Scaling Up Online Appointments: the local and national experience
Findings & Practical lessons
Dr Shanti Vijayaraghavan, Consultant Physician – Diabetes & Endocrinology, Barts Health NHS Trust
The TeamBarts Health NHS TrustShanti Vijayaraghavan Alice MorriseyJoanne MorrisSatya BhattacharyaPhilippa HansonCharles GutteridgeDesiree Campbell-RichardsRita Sudra
University of OxfordJoe WhertonSara ShawTrisha Greenhalgh Chrysanthi Papoutsi
NHS England Harpreet Sood
Digital health consultant Bob Gann
MicrosoftPaul Thomas
Tower Hamlets CCG Isabel Hodgkinson,Sam Everington
WELC CCGs Luke Readman
Anthropologist Anna Collard
1. Background – Newham, why we introduced webcam appointments
2. The research studies – key findings3. Scaling up nationally - our experience so far4. Practical steps to consider for a department /
organisation setting up webcam appointments
Overview
Borough of Newham (GLA data)
Setting: Newham, east London
• Approx. 332,600 (2015)• Approx. 70% from BME groups (South Asian
ethnic groups being 33%)• 6th most deprived borough in England• Approx. 40% aged 25 and under (compared to
30% for London)• Alarming rise in diabetes in the young, mainly
associated with obesity• Diabetes prevalence 10.4%, 2015 (compared to
7.6% for UK), NDIS 2010 prevalence model.
Challenges in Newham
Newham Diabetes Service exemplifies challenges within the NHS –
• Rising demand on services: estimated rise in prevalence to 13.5% by 2030
• Pressure to cut costs / improve efficiency• Inflexible and inaccessible services • High non-attendance rates (previously 50% in
young adult clinic)• Poorer health outcomes e.g. repeat A&E
admissions• Finding the balance between life & disease management• Feeling unprepared for the level of responsibility (isolation, stigmatisation)• Accessing support
Solutions? Already tried…
• Integrated Community Diabetes Service since 2000; Cluster-based Community Diabetes Model
• Multi-disciplinary clinics; near-patient testing• Telephone clinics, use of email• Evening Nurse-led Clinics & walk-in service• Text reminders• Widespread use of Bilingual Health Advocates
DAWN
• Diabetes Appointments via Webcam in Newham, Health Foundation (SHINE) 2011-2012
• Focus: examining the scope and feasibility of web-based diabetes care
DREAMS
• Diabetes Review, Engagement & Management via Skype, Health Foundation 2013-2015
• Focus: changing the nature of a follow up appointment in diabetes
VOCAL
• Virtual Online Consultations-Advantages and Limitations, NIHR 2015-2017• Focus: examining micro (consultation), meso (organisational), and macro
(policy) levels
Developing online consultations
• Scaling up virtual consultations across the NHS – implementing, evaluating and sustaining improvements (2017 – 2020). Health Foundation.
• Focus: Virtual Consultation Unit at Barts Health, Roll out locally and nationally, engage with national level decision makersScaling
Up
NHS Choices pilot
Access to the internet broadband at homeNewham 2010
Above figures obtained from London Borough of Newham. National Average (ONS 2009) - 63% have internet broadband
Digital exclusion figures 2017UK wide (Ofcom Connected Nations report) -http://heatmap.thetechpartnership.com
Age Broadband usage
16-24 86%
25-34 83%
35-44 73%
45-54 66%
55-64 63%
65+ 21%
Average 70%
DAWN & DREAMS –key findings
DAWN and DREAMS Findings Recruitment• Approx. 20 % patients ‘Clinically unsuitable’ (need physical examination, complex
comorbidity, lack of relationship) • 62% uptake from those considered suitable• Ages of those who agreed to participate:
Main reasons for NOT participating were: no access to the internet at home (52%), ‘prefer face to face contact’ (18.5%), not confident with the internet / computer (9%)
• Over 3 and half years, 104 Skype users
Patient ages % agreed
Under 50 82%
50 -59 64%
60-69 29%
70-79 11%
Total 62%
‘Do Not Attend’ (DNA) rates
Plus, extra 152 ‘patient initiated’ appointments (by the nurse). DNA rate zero!
NB: Clinical case mix different face to face
Increased productivity of 22% (average extra 2 patients) in consultant clinics and 28% in nurse clinics.
Appointment type Number appointments
Average DNA rate
Face to face and webcam
1644 28%
Webcam 480 13%
Duration of appointmentsAppointment type Mean duration
Face to face with consultant / nurse 25 - 30 mins
Webcam with consultant / nurse 9 mins
Patient perspectiveDAWN and DREAMS: 43 patient interviews, 4 patient focus groups, 28 completed on-line questionnaires
1. Convenience; saves time‘better waiting experience’. ‘fitting appointments’ around every day lives
2. More likely to keep webcam appointments “Skype would have been really good when I was at Uni. I hardly came to appointments because I just wanted to forget I had diabetes. Diabetes is a loooooooong journey! I use it a lot now as I can’t always get time off to come to my appointments and I need my job.”
3. Quality of care same as face to face“If you are not well and you are Skyping they can see you are not well”
4. Prior relationship with the clinician Quality of the conversation via webcam attributed to quality of existing relationship with clinician
5. Feel more in control / ownership Of the discussion ‘Patient-initiated ‘consultations - “There’s a big safety net because if I’ve got a problem I can just look online and see the nurse is online and quickly call”.
