Diabetes Appointments Online:
the Newham Experience
Care from home –
Logo designed by
Karen O’Leary,
Service User
Our support consultant:
Funded by:
Introducing Newham
Borough of Newham
332,583 (2015)
Approx. 70% from BME groups (South
Asian ethnic groups being 33%)
6thmost 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 9.4%, 3-4 times
the national average in some parts
The Problem
Newham Diabetes service exemplifies challenges within NHS:
Rising demand on services: estimated rise 13.5% in 2030
Pressure to cut costs/ improve efficiency
Inflexible and inaccessible services
High non attendance rates: e.g. approx 50% in the Young Adult clinic
Poor patient self-management, related to poor engagement with
service and lack of flexibility of services (Local MORI survey ‘09)
Poor health outcomes e.g.
Repeat admissions via the emergency department, particularly for
young adults
Increased complications – cardiac, renal, foot disease
Poor pre-pregnancy care, late booking into antenatal services
The Local Diabetes Service
• 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
NHS Choices Pilot
Small proof of concept study Feb 2010 :
Diabetes Unit and NHS Choices used readily available standard
video-conferencing software for web-based consultations:
15 patients:
Established Type 1 and 2 diabetes
Age 18-25 years, both sexes
Range of ethnicity and self management skills
2 consultations per patient followed by online survey for all
patients, and telephone interviews of staff and patients
NHS Choices Pilot - findings
Patients Staff
Convenient: not having to take
time off work/school
Did not need others e.g.. parents to
take them for appointments
Liked being in the comfort of
home/privacy
Felt health professional was giving
them undivided attention and preferred
this to telephone consultations
Reduction in carbon footprint!
Potential to reduce DNAs
and useful in those with poor self
care
Good complement to face to
face but cannot fully replace it - ?
50: 50 split (could replace
telephone consults though)
Consultation tended to be
more focussed
? More useful with younger people
Role in housebound people
Internet Broadband Usage in Newham
2008-2009
Age Broadband usage
16-24 86%
25-34 83%
35-44 73%
45-54 66%
55-64 63%
64+ 21%
Above figures obtained from LBN
National Average (ONS 2009) - 63% have internet broadband
DAWN - Diabetes Appointments via
Webcam in Newham (2011) Aim:
Learn IF and HOW web-based consultations can provide more accessible and cost-
effective care in the diabetes department; using readily available, affordable
technology Scope:
Offer online consultations to all
patients, where clinically
appropriate and where examination
not required, under care of one
consultant and one nurse specialist
(from May 11), within the existing
clinic
Include all ages
Evaluate using quantitative and
qualitative methods
Webcam
DREAMS
Diabetes Review, Engagement And
Management via Skype
January 2014 – December 2015
Web-based Consultations in diabetes: A tool
for improving patient self- management?
• Use Online Consultations to establish contact with
patients labelled “ hard to reach”
• Change the outpatient consultation process – more
flexible, user-led, “ open access” consultations
• Explore the role of social media in improving user
engagement and self-management
• Evaluate the impact on health outcomes, quality of
like and efficiency of care
VOCAL – Virtual Online Consultations:
Advantages and Limitations
NIHR HS & DR grant, commenced March 2015
• Micro Level: examining the dynamics of the
clinician-patient relationship in greater detail
• Meso Level: What is the organisational impact
of increased online contact?
• Macro Level: How do online clinical contacts fit
in with the evolving NHS policy?
Action Research - outputs
For further information:
www.health.org.uk/programmes/shine-2011/projects/web-based-outpatient-consultations-
diabetes
www.vocalproject.co.uk
Outcome data
• DNA rates: 28% versus 13% for the same patients
pre and post-Skype
• Yearly increase in the retention rate 2011 (39%) to
2015 (100%).
• A &E: too small a sample, too many variables,
observational study and not a controlled
experiment
• Average Hba1c pre-Skype 70 mmol/mol; post-
Skype 65 mmol/mol
Feedback from Patient Focus Groups ACCESS
“Skype is ‘great for diabetes’. Previously it meant taking a day off university to come to
clinic.”
POSITIVE SHIFT IN CLINICIAN-PATIENT DYNAMICS
“I don’t think the consultant or the nurses actually realise, their whole attitude
changes when they are in the consultation clinic, they have got the papers in
front of them, they are fiddling with that, they are reading through it, but when
they are on Skype they just look straight at you and they talk at you”
OWNERSHIP
“Skype has helped to change my mind set in terms of management. There’s no excuse for missing appointments now”
LESS ANXIETY
“I feel better controlled since using Skype and less anxious”
General findings
• Many patients value the convenience of Skype
• Benefits included patient-initiated contact, which increased
patient confidence
• Patients were satisfied with the clinical encounter
• Some patients found that the clinicians appeared more
engaged than they were in the face to face encounters
• Most patients want a mix of face-to-face and online rather
than online only
• Some patients will resist online consultations
• Some patients will resist clinical support in any form
Conclusions
1. Patients much preferred webcam appointments & say they are more likely to attend;
generalisable across ages and ethnicity
2. You need time to demonstrate hard quantifiable benefits:
To gather sufficient data to draw conclusions
Transition time as patients move to new system; before they start to rely on it and
use it to it’s full potential
3. Choice of software provider is important - ease of use and reliability of system matters
4. A flexible approach will maximise the potential of webcam consultations e.g. video
phone and ad-hoc consultations may have the greatest impact
5. Efficiency savings:
Quick wins: shorter more focused consultations (increased capacity), savings for
patients
Early findings suggest DNAs and A&E attends will reduce with time, with
associated cost benefits
Greater efficiencies with increasing volume of web-consults, allowing web
appointments to be grouped together with release of clinic infrastructure costs
What next?
Health Foundation Scale Up Award
• National policy attention and interest from other hospitals
• Seek to support the spread of virtual consultation services by:
1. Creating a virtual consultation unit (VCU) to facilitate local
and national roll-out, and sustained improvements
2. Developing a national network, with new sites acting as
local hubs for further spread
3. Working with national-level decision makers to jointly
develop standardised policy (e.g. on tariff, quality
assurance, staff training)
4. Evaluating the work, continually reflecting on mechanisms
for change
The team
Trisha Greenhalgh
University of Oxford
Shanti Vijayaraghavan
Barts Health NHS Trust
Sara Shaw
University of Oxford
Joe Wherton
University of Oxford
Emma Byrne
Queen Mary University of London
Desiree Campbell-Richards
Research Nurse, Barts Health
Jo Morris
Barts Health NHS Trust
Satya Bhattacharya
Barts Health NHS Trust
Philippa Hanson
Barts Health NHS Trust
Isabel Hodgkinson
Tower Hamlets CCG
Charles Gutteridge
Barts Health NHS Trust
Rita Sudra
Diabetes Nurse, ELFT