When we look back at the NHS’s many achievements during the coronavirus (COVID-19) pandemic, the wholesale shift to virtual communication with patients will rightly feature high on the list. Many clinicians and patients have had to set aside their qualms about doing health care remotely. Across the UK, teams have broken down corporate silos and worked together to overcome all manner of practical and technical obstacles.
While emerging evidence suggests that telephone remains the dominant channel for remote consultation, there has been a particular push to expand video consultations in response to COVID-19. In England, for example, general practice has been asked to use video consultations ‘as much as possible’. And according to NHS England, all secondary care providers and 95% of practices now have video consultation capability – with the remaining few asked to complete implementation over the coming weeks. There have been similar rapid roll-outs in Scotland and Wales.
A few months ago, no one would have thought this achievable. As a story of radical change, one that has required established service models and entrenched attitudes to adapt to a different way of working, it takes some beating. It should certainly challenge the stale narrative about ‘professional resistance’ to change in the NHS.
But with the immediate period of implementation nearing completion, it’s perhaps time to reflect on the challenges highlighted by this shift, and the implications for care quality and patient experience. The recent roll-out has been motivated by the need for social distancing – the need to avoid in-person contact – and remote consultations automatically achieve that. However, that’s different from the objectives of improving patient experience, access or clinical productivity that had until now motivated interest in this agenda.
Over the last decade, the Health Foundation has supported several teams to test and develop video consultations. These projects have surfaced some key quality considerations – for video consultations and for remote consultations more generally – three of which we explore here.
1. Privacy and confidentiality
As the Q Community’s virtual consultations learning log has highlighted, a key concern is whether patients will be able to find a suitable space at home for a confidential consultation. And as a recent academic review found, it can be equally hard for professionals to find a space that will offer privacy and avoid disturbances.
This was initially an issue for the Health Foundation project Connecting with Telehealth to Children in Hospital, which offers virtual child and adolescent mental health appointments to young people in Wales. In response to early staff feedback, a dedicated telehealth room was created to hold video consultations. As well as removing anxiety about confidentiality, it has made videoconferencing more accessible. Dr Alka Ahuja, the project lead, is now supporting the roll-out of video consultations across Wales. Where privacy is needed, constraints on clinical space have also proved a challenge for other kinds of service transformation the Health Foundation has supported, such as teams aiming to embed a mental health component into a physical condition clinic.
Given the severe pressures on space in most NHS buildings, the challenge of securing appropriate facilities is likely to be one faced by almost all remote consultation services. Hanging onto space in the aftermath of COVID-19 may prove difficult too. And while the possibility of staff working from home could partly address this challenge, this in turn raises questions of governance, patient record management and pathway redesign.
It’s an issue that must be considered as part of broader plans to transform the use of the NHS estate – for example, through the redesign of outpatient services envisaged in the Long Term Plan – and something system leaders and providers should be planning for as we look beyond the current period of pandemic response.
2. Continuity of care
An important lesson from the very first Health Foundation project to implement video consultations, led by Newham hospital’s diabetes service back in 2011, is that the person behind the technology matters. Video consultations worked best, according to service users, when they were able to engage with a familiar and trusted face. And it can be hard to build that trust for the first time online. A hybrid approach was used in Newham, with face-to-face appointments used to build relationships first, with subsequent follow-up by video.
Now expanded to other services across Barts Health as part of the Health Foundation’s Scaling Up programme, an NIHR-funded evaluation of the approach has further highlighted the importance of continuity. It found the quality and flow of video consultations depended on the degree of ‘shared knowledge’ and ‘common ground’ between patient and clinician, and that ‘effective communication seemed to follow from an existing, positive interpersonal relationship’. And as recent Health Foundation research has shown, certain patient groups (including heavy users of primary care) can particularly benefit from continuity of care.
How can relational continuity be built when face-to-face appointments aren’t an option? More work is needed to answer this, but some useful learning is likely to come out of the Health Foundation’s Continuity of Care in General Practice programme.
3. Empathy and person-centred communication
Empathy is a key component of effective clinician-patient communication, associated with a range of benefits for patient satisfaction and outcomes. For example, studies have found that when clinicians are empathetic patients disclose more and are more likely to adhere to medication.
But there can be challenges in being empathetic online. Empathy involves ‘attunement’ to the patient, which requires being able to pick up on, and deploy, a range of verbal and non-verbal cues. There is a risk some of these can get lost in remote communication, as Martin Marshall, Chair of the RCGP argued recently. Clearly video consultations have an advantage over telephone for being able to detect non-verbal cues, but there can still be challenges; authentic eye contact, for example – an important aspect of empathetic communication – can be harder if a camera isn’t exactly aligned with the screen.
In the early days of virtual consultations there were concerns about whether or not clinicians would be able to deploy person-centred, empathetic communication remotely. There was a sense they were more transactional than face-to-face consultations (possibly in line with the fact that they tend to be shorter). Some initial studies found clinicians were less empathetic when communicating online.
In fact, more recent studies have concluded that video consultations can be just as empathetic as face-to-face ones. But this has also coincided with a growing awareness that communicating effectively online requires specific skills and that this is an area where investment in training could pay dividends – given that video consultations are part of the long-term vision for the NHS in all parts of the UK.
Video consultations are also an area where communication preferences can differ strongly –when it is or isn’t appropriate to deliver sensitive messages remotely, for example. For some, the idea of being given bad news via video link, such as the diagnosis of a serious condition, is inappropriate. Others may prefer to receive bad news at home, in a familiar environment, without a long journey home afterwards. Clearly, this is an area in which norms are still developing, making the need to take preferences into account particularly important. Rather than attempting to generalise about what patients do or don’t want, we need to find practical ways of capturing and sharing communication preferences.
Bringing quality to the fore
The increased use of remote consultations is one of those evolutions of care delivery that have been turbo-charged by the response to COVID-19, but which potentially offer long-term benefits if used appropriately. And NHS leaders are clearly aware of this. For example, NHS England recently signalled their desire to ‘lock in’ the beneficial changes of recent weeks, including the new focus on video consultations.
But the technical achievement of rapidly rolling out video consultations to meet social distancing requirements doesn’t mean that teams have yet achieved – or even come close to achieving – the quality objectives that provide the longer term rationale for this agenda. As the Health Foundation’s report The Spread Challenge argued, putting in place the ‘external form’ of a health care intervention is one thing, replicating the best patient outcomes is quite another. Far from simply ‘locking in’ recent changes, achieving the latter may require significant work to reorient remote consultations towards more centrally serving those broader quality objectives we know they are capable of delivering.
Bryan Jones is Improvement Fellow at the Health Foundation