6. Need a balance of face to face & webcam • Examination Hands on assistance e.g. insulin pump Sharing of numerical or visual information easier
7. Saves patients money
8. Carbon footprint
VOCAL –Virtual Online Consultations: Advantages and Limitations;
NIHR-RFPB Programme
Study DesignTwo year action research studyTwo clinical settings: Diabetes and HPB Cancer Surgery
MICRO: Interactional dynamics via Skype- examining the nature of the clinician-patient interaction
MESO: Administrative and clinical processes that will need to change to embed online consultations-ICT, governance, service re-design
MACRO: National policymakers and other key stakeholder perspectives
Output
For further information:www.vocalproject.co.uk• Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels:
Mixed-Method Study.https://www.ncbi.nlm.nih.gov/pubmed/29625956 2018
‘Scaling up’ Scaling Up virtual consultations across the
NHS – implementing, evaluating and sustaining improvements (2017 – 2020).
Health Foundation Funded.
The plan: technology enabled service re-design
Work package 1Create Virtual Consultation Unit Cross-departmental
support team to facilitate spread
Online forum and resource directory (SLACK group)
Demonstration clinics Shared learning
(knowledge exchange workshops)
Work package 2Phased roll-out of virtual consultations Locally: Transforming
Services Together (TST) Outpatient programme
Nationally: 60 expressions of interest; work commenced with Oxford/ Norwich/Northumbria
Work package 3Engage with national level decision makersAlign national policy, tariff, and governance, with:
Local partners, and virtual consultation working groups
Policymakers (e.g. NHS England, NHS Digital)
Industry (e.g. Microsoft)
Professions (e.g. GMC)
Ensure sustainability
Dissemination
Locally:
Progress so far
• 10 services now started or in the process of offering virtual consultations within the Trust
• Virtual Consultation HUB: Information Governance + ICT+ Business Informatics + Project Management
• PPI group• Virtual Consultations incorporated into Trust strategy
For further information: [email protected]
Nationally
Progress so far:
• NHS England re: national tariff for online consultations• HEE re: developing training modules for doctors in training and
newly appointed consultants• Working with other software providers – Microsoft Teams 365
and NHS Attend Anywhere trials• NHS Improvement - improving outpatient processes• RCP – estimating carbon footprint
Working with Surgical teamsTom Cosker, Consultant Orthopaedic Surgeon, Oxford University Hospital Foundation Trust – Skype for Business
“”The Oxford Sarcoma Service cares for patients across a very substantial geographical area, ranging from Cornwall in the South West to South Hampshire in the South, up to Northamptonshire in the North and across to West London.Many of our patients have to travel a very substantial distance and often only have a very short consultation time with us in the clinic due to the pressures on clinic capacity. We were therefore extremely interested in pursuing Skype Consultations as a way of following up some of our routine patients.Last week I had an online appointment with a patient who lives in Bristol and who has had an extensive tumour resected from the side of her ankle. The patient had successfully had the tumour excised and I was able to follow her up in detail via Skype. The consultation was very effective and she felt able to get all of the important points across. It transpires that she required a repeat scan, which I was able to request locally in Oxford. This would have saved her a two hour journey each way, to and from the hospital and also saved her parking and care for her husband, who is also unwell.We hope to have more online consultations and embed this as a routine part of our clinic. The experience so far has been successful and although we experienced some initial logistical hurdles, we now feel that much of the processes and procedures are now underway, so that we will be able to undertake this effectively.”
Working with Surgical teams
“In the Hepatobiliary and Pancreatic Cancer clinic (a tertiary referral service), virtual consultations were popular and generally unproblematic for follow-up after cancer surgery (a time when it was neither convenient nor clinically recommended for patients to make a long journey to the clinic). Clinicians reported that the dynamic of consultations was more relaxed (e.g. being introduced to family members and pets), and some patients said they preferred to receive bad news (e.g. signs of recurrence) in the comfort of their home without the ordeal of a long journey home afterwards. The proportion of all cancer follow-up consultations undertaken via video link rose from 7% to 20% during the course of the study”
Satya Bhattacharya, Consultant HPB Surgeon, Royal London Hospital –Consumer Skype. To trial Attend Anywhere
Working with Surgical teams
Trial within the Brain Injury and Neuro-Oncology Clinic - commencing May 2019
Would like the option to review scans along with the patient – Microsoft Teams 365?
Edward Mckintosh, Consultant Neurosurgeon, Royal London Hospital – to trial Microsoft Teams 365
Learning from a culmination of research and practice at Barts Health highlights practical steps to consider:
1. Why & How?Business case justification
2. Trust wide support: Approvals and buy-in
3. Setup (technical & practical)
4. Implementation (recruitment and consent)
5. Evaluate and feedback
Summary1. Patients report it saved them time and money and are more likely to attend2. There are a variety of clinical environments which this could be used, mainly forfollow up appointments.3. Need to create time to innovate, start small, test and iterate4. Efficiency savings:
• Quick wins: shorter focused consultations (increased capacity)• Longer term savings from reduction in DNAs and potential associated benefits
from greater patient engagement • Greatest savings if you can release clinic space
5. Implementation into clinical management systems and routines is complex– engaging support departments and local team, technical and practical issues, recruitment and consent, evaluation
Thank you
www.bartshealth.nhs.uk/virtual-consultationsTwitter: #videoconsultsNHS
Please get in touch for a link to our SLACK group(videoappoints-BH-nhs.slack.com)
