Staff experiences of implementing patient-initiated follow-up (PIFU) in the NHS in England: findings from a rapid qualitative evaluation

Abstract

Objectives

The NHS in England has introduced various innovations to keep up with the growing demand for elective care, one of which is patient-initiated follow-up (PIFU). This evaluation sought to understand staff experiences of implementing PIFU.

Methods

We conducted a rapid qualitative service evaluation between June 2022 and July 2023, based on semi-structured interviews (n = 36) with operational/managerial and clinical NHS staff from five English NHS Trusts, and an online workshop with 21 additional members of staff from the English NHS. We drew on the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to structure qualitative data collection and analysis and to generate new insights into the adoption of the innovation of PIFU.

Results

We found that implementation of PIFU affected staff roles, workload, and job satisfaction. Levels of PIFU uptake, and experience with similar models, affected the extent to which participants experienced the impact of PIFU. How PIFU was implemented varied. Some staff saw changes in their role because of new administrative demands, safety-netting procedures (such as proactive measures by specialty teams to mitigate the risk of patients not initiating appointments when necessary), and selection of suitable patients. PIFU was felt by some staff to increase, and by others to decrease, workload. PIFU affected intensity of work, interrelated with other factors such as the size of waiting lists, and conditions experienced by patients. Whether staff were satisfied with PIFU related to its impact on their role and workload. Satisfaction was also affected by whether staff believed PIFU delivered benefits for patients, and by the aims they felt were driving rollout.

Conclusion

PIFU can significantly affect the experiences of staff and change staff roles and workload. However, the impact of PIFU is not uniform. Staff perspectives on PIFU from all parts of the health system should be better understood and considered during pathway design.

Introduction

The National Health Service (NHS) in England faces several fundamental challenges to its ability to provide high quality, sustainable and equitable care to the population. ¹ Notable amongst these has been a failure to keep up with growing demand for elective care, especially in the wake of the COVID-19 pandemic. ² To respond to these challenges, NHS England has pursued many innovations with the aim of better managing demand within existing service capacity. Patient-initiated follow-up (PIFU) is one such innovation that has been prioritised, with the NHS 10-Year Plan framing PIFU as a key tool that can benefit patients, free up clinical capacity and boost productivity. The plan states that PIFU will be the standard approach for all clinically appropriate pathways by 2026. ³

PIFU is a system which enables patients to request outpatient appointments as and when they need them, rather than following a fixed schedule of appointments. This is intended to free up appointments for those who need them most and reduce unnecessary burdens on outpatient services. ⁴ This is not a novel concept – similar models have been used in a range of settings since, at least, the early 2000s, described as, for example, “open appointments,” “open access” and “self-managed follow-up”. ⁴ Despite a paucity of detailed evidence on international PIFU pathways, a scoping review covering studies of 17 models of PIFU (11 of which were outside the UK) found that many pathways included elements which our evaluation has found to impact staff experience (Figure 1). ⁵ These studies were of variable quality, and outlined variable implementation models and levels of impact. This review also drew a basic distinction between PIFU models that required less and more intensive input from services. ⁵

Figure 1.

Number of international models containing relevant PIFU elements ⁶ .

PIFU in its current guise in the NHS has been formally in place since 2021. Records analysed as part of the quantitative workstreams of this rapid service evaluation (from the Provider Elective Recovery Outpatient Collection (P-EROC)) show that the number of patients in England moved or discharged to PIFU pathways trebled from approximately 60,000 in September 2021 to around 185,000 in March 2023. The number of outpatient attendances in March 2023 was around 7.4 million, meaning that reported movements to PIFU pathways represented about 2.5% of these. Incomplete reporting of PIFU activity means the actual number was likely higher. ⁶

Numbers of PIFU patients were highest in trauma and orthopaedics and physiotherapy, accounting for 6-7% of outpatient attendances. Combined, these two specialties made up 35% of all reported patient transfers to PIFU pathways between September 2021 and March 2023. While some level of PIFU use was recorded in most major hospital specialties, proportions and overall numbers varied significantly. Within specialties there was also large variation by NHS Trust. ⁶

The existing evidence base on the impact of PIFU and comparable models is relatively limited. ⁵ Previous research has not sought to extensively understand how managing patients who are on PIFU pathways may affect staff. Staff experiences of new forms of service delivery should be understood to optimise implementation and avoid unintended consequences such as exacerbating anxiety and burnout. ⁷

This rapid qualitative service evaluation sought to describe different PIFU implementation approaches and understand experiences of clinical and non-clinical staff involved in implementing PIFU, including their attitudes towards the innovation and PIFU’s impact on role and workload, to generate information to inform local, NHS Trust- and- specialty-level, decision-making. We drew on the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework ⁸ to inform data collection, synthesis and analysis. We applied the framework, which was developed primarily to understand technological innovation, to analyse the adoption and spread of PIFU as an innovation which was supported by, but not primarily concerned with, the introduction of new technology.

