Connect Health “Change” brings you the latest in a series of webinars to make and embed transformation in healthcare. Aimed at system leaders and clinicians across the NHS, the webinars provide practical solutions to the challenging issues we are all grappling with.
The pandemic resulted in a rapid expansion of virtual consultations in primary, secondary and community care services. Although virtual and telephone consultations have been available for a long time, they were not widely adopted. Now we need to better understand how to promote virtual consultations without worsening existing health inequalities, indeed looking at how virtual consultations may in fact help to address health inequalities across the population.
Delegate feedback included:
- Interesting to hear about group remote consultation for shoulder pain – will look at utilising methods like this in our service
- Bhavna Patel raised some really important issues that health inequalities are complex and virtual grouping activity for simple MSK might work and help to triage out the more complex patients who should be flagged on their records for better 1-1 input.
- It provided a framework around patient burden to consider consultations and self management
- Range of speakers and experience in different aspects
- Excellent presentations, information sharing, discussion and excellent chairing/ moderating by Andrew for Q&A
Watch the Webinar in Full
Chaired by:
Andrew Cuff, Consultant Physiotherapist & Head of MSK, Connect Health, Honorary Associate Professor, Musculoskeletal Care
Q&A
Anthony Gilbert, Postdoctoral Research and Improvement Physiotherapist, Royal National Orthopaedic Hospital NHS Trust
Question 1: You say it’s about having the right tools in place but what about the different skills required to use those tools?
Answer: There are definitely some skills that are needed on both parts. Simple things like the interactions that you might have, I’ve conducted over 100 interviews as part of my PHD and what’s come up quite a lot is the notion of trusting what’s going on over a screen. It’s a very different interaction over screen so even simple things like when you’re talking, I’ve got two screens up here so my notes are on one screen and then I’m looking at the patient over on the other. If I’m having that conversation it feels to me like we’re talking but a patient can only see my ear or my jawline [because I’m looking at you rather than the camera.] There’s always ways that we can interact that would help patients to get on board and engage.
We need to accept that when we’re asking patients to do things, I feel that we’re delegating more work on them so the whole thing about getting them to assess themselves, they might not understand what it is they need to do We probably need to give them a little bit more upfront knowledge about what they will need to do during their consultation. Taking a step back and thinking what is the best thing for this patient in this particular time and having more of a two-way conversation about that rather than having set pathways. If we start thinking about skills and looking at auditing skills that patients have and what patients may need, developing resources and sharing these resources across physiotherapy or will be really helpful too.
Question 2: Where do you see Virtual Consultations in 10 years’ time?
Answer: A lot of stuff that has come through in the discussions has been that it needs to be an option rather than mandatory but I think to do that we need to understand where it’s best placed. There’s been some excellent research that was conducted and published about video consultations before COVID and this is something I’ve reflected on in my own research.
Technology really excites some people but it also turns people off and if you think about research and how that’s informed, participation and research is often voluntary and many of the people in the olden days may have been excited to try it because it wasn’t common practice. So things might have been a bit skewed and also some of the research that has been done doesn’t necessarily report a lot of the negative stuff. Although implementation science literature is really filling that gap and if we look at things now, phone and video consultations are mainstream but we need to not forget how scary COVID was. Lots of places shut their doors and they cancelled clinics, elected procedures were cancelled and virtual was the only option and that’s a very different context to where we are now and likewise pre-COVID was very different. Research is important but we do need high quality research to help us figure this out.
One of the main barriers to use is around expectations and people not believing it might be as effective as face-to-face consultations. People are worried about what happens if something bad happens, will patients sue us if we don’t get better, there are all sorts of issues and high quality trials are needed to answer the effectiveness question.
The Best MSK Health stuff is really important, it’s linked to GIRFT we need to work with data. I’d ask do you know anyone who’s experienced this, what data have you collected, what we’re doing with our data and how can we build a national infrastructure to use data to shape the future of video consultations. I think it could be really good having video consultations and I think it has a potential to transform the lives of MSK patients in 10 years time but we’ve got a lot of work to do to collectively maximise its potential and figure out where it’s best suited.
Question 3: Think all intervention should be quality and agree that if a video consult is very short unlikely to be of great benefit and hence reported to be reduced benefits. Great to hear group consultations can reduce cost as not sure 121 are much more cost effective for Physio departments (though are to patients)
Answer: There is a lot of stuff about the digital divide and how virtual exacerbates care inequalities… but there are also socioeconomic benefits to virtual care (less travel, less time off work etc) that actually make care more accessible if it is virtual for some people
Gail Sowden Consultant Physiotherapist, Head of Pain Services, Connect Health
Question 1: Is there any evidence that blended care works?
