• Welcome!

• We’ll be starting in a few minutes.

• In the meantime, please:

✓ Put your mic on mute

✓ Turn on your video

✓ Open chat – and introduce yourself:

✓Where are you from?

✓What’s your role in implementing video consultations?

• If you need help with any technical issues, please email: Fiona.Conaty@health.org.uk

Video consultations: maximising the benefits

Please note: this webinar is being recorded

Video consultations:

Maximising the benefits

21 May 2020

About Q

• A connected community working together to improve health and care quality across the UK and Ireland.

• Supports people in their existing improvement work: making it easier to share ideas, enhance and learn skills and knowledge, and collaborate to make changes that benefit patients.

• Led by the Health Foundation and supported by partners across the UK and Ireland.

#VideoConsultations

Video consultations

What should we be doing now to give the best chance of delivering sustainable, high-quality care across all the settings that could benefit?

#VideoConsultations

What to expect

Fabulous speakers

Lively Q&A

Peer sharing

Introduce yourself in the chat box.

Where are you from? What’s your role in implementing video consultations?

#VideoConsultations

Speakers

Webinar supportChat box facilitators

Facilitators

Dr Shanti

VijayaraghavanProfessor Alka

Ahuja

Clare Morrison Penny Pereira Tim Horton Matthew Hill

Jo Scott Robyn LewesChar BowdenBryan Jones

#VideoConsultations

Process

• Keep your mic on mute

• Use the chat box if you like:

• Feed in questions

• Reflect on what you’re hearing

• Share stories, work and resources

• Tweet: #VideoConsultations @theQCommunity

#VideoConsultations

Poll

#VideoConsultations

Dr Shanti Vijayaraghavan

Consultant Physician, Barts Health NHS Trust

Scaling Up Online Appointments

#VideoConsultations

Borough of Newham (GLA data)

The Setting

• Approx. 332,600 (2015)

• Approx. 70% from BME groups (South Asian ethnic groups being 33%)

• 6th most 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 10.4%, 2015 (compared to 7.6% for UK), NDIS 2010

prevalence model.

#VideoConsultations

The Problem

Newham Diabetes service exemplifies challenges within the 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

#VideoConsultations

DAWN

• Diabetes Appointments via Webcam in Newham, Health Foundation (SHINE) 2011-2012

• Focus: examining the scope and feasibility of web-based diabetes care

DREAMS

• Diabetes Review, Engagement & Management via Skype, Health Foundation 2013-2015

• Focus: changing the nature of a follow up appointment in diabetes

VOCAL

• Virtual Online Consultations-Advantages and Limitations, NIHR 2015-2017

• Focus: examining micro (consultation), meso (organisational), and macro (policy) levels

What have we done so far

• Scaling up virtual consultations across the NHS – implementing, evaluating and sustaining improvements (2017 – 2020). Health Foundation.

• Focus: Virtual Consultation Unit at Barts Health, roll out locally and nationally, engage with national level decision makers

Scaling

Up Up

#VideoConsultations

DAWN and DREAMS Findings

Recruitment

• ‘Clinically unsuitable’ (need physical examination, complex comorbidity, lack of relationship) - approx. 20%

• 62% of those considered suitable agreed to participate

• Over 120 Skype users

• Ages of those who agreed to participate:

Main reasons for NOT participating were: no access to the internet at home (52%), ‘prefer face to face contact’ (18.5%), not

confident with the internet/computer (9%)

Patient ages % agreed

Under 50 82%

50 -59 64%

60-69 29%

70-79 11%

Total 62%

#VideoConsultations

‘Do Not Attend’ (DNA) rates

Plus, extra 152 ‘patient initiated’ appointments (by the nurse). DNA rate zero!

NB: Clinical case mix different face to face

Increased productivity of 22% (average extra 2 patients) in consultant clinics

and 28% in nurse clinics.

Appointment type Number appointments

Average DNA rate

Face to face and webcam

1644 28%

Webcam 480 13%

Duration of appointments

Appointment type Mean duration

Face to face with consultant / nurse 25 - 30 mins

Webcam with consultant / nurse 9 mins

#VideoConsultations

A&E and Hba1c levels before and after

Promising but inconclusive –not a controlled trial, too many variables.