Methods

Study design

We carried out this rapid qualitative service evaluation in two phases over 14 months. Phase 1 was carried out between June and September 2022. Phase 2 was conducted between January and July 2023. This service evaluation formed part of an NIHR-funded mixed-methods evaluation which also explored how patients experienced and engaged with PIFU, how it was implemented in different services, and its impact on hospital activity. ⁶

Sampling of sites

We selected sites (NHS Trusts) using variation sampling, considering factors including geography, size, and demographic features of local populations (see supplement 2).

In Phase One, we aimed to understand similarities and differences in how PIFU looked in practice across different trusts and specialties. We selected sites and specialties that represented different levels of maturity of PIFU implementation, while also focusing on high volume outpatient specialties. Our focus on volume meant that most specialties covered in Phase One predominantly managed short-term PIFU pathways, such as post-operative pathways.

In Phase Two, we focused on clinical specialties managing long term or chronic conditions with high variation in PIFU uptake across trusts, based on a combination of national data and conversations with Trust-level staff (to account for data deficiencies). We recruited three sites in Phase 1 and two in Phase 2. In each phase, one additional site was approached but declined to take part. The five NHS Trusts included were diverse in terms of organisational characteristics and populations served (see supplement 2).

Sampling and recruitment of interviewees

We used purposive sampling for staff interviews, inviting staff directly involved in setting up PIFU at a Trust-wide or specialty level, or working in teams managing patients on PIFU. We interviewed staff in clinical and managerial/administrative roles. Trust PIFU or service leads acted as the primary facilitator of contact between the research team and specialty teams. After establishing contact with one member of a specialty team, we used purposive and snowball sampling to identify other relevant staff members. We also interviewed a small number of NHS staff involved in the rollout of PIFU nationally during Phase One to understand progress and aims at a strategic level. In Phase Two, we also interviewed general practitioners (GPs) working alongside one site to understand how PIFU affects and interacts with primary care.

We invited participants via email, which included a participant information sheet and consent form. Verbal or written consent was obtained and recorded prior to the interview. Interview data was stored in a secure folder only accessible to the research team. A COREQ checklist for the staff interviews has been completed (see supplement 1).

Data collection

Interviews

A total of 36 interviewees participated in the evaluation. We interviewed 31 NHS staff, who held clinical and/or managerial/administrative roles at organisation (NHS Trust) or specialty level. They worked in a broad range of specialty areas, managing both short- and long-term patients (see supplement 6). We also interviewed two people with PIFU roles at a national level to understand the broader implementation context, and three general practitioners providing primary care within the locality of one of the evaluation sites (see Figure 2).

Figure 2.

Summary of interview participants.

Semi-structured interviews were conducted remotely using MS Teams. The Phase One topic guide (see supplement 3), informed by the NASSS framework, covered the aims and main components of PIFU within the interviewee’s organisation or specialty, factors which acted as barriers and enablers to the rollout of PIFU, and the impact on their role. Informed by early analysis in Phase One, we adapted the topic guide for Phase Two (see supplement 3) to increase focus upon specific areas of interest, such as facilitators of successful PIFU implementation. Patient representatives reviewed the topic guides. Interviews lasted a maximum of 60 minutes and were carried out by two researchers (from among SR, NC, CO, RH and CL) wherever possible. Audio recordings were captured and transcribed by MS Teams, with transcripts compared to the audio recordings to ensure accuracy.

Online workshop

Following interviews, we held an online workshop with additional NHS staff. Using interview data to inform the discussion, we gathered information and developed consensus on shared challenges and solutions related to implementation. We invited a convenience sample of staff from NHS trusts through an open invitation on the FutureNHS platform. ⁹ Interested Trusts nominated two representatives – one managerial/administrative and one clinical. All attendees received a Participant Information Sheet (see supplement 4) in advance outlining the purpose of the workshop. Twenty-one participants in a mix of Trust-level and national roles attended (see supplement 6). Research team members (CSJ, SR, CL) facilitated breakout sessions, which were recorded on MS Teams.

Data analysis

We analysed staff interviews and the workshop using Rapid Assessment Procedure (RAP) sheets (see supplement 5), ⁷ which allowed interviewers/facilitators to record key points in real time. This meant interim analysis could be fed back to NHS England, and it also allowed more agility to adapt the interview topic guide between Phases 1 and 2. The NASSS framework provided the theoretical underpinning for RAP sheet development, informing the inclusion of key relevant areas of analysis, including changes to staff roles (Domain 4A). NASSS was also applied as a lens to interpret how other factors linked to staff experience could impact the success or failure of PIFU implementation. These structured templates were refined between Phases One and Two to reflect evolving focus areas. The research team analysed RAP sheets using deductive coding to explore staff experiences of PIFU. Weekly data analysis meetings with the wider team (CSJ, AR, TG, SK, JS, SB) facilitated discussions and interpretation of emerging findings. A patient and public involvement (PPI) representative contributed to interpretation of the findings.

