Outpatient Appointments: Stuck in a rut?

“The way we deliver care remains locked into the service model largely created when the NHS was founded in 1948.”

This statement, which appears in Chapter 5 of the NHS Long Term PlanLink opens in a new window, might raise a few eyebrows, but although the NHS has embraced some great technological advances, in other ways my experiences as a patient could be considered broadly similar to the experiences of the first patients that walked the corridors of the first NHS hospitals. Take attending outpatient appointments, for example. Whilst I now receive appointment letters that have been produced through a centralised booking system, I am reminded to attend through text message, and though my hospital notes are now digital, I, just like the first NHS patients, visit the hospital, see a nurse who confirms my name, date of birth and the first line of my address, have my weight checked, and then wait patiently in the corridors waiting for those words: “The doctor will see you now.”

The vision, as set out in the NHS Long Term Plan, is that patients should expect a ‘digital-first’ option. This would enable ‘richer, faceto-face consultations with clinicians where patients want or need it.’ Providing video consultations is one way of offering a ‘digital first’ option. Instead of visiting the hospital to see the consultant, you could have the consultation from your home/workplace. It’s still a face-to-face interaction, although you wouldn’t need to attend in person.

Through the COVID-19 pandemic many of us have experienced connecting with others through videoconferencing software: it might be connecting grandparents and grandchildren through FaceTime; chatting with friends through HouseParty; or meeting with colleagues through Zoom or Microsoft Teams (with many other video conferencing tools available). Whilst we all may have experienced teething problems ‘learning to drive’ the new technologies, most of us have now learnt to embrace this new way of communicating. Unlike telephone calls, it’s so nice to see the other person and their reactions. I’m definitely a convert.

Video consultations in the NHS: a patient perspective

Although video consultations are currently on offer to some patients, this practice isn’t widespread: it’s something I have never personally been offered. I’m no expert in video consultations and there is already a large body of literature on the ‘barriers and facilitators’ to digital technologies in healthcare. However, if I draw on my personal experiences as a serial outpatient-appointment attender there are some definite positives to video consultations and some things that I think merit further consideration. I’ve listed these below:

Pros

• I will save money – I won’t be spending money on traveling to hospital, or any parking charges.
• I will save time – I won’t need to travel to hospital, which includes factoring in time to find a parking space and booking into the appointment.
• It will be more convenient – I could have the consultation from the comfort of my own home; I might even make myself a cup of tea!
• It may be less disruptive – Having several autoimmune conditions is disruptive enough. Video consultations would allow me to have the meeting at work, making it is less disruptive to my daily life.

Considerations

• Will I have the right equipment? – What technology do I need (i.e. will my ancient phone/laptop support the technology?) // Will my internet connection be good enough to support the software?
• Training – I am no IT expert, so can I get the technology to work and get support if things go wrong?
• ‘Laying on of hands’ – Whilst this might work well for conversations about my health, what if the doctor wants to examine me? How is that going to work?
• Trust – I would be fairly comfortable with a consultant or nurse that I know well, but what if I’ve never met the person before? How important is a physical interaction in establishing a good relationship?
• Monitoring – I usually get my bloods done at my appointments, along with other routine monitoring (blood pressure/weight). How will that be managed?

Video consultations in the NHS: needs of the services

Whilst there are plenty of things that I would need to consider as a patient before agreeing to have a video consultation, I can only imagine the hurdles that need to be overcome before services can offer this ‘digital first’ option. In addition to the challenge of winning over hearts and minds to embrace this newfangled way of working, there are many practical and technical factors. I’ve listed a few below, but I’m sure you can think of others:

• Deciding which videoconferencing platform to go for.
• Providing support to patients to use the new software.
• Providing training to staff to use the software.
• Ensuring patient confidentiality.

COVID-19: needs must!

All this consideration takes time: fools rush in where angels fear to tread. Where patients are concerned, and their health and wellbeing is at stake, getting things wrong isn’t an option. Services need to ensure that the quality of the patient-clinician interaction is the same as attending a physical appointment. It’s also important to get things right first time: if the first attempt at video consulting doesn’t work, will patients and clinicians have the patience and determination to persevere?

During the COVID-19 pandemic hospitals have not had the luxury of time to develop different ways of working. Staff have had to adapt quickly and find alternative ways of ‘seeing’ patients without them attending in person. Service providers have had to use ‘digital first’ options out of necessity (and necessity, as they say, is the mother of invention). Whilst some barriers may have taken weeks, months, even years to overcome in ‘normal times’, now teams in hospitals have come together and solutions have been found. In the case of video consultations, these are being offered to some patients, enabling them to receive the ongoing care they need to help them manage conditions.

No going back?

What we will all want to know is whether these changes will last? COVID-19 has forced many of us to make significant changes in our lives, and I’ve read many articles in the media saying that it’s unlikely that things will return to the way they were before. Surely, this is true for health and social care. Patients and clinicians are embracing new ways of interacting in these strange COVID-19 times, but are these forever-changes?

I’m in no doubt that having to make changes quickly without careful preparation will mean that clinicians and patients have experienced teething problems adapting to these new ways of working. I’m sure everyone would agree that the change could be better supported in other circumstances. But surely now that we’ve seen that barriers can be overcome very quickly, perhaps it leaves a door wide open to really explore the range of ‘digital first’ options and the technological possibilities available to us.

What’s important now is evaluating our experiences. Both during and after the COVID-19 pandemic we need to look at what has worked well, what hasn’t worked well, and what aspects require further work to ensure that the NHS can deliver on its promises in the NHS Long Term Plan to offer a ‘digital first’ service for patients. And with the groundswell of support for the NHS that is evident during Thursday evenings, where communities unite in applauding NHS staff, we should capitalise on this support and work with patients to co-design health and care services.

As a Centre with a focus on service design and delivery, ARC WM is well-placed to evaluate digital technologies. Indeed, video consultations is just one area that researchers in our Research Methods and Rapid Response theme are focusing on. We hope this research will feed into the design of services, which will help the NHS design and deliver health services of the future.

Magdalena Skrybant, PPIE Lead