Virtual Consultations

Barnet Hospital, Royal Free Trust- Transformation of high risk ante-natal anaesthetic clinics from face to face to virtual clinics in a busy DGH

What was the problem/issue?

High risk obstetric patients requiring anaesthetic pre assessment during pandemic, with the need to offer an alternative from face to face appointments.

How did you know there was a problem?

• Speed of pandemic and need to limit patients coming into hospital unnecessarily to reduce patient risk
• Some patients who would benefit from pre assessment were not recieiving it until in active labour

The number of patients affected?
8-10% on background of 5.5-6,000 deliveries.
With approx. 70% women receiving anaesthetic care during their delivery. So a small proportion of women are referred.

What solutions were identified?

1. Utilising digital technology (telephone calls and video calls) during pandemic to ensure good, effective and seamless anaesthetic peri-operative assessment of obstetric patients
2. Collaborative working amongst health care professionals and patients using different technology applications. Ensuring feedback was gained throughout in order to make positive tweaks and changes to the virtual clinics for a successful outcome
3. We have implemented an e-learning which covers how staff should use the platform to connect with patients. As this is new territory for a lot of staff there isn’t training in place for staff on how to get the best out of a video appointment in respect to consultation technique. We have worked closely with the undergrpointments.
4. Every medical school in the country is now teaching about remote consulting.  It’s also important to bear in mind that we are still in an 'emergency operating mode' of teaching, having had two national lockdowns and both national and local restrictions that have caused huge and rapid changes in the way that medical school teaching is delivered - to enable students to continue to learn under these circumstances - at the same time as considerable upheaval in health service delivery.  
5. Telemedicine is not new, particularly for some countries, and medical schools across the UK have been collaborating to share ideas and learn from each other over the past eight to nine months.  
6. New subjects and domains of professional behaviour are added to the curriculum all the time and incorporated into assessments - this isn’t an unusual situation in that regard; evaluation and reflection are part of the course,aduate programme leads to ensure there is a clear process in place for students to join in on video ap

Why were these solutions chosen?

• Digital technology widely utilised amongst anaesthetists and obstetric patient cohort (patient cohort tends to be young, have smart phones and are technology savvy)
• National recommendations to perform virtual clinics and avoid unecessary patient footfall within hospitals
• Several digital platforms to use that were NHS ‘safe.’
• Prior to pandemic, NHS plan to use technology to develop stronger relationships between care givers and service users, and to develop better-integrated, team-based services and to deliver holistic, whole-person rather than narrowly bio-medical care
• Individual services are responsible for the quality of their consultations/training in the same way they would be for a face to face clinic. There shouldn’t be a distinction between the 2 because they are just as important. In the event that a video or telephone consultation is insufficient staff always have the open to use face to face clinics to complete the consultation.

What were the barriers?

• Change behaviour always takes time to create a uniform and seamless process
• Digitial technology and data warehousing in the NHS (success of digital innovation often depends on what might appear to be small details such as how long it takes for health care staff or patients to log on or how hard it is to rectify a small inputting error.)
• Non face-to-face clinics can help reduce unnecessary visits to hospitals, but are still a relatively new model of care. Guidance in the current climate is changing at a rapid pace
• Small percentage of patient cohort will find using the technology difficult
• Work space: finding appropriate rooms to undertake videocalls that met appropriate social distancing requirements
• Key challenges are around equipment and internet connection largely on the Trust side as well as having a place for patients to contact much like you would have in a physical clinic.  IT are working extremely hard to upgrade the infrastructure to deal with the rapid shift to remote working.  We have implemented a virtual receptionist which greets patients and checks them in . They are also a point of contact should the patient have issues joining.

What were the enablers?

• Enthusiastic and committed staff
• Digital savvy users (Clinicians and patients)
• Able to use translator service during virtual clinic
• Less admin required compared to face to face clinics
• Overall NHS trend to move from face to face clinics to virtual clinics
• Less resources required- fewer rooms required, digital applications can be downloaded on personal mobile phones, clinic can be carried out whilst working from home
• National mandate on virtual clinics to be offered

Which disciplines were involved?     
 Anaesthetics, admin anaesthetic staff, midwives, obstetricians, managers, patients

What evidence (qualitative or quantitative) is there to demonstrate impact (either positive or negative) on:

• morbidity/mortality
• patient record outcomes
• patient experience
• process measures (e.g. reduction in referral times, hospital bed days, readmissions, cancellations etc.

Positives
Positive staff feedback and informal patient feedback
Reduced wait times by patients
Flexibility within system to allow last minute additional appointments to be booked
Less inconvenience for patients when attending virtual appointment (no need for travel, childcare, time of work)
Records are electronic- minimises risk of some records being on paper and some being recorded electronically.

Negatives
Patient DNAs still remain
Unable to physically examine patient

e-learning for health care has developed several resources for healthcare staff to aid learning in virtual consultation. 

• Remote consultation masterclass 
• Video consultation information for NHS Trusts and foundation trusts available here
• Video consultation information for GP's

The Royal College of Surgeons England has released guidance on virtual consultation.

The guide provides practical advice for surgeons and managers for delivering virtual consultations with surgical patients.

Find out more here.

The King's Fund has developed a set of short resources on consultation and working in a more remote way.

• Leading teams virtually
• An Introduction to teaming