Initial insights from implementing virtual consultations

Working with a cohort of those rapidly rolling out virtual consultations as a response to coronavirus (COVID-19), this project captures and shares emerging insights through regular learning logs and webinars. This first blog captures personal reflections and experiences from 25 participants across the UK implementing video consultations from mid-March to 19 April 2020. Participants come from a variety of backgrounds including clinical and non-clinical leadership roles; a range of settings (including primary care, secondary and community mental health, paediatrics, physiotherapy and orthopaedics); those with experience of video consultations and those entirely new to it; and those using a range of different platforms including AccuRx, Attend Anywhere and Microsoft Teams. We hope these insights will immediately begin to support those doing this work, as well as generating evidence and learning for the longer term. We’ll be sharing fortnightly what we’re hearing.

Key themes

From the first learning logs, we’ve identified five key themes relating to traditional roles and approaches to improvement, and the different enabling factors for rapid change.

Different forms of leadership have emerged – both more directive at a national level and more dispersed at organisational level
The benefits of a whole-system approach to change with clinicians, patients, managers and leaders working together to maintain high quality and safe care
Urgency and common purpose have forged new collaborations and ways of working
Huge potential for longer-term transformation but also tensions around speed versus sustainability and competing visions of the future
Departure from traditional approaches to piloting new interventions has facilitated rapid roll out but may hinder sustainability

Firstly, the speed and scale of change is unprecedented. In one case, that is not unusual, the service has gone from 5% virtual patient contact to 95%. This is alongside transformation of how staff and clinicians work together remotely and rapidly changing processes and procedures to support this new mode of working.

The situation has changed at lightning speed. Setting up these consultations previously took years and was rarely successful.

While this is incredibly challenging on a personal and professional level in terms of the pace of change, demands on people’s time and long working hours, there is a lot of pride and satisfaction shining through in people’s reflections about being part of something that is enabling the continuation of quality and safe care in the current circumstances; in how people have developed new ways of working and learning how to work with the technology; excitement about getting virtual consultations off the ground, and the longer-term potential for service improvement.

It is incredible to see us transform the delivery of our services through the harnessing of technology at such a rapid pace.

Different forms of leadership have emerged

We’re seeing different forms of organisational and system leadership – both more directive at a national level (e.g. national policies and expectations from the executive bodies) and more dispersed at organisational level (e.g. clinical teams given more authority and ownership to implement virtual consultations in their own way). This prompts questions from us about the different types of leadership needed to support rapid change and how this differs in times of crisis compared to ‘peacetime.’

The benefits of a whole-system approach

The current experience exemplifies how a whole-system response can enable health and care improvement and break the financial, bureaucratic and personal barriers that often prevent change. A key enabler has been the public acceptance of virtual consultations, and pragmatism of clinicians who are having to “give it a go” to deliver high quality and safe care. Some participants reflected that previously held assumptions and reservations that may have hindered engagement before are being proved wrong.

This mode of working is challenging many of my assumptions about consultations – prior to COVID, I would have argued that clinical examination was essential, which simply has not been the case.

Urgency has had an impact on collaboration

There has been a remarkable transformation in how teams are collaborating and working together. Participants are generally very positive about their experiences of how IT, admin, clinical, operational staff are all working together to rapidly put everything in place. This is working well because of the sense of urgency and common purpose around safety. As one participant put it: “there is no time to conform to the usual social norms of taking time to establish common ground and build relationships”. We think this is an interesting area to explore further, given the importance of collaborations and relationship-building to achieve change in complex environments.

Speed versus sustainability

We’re identifying some tensions around setting virtual consultations up fast in response to the current crisis or setting them up to be sustainable. It’s clear that COVID-19 provides a “compelling need to change”, but the future role and level of virtual consultations is more contested. Participants are interested in understanding what they need to put in place to ensure the infrastructure, staff expertise and evidence base is there to support this as a long-term change and service improvement; and what specialities and interventions are more suited to this as a long-term option. People are learning first-hand about the benefits for patient experience and access, reducing unnecessary appointments and travel.

Departure from traditional approaches

There is a radical departure from the traditional approach to piloting service changes. Participants described how they were doing rapid small-scale tests and working initially with “coalitions of the willing” to take the lead but some are uneasy about the lack of more substantial piloting and we’re interested in exploring the longer-term implications of this.

I do sometimes get concerned about the pace of change meaning that we make obvious mistakes or miss important learning points.

Early positives and challenges

What’s working well

Using videoconferencing for internal/professional meetings builds familiarity and gives people confidence before using it with patients
For teams and services that were previously split across different sites, using virtual consultations and meetings is a much more efficient way of working. People are also recognising longer-term benefits in newly flexible home working policies to support extended clinic hours.
Some participants reflected on the positive relationships they are forming with patients through video consultations: that it feels like a more “human” interaction, enabling more person-centred care when compared to telephone consultations.
A number of people have started capturing patient and clinician feedback through online questionnaires to provide regular feedback to support ongoing improvement.

What people are finding hard

While people have been generally positive about IT support there are still challenges with technology. This includes knowing which system to use; making sure the different platforms work for different purposes; ensuring there are streamlined supporting processes and administration; having high quality and compatible equipment.
A key concern people have related is digital inequality: access to broadband, smartphones, digital literacy, and an appropriate home set up to ensure confidentiality and engagement.
Participants identified some concerns about certain aspects of quality and safety including risks of non-attendance, the longer-term implications on delays to non-urgent appointments; safeguarding concerns and what may be being missed by not seeing people in person. These concerns may be more pronounced in some specialities than others and have implications on short-term up-take and longer-term sustainability so is worth exploring further.
In addition to working (unsustainably) long hours to respond to demand and the rapid need for change and feeling “daunted” by the pace of it, some participants report how tiring virtual consultations and virtual meetings are. Alongside the other (short-term) changes happening such as redeployment/role changes, changing sites, it is a challenging environment to be working in.

Additional questions

Every fortnight we will post key questions that participants would welcome support with. Please email, comment below or join the online group to contribute to the discussion.

What are the effective processes for setting up appointments, from initial allocation to the clinician to the appointment taking place? Can people share what is working well in their Trust?
How are people involving patients (through co-creation/patient participation) in the changes?
Can people share feedback surveys, and approaches to monitoring and evaluation that have worked well?

We’ve been genuinely inspired by what we have heard about the energy and commitment that people are giving to this work. The second learning log will focus on the longer-term sustainability of the work in response to COVID-19 and we look forward to sharing in a couple of weeks.

Are you undertaking work implementing video consultations? Why not join the Video consultations Special Interest Group to share your experiences with other Q members.