Answer: There’s a lot of literature on this and much of the literature that exists relates to mental health so particularly IAPT have published some papers on this and there is some evidence to support pre-post changes from blended care compared to usual care or weight loss controls. There’s also a paper where patients accessed online components before they came through to face-to-face care and 20 of the patients were recovered using the kind of IAPT definition of that before they had their first face-to-face contact. There were other papers that suggest face-to-face is preferable so there’s a bit of a mixed picture.
There are also a number of other studies being published so, thinking about my area of expertise which is particularly around persistent pain, there are a number of clinical trials published relating to clinicians, supported online care or packages which might fit the definition of blended care. There is a quite a lot of literature there and again some say equivalence compared to face-to-face care, some show superiority and some show inferiority.
I think it is important to keep that broader definition of benefit in mind, not just clinical outcomes, but ease, access, equity, cost and all of these things. One of the challenges of blended care is that if we are very much sticking to the idea of it being truly individualised and personalised, it’s challenging then to make sense of outcomes because we may have different people accessing care. What they’re accessing in terms of the total package may be different and so it becomes more and more challenging to try and figure out what works best for whom, but we certainly need to try and move in that direction.
Question 2: There is a genuine concern about confidentiality and security – how do you overcome these worries?
Answer: Thinking about things like Microsoft Teams or Zoom based group online programs, wherever possible we would try to assess somebody to try and make sure that people are coming through to something that was appropriate for them and that any risk issues or concerns had been dealt with or could be managed in that environment. We tend to have two members of staff involved on those sessions and the second member of staff or both members of staff would have access to all the patients phone numbers and would know the GP phone numbers. Much in the same ways you might do in a face-to-face encounter, if issues arise that cause concern, the second person can ring the patient and try and check in with them and make sure that they’re okay and follow the safeguarding process if there’s concern raised and action is needed to be taken.
Question 3: Will there be an option for old people? Those in their eighties or nineties living alone? I do agree with your concerns. Some practitioners are finding it difficult to assess people of colour in person, so how sure will they be when it’s done virtually?
Answer: We have an Urdu Pain Management Programme (culturally adapted) in Connect Health and are keen to develop more translated and culturally adapted offers
John Paul Gowland, Upper Limb Clinical Specialist, Tyneside Integrated Musculoskeletal Service (TIMS) and Academic Tutor, Sunderland University
Question 1: What are the future plans for Virtual Group Consultations in your service?
Answer: We’ve structured the sessions to have that question because we’re very much looking at a blended approach. Virtual group consultations aren’t suitable for everyone, people can’t access the service, some people can’t use laptops, some people prefer face-to-face, so we’re looking at running the sessions face to face once COVID restrictions allow and we’re looking at utilising it for other pathologies and other patient groups. One idea we have at the moment is a session for people with risk fractures who come out of cast that just need that quick kind of support and advice, that could help with seasonal kind of variations in referrals but it’s not just the upper limb, we’re working across lower limb, spinal and complex pain as well. My colleagues are very busy behind the scenes and I’m looking at scaling up this these sessions.
Question 2: If patients have never had a video call how can they make an informed preference?
Answer: The attendance rate is probably falsely low because patients were called the day before the session to have data collection outcomes taken etc. I also think we were dealing with patients in lockdown which was a very unique situation, this was the only option we had some patients who had been sitting on shoulder conditions for months and months. The did not attend rates maybe slightly falsely low but it’s a good question about preference.
Our patients have been sent an information video explaining what the sessions are, telling them what’s going to happen, making sure they realise they’ll be with other patients but we’ll also tell them the benefits of those sessions. Then we give patients the choice so if they join in and you use your verbal communication skills, you can just sense if someone’s not enjoying it and you can say look you’ve tried it, would you like to have an alternative and come in to see us. I think it’s about trying new things.
Bhavna Patel, Life Coach, Health and Wellbeing therapist
Question 1: What advice would you give others who are just embarking on the virtual world for their care?
Answer: The communication virtually is great because you can still see the body language, you can understand where their eye movement is going, how they’re talking, their body language in general, you can also see their skin tone. A paramedic, when he came to my house, asked my son ‘how do you know when your mom’s not well? How do you know she’s going to have an episode?’ At this point I was shaking and clammy and sweaty and I thought I was having a massive heart attack, I wasn’t. I was having a massive thyroid storm and my son was quite young at the time and he said ‘mommy always said my skin tone might change so if I go a bit peaky looking, we can still tell’ and I think these are the signs that carers need to see because if we don’t notice it in face-to-face, have we thought about it on a virtual consultation?