Patient and public involvement

A PPI representative with experience of outpatient care acted as a study advisor throughout the project. They joined team meetings and reviewed the study protocol and topic guides to ensure that participants were being asked questions of most relevance to patients. They were also involved in interpreting interim findings, as well as reviewing key documentation and outputs. They were part of a wider PPI Advisory group for the evaluation, other members of which also supported project design and early scoping.

Ethical approval and informed consent

This paper is based upon Phase 1 of the evaluation and the Phase 2 staff interviews component. These were categorised as a service evaluation by the Health Research Authority (HRA) decision tool and UCLH/UCL Joint Research Office as they involved NHS staff only and aimed primarily to evaluate current services within participating trusts.

We followed appropriate governance processes for service evaluations, including engagement with local clinical governance teams and adherence to Trust policies for service improvement activities.

Results

Results are presented in three categories: the impact of PIFU on roles and practices of adopters, the impact of PIFU on workload, and staff views and satisfaction with PIFU. Where relevant, we provide further subthemes and indicate relevance for different staff groups. We map results to the various domains of the NASSS framework to highlight their relevance to the implementation of innovations, with a summary of this provided below.

NASSS framework analysis overview

Table 1 summarizes how key elements of PIFU implementation discussed in the following sections relate to different domains of the NASSS framework, as relevant to staff experience.

Table 1.

Summary - NASSS analysis of staff experiences of PIFU.

NASSS domain	PIFU implementation element	Possible relationship to staff experience
Domain 1A: Condition (nature of condition/illness)	Patient selection	Clinical judgment with variable criteria affects staff confidence and workload; condition type determines implementation approach. Risk levels create different staff responsibilities and safety concerns
Domain 1B: Condition (sociocultural factors)	Patient capability assessment	Staff responsibility for assessing patient and carer ability to monitor symptoms affects role complexity and risk concerns
Domain 2: Technology	Booking and contact systems	New patient contact channels can require administrative staff to manage calls and appointments, reshaping interactions with clinical staff
	Monitoring and tracking	Digital dashboards and remote monitoring can create new technological responsibilities for staff
	Electronic patient records	Poor integration can force staff into time-consuming workarounds, affecting administrative workload
Domain 2C: Technology (knowledge/support required)	Safety-netting and monitoring	Complex new safety-netting elements can require training and ongoing organisational support for staff implementation
Domain 3: Value proposition	Reasons for rollout	Staff can be resistant to PIFU where they do not perceive patient benefit to be the main driver at an organisational level
	Efficiency expectations	Staff scepticism exists about whether PIFU delivers promised capacity gains versus increased administrative burden
Domain 4: Adopters (staff and patients)	Patient induction and education	Staff responsibility for patient consent, education, and ensuring understanding can affect roles
Domain 4A: Adopters (staff)	Risk tolerance and decision-making	Individual clinical judgment and variable risk tolerance can affect patient selection decisions and staff anxiety
Domain 5A: Organization (capacity & capability)	Resource allocation	Lack of ringfenced capacity can mean staff absorb PIFU alongside existing responsibilities, affecting workload
	Staffing models	Creation of dedicated PIFU-specific roles can affect job roles and responsibilities within teams
Domain 5D: Organization (extent of change to routines)	Escalation and triage processes	New triage responsibilities and appointment management processes can change administrative and clinical workflows
	Practice formalisation	More formalised procedures compared to previous “open appointment” models can require staff adaptation
Domain 5E: Organisation (work to implement change)	Role changes and new tasks	Administrative tasks, safety-netting, and patient selection responsibilities can affect different staff groups
	Administrative burden	PIFU administrative processes can particularly impact administrative staff with increased workload and complexity
Domain 6: Wider system	Primary care interface	Poor communication between hospital and GP practices can create confusion and have unintended consequences for primary care workloads
	Service pressure context	Implementation during significant waiting lists and capacity pressures can affect staff ability to perceive PIFU benefits

Impact of PIFU on roles and practices of adopters

The results in this subsection relate primarily to NASSS domain 4A (Staff role, identity), whilst also interacting with other domains. During the period of data collection, NHS Trusts, including those involved in the evaluation, were at various stages of PIFU implementation. PIFU pathways varied in their design (Table 2), maturity and volumes of patients, both between specialty areas within sites and between sites. Our findings expand significantly on previous work, ⁵ by applying the concept of less and more intensive input from services in PIFU delivery to more specific elements of the PIFU pathway, delivering more detail on how variation in intensity looks in practice, and linking intensity to PIFU’s programme theory.

