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Research and Projects

Systematic review of patient initiated clinics (PICs) in patients with chronic or recurrent conditions managed in secondary care

Theme: CLAHRC - Person-Centred Care
Status: Complete

This review was led by the Evidence Synthesis Team 

Why did we do this review?

Around 17.5million people in the UK have a chronic condition. Most of these people have regular appointments at the hospital to manage and review their care. However, these hospital appointments are often missed or inappropriate for the patient at that time and so cost the NHS is considerable money and resources and at the same time reduces capacity for urgent appointments and to see new patients possibly waiting for diagnoses. 

We wanted to explore if a patient-initiated appointment system could improve efficiency in the health care system without losing the quality and safety of care for patients. In this new system a patient would be able to ring a nurse-led helpline for advice and when necessary arrange an immediate appointment to see a consultant in hospital.


How did we do this review?

The research was a systematic review. This brings together all existing research on a particular question. To find studies that might help us to answer the question we searched the relevant academic literature. 

We found nine studies all conducted in the UK. The studies covered three health conditions: rheumatoid arthritis, irritable bowel disease and breast cancer. Asthma was not picked up in this review as it is largely managed by a GP.


What did we find?

  • Minimal differences in psychological and quality of life measures between patient-initiated appointments (PIA) and usual care suggest PIA systems appear safe to use.

  • Patient satisfaction with PIA systems is mixed but generally positive, the doctor-patient relationship plays an important part in this.

  • There were few differences in outcomes between PIA systems and usual care, some research suggests there could be cost savings and better use of resources.

  • Ongoing evaluations of long term outcomes and costs is necessary.


Quality of the research and cautionary notes

Although most of the studies were randomised controlled trials, one of the most reliable types of evidence, the quality of the research was often poor with important details missing from the reports. With the potential impact of the resulting bias unknown this limits the interpretation of the results and also their use in other contexts.

There are two areas where safety may be a concern: the PIA system relies on patients knowing when to ask for help and being confident in asking for help, there may be people for whom this system is not suitable; and there may be elements of preventative care or patient education that are not covered in a more urgent appointment, though this may be resolved with use of an appointment checklist.


What next?

PIA systems may only work for those who have conditions where it is easy to identify when there is a problem requiring advice or treatment. Future research would benefit from identifying important components of the PIA system such as the use of personal health plan guidebooks a, the patient-clinician relationship and any necessary ‘safety net’ procedures.

Mixed methods research exploring patient, clinician  and NHS resource outcomes would help to inform future development and implementation of the PIA system across other conditions and geographical locations.

More work has been conducted in this area with an implementation trial and understanding contextual issues around implementation.

An updated and revised version of this systematic review has been published with Cochrane in April 2020, take a look at the Cochrane protocol or the full review.

Further information

For more information, view the protocol. Read a printable version of this summary here.

The project paper is also available to read: