Video and telephone consultations have, through the course of the pandemic, become a central of daily operations across the NHS. In this blog, Ben Gadd and Amanda Nash of University Hospitals Plymouth NHS Trust share their experiences about how they are being received and the potential lessons we can learn.
Necessity is indeed the mother of invention, but it is also something else: the acceleration of transformation. Transformation is a word we often overuse in healthcare, but the last 18 months have genuinely accelerated the transformation of outpatient services in a way that, hand on heart, none of us could say we ever envisaged pre-pandemic.
About six months before COVID-19 first came into our lives, we had already met with patient council members to talk about introducing more non face-to-face consultations and get their involvement. At this time, around 7% of new consultations and 13% of follow ups were by video or telephone. Fast forward to the height of lockdown, we were doing 70% and 78% respectively. So what have we learned, particularly what have we learned about user experience – both patients and clinical staff? We've had some surprising results.
In the early summer of 2020, we established an insight group and committed to use this to help shape the support and information given to patients; support and training for staff to use these methods; and the future development of our outpatient programme.
The insight group developed a patient survey (with input from a member of the patient council) based on research into experiences of distance consultations, and where possible, validated and tested questions. The survey explored the following domains:
- Format and usage data including type of consultation, who with, number of consultations, technological problems.
- Benefits and disadvantages of remote.
- Quality of consultation such as impact on information, communication, decision-making, practitioner understanding of and resolving of concerns.
- Experience and attitudes including confidence in use, perceived effectiveness, willingness to continue using beyond COVID-19, how technology mediates the consultation, and circumstances in which respondents would not want to use this method.
Most of our respondents (2,487) had video appointments, with about one-sixth of respondents (504) having telephone appointments or both.
What we found
Contrary to some current media coverage about remote appointments, patients said they had good experience and willingness to reuse is relatively high.
92.6% of the total 2,991 respondents rated their experience of telephone and/or video consultations as good or very good. 80.5% of respondents said they would be willing to continue using video/telephone appointments in the future.
But video is more popular
Patients' are more willing to use remote video consultations as a regular part of their healthcare. 83% of patients using video consultations and 66% of patients who had undergone a telephone appointment said that they were willing to reutilise.
Respondents reported a better experience overall with video. The results of the comparison of both ratings and comment analysis between the two groups suggest that patients view video consultations as more closely comparable to a face-to-face appointment and so a more feasible alternative. Telephone respondents indicated that some patients see telephone appointments as a stop-gap during COVID-19 rather than a viable substitute for in-person consultations.
People who have undergone telephone consultations rate every aspect of experience lower than those who fed back about video consultations. However, we should be cautious with a direct comparison between these two groups. There may be differences in the cohorts; for example, the age profile for the telephone cohort is older or collection method may impact, as video consultees completed their survey online immediately following their appointment whereas telephone patients returned a paper survey up to three months after their appointment. This is important because their global satisfaction level may be lower: telephone users rate communication during face to face appointments with their clinicians as lower than the video cohort.
It’s not quite as good as face to face
Both cohorts of respondents (telephone and video consultees) rated the quality of communication in non-face-to-face consultations as lower than in face-to-face consultations, although this difference is more significant for the telephone cohort: video consultees rated it 2.2% lower quality and telephone consultees 10.2% lower.
There are benefits
Patients highlighted these as including avoiding travel and car parking costs and other practical benefits such as preventing time off work or not having to arrange childcare. They also value not having to wait in outpatient clinics. The majority of respondents said there weren't any disadvantages to remote consulting (for both phone and video). Of those who did, they described the limitations of not being physically examined or assessed.
Barriers to use
Age does not appear to be a barrier to using technology for healthcare appointments (willingness to reutilise is similar for each age cohort, although drops slightly for children). Regression analysis shows that the key drivers for positive experience are that the practitioner had a good understanding of and could effectively address the patient's health concerns, involvement in decisions, and the perception that this is an efficient way of receiving healthcare. Barriers do exist, however. In an audit of people declining video consultations, more than half lacked the required equipment or internet access. A small number were also people with learning difficulties. We have explored this with our user group for people with learning disabilities and they have created guidance for clinicians, including advice on making reasonable adjustments, for example, allowing additional time.
These results are consistent with the National Voices Insight Report The Dr will Zoom you now: getting the most out of the virtual health and care experience. The national report found that, for many people, remote consultations can offer a convenient option. They appreciate quicker and more efficient access, not having to travel, less time is taken out of their day and an ability to fit the appointment in around their lives. Most people felt they received adequate care and more people said they would be happy with consultations being held remotely in future.
We mirrored our patient survey with a questionnaire for staff. 174 staff who had undertaken remote appointments; over half of these (97) were consultants. The breakdown of the role types of staff completing the survey are shown in Fig 2.
Staff were less enthusiastic about continuing to use this form of consulting, and as with patients, preferred using video. Overall, the ratings of clinical staff were consistently lower for all measures than those of patients. We might have expected the reverse to be true. While it is interesting to compare the responses of clinical staff with those of patients, the context within which the two are operating is very different. Patients were largely appreciative of the opportunity to talk to clinical staff during lockdown from the comfort of their own home or chosen other space. On the other hand, clinical staff had to change their working habits, adopt new practices and workflows, and manage clinical risk differently. The issue of the unreliability of video consultations added to the challenge.
There was wide variation in the opinions expressed by clinicians as to the suitability of remote consultations based on appointment type, conditions and patients. For example, while some clinical staff said they were ideal for initial meetings and history-taking, others viewed them as only suitable for follow-up and surveillance. This variation supports the concept that the use of non-face-to face consultations needs to be determined at a local level on a specialty by specialty basis. It cannot be dictated; it needs to be adopted.
Fig 2: Respondent role type
We recommended that when offering non face-to-face appointments, services should strive to offer a choice of video over telephone, because users and staff report a better experience of these appointments. However, remote consultations are not suitable for everyone or in every circumstance. Patients should be able to opt for an alternative, depending on their needs and circumstances. This is essential to ensure that existing health inequalities are not widened by moving towards remote appointments as default, without an alternative. This is particularly important for particular groups of excluded, disadvantaged, or marginalised patients.
We have established a digital inclusion group across Plymouth health and social care to ensure we support those currently digitally excluded in digital healthcare options. This work includes linking with a network of providers and community organisations, including Digital Health Devon, primary care, and Complex Lives Plymouth. We continue to recruit volunteers to become digital health champions to support patients, and have developed guidance for clinicians who are offering remote consultations to more vulnerable patients. We are also looking at recycling hardware, working with local community groups.
Digital is here to stay, how we use it and get the best out of it is still open to much learning.