An Evaluation of the Impact of Community
Specialist Clinics (CSC) on a Local
Community in London
Feray Ozdes1, Anwar Khan2* and Pasquale Giordano3
1Foundation Year 1 trainee, Princess Alexandra Hospital, England
2Senior Research Fellow Kings College (London), Ching Way Medical Centre, England
3Consultant Surgeon, Whipps Cross University Hospital and Ching Way Medical Centre, England
Submission: September 1, 2019; Published: September 17, 2019
*Corresponding author: Anwar Khan, Senior Research Fellow Kings College (London), Ching Way Medical Centre, England, United Kingdom
How to cite this article: Feray Ozdes, Anwar Khan, Pasquale Giordano. An Evaluation of the Impact of Community Specialist Clinics (CSC) on a Local Community in London. Open Access J Surg. 2019; 11(1): 555804. DOI: DOI:10.19080/OAJS.2019.10.555804.
Keywords: Care setting; NHS Operational target; Public satisfaction; Cost effective healthcare; Community clinics; Colorectal surgery
Community specialist clinics (CSC) are consultant-led services run within a primary care setting . Within recent years, the waiting times for referral to specialists has reached an all-time high [2,3]. The national waiting time target for referral to consultant-led treatment, known as Referral to Treatment (RTT), has been set at 18 weeks [2,4]. However, in 2019, this target was met for only 87% of patients, falling significantly below the NHS operational target of 92% . If it is not possible for treatment to be provided within the target waiting times, the Clinical Commissioning Group (CCG) is responsible for offering alternative providers  which often adds further costs to the service. As well as waiting times, patient satisfaction and quality of care within the NHS is declining . Public satisfaction with the NHS overall was as low as 53% in 2018 – a 3% point drop from the previous year and the lowest level since 2007 . At the levels of funding provided, the NHS is struggling to meet demands and cost pressures are likely to worsen [3,6]. With CCGs also beginning to fall into financial deficit  at a time of increasing power and financial independence of general practitioners (GPs) , there has been a growing demand for CCGs to outsource their specialist services in order to ease the burden on their secondary care providers.
In 2001, a national evaluation of specialists’ clinics in primary care settings concluded that the benefits of community clinics included shorter waiting times for appointments, shorter waiting times at the clinics themselves, the need for fewer follow-
up appointments, higher patient satisfaction, and lower personal costs to the patients such as those for travel and parking . Nevertheless, the costs to the NHS per patient were found to be higher in community clinics when compared to secondary care outpatient clinics .
This paper aims to evaluate the impact of implementing a CSC on a local community in Waltham Forest, East London. The particular provider we will evaluate was established in 2008 and includes three specialist services; colorectal, gynaecology and dermatology. The data for the latter specialty was limited and therefore we will evaluate colorectal and gynaecology clinics only. We will aim to compare the impact of these services from three different perspectives; that of the NHS, the patients, and the doctors.
In order to compare the financial impact of community clinics to secondary care clinics, the cost to the CCG and therefore to the NHS, will be compared. Outpatient appointments for new patients, outpatient appointments for follow-up patients, and each individual outpatient procedure is coded for using a healthcare resource group (HRG) code. Each HRG code is valued by pre-determined tariffs set out by the care provider and the CCG at the start of each working year . These tariffs paid to the CSC differ to those paid to secondary care providers, most likely due to the higher costs associated with running a hospital.
As well as the tariffs paid to the providers, the CCG also pays an
additional 21.28% market force factor (MFF) to the secondary
care provider, but not to the CSC. An MFF, which varies between
CCGs nationally, is an estimate of unavoidable cost differences
between health care providers based on their geographical
location [10,11]. This data should reflect the cost differences
and therefore the financial impact on the NHS of each service
The patients’ perspective will be evaluated using
questionnaires voluntarily completed by patients at the end of
CSC clinics. These will aim to provide qualitative information
on the views and attitudes of patients to community-run clinics.
Written feedback from patients will be observed and both
positive and negative comments referring directly to the quality
of the service will be evaluated. In addition, the questionnaires
will be used to ascertain how long patients waited between their
initial GP referral to clinic and their first CSC appointment. These
waiting times will be compared to publically-accessible data on
waiting times by the same NHS Trust’s secondary care clinics in
the same year. This information should summarise the impact on
patients of community clinics in comparison to secondary care
The perspective of the doctors working in these clinics will
be evaluated using questionnaires which will be sent to them via
email. The specialists who complete these questionnaires may
be either a GP with specialist interest (GPwSI) or a consultant
in their specialty but must have at least one year’s experience
in working in both community and secondary care clinics. The
questionnaires will aim to gather information about the quality
of care, advantages and disadvantages of both primary and
secondary care outpatient clinics in their experience. This will
enable a comparison of views and attitudes in each setting from
a clinician’s point of view.
Total costs were collected for the year commencing April
2018, for both primary and secondary care outpatient clinics.
The data revealed that the cost to the CCG of funding both new
and follow-up patient appointments, as well as for all outpatient
procedures were higher for secondary care clinics than for
CSCs. This was true for both colorectal and gynaecology clinics
(Figures 1 & 2).
According to CSC practice data, 100% of patients were
offered appointments within 6 weeks of referral from their GP.
