This blog captures personal reflections and experiences from 27 people currently implementing video consultations covering the period to 31 May. It explores how services are addressing the quality of consultations and tackling inequalities.

Key themes

• Participants are continuing to improve service quality and access for different population groups
• What we are learning over the course of this project makes a strong case for video to remain part of a high-quality health care service in the future. But the insights also highlight continued concerns about the quality and appropriateness of video consultations in some situations and the varied impact of roll out on different groups
• While the majority of services have measures in place to collect feedback on quality and effectiveness in the short-term, very few are systematically considering the impact of video consultation services on health inequalities and much more attention is needed to enable this.

A useful tool for quality care, but not in all settings

As we have heard and reported throughout the project, most participants recognise the many quality benefits of video consultations including:

• Generally high levels of satisfaction and acceptance among clinicians and patients – especially for allowing the continuation of services during COVID-19. Participants report that staff are increasing their understanding and confidence for using video effectively
• For some services, the increased eye contact and integration of visual aids is seen as an advantage over phone consultations
• For some locations and types of interaction, video offers greater efficiency than face to face.

However, given the limitations of the current evidence base, there continues to be uncertainty about the long-term quality and clinical effectiveness of video for all settings and specialisms.

I am feeling glad that we can still deliver some form of service, but it is certainly not up to my standards

Signs that video consultations can both address and exacerbate inequalities

Some participants noted that the convenience of video can help those less able to take time off work, school or from caring responsibilities, or where there is a stigma attached to attending appointments in healthcare settings. In addition, video consultations can make arranging interpreters easier when the right processes are in place (Dr. Shanti Vijayaraghavan discussed this issue in a recent Q webinar).

Yet, participants raised concerns about unequal access to video consultations due to some patients lacking skills and confidence with digital technology, having limited access to hardware and a reliable internet connection, or not having a suitable and safe home environment. In some cases, this lack of access was seen to coincide with existing health and socio-economic inequalities.

We may be able to deal with some patients by video more quickly and more fully than we can those who do not have access to that technology

Many participants acknowledged that they need to do more to fully understand both the short and long-term impact on equality of access to and experience of, video consultations.

How are these issues being addressed?

The main actions being taken to improve the quality and accessibility of video consultations are:

1. Embedding staff and patient feedback processes to collect immediate feedback on satisfaction and quality.

2. Participants describe using QI approaches to reflect and act on what they are learning and are providing feedback to the technology providers to ensure the platforms are developed to better meet people’s needs.

3. Efforts to ensure integration with existing processes and pathways to increase quality and efficiency, and to increase uptake to different specialisms and user groups, for example through integration with interpreter services and expansion to group settings.

4. To tackle digital exclusion, services are:

a. Using alternative platforms if the technology fails; if the default platform is not suitable, or to respond to patient preferences.

b. Increasing patients’ and staff members’ skills and confidence through training, written guidance, and sharing good practice.

c. In a minority of cases, participants describe providing more targeted support to patients including coaching calls, test call facilities, home visits to support initial set up, providing hardware, and proactive partnerships with care homes and local community and voluntary sector groups.

As we share more positive experiences and reflect on how challenges would be different in a face to face environment, the clinicians are becoming more open and receptive to persevering with video consultations

What more do we need to do?

Despite this work – which is by no means easy, and has been introduced at rapid pace – the insights from the learning logs suggest that a number of developments are needed including:

1. Increasing monitoring and evaluation capacity and capability. There is a need to measure uptake and experience of different demographic groups, and to capture evidence on clinical outcomes and effectiveness. This needs to be tackled by individual services – few of whom are collecting such data currently. But there is also an urgent need for those leading on the roll-out of video consultations nationally to fully understand and report on the impact on quality and inequality. This echoes calls for impact assessments for other COVID-19 digital innovations.

We aren’t currently collecting data on who is turning down the option of video so we aren’t yet able to understand the issues why people are excluded. This is a huge gap

2. Establish local partnerships. Where there aren’t coordinated, local approaches, it is much harder for health care services to address issues of inequality of access.

3. Increasing clinical capability and support. There is a feeling that the quality of the video consultation may depend on the clinician’s confidence and experience. More needs to be done to support the training, supervision and digital capabilities of the workforce so that video is the default option for all when it is appropriate. However, this is a mode of working that will not suit everyone and staff will need adequate support through the change.

4. Greater access to equipment and integrated platforms. Access to high-quality equipment and connectivity for clinicians, and improvements to the quality and integration of platforms that facilitate different types of video consultations including groups is essential.

5. Patient participation and co-design. Very few participants have embedded co-design and patient participation into their service development. This will be needed over the next phase of implementation.

[What’s hard is] videoconferencing fatigue – physical fatigue after repeat conferencing and emotional fatigue of having to work in a way that none of us trained for and most do not wish the job to become

6. Leadership support and resources. As highlighted in previous blogs in this series, the demands on staff time and impact of the pace of work is a continued concern. This is exacerbated by increasing demand to resume pre-COVID work when there are still fundamental issues and processes that need addressing. For the people leading on video consultations, they want national and local leaders to prioritise and effectively resource the work.

Participants in this project are finding many different ways to address issues of quality and inequality. As services enter the next phase of implementation, it has become increasingly clear that more work needs to be done at all levels to fully understand and systematically address these, in order to build on the remarkable progress we have seen so far.

I’m feeling anxious about workload and wider organisational understanding […] I feel a bit alone and unsupported

Any questions to explore?

• Are there other positive or negative impacts of video consultations on socio-economic or health inequalities that we haven’t raised?
• How can we embed patient participation and co-design given the constraints of the current context?

Get in touch or join the Video Consultations Special Interest Group to share your views.

Read the previous blogs from this project on our initial insights, building for the long term and continued progress.