Table 2.

Examples of low- and high-input PIFU implementation models with underlying programme theory, expanding the framework developed by Reed and Crellin (2022) ⁶ .

Pathway aspect	Low-input implementation	High-input implementation	Programme theory rationale
Patient selection	Clinical judgment with loose, subjective criteria	Localised protocols and standardised clinical guidance	Low-input models assume sufficient patient self-management capacity is widely present for the clinical context; high-input models assume systematic assessment is needed to identify suitable candidates
Monitoring and tracking	None	Digital dashboards and remote monitoring	Low-input models rely on patient initiative as sufficient safety net in the clinical context; high-input models assume proactive monitoring is needed to ensure patient safety
Safety netting	Only patient initiates contact	Regular clinical reviews for patients as well as relevant tests and scans	Low-input models assume patient-initiated contact captures all clinically significant issues; high-input models assume clinical oversight is needed to maintain safety standards
Induction and sign-on	PIFU by default (all patients placed on PIFU)	In person consent, multiple conversations and information about PIFU	Low-input models assume PIFU is universally beneficial and self-explanatory in the clinical context; high-input models assume patient understanding and engagement requires active facilitation
Discharge processes	Automatic discharge at pathway end	All patients have clinical review and appointment with clinician	Low-input models assume discharge is appropriate if no issues have been raised during the pathway; high-input models assume clinical assessment is needed to ensure appropriate care transitions
Escalation and triage	Everyone requesting an appointment gets one	Clinical assessment and questionnaires	Low-input models assume patient or carer judgment about need for appointments is reliable in the clinical context; high-input models assume clinical triage optimises resource allocation and patient safety
Booking and contact	Phone/email and no ringfenced capacity	Multiple booking methods and capacity/slots reserved for PIFU patients	Low-input models assume existing capacity can absorb PIFU demand; high-input models assume dedicated resources are needed to ensure responsiveness to patient need, and to avoid overwhelming existing capacity

The nature of conditions managed (NASSS domain 1A) was a key driver of variation. ‘Lower-input’ PIFU implementation models were typically deployed in clinical areas that were lower-risk, where minimal intervention was not deemed to negatively impact patient safety, such as post-operative pathways. These relied heavily on patient decision-making. ‘Higher-input’ models tended to be deployed where it was not deemed safe (by guidance and/or clinical teams) for outpatient teams to take such a hands-off approach (e.g., some oncology pathways). The diversity of models led to diverse levels of changes needed to routines (NASSS domain 5D, Change to routines). For some participants, implementing PIFU entailed distinct new approaches to practice, whilst others were experienced in implementing similar models (NASSS domain 5D). These contextual factors had a significant bearing on how staff experienced PIFU.

When discussing the impact of PIFU on staff roles (NASSS Domain 5E, Work to implement change), the key themes that emerged were administrative tasks, safety-netting or monitoring, patient selection and onboarding, and dedicated PIFU roles. In this section, we consider the implications of PIFU for different roles.

Administrative tasks

For teams which did not previously use “open appointment”-type models, managing patient calls and arranging PIFU appointments were new processes. PIFU reshaped interactions (NASSS domain 5D, Change to routines) between clinical staff, administrators, and electronic patient record systems, though the greatest impact fell on administrative teams. Patients were typically given a PIFU-specific telephone number for direct access to the administrator team, who managed appointment scheduling and recorded PIFU details in electronic patient record systems. In some cases, administrators triaged patients before arranging appointments or directing them to alternative care, though this role varied across specialities.

Safety-netting tasks and patient monitoring

Even in teams with “open appointment” models already in place, PIFU introduced new elements (NASSS domain 5D, Change to routines), including more proactive forms of patient monitoring or safety-netting (meaning measures to ensure patients did not miss out on necessary care even if they had not contacted the service). A key example of this was clinical reviews, either of patient notes before an individual’s pathway expired, or, in higher-risk cases, through scheduled appointments at certain points in their pathway (such as the halfway point). While not universally adopted, (e.g., physiotherapy and post-operative pathways rarely used them), these reviews were reported across multiple specialties and trusts (e.g., in rheumatology and breast care).