Average Hba1c pre-Skype 70 mmol/mol; post Skype 65 mmol/mol

#VideoConsultations

What do patients think?

DAWN and DREAMS: 43 patient interviews, 4 patient focus groups, 28

completed on-line questionnaires

1. Convenience; saves time, ‘better waiting

experience’; saves money

Fitting appointments around every day lives

2. More likely to keep webcam appointments

“Skype would have been really good when I was at Uni. I

hardly came to appointments because I just wanted to

forget I had diabetes. Diabetes is a loooooooong journey!

I use it a lot now as I can’t always get time off to come to

my appointments and I need my job.”

3. Quality of care same as face to face

“If you are not well and you are Skyping they can see you

are not well”

4. Prior relationship with the clinician

Quality of the conversation via webcam attributed to quality of

existing relationship

5. Feel more in control / ownership

6. Need a balance of face to face & webcam

▪ Examination

▪ Hands on assistance e.g. insulin pump

▪ Sharing of numerical or visual information easier

▪ Interpersonal interaction face to face

#VideoConsultations

Implementing, evaluating and sustaining

improvements

SCALING UP VIRTUAL CONSULTATIONS

ACROSS THE NHS

#VideoConsultations

The plan: technology enabled service re-design

Work package 1Create Virtual Consultation Unit

▪ Cross-departmental support team to facilitate spread

▪ Online forum and resource directory

▪ Quarterly demonstration clinics

▪ Shared learning (knowledge exchange workshops)

Work package 2Phased roll-out of virtual consultations

▪ Locally: Transforming Services Together (TST) Outpatient programme

▪ Integrate with eLPR (real time record sharing) and Population Health Informatics programmes

▪ Nationally: 60 expressions of interest; 2 services identified

Work package 3Engage with national level decision makers

Align national policy, tariff, and governance, with:

▪ Local partners, and virtual consultation working groups

▪ Policymakers (e.g. NHS England, NHS Digital)

▪ Industry (e.g. Microsoft)

▪ Professions (e.g. GMC)

Ensure sustainability

Dissemination

#VideoConsultations

How are we doing?

1. Covid – national and local surge: 18 services set up within Barts Health; 13 waiting

2. Working with 3 main external partners and informally as part of a network of sites using online consultations

3. Widespread roll-out of Attend Anywhere, supported by NHSI

4. Resource material including patient and staff guidance, SOP, animation film for patients, publications,

Information Governance incl. for working from home

5. Evaluation

For further information

https://www.bartshealth.nhs.uk/videoconsults

Twitter: @NHSBartsHealth @AliceMorrisey #videoconsultsNHS

“Interaction in Video Consultations: a linguistic ethnographic study

of video-mediated consultations between patients and clinicians

in Diabetes, Cancer, and Heart Failure services”. Sara Shaw, Lucas Seuren, Joseph Wherton, Deborah Cameron, Christine A'Court, Shanti

Vijayaraghavan, Joanne Morris, Satyajit Bhattacharya, Greenhalgh Trisha. May 2020, JIMR.

#VideoConsultations

Summary: key points

• Patients like the convenience of webcam appointments, said it saved them money and they are more likely to attend;

generalisable across age & ethnicity

• A flexible approach will maximise the potential of webcam consultations e.g. patient initiated’ consultations, using video

phone

• You need time to demonstrate hard quantifiable benefits

• Efficiency savings:

• Quick wins: shorter focused consultations (increased capacity), patient savings

• Longer term savings from reduction in DNAs and potential associated benefits from greater patient engagement

• Greatest savings if you can release clinic infrastructure costs

• Complex challenges are faced

• Practical steps to consider:

Why

&

How?

Trust wide

support

(IG & ICT)

Setup

(technical &

practical)

Implement

(recruitment

& consent)

Evaluate

&

feedback

#VideoConsultations

Professor Alka Ahuja

National Clinical Lead for Technology Enabled Healthcare in Wales

@AlkaSashin

What’s Occurring in Wales?

#VideoConsultations

The National Video Consultation (VC) Service?

