At the heart of healthcare are relationships; communication is foundational to good relationships and the work of healthcare. This communication in caring has predominantly been carried out face-to-face, though remote forms of communicating (e.g. telephone) are embedded in existing care pathways and an aspiration to increase digital care was set out in the NHS Long Term Plan.
The massive shift in practice this year towards remote communication and care, as a result of the coronavirus pandemic, has provoked fevered debate on the benefits, limitations, creative opportunities and pitfalls of running healthcare services remotely at scale.
On the 25 November 2020, we held the first of our Connecting Q Locally virtual event series which posed the question 'Remote consultations: what is their role in sustainable healthcare?'
Our inspiring speakers weighed up the impact of remote consultations and care using a sustainable healthcare lens, focussing not only on clinical outcomes but also impacts on the environment (on which we all depend for our health), social wellbeing (of staff, patients and community) and cost.
We heard from:
- Dr Andrew Appleton, Clinical Digital Lead & Chief Clinical Information Officer, Bristol, North Somerset and South Gloucestershire CCG, who discussed remote consultations and their role in primary care.
- Dr Shanti Vijayaraghavan, Consultant Physician in Diabetes & Endocrinology, and Joanne Morris, Senior Project Manager at Barts Health NHS Trust, Newham University Hospital, who discussed the role of remote consultations in secondary care.
- Ben Tongue, Head of Sustainability at NHS Digital, who discussed the main carbon footprint contributors of digital services.
Resources for learning and discussion
1) Watch the recording of the whole event [54.35 mins], here
2) Try this exercise with your team, organisation or at a regional meeting :
- select some video clips from the event on different topics and watch these together. You can find the clips below in the 'video clip library' or on this playlist on YouTube. Each clip is accompanied by the key learning points.
- After watching the clips use this prompt for discussion: "To make your service more sustainable what remote/digital solutions would you: a) add in b) optimise (and how) c) stop using?"
- Depending on the size of the group you could have a whole group discussion or small group discussions in break-out rooms (for online groups).
- You may like to try using virtual whiteboard softward like Jamboard, Miro, Mural or Padlet that allows the whole group to collaborate whever they are and also creates a colourful record of your discussion that can be saved and used later on to further your ideas. Here is a jamboard with example answers and here is a master copy of the jamboard that you can copy and use in your own session.
3) A series of conversation starters and video clips from the event were posted in the Sustainable Healthcare Special Interest Group on the Q Community platform that brings together healthcare professionals with an interest in quality improvement. Please do come and join in and contribute to the conversation! Apply to join the Q community if you aren't already a member, and for existing members do visit the Sustainable Healthcare Special Interest Group; we'd be delighted to welcome you!
4) Join the Centre for Sustainable Healthcare in piloting a new carbon calculator for remote consultations! With the support of the Health Foundation, The Centre for Sustainable Healthcare has developed a carbon calculator to assess the carbon emissions savings of avoided patient travel due to switching from in-person outpatient or GP appointments to remote consultations. The calculator is accompanied by a a step-by-step guide. Please contact Mrs Ingeborg Steinbach, Carbon Modelling Lead, if you're interested in piloting this exciting new tool.
How do remote consulting and digital systems contribute to sustainable primary care? [8 mins]
Listen to Dr Andrew Appleton:
- The journey of introducing digital care systems in one practice.
- Benefits for patients and staff of introducing digital systems.
- How digital systems contribute to sustainable primary care through patient empowerment and lean systems of working.
How do remote consulting and digital systems contribute to sustainable secondary care? [ 6 mins]
Listen to Dr Shanti Vijayaraghavan & Jo Morris:
- Social sustainability was the main driver for introducing video consultations
- The journey of introducing video-consultations in the diabetes service in Newham.
- The impact of video-consultations on reducing patient travel and reduce emissions.
The benefits and impacts of digital systems in healthcare [20 minutes]
Listen to Ben Tongue, Head of Sustainability at NHS Digital:
- although digital healthcare often contributes to environmental and social sustainability, running the infrastucture of digital systems does have a environmental and social costs.
- the 3 main contributing factors to the carbon footprint of digital services in healthcare are:
- Data hosting (ie on the Cloud or servers)
- Networks (require wiring)
- End user devices e.g. phones, laptop, iPad
- that the manufacturing phase accounts for 80% of the energy of the lifecycle use of digital devices and an important change needed is using fewer devices designed to be repaired and updated.
Q1. Does travel required to pick up prescriptions increase the carbon footprint of video-consultations in primary and secondary care? [1:30 minutes]
- Many secondary care physicians do not prescribe in outpatients but ask primary care colleagues to prescribe.
- In primary care nearly all prescriptions are transmitted to pharmacies electronically saving printing materials and travel between the practice and the pharmacy for patients and staff.
Q2. How does staff working from home effect the carbon footprint of healthcare organisations? [3:27 minutes]
- Staff working from home, rather than in the office has a lower carbon footprint.
- In primary care where the number of staff are increasing and existing buildings are becoming too small for teams, homeworking could reduce the need for new building, which is important as the process of building has a high carbon footprint.
Q3. How reducing ‘did not attend’ rates through using video-consultations improves sustainability through creating a leaner process, making it easier to access services and through empowering patients. [3:02 minutes]
- reducing ‘did not attend’ rates through using video-consultations improves sustainability through creating a leaner process, making it easier to access services and through empowering patients.
- 'did not attend rates' in the diabetes clinic reduced from 33-50% (depending on age group) at baseline to 26% once remote working introduced. This dropped further to 13% when user-initiated contact was introduced. At the same time glycaemic control improved, probably due to better self-management. Similar results have been replicated in other services.
- Technology needs to be easy to access and use.
- The whole pathway needs to be redesigned (through co-design with patients) when introducing video-consultations, including patient-clinician interaction, booking, feedback of results.
Q4. Limiting digital exclusion for socially sustainable remote consulting [3:27 minutes]
- Volunteers, family members and receptions have been deployed to help patients to access remote healthcare consultations.
- Don’t make assumptions about different groups accespting and being able to use remote consultations. It is often assumed that digital solutions do not work for elderly people but often it works better for patients and families, especially given the inconvenience and risk of travel (especially during COVID).
Q5. If you are redesigning a pathway around digital solutions how are face-to-face options included? [3:45 minutes]
- In both primary and secondary care both digital and face-to-face/in-person are offered to allow for the need to examine patients and for patient preference.
- There are different methods of achieving a mix of remote and face-to-face appointments discussed further in this clip.
Q6. What do patients feel about having sensitive conversations online? [2:45 minutes]
- Many people prefer having sensitive conversations bad news online when they can be at home in a supportive and familiar environment, evidenced by the VOCAL study carried out in the tertiary cancer care centre at Barts.
Q7. Co-production for social sustainability when introducing digital care and video consultations in primary and secondary care [2:12 minutes]
- Working with the patient participation group in primary care is important and helpful at the early design stage and in giving feedback as plans take shape. The video discusses various examples of co-production in practice.