Because PIFU was often more formalised than previous processes, standard operating procedures for PIFU sometimes mandated these safeguards when they had not been required under “open appointment”-type models (NASSS domain 5D, Change to routines). Some staff raised concerns that these additional activities were not sufficiently accounted for in individual work plans, partially offsetting the intended capacity gains of PIFU:

Those who are placed on a PIFU list, they might be monitored and certainly when it gets to the end of that PIFU period there should be a form of clinical review. (Administrative role, specialty-level, Site 1)

Patient selection and onboarding to PIFU pathway

Additionally, staff noted the importance of selecting appropriate patients for PIFU for patient safety. For example, many staff considered the ability of individuals (or their carers) to monitor and recognise symptoms before placing patients on PIFU. NASSS identifies the importance of expectations the adoption of innovations places upon patients in domain 4B (Expectations upon patients). Clinicians had different attitudes towards risk. Whilst specialty-specific standard operating procedures (SOPs) outlined selection criteria, individual clinical judgement played a key role in patient eligibility decisions. This responsibility caused concern for some staff. Clinicians’ risk tolerance – shaped by factors such as level of experience – often influenced how many patients they deemed eligible for PIFU.

Clinicians were often also responsible for introducing patients to PIFU and facilitating informed consent to join PIFU pathways. In practice, approaches to this were highly variable, ranging from automatic ‘discharge to PIFU’ models with little patient engagement, to face-to-face consultations. Some examples were raised of patients selected for PIFU who had failed to initiate PIFU appointments when needed. This suggested failures in patient selection and education.

[Patient selection] might be outlined in the SOP but it would be done very subjectively [on a patient-by-patient basis]. (Clinical role, Specialty-level, Site 1)

Development of dedicated PIFU roles

In a minority of instances, NHS Trusts created PIFU-specific roles to support rollout. Some teams employed a PIFU-specific clinical nurse specialist, whilst another employed a member of administrative staff dedicated to PIFU (NASSS domain 5A, Capacity to innovate, and domain 5E, Work needed to implement). These clinical nurse specialists provided clinical triage: determining whether PIFU requests required consultant appointment, nurse appointments or advice and information (such as around how to monitor symptoms) via telephone from the nurse specialist. One was also qualified to prescribe medication. Staff in this role recognised their value in delivering more consistent monitoring of patients. This was especially critical as both PIFU-specific clinical nurse specialists interviewed managed oncological pathways:

[Patients] know they can phone me and then I can give them advice or sign post them and most, if not all, have said that it's been very good and it's been helpful. (Clinical role, Specialty-level, Site 2)

Another nurse specialist had a broader role which was intentionally split between PIFU and other responsibilities. However, a low volume of PIFU patients in the specialty, and the fact that PIFU was not a major departure from previous practice, meant PIFU had not considerably impacted their role. Conversely, where PIFU-specific roles were absent, staff sometimes struggled to juggle PIFU and non-PIFU responsibilities. This relates to NASSS domain 1B (Nature of condition), showing how the complexity of a condition that is targeted by an innovation shapes implementation.

Impact of PIFU on workload

The extent to which PIFU impacted staff workload depended on the extent to which it differed from previous practice (NASSS domain 5D, Change to routines). Further, although NASSS does not explicitly cover workload implications, the value proposition of an innovation (domain 3) is a central consideration of the framework, and positive impacts on workload were a key value proposition of PIFU. Staff who were accustomed to managing patients on fixed follow-up schedules, or those who were met with significantly increased administrative demands compared to previous “open appointment” models, were more likely to note changes in workload.

Whether staff involved could perceive any impact of PIFU upon their workload was also dependent on the volume of PIFU in their specialty. Where PIFU pathways formed a very small proportion of patient pathways, they could only speculate about future impact. Where PIFU formed a considerable proportion of overall patient pathways, staff were more confident reflecting on the impact of the innovation:

From a day-to-day, I don't think it makes too much of a difference really. We don't get huge numbers of people using PIFU. (Clinical role, Specialty-level, Site 2)

People leading PIFU, nationally and within NHS Trusts, highlighted PIFU’s potential to better match staff time to clinical need as a key rationale behind implementation (NASSS domain 3, Value proposition). This was noted as especially important in the context of managing waiting lists (which were at a record-breaking high level) within existing capacity. However, there was more scepticism around whether PIFU would deliver these aims among some staff within specialty teams.

PIFU affected the workload of administrative staff, clinical hospital staff and primary care clinicians in different ways (NASSS domain 5E, Work to implement).