Also, with a lady that I took recently for dressing her leg diabetic wounds, she understood what they were telling her and she was speaking broken English but I understood her and I went there to ensure that communication was concise and still the district nurse didn’t understand what was being said, even after I translated it. I think if that was a face-to-face consultation, how would it be if it was virtual? On a virtual consultation, how would we address that, especially with the language barrier?
Question 2: Do you feel confident that health is listening to the concerns you’ve articulated?
Answer: From clinical care, clinical research implementation, making sure that we don’t have a one-size-fits-all approach to digital labels. There are areas that I have found exclude people. Have we thought about conditions that intertwine? I would say it has been looked at but I think there’s still more work to be done, certainly. From when I was in clinical trial and coming to today’s session I do question, have some areas just been looked at in depth or have they just been skimmed over.
We need to make sure we’re doing our bit for future generations.
Devon Elliott, Senior Programme Manager, BestMSK Health Programme, NHS England and NHS Improvement and Melanie Martin, Senior Delivery Manager at NHSX
Question 1: Video consultations is not for everyone. Some people don’t have the technology, the connectivity or the confidence. What is being done for those people?
Answer: That paper has shown a very important spotlight on what existed before the pandemic and which may have, in some communities, been widened and that’s a great concern to us all. What we’re all trying to do by coming together is to understand what equity means, what does equal access mean in a way that it meets the needs of individuals. What we’re looking at doing together is looking at offering equity. Let’s make no assumptions that perhaps our older patients and patients from other communities may not want to use it. We do need to look at equity of access and that’s in terms of having access to the hardware, the connectivity, as well as having the opportunity with the skills that you need to use the technology as well.
We recognise the side of the clinicians and of the patients that may be invited to use virtual consultations and I refer back to what I consider Anthony’s model answer on this around preference is we need to ensure there is choice built into service redesign.
It’s not digital by default, it’s digital through choice and we’ve heard, through many of the events that I’ve hosted or attended, is that patients and citizens want choice to keep channels open for those that can’t or don’t want to use technology. It’s really important that we look at both the access but also opportunity with the technology and also motivation.
Does someone need some encouragement and better education to use the technology? And there is a real strong shift of power from the doctor knows best to the patient knows best model and I’m absolutely behind this but I think it’s really important to go back to Gail’s point that care is to be digitally enabled, not digital first. My message here is around choice and ensuring that everyone has access to the education, the skills, the hardware in order to take up the offer of a virtual consultation when it’s made in the right context.
Question 2: What are we doing around national infrastructure and particularly data to support embedding video consultations or virtual consultations throughout the healthcare system?
Answer: If we’re doing the Best MSK Health programme well we can make a reasonable assumption that for other long-term conditions things are progressing. As a physiotherapist and an observer across this program, we haven’t collected data well over the years, we haven’t been able to take the data where our patients have gone. What we’re really now starting to do is to aggregate data, standardise what we all want to learn through data collection and put the shared responsibility between both the patient in the form of collecting patient reported outcome measures which I think is much more mainstream now and also experience measures and linking it to what adds that greatest value, linking it back into the high impact strategy recommendations and outcomes.
We need to have a data workstream that is looking at Best MSK Health and saying what do we want to collect, when do we want to collect it, who needs to provide that data, what will it tell us and what will we do with it so it has real meaning and it really has a traceable sort of value to the patient’s care. The problem we still all face is how do we get the data from point a to point b when the patient moves from primary into secondary care and across primary mental and physical health services. What we’re starting to see is there’s more patient held records, patients using technology where they take their data with them and it’s starting to be integrated into primary care held records but I think there’s still a long way to go in that interoperability piece but integration of care and data is very much front and centre now where I don’t think it was in the past. It’s underpinned by greater trust in the use of technology and also trust in what data needs to be shared that will help my care.
I can share an example of having co-designed and co-delivered a service across the Southeast London integrated care system myself with a team, with patients, designed for patients. They told us they trusted to share their data if they knew what we were going to do with it and if we showed it back to them and how it was impacting upon care. It’s not just about what data, it’s about when and how to collect it in a way that’s trustworthy for patients and then we’re still working on making sure the data travels where the patient needs to go, the Best MSK Health programme are definitely on to this.
Watch the webinar again, which includes further insight from the speakers including a full Q&A session, and read more about the speakers here:
Wednesday 13 October 2021
View our speakers’ biographies
;