However, patient questionnaire data from the CSC revealed
that 88% of patients were actually seen within 6 weeks of
their GP referral, which was attributed to patient preference,
patient cancellations, or patients not arriving to their given
appointments. Overall, the median waiting time for referral to
this CSC fell between 2-3 weeks. Practice data also revealed that
the mean waiting time from clinic appointment to undergoing
a procedure with the CSC was 16 days, thereby giving a total
RTT waiting time of approximately 5 weeks, falling well below
the NHS 18 week RTT target. In fact, 100% of patients at this
CSC met this 18 week target. Contrastingly, NHS England data
for the same NHS trust reveals that only 85.5% of patients were
meeting the 18 week RTT target in secondary care clinics in the
same year (Figure 3).
When asked to rank the overall service provided at the CSC,
80% of patients rated this as “excellent” or “very good”, while
less than 1% rated it as “poor”. Moreover, 96% of respondents
would recommend the service to friends and family (Figures 4
Of the 3204 patients who completed the questionnaires,
436 left additional comments. Of these comments, 121 were
relevant to the service provided as opposed to other factors
such as the quality of the doctors and other staff members.
Of all of the comments relevant to the service provided, 102
(84%) comments were positive while 19 (16%) were negative
or suggested improvements that could be made to the service.
Positive comments included forty patients commending the
CSC’s “excellent service” with thirty eight patients using other
positive descriptive terms for the service such as ‘brilliant’ or
‘outstanding’. Nine patients praised the service’s efficiency,
punctuality and organisation. One patient commented that there
were excellent parking facilities. Another stated that the CSC was
very convenient and close to home, while one patient felt it was
much better than being seen at the hospital. On the other hand,
eight patients expressed the need for improved waiting times.
Four patients asked for better waiting room facilities such as
more space and chairs, and one commented that car parking was
not always available. Overall, comments were generally positive,
and the suggested improvements have been fed back to the
practice for action.
Eighteen doctors working at the CSC were sent a
questionnaire via email. 10 doctors completed the questionnaire
anonymously. 70% of respondents were male, while 30% were
female. 70% were specialists in colorectal, while 30% specialise
in gynaecology. 70% were consultants, while the other 30% of
respondents were GPwSIs./p>
When asked about how late clinics usually run in both
primary and secondary care settings, doctors revealed that,
on average, their secondary care clinics run later than their
community clinics. In the CSC, 40% stated their clinics run on
time, 40% claimed they run 5-15 minutes late, and 20% claimed
clinics run 20-30 minutes late. Contrastingly, when asked about
secondary care clinics, only 14% claimed their clinics were on
time. Furthermore, 14% of secondary care clinics were said to
run 5-15 minutes late, 43% run 20-30 minutes late, and 29%
run more than 45 minutes late. These responses indicate that
community clinics are, on average, more punctual than clinics
for the same specialty in a secondary care setting (Figure 6).
Doctors rated the overall quality of care provided at the CSC,
as perceived by them, higher than that of their secondary care
clinics. 60% rated the quality of care at the CSC as ‘excellent’.
which corresponds similarly to the 53% of patients who also
gave the service this rating. Meanwhile, 30% of doctors rated
the service as very good, and 10% as good. In regard to the
secondary care clinics, the results were less positive. 20% of
doctors rated the quality of care provided at secondary care
clinics as excellent, 20% rated it as very good, 30% said it was
good, 20% claimed it was fair, while 10% claimed it was poor
100% of respondents believed the CSC was of benefit to the
local community. The main advantages of the CSC, as described
by doctors, tended to relate to the locality and ease of access of
the service, particularly easier and cheaper travel and parking
for both the patients and staff. Timely referral from CSC to local
endoscopy services was also highlighted by several practitioners
as an advantage to patients, as was improved waiting times from
referral and waiting times at clinics themselves. The continuity
of care provided at CSC was also commended. Some felt that the
availability of on-site treatments such as haemorrhoid injections
and banding was practical and, again, improved patients’ waiting
times for referral to treatment. Some doctors believed that having
a community clinic allowed them to cut down on unnecessary
referrals to their secondary care clinics, consequently improving
their efficiency when working at the hospital. Many believed it
was well organised and well-staffed, particularly admin staff
which lightens the burden on doctors so that they can focus on
clinical aspects. This also means more time can be allocated to
meeting patient needs and as a consequence doctors feel that
they are able to provide better care. The lack of interruption
from the rest of the hospital while working in community was
also a benefit.
As for disadvantages of the CSC, some doctors claimed
they were not always able to access information from patient’s
hospital notes. Additionally, results of recent investigations
are not immediately available in community clinics and do not
always arrive in time for patients’ follow-up appointments.
Numerous doctors claimed that a disadvantage of working in the
community was the use of paper notes rather than a centralised
The main advantage of secondary care clinics for many
doctors was the fact that all services were on-site, and more
facilities were available and accessible. There is also the
possibility of seeing specialist nurses where appropriate.
Additionally, all results of investigations taken in secondary care
are immediately available in clinic. Some doctors felt that always
having other specialists on site from whom a second opinion
could be sought was an advantage of working in secondary care.
Moreover, the clinics in hospital were felt to be well-staffed and
On the other hand, most respondents felt that the long waiting
lists in hospital were a major disadvantage. They also felt clinics
were overbooked and therefore waiting times in clinic can often
be very long, as were waiting times for many procedures. Some
felt that the care was depersonalised in hospital and patients
were not always able to see the same consultant. Accessibility,
travel, and the cost of parking was highlighted as a disadvantage
for patients and staff. Some felt the hospital was a more stressful
environment to both work and be treated. Some feel they are
overworked in secondary care and the system does not value its
This clinic not only provides cost effective healthcare (below
the national tariffs) but also has good satisfaction ratings by both
staff and patients. It also provides a good learning environment
for both surgical trainees and GPs wanting to develop a special
interest in colorectal surgery.
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