Administrative staff

Administrative burden

Typically, administrative staff acted as intermediaries between PIFU patients and clinicians. Changes in their roles exposed administrative staff to significant changes in workload. This could be especially problematic when administrative teams were required to absorb PIFU alongside existing responsibilities (NASSS domain 5A, Capacity to innovate). Additionally, electronic patient record systems poorly suited to recording PIFU could result in staff being forced to perform time-consuming workarounds for each entry. Administrative staff saw further increases to workload when clinicians’ communications or recording of PIFU were unclear, such as incomplete patient notes when PIFU pathways commenced. High staff turnover within administrative teams meant that staff were often inexperienced at administrating PIFU; some suggested that such demands could even drive staff turnover:

…for non-clinical staff, I think it’s been a nightmare. Because they have to deal with all the outgoing patients, and which pathway and partial booking list [to place patients on]. And also, clinicians are not writing particularly clear letters. (Clinical/operational role, Specialty/region-level, Site 2)

Clinical hospital staff

More ‘new’ patients

Clinical hospital staff had different views on how PIFU had affected their workload. Generally, staff reflected that PIFU had not delivered on proposed value related to staff capacity. Many had seen a neutral effect due to low PIFU volume or lack of significant change from previous practice. In some cases, PIFU meant clinicians could reduce the amount of time spent on follow-up appointments and dedicate more time to new patients - some staff attempting to reduce huge waiting lists valued this very highly. Staff reflected that the broader context of care backlogs made it very difficult for PIFU to reduce overall workloads (NASSS domain 6, Wider context). For example, in specialities contending with large waiting lists and high average waiting times (NASSS domain 5A, Capacity to innovate), any staff time saved by PIFU was quickly filled by new patients, and patients who triggered appointments through PIFU often still endured long waits to be seen:

We have such significant backlogs of new patients and already listed follow-ups that all we do is free up space for clinicians to see those people – we’re not actually gaining any time. (Operational role, NHSTrust-level, Site 2)

However, in services such as oncology, which had more flexibility to adapt their clinics, staff time freed up by PIFU was less likely to immediately be reassigned to other patients. This time could be used to be more reflexive to the needs of patients already in the service.

[Patients] know that if they have any questions or any issues, they could phone me and I could even get them in to see the consultant in a couple of weeks or I can give them advice over the telephone [right away]. (Clinical role, Specialty-level, Site 2)

Increased intensity

Some participants raised concerns that PIFU resulted in spending a greater proportion of time with patients with more complex needs by its elimination of ‘routine’ check-ups. Whilst this was an intended feature of PIFU’s value proposition of better matching service capacity to the most acute needs, the effect was to increase the overall intensity of a clinician’s workday. Hence, staff were worried that it would lead to more stress and burnout within clinical teams. They did not believe that this changing need profile was always being supported in the way outpatient clinics were organised. In addition, some staff felt PIFU was increasing overall workload due to new processes such as clinical reviews, which was not supported by additional capacity within teams:

The more patients are placed onto PIFU, the higher proportion of patients will have greater acuity… The patients on PIFU are not going to be the 'well' -- we need more time. I know from colleagues PIFU patients may take 20 minutes rather than the standard 15, they're just a higher demand and you know they're flaring. (Clinical role, specialty-level, Site 2)

Increased demand

Some staff managing longer-term pathways, where patients might have more reasons to contact the service, expressed anxiety that high volumes of PIFU could lead to increased demand versus fixed follow-up pathways. This suggests PIFU could generate unintended consequences for staff. On the other hand, short-term pathways (e.g., post-operative pathways), in place to account for unlikely complications, saw most patients recover without issue, and not request a PIFU appointment. This variation caused by differences in the conditions and illnesses for PIFU reflects NASSS domain 1A. The impression that PIFU might stretch team capacity further was a key driver cited behind reluctance among some staff members to place patients on PIFU, and assurances or evidence given by managers were not always deemed sufficient to counter these concerns.

So they just feel that they would be not managing the expectations of the patients well. Patients will be oversubscribing to the service and they don’t have the necessary resources [to increase the volume of outpatient appointments]. (Operational role, NHS Trust-wide, Site 1)

Some participants were concerned that all of these challenges could intensify if, as was intended, more patients were placed on PIFU in the future. Managing large volumes of patients on PIFU had clear implications for how teams work. Some staff also wanted to see more comprehensive safety-netting and revised organisation of clinics. Some services had already adapted clinics by including PIFU-specific slots:

In our service we've reduced the chance of clinician burnout [because] we've reduced how long our clinics last. We've [also] heard about better experiences from patients coming to our clinics. (Clinical/operational, specialty/NHS Trust-level, Site 2)

Primary care staff

GP interviews brought a perspective from primary care about PIFU rollout. Many hospital-based staff saw PIFU as an opportunity to free-up capacity in primary care by offering a direct route to outpatient teams. However, some hospital staff commented that patients who do not have a good understanding of how PIFU works may still try to access the service through their GP (NASSS domain 4B, Patients). Additionally, some were aware that communication between outpatient teams and GP practices regarding key PIFU-related information was sometimes poor:

There’s supposed to be a set bit of text that goes to the GP and patient so they understand what is happening – we know from our audit work that that’s not always being done. (Clinical role, NHS Trust-level, Site 2)

