In response to Coronavirus (COVID-19), the NHS is scaling up the use of virtual consultations. Trish Greenhalgh is a GP and Professor of Primary Care Health Sciences at Oxford University, and an expert in the adoption of service and technology changes in the NHS. She has led the evaluation of initiatives to implement virtual consultations in Barts Health NHS Trust and in Scotland – both of which had their origins in Health Foundation innovation projects and have since received further funding to develop and scale up their work. We spoke to her about the rapid implementation of virtual consultations and what we can learn from the research in this area to date.
Virtual consultations have often been considered in terms of convenience or patient and staff preferences, but now they are a necessity. How does that change the approach to putting them in place?
Twenty years ago, around the time I got my first research grant to look at innovation, I read a book by Everett Rogers, called Diffusion of Innovations. Rogers was a social psychologist, who studied the uptake of new farming practices in America after World War Two. He came up with the concept of ‘relative advantage’. Overwhelmingly, the thing that determines whether and how quickly people take up an innovation is whether it’s better than what they were doing before.
Until a few weeks ago, unless you lived somewhere really remote, it was easy to pop to the hospital or the GP. With COVID-19, if you’re a patient and you go to a GP surgery or you’re a doctor and you see patients face-to-face, there’s a high risk of infection. Suddenly the relative advantage of virtual consultations has changed dramatically.
I cannot think of any comparative situation in the history of the NHS. This is such a complex innovation, changing the way we relate to patients and the workflows of the NHS. This is not just about video and telephone consultations, but also what’s known as the total triage system, where a patient can’t just phone up and book to see a doctor, they can’t walk in to the surgery to ask for a prescription. This is a radical and complex innovation, but the relative advantage is huge.
Do you think this moment will leave a lasting legacy in terms of shifting the culture of healthcare in the UK more towards ‘virtual’ and away from ‘face-to-face’?
I think it will. The other key things Everett Rogers wrote about were trialability and observability. People are trying out virtual consultations, they are seeing that it works and it’s easier than they thought it was going to be.
I’m hearing from 20-30 GPs a day, telling me they never thought they’d do video consultations, but they’ve tried it, they can do it and their confidence is growing. That is not to say video consultation is easy. Connecting with people by video isn’t that hard, but the logistics and the workflows around video consultations can be difficult. The difficulties come from wondering whether or not a patient needs swabs and how to manage the logistics of self-swabbing, for example. But soon, those new workflows will be developed.
There have been various trials, evaluations and research about virtual consultations. How relevant are they to the current situation and what can we learn from them?
There is a large body of research on video consultations, but almost all of it is completely irrelevant.
Most of the randomised trial research has been in hospital outpatient settings, where a keen consultant randomises his or her patients to either coming back for an ordinary appointment or doing it by video. The sort of patient being asked to try out video consultation in those circumstances is usually clinically stable.
In that population, the results are good, including the quality and safety of the consultation and patient and staff satisfaction. But while the results are encouraging, the trials are almost all underpowered and their relevance to the current COVID-19 outbreak is almost zero.
What we’re doing now is consulting with a quite high-risk population, who are understandably anxious, in a fast-unfolding pandemic, where the level of uncertainty is unprecedented. We don’t know whether video consulting is safe in those circumstances, but we have to take an educated guess. What we do know is that the risks of consulting face-to-face are high.
The qualitative literature on virtual consultations is more interesting. Introducing video consultation within a service that hasn’t been using it before can be difficult, because of the major changes to the roles, routines and processes. One thing my team has demonstrated in work we’ve done in Scotland and also to an extent in the work we are doing at Barts Health NHS Trust – both initiatives that had their origins in Health Foundation innovation projects, and which have since received further funding to develop and scale up their work – is that the initiative tends to work better if you’ve got a quality improvement mindset. Rather than saying ‘we’re going to implement the technology’, you say ‘we’re going to improve the service and the way we improve the service is by using the technology’.
We’ve also done a lot of work in which we record both sides of the video consultation, interview people about how it went, and analyse the interaction. A really important issue is that the connection has to be dependable, otherwise people lose confidence and trust. If the technical quality of a video connection is bad, you may as well hang up and phone the patient so you can hear each other properly.
Physical examination by video consultation is limited, but it is surprising what you can do. If you’re lucky, you can get a view of the back of someone’s throat, for example. But the most important thing is that you can ‘eyeball’ them. As soon as you see a patient, you can tell whether they are ill or well, you can see whether they are distressed, whether they are dressed, whether they are in bed. You can ask them, of course, but there’s nothing like that visual input.
It’s also possible to ask patients to take their blood pressure, if they’ve got a blood pressure machine, or ask them to blow into a peak flow meter. The patient has to have the gadget at home, but with all the self-management we do, they often do.
What work have you been involved in recently to support the NHS to put virtual consultations in place rapidly?
First of all, I wrote guidance on video consultations for GPs. I worked with Claire Morrison, who, following the success of her Health Foundation projects to set up video consultations in NHS Highland (Pharmacy Anywhere and NHS Near Me), has been introducing video consultation right across Scotland as a quality improvement exercise. I adapted guidance Claire had written for the Scottish context, simplifying it and making it more generic. That guidance includes information on when video is appropriate, how we begin to get set up, how we do high-quality video consultation, and a guide for patients on consulting by video.
I’m also publishing a fast-track paper in The BMJ on how to do a ten-minute consultation by video or phone with a patient with query COVID-19. And I’m doing lots of webinars, including with NHS England and NHS Improvement, linked to their roll-out of total triage across England.
I’m getting the message out that this is not just about installing a technology, it is about a different way of managing patient flows, but I’m also reassuring people about the relative advantage. This is going to save lives. When you have a rapidly spreading disease, you’ve simply got to reduce the number of people consulting face-to-face.
How can we ensure the focus on quality in remote consultations doesn’t get lost, even in the current emergency?
What we need right now is ‘good enough’ consultations. There is a trade-off and the more quality and time you put into one consultation, the less you can give to the 99 other patients who are still waiting for you to call them back.
Having said that, one thing to bear in mind is that patients report that doctors sometimes come across as quite abrupt in phone consultations. Obviously, we’re in a hurry and we’re using a new medium, but it doesn’t take much time to be kind to someone, to acknowledge that they are frightened and feeling rotten. If we do that, there is some evidence that they are less likely to call back unnecessarily. One of the things that most doctors and nurses are good at is being supportive and empathetic to patients. You can still do that, even if it’s through a different technology.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.
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