Virtual follow up of hip and knee replacement care in Cornwall

In Cornwall, the Royal Cornwall Hospitals NHS Trust (RCHT) has pioneered a virtual follow-up service for people who have had hip or knee replacement surgery. The Trust sees 1,200 people for hip or knee replacement every year, and patients live across a wide area. Predominantly working with older people, RCHT has introduced an innovative virtual follow-up model, which aims to improve convenience for patients while also increasing clinic capacity.

National guidelines recommend that patients are followed up at 1, 7, 10 and 13 years after joint replacement surgery. At these points, a surgeon would check X-ray films and assess reported pain and function. Most patients have no problems, but for a minority these follow-up assessments are important opportunities to identify issues that require attention.

Saving travel costs and time

Traditionally, patients come to the hospital for all their follow-up appointments and for some people this can be a considerable inconvenience and expense, especially if it is just to tell a surgeon that they are doing well. Under the new ‘virtual clinic’ follow-up pathway, patients can opt to have X-rays done at a community clinic local to them, and complete hip and knee scores at home on a web-based system called ‘My Clinical Outcomes’. The X-ray films and scores are then assessed by a surgeon in a virtual clinic, and they can then report back to the patient and their GP.

Dan Williams, consultant orthopaedic surgeon at RCHT, tells us, ‘Patients who live down in Penzance or way up in Padstow – they might have a three-hour round trip to travel to hospital. The virtual clinic system saves them that time, as well as saving travel costs and car parking costs.’

For the trust, having patients in the virtual clinic system saves time for consultants – five virtual clinic appointments take the time of two face-to-face appointments – freeing up time to see more patients. Dan says, ‘We want to better target our limited face-to-face clinic capacity to those patients who need it most’.

Encouraging use of the virtual clinic by patients and clinicians

The virtual clinic system is a positive step forward for many patients. As with any system change of this kind, there’s work to be done in encouraging clinicians to embrace it and in communicating the advantages to patients. Dan says the key to encouraging patients to opt for the virtual clinic pathway is to give them information about it early and often.

‘Registering with the My Clinical Outcomes website is in the local guidelines for referral to hip and knee joint replacement, so the GP should be mentioning it as part of the initial appointment. It’s mentioned in their appointment letter, and we give them a leaflet and talk to them about it when we see them in clinic. We then see them at operation and check that they’re in the system. Then we see them at six weeks after their operation and it’s at that point that they get a choice – do you want to be followed up in a virtual clinic?’

Embedding the system in the department’s processes has helped to keep momentum going. A short-term dedicated project manager worked on consultant buy-in, getting the virtual pathway on to outcome forms and improving the language in patient letters and leaflets.

Dan says, ‘It’s seen as established now, but it’s still under-utilised. I hope that improves in time, but it is the major challenge – getting people to buy in to changes. It’s difficult, keeping the momentum going, when every day other things take away people’s attention. If we’re on black alert, with not enough bed capacity to cope with the number of patients coming in, it’s easy to think we’re just too busy to improve.’

Dan is passionate about collecting patient outcomes and sees patients who enjoy being able to monitor themselves using the web-based system. He can see the potential for similar systems to be used in other areas, for example in follow-up after gastric-band surgery. ‘Patients are brought back every week to be weighed and that costs the commissioning group £72 a visit but what if patients could enter their own weight in a web-based system and fill out a symptom score?’

What is clear is that as doctors and patients become more confident using digital technology, more opportunities will arise to deliver services in ways that are both more convenient for patients and more cost-effective for the NHS.

This project was supported by our Shine 2014 programme. Read more about the project on our website, or watch a short video developed by the Royal Cornwall Hospital Trust explaining virtual clinics.