• Funded by Welsh Government• Accessible across health and social care• A Healthier Wales• Safe and secure way to see patients - ‘Attend Anywhere’• TEC Cymru hosted by ABUHB• “CWTCH” as an exemplar

#VideoConsultations

Video Consultation – Different settings

• Primary care • Secondary care• Community care• Care homes• Other settings…..

#VideoConsultations

Primary care/OOH Service

• Almost 90% of GP surgeries live• More than 3000 consultations • Out of hours service and 111 service

“Would be great if these could be done more often once lockdown restrictions have been lifted. I didn't have to spend time away from work, I saved on fuel and time for travelling

to the surgery”

#VideoConsultations

Secondary and Community care

• Secondary Prioritisation tool• COVID wards, Palliative care, Hospices, Frailty, Haematology, ITU,

Mental Health, CAMHS….• Podiatry, SALT, Physiotherapy….

“Our first VC was with a couple in their 70’s….His wife expressed huge relief that we saw the foot wound and guide her with his care”.

#VideoConsultations

55% female patients (P)69% female patients (S)

42% male patients (P)28% male patients (S)

GP LocationHome 7% Work 93 %

<12 13-17 18-24 25-44 45-64 >65

16%30%

7%9%

7%5%

31%41%

24%9%

15%6%

Time 8062 mins

Travel 3875 miles

Carbon 1030 co2

1988

1024

318

Clinical & Evaluation Update

3% other/PNTS (P/S)

Sec Care LocationHome 34% Work 66%

Overall Star Rating 4 out of 5

F2F Prevention87% (Primary) & 75% (Secondary) VC prevented a F2F appointment

Primary

Secondary

Survey ResponseOver 1300 responses

#VideoConsultations#VideoConsultations

Care Homes

• Partnership with Digital Communities Wales• Training and equipment to care homes• Vulnerable, high risk and isolated individuals• Virtual ward rounds by GP• All Wales Care Home- Digital Cwtch

“It was easy and I’m not the most tech savvy. The GP sent the link which is now

saved onto the tablet……..it was all seamless.”

#VideoConsultations

Other settings

• Prisons• Schools- postvention clinics• WAST• Police/MHA assessments• Dentistry• Optometry• Pharmacies

“Using this technology in schools following a serious incident allowed young people to receive almost immediate access to CAMHS”

#VideoConsultations

Groups

• Running groups for more than 5 years• SALT, Dietician, OT, Education, Psychologist etc.• Support parents/carers of children and young

people with autism • Partnership- education, social services & 3rd sector

“People able to ask questions”

“Excellent opportunity for parents”

“Time saving and access to busy people”

#VideoConsultations

What is the CWTCH Model?

• CWTCH (Connecting with Telehealth to Communities and Hospitals for Healthcare) funded by the Health Foundation in 2019

• Endorsed by the Royal College of Psychiatrists in Wales

https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/digital-covid-19-guidance-for-clinicians

#VideoConsultations

“Our team have used for communication with families of critically ill patients…allow us to build close relationships and trust with families who are unable to visit and puts a human face

on interactions and allows real-time updates. We couldn’t provide the service without it“

#VideoConsultations

#VideoConsultations

@cwtchgwent@teccymru

THANK YOU

Cwtch Gwent

https://digitalhealth.wales/tec-cymru

Clare Morrison

National Near Me Lead, TEC Programme

@clareupnorth

Near Me: enabling consultations by video

#VideoConsultations

What is Near Me?

#VideoConsultations

March 2020

“Suddenly the relative advantage of virtual consultations has changed dramatically.”

Professor Trisha Greenhalgh

(March 2020)

#VideoConsultations

Covid response: rapid scale up

February300 calls/week

Mid May13,200 calls/week

Technical set up

Service processes

Individual training

0

2000

4000

6000

8000

10000

12000

14000

Week 0 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

Near Me Consultations from 1 March

#VideoConsultations

Accident & Emergency, Addiction Services, Advice Services, Anaesthetics, Art Therapies, Cardiology, Cardiothoracic Surgery, Chemical Pathology, Child & Adolescent Psychiatry, Chiropody/Podiatry, Chronic Pain, Clinical Genetics,

Clinical Neurophysiology, Clinical Oncology, Clinical Psychology, Clinical Radiology, Community Mental Health, Community Nursing & Health Visiting,

