This blog shares learning from the fifth fortnightly learning logs in our video consultations insight project. It captures personal reflections and experiences from 19 people implementing video consultations covering the two-week period to 14 June.

Over the last ten weeks, the participants in this project have helped us to capture the changing reality of implementing video consultations at pace in response to COVID-19.

Key themes

• There seems to be a more settled and managed pace for implementation as many services move on from the urgency of the crisis response
• Uptake is still low for some services and overcoming this will require clear organisational leadership, system-wide behaviour change and greater clinical and operational team ownership
• Teams are supporting each other through the challenges of remote working through a focus on wellbeing, embedding improvement cultures and offering team training and supervision.

Pace of change is more managed

The latest logs suggest that in many cases, teams are more settled and in a phase of more managed and manageable growth compared to the reflections in previous weeks. This likely reflects the incredible work to implement video consulting capability at pace in different services, as well as the fact that organisations are moving on from the immediate crisis response. The participants recorded that:

• Video consultations are becoming more embedded and integrated in some services and pathways
• Iterative improvements and learning continue to better integrate and align processes, and improve platform functionality
• Some teams are starting shift project management away from a central project team to individual clinical teams and specialties.

Uptake remains low in some services

On the whole, a more planned and managed growth is welcomed by participants as it enables more opportunities for improvement and learning. However, in some cases, this slowdown is because of low or reduced uptake and engagement in some services. As one participant reported, the findings of a survey across 29 services in their organisation found that the majority are only using video consultations for 0-20% of their appointments. This compares to a small minority of “super users” that are using it for 80-100% of consultations.

Participants articulated frustration that the capability is there but not being used. Reflections from the learning logs suggest a number of reasons behind low uptake:

• As previous blogs have highlighted, there are concerns about the quality of the interaction, the impact on longer-term health outcomes and equitable access
• Ongoing tech issues (specific platform issues and connectivity) have a negative impact on patient and staff acceptance of this mode of consultation
• Clinicians revert to phone by default as it is more familiar and seemingly straightforward, or assume it is more appropriate for specific patients
• Video consultations are considered a “stop gap” as part of the pandemic/lockdown response. This means that staff or patients don’t consider the additional effort to set up and become familiar with the video consultation technology a good time investment if phone, or a delayed face to face, appointment is possible
• Staff feel threatened or are suspicious of a “hidden agenda” about moving increasingly to remote working.

[There is] fear among some clinicians if they will be allowed to continue using video consultations and fear among others that it will be misused by management to address waiting list targets

Addressing issues affecting uptake

The insights from the learning logs suggest a couple of areas for concern about the limited uptake and engagement with video consultations:

1. Some services and patients will be put at a disadvantage. Where video consultations are a more appropriate mode than phone, the longer people are unable to access or are uncomfortable seeking face to face support, the greater the disadvantage will be
2. Insufficient preparations for a second wave. Health services may not be sufficiently embedding and developing their video consultations capabilities for a second wave of COVID-19.

Participants highlight the following actions needed to increase uptake:

• Clear governance, leadership support and direction are important enablers to address staff resistance and inconsistency in use across services. Yet only a minority of participants reflect that their organisations and teams have a clear vision for the role of video consultations, and how they will work alongside face to face and other remote care provision in the future
• Evidence for the appropriate use of video and both individual and system behaviour change are important aspects of integration. Changing traditional ways of working takes time, but until video consultations are easy and familiar, and the evidence of the benefits are understood, most people will, as one participant put it, “follow the path of least resistance [which is] face-to-face consultations and phone calls.”
• Clinical and operational team ownership to champion the use of video consultations and ensure it works for specific services and specialties. However, devolved decision-making and autonomy can be in tension with organisation-wide decisions or policies (such as the choice of platform or a policy that all staff need to wear face masks even during video consultations).

Supporting staff who are working remotely

Participants continued to reflect on the personal challenges and adjustments needed for working remotely, especially when video consulting is a key part of their role. Some miss the “human touch” of patient contact and find remote working isolating, despite regular team meetings.

It is hard, and emotionally different sitting in a room on your own

There were a number of good examples of what teams have in place to support staff, including:

• Focusing on staff wellbeing and embedding supportive team cultures
• Using improvement approaches to embed learning, reflection and improvement. The ability of teams to adapt to constant change has been important for maintaining morale
• A focus on team training and supervision. Some participants described how they have embedded peer supervision and joint consultations to provide “an extra pair of eyes” to improve the quality of the consultations and to enable learning and development.

Making video part of “the new normal”

The incredible response and hard work participants have described over the last ten weeks mean that video consultations can now be part of “normal” health care provision, given the many benefits of doing so.

But, as this week’s blog highlights, health services risk defaulting to only offering video consultations as an exception unless we continue to take action informed by learning from this work and build on the significant progress that has been made.

Any questions to explore?

• In your organisation, do you see lower uptake of video consultations in some services more than others? What do you think are the reasons behind this?
• How are you supporting clinicians working remotely to overcome the wellbeing challenges? Do these differ from the examples in this blog?

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, continued progress and improving quality and tackling inequalities.