The small sample of GPs participants did not report any reduction in workload due to PIFU. Rather, they raised concerns that failures of outpatient departments to manage PIFU lists would result in unintended consequences upon workload for GPs, as patients would be forced to seek alternative routes to have their needs addressed. One GP participant reported experiences of patients who resorted to visiting their practice after failing to get through to a PIFU service. A GP participant also recounted experiences of outpatient teams demanding referrals for PIFU patients before seeing them, seemingly contradicting one of the core principles of PIFU. GP participants in the evaluation did not feel that the impact of PIFU on GP was being systematically considered, and that it was largely excluded from discussions on PIFU:

So in theory it might reduce contacts with primary care because they have a pathway into secondary care, but I don’t think that’s been evaluated or anyone thought about how we measure the impact. (GP)

Staff views on and satisfaction with PIFU

Staff who had positive overall attitudes towards PIFU tended to be influenced by both the positive impact upon their day-to-day role and workload and the potential for tangible benefit for patients. Staff who believed PIFU was delivering outcomes such as increased patient autonomy, better needs-based prioritisation, decreased stress caused by the avoidance of unnecessary follow-ups, and no adverse impact upon patient safety viewed it positively (NASSS domain 3B, Value proposition - efficacy):

[PIFU is] about empowering [patients] and letting them know what to look out for, what’s normal for them post treatment and that they have the power to do something about it in a much more straightforward way. (Clinical role, specialty-level, Site 2)

The reasons for rolling out PIFU were also influential. Specialty-level staff typically wanted PIFU to be ‘sold’ to them by colleagues at national or trust level to show how it could tangibly benefit patients (NASSS domains 3, Value proposition, and 6, Wider context).

Conversely, if staff believed PIFU was an imposed, ‘top-down’ change they were being encouraged to adopt by management with the primary aim of meeting targets, they tended to be resistant to adopting PIFU. Fatigue due to the regular imposition of new innovations, as well as the general struggle to meet patient demand, were also expressed by some as reasons why they were not enthusiastic to adopt PIFU:

So if it’s just a target, I don’t think people are interested. I think people are interested in getting to see the people they need to see… But I don’t think that’s what people feel is driving [PIFU]. (Clinical role, specialty/NHS Trust-level, Site 2)

Concerns around excessive risk or unintended consequences also informed negative attitudes and resistance towards PIFU. These included the exacerbation of health inequalities due to PIFU being less suitable for certain demographic groups, and risks to patient safety due to the model relying on patient initiative (with the prospect of patients becoming ‘lost in the system’ often cited). They relate to NASSS domain 1B (Relevant sociocultural factors and comorbidities):

I always worry about [PIFU] patients being lost in the system. (Clinical role, specialty-level, Site 2)

Discussion

Staff experiences of PIFU were complex and varied, shaped by differences in implementation and clinical and organisational settings. Staff roles and workload were most likely to be affected where staff managed a sufficient volume of PIFU patients, especially where it marked a major shift from previous practice. Careful, context-specific pathway design mitigated challenges, yet many participants worried that PIFU could add strain to already overstretched teams, particularly by altering case mix.

Staff perceptions of PIFU were influenced by how they understood its impact on their workload, risks and benefits for patients, and perceived intentions of PIFU rollout. Long waiting lists for elective care meant most staff saw little potential for PIFU to ease overall workload, but, importantly, some saw it as a tool for ensuring limited resources were better directed towards the highest need.

How findings relate to previous research

This evaluation aimed primarily to evaluate services within participating NHS Trusts, however, the findings add to the wider evidence base. There is minimal existing evidence about the specific impact of PIFU on staff experience, as much research to date has focused upon PIFU’s impact on service capacity and volume of outpatient attendances.

Findings from this evaluation align with those from previous studies, which have also found that organisational factors, such as relationships between frontline and managerial staff, affect PIFU implementation.^10,11 Previous studies have also highlighted staff concerns around how PIFU may impact patient safety. ¹² Loreno et al. (2022) raise that one route to allaying staff concerns around patients on PIFU becoming ‘lost’, is to implement quick and reliable routes for recalling patients. The same study raises the importance of monitoring the burden of PIFU upon the workload of several professional groups. ¹³ Existing studies vary in quality and deliver a range of conclusions on impact with varying degrees of confidence. ⁵ The lack of uniformity in how PIFU is implemented (and studied) in different specialty areas and organisations is likely to relate to this lack of consensus across studies. Evidence from this evaluation draws on a specific framework to analyse the different components of implementation of PIFU, and hence aids better understanding of the factors which may underpin this variation.

The use of the NASSS framework allows us to consider our evaluation findings in relation to the wider literature on the influences on the implementation of innovations in health care, in particular, the impact on the adopters of the innovation, the organisation and the wider policy context. ⁸ Changed staff roles are fundamental to the concept of PIFU, as these are needed to accommodate patients having more control over their outpatient pathways.

