workforce and contractual stories of the decade, and expect the "twice the space" claim to be the flashpoint around which the estates argument is fought.
NHS Online will expand its scope faster than its initial launch suggests. Starting with a handful of gynaecology and urology pathways is prudent, but the logic of a national, app-based specialist advice service does not stop there. Dermatology, with its reliance on images, is an obvious next candidate. So are the management of stable cardiovascular conditions, diabetes reviews, and much of routine mental health follow-up. By the end of the decade NHS Online is likely to be handling a meaningful share of what is currently first-appointment outpatient activity, and the political question will shift from whether it works to whether it is hollowing out local hospitals.
The referral itself will become a contested concept. NHS Online is framed as advice rather than referral, and that framing will spread. Advice and guidance, already widespread, will become the default first step for most non-urgent specialist input. GPs will increasingly find that the route to a specialist runs through a triage layer, digital or human, that decides whether a face-to-face appointment is warranted. That will reduce hospital demand, but it will also intensify the tension Dash's speech touched on, in which GPs feel their clinical judgement about who needs a specialist is being second-guessed by the system.
The single patient record will be delivered incrementally rather than as a single event. There will not be a day on which every citizen has one record. There will instead be a widening set of data that flows into the NHS App and into shared care records, with the care plan becoming the object that different organisations contribute to. Progress will be measured by how many neighbourhood teams can see the whole record rather than by whether the architecture is complete.
And finally, the HealthTech market will reorganise around the neighbourhood as the unit of purchase. For the past decade, digital health companies selling into the NHS have targeted trusts, integrated care boards, or individual practices. The neighbourhood, a population of perhaps thirty to fifty thousand served by an integrated team, is a new kind of customer. It is small enough to move quickly and large enough to justify real investment. Companies whose products only work within a single organisational boundary will struggle. Companies that can demonstrate value across the primary, community and specialist interface will find themselves selling into the most important growth segment in the system.
What this means for HealthTech investors and founders
For those of us who spend our time looking at the digital health market, the strategic signal from Dash's speech is one of demand creation. When the chair of NHS England says the system must "get on" with dismantling a 120-million-appointment-a-year model and replacing it with something that does not yet exist, she is describing a very large amount of work that will need to be enabled by technology.
The most defensible positions will be in the workflow layer that makes the new model function: care planning, population segmentation, remote monitoring integrated with clinical pathways, asynchronous specialist advice, and the interoperability infrastructure that stitches the single record together. The riskiest positions will be in point solutions that replicate the old model in digital form, such as video outpatient appointments that simply move the follow-up onto a screen without questioning whether it should happen at all.
There is also a consolidation story in the supplier base that mirrors the consolidation story in general practice. If the NHS is going to buy at neighbourhood and system scale, it will want fewer, broader vendors capable of supporting an integrated model rather than dozens of narrow tools. That will drive M&A activity among digital health companies, particularly those with strong primary care footholds that lack community or specialist capability, and vice versa. The next two years are likely to see a wave of combinations as suppliers position themselves for the neighbourhood contracts that will follow the 2027 launch of NHS Online and the rollout of integrated neighbourhood teams.
Conclusion
Penny Dash's speech at the King's Fund said nothing that health policy audiences had not heard before. That was, in a sense, her point. The outpatient model has been declared outdated for twenty years. General practice has been told it needs to work at scale for almost as long. The single patient record has been promised since the early days of the NHS IT programme. What has changed is not the analysis but the willingness of the system's leadership to say, publicly and repeatedly, that the analysis is settled and the delay is now the problem.
Whether the 10 Year Plan succeeds where its predecessors failed will depend on execution rather than intent. The neighbourhood model has to be built before the outpatient model can be dismantled. General practice has to be brought along rather than simply reorganised. NHS Online has to earn the trust of both the GPs who refer into it and the patients who use it. And the data infrastructure has to work, reliably and at scale, in a system that has rarely managed that before.
But the direction is set, and it is set with unusual clarity. The NHS is moving away from the appointment as its unit of care, away from the isolated practice as its unit of primary care organisation, and away from the referral as its mechanism for accessing specialist expertise. For clinicians, that is a profound change in how they work. For patients, it should be a profound change in how much of their lives they spend waiting. And for the technology companies that will build the new model, it is the clearest statement of demand the NHS has made in a generation.
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