Counselling, Dental, Dermatology, Dietetics, Ear, Nose & Throat, Endocrinology & Diabetes, Forensic Psychiatry, Gastroenterology, General Medicine, General Practice, General Psychiatry, General Surgery, Geriatric Medicine, Haematology, Health Visiting, Immunology, Infectious Disease,

Integrated Care, Intensive Care Medicine, Learning Disability, Link Workers, Medical Oncology, Mental Health Nursing, Midwifery, Neurology, Neurosurgery, Obstetrics & Gynaecology, Occupational Medicine,

Occupational Therapy, Ophthalmology, Paediatric Surgery, Paediatrics, Palliative Medicine, Pharmacy, Physiotherapy, Plastic Surgery,

Prosthetics/Orthotics, Psychiatry & Old Age, Psychotherapy, Public Health, Rehabilitation Medicine, Renal Medicine, Respiratory Medicine,

Rheumatology, Sexual & Reproductive Health, Sleep Therapy, Social Work, Speech & Language Therapy, Trauma & Orthopaedic Surgery, Urology

Primary care, Outpatient, Inpatient & Community services

#VideoConsultations

Patient survey:Would you use Near Me video again?

97.8%

2.2%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Yes No

Per

cen

t

#VideoConsultations

Patient feedback from survey

#VideoConsultations

Back to the beginning

#VideoConsultations

Back to the beginning

1: Co-design2: Systems thinking

#VideoConsultations

Co-design#VideoConsultations

Systems thinking#VideoConsultations

Why the QI approach? examplesArea Issues Changes made

Patient access URL confusion Patient information too complex

No kit or accessLack of confidence

Single point of accessCo-designed patient information website, leaflets, videosRemote patient roomsOpen “try it out” sessions

Virtualreception

Patient wish for “normality” Role of the receptionist Concerns about call waiting

Receptionist greets patientsMultiple tests before final modelInformation added to screen

Appointment booking

Separate systems are problematic

Need for flexibility in clinicsHow to involve third party callers (family, interpreters)

Embed Near Me into existingbooking systemsIntroduced mixed clinicsGuidance produced

Clinician set up

What eHealth kit to use Introduced: second screen, privacy covers, speakersDealt with: digital dictation device clash, settings locked

#VideoConsultations

Scaling up: In response to Covid

#VideoConsultations

Technical set up

Service processes

Individual training

Rapid expansion: 3-step process

#VideoConsultations

Rapid expansion: support

• Core Near Me national team and local NHS board teams

• Attend Anywhere (platform provider)

• National VC team

• Scottish Government – divisions, policy & clinical leads

• NHS Board eHealth and strategic teams

• Healthcare Improvement Scotland

• Scottish Access Collaborative

• Care Inspectorate

• Communications company

• Professional bodies …..and many more

#VideoConsultations

https://tec.scot

Rapid expansion: processes#VideoConsultations

Rapid expansion: patient info

www.nearme.scot

#VideoConsultations

Rapid expansion: training

https://learn.nes.nhs.scot/28943/coronavirus-covid-19/remote-consulting

• Technical skills (how to use Near Me)

• Video consulting skills (for clinicians)

• Practices processes and other resources

#VideoConsultations

Rapid expansion: shared learning

#VideoConsultations

Scaling up: Near Me in the new norm

#VideoConsultations

Clear rationale

For 3 reasons…

All health and care consultations are provided by Near Me whenever it is clinically appropriate

#VideoConsultations

1. Enables continued physical distancing

#VideoConsultations

2. Person-centred care & meets demand

#VideoConsultations

3. Environmental imperatives

#VideoConsultations

Next steps

@clareupnorth @nhsnearme

• Develop our vision into a delivery plan

• Set up Near Me improvement collaborative

• Improve the data system

www.nearme.scot

#VideoConsultations

Questions?

#VideoConsultations

Staying connected

• We’ll be sharing slides and video snippets

• Share on Twitter: @theQCommunity #VideoConsultations

• Join the Video Consultations Q Special Interest Group

• Keep an eye on Q insight project

• Get in touch: q@health.org.uk

Thank you

Just before you go, tell us in the chat box:

What Went Well (WWW)

Even Better If (EBI)