Other literature also highlights that negative impact of an innovation can be mitigated by ensuring the demands on workforce capacity are understood, and necessary capacity is in place. ¹⁴ Additionally, studies have found that the implementation of innovations can significantly change staff roles and redirect staff time, including through increased administrative burdens. ¹⁵ Alongside the general upheaval that is often caused by implementation, NASSS frames this as a threat to long-term success. ⁸ Previous work also highlights barriers to innovation which are prevalent in the NHS, including organisational culture, technological capacity and acute service pressures. ¹⁶

Implications for policymakers and service managers

The elective care backlog in the English NHS stood at almost 7.4 million in June 2025, ² and reducing waiting lists remains a headline priority for the government. ¹⁷ The NHS 10-Year Plan states a clear intent to adopt PIFU as a standard approach, where clinically appropriate. ³ The Plan’s major strategic push suggests growing numbers of patients will be placed on PIFU pathways. Findings from this study can support local teams as they seek to evaluate the outcomes and impacts of PIFU at speciality level, and are further developed into an evaluation guide. ⁶

Teams deploying similar models outside England should also be able to draw learning from this evaluation. However, they should account for contextual differences such as workforce capacity and levels of familiarity with such models amongst staff and patients.

Understanding some of the different ways PIFU can affect the working lives of healthcare professionals can allow for better workforce and service planning. Additionally, understanding that impact of PIFU is context-specific should discourage attempts to apply one-size-fits-all models to very diverse environments. Appropriate safety measures should be implemented to manage the level and type of clinical risk present in each context. Organisational leads should also consider that PIFU is not equally beneficial or suitable for all patient conditions or specialties.

Intense capacity pressures were a consistent theme amongst the teams that participated in this evaluation, and staff often struggled to implement new models of care when capacity was dominated by immediate patient demand. This environment also sometimes created a belief amongst staff that innovations were not being driven primarily by a desire to improve quality of care. These learnings should be considered before implementing innovations to avoid issues such as the exacerbation of burnout and attrition among staff groups, ¹⁸ and to aid the creation of positive dialogue between frontline and managerial teams.

Strengths and limitations

This paper adds to the limited evidence base on how PIFU affects staff experience. It draws on evidence from a range of sites in different parts of England, serving diverse demographic population profiles, and a varied sample of clinical specialties. Our interviews included both clinical and managerial/administrative staff at trust and specialty level, providing a range of perspectives on PIFU.

However, the context of considerable strains on service capacity affected the range and number of staff we were able to interview, and limited the range of specialities included in this study. The variable maturity of PIFU in participating sites and specialty teams meant it was not possible to obtain the intended level of detail regarding how PIFU is implemented to manage long-term conditions. A clear finding of the evaluation is the lack of uniformity in PIFU’s impact upon different specialties. Additionally, a focus at the level of clinical specialty may have obscured how PIFU varies for specific conditions. The quality of findings would also have been improved if the evaluation had covered a greater variation of staffing models and levels of PIFU implementation maturity. Employing a broader range of research methods, such as non-participant observation, may have provided a more comprehensive understanding of PIFU’s goals and implementation. However, the evaluation guide developed during the study ⁶ creates the opportunity to collect more comprehensive data.

Conclusion

Patient-initiated follow-up (PIFU) is an innovation with significant potential to affect the way services are delivered and, consequently, the experiences of staff. Staff roles and workload can change due to implementing PIFU. However, the impact of PIFU was not uniform across the specialties and NHS Trusts that participated in the evaluation. Characteristics such as the volume of PIFU patients managed, previous staff experience with ‘open appointment’ models, and the types of conditions managed, as well as pathway design choices, had a major bearing on how PIFU impacted roles and workload. Additionally, staff satisfaction with PIFU was driven by its impact upon their working lives as well as perceptions of risk and impact upon patients, and of the main drivers of rollout. Staff perspectives on PIFU from all parts of the health system should be better understood and considered during pathway design. For those involved in implementing PIFU, understanding staff experiences is key to driving staff engagement, which is a central factor in successful implementation.

Supplemental material

Supplemental material - Staff experiences of implementing patient-initiated follow-up (PIFU) in the NHS in England; findings from a rapid qualitative evaluation

Supplemental material for Staff experiences of implementing patient-initiated follow-up (PIFU) in the NHS in England; findings from a rapid qualitative evaluation by Cyril Lobont, Rachel Hutchings, Stuti Bagri, Nadia Crellin, Theo Georghiou, Stephanie Kumpunen, Jenny Negus, Pei Li Ng, Camille Oung, Angus Ramsay, Sarah Reed and Chris Sherlaw-Johnson in Antiviral Therapy