The NHS published in January its long-term plan in which it promised to redesign services so that, by 2024, up to a third of hospital outpatient consultations would be undertaken by video link. The idea is that this will increase convenience, reduce costs and free up staff time for other tasks. But this aim is unlikely to be realised quite so quickly.
Yes, video consulting is no longer science fiction. The same technologies (Skype, FaceTime, WhatsApp and others) that connect us with our friends and family can potentially connect us to our doctors, nurses, psychotherapists, pharmacists, dieticians and interpreters. Proof-of-concept examples (mostly in primary care) already exist and are gaining traction.
It is probably self-evident that not every patient, and not every clinical situation, is appropriate for a Skype consultation. That acknowledged, research from around the world has shown that patient satisfaction with video consultations is high and that when clinically appropriate (such as when there is no need for a physical examination), the quality and safety of care can be maintained.
At Barts Health Trust in London, we began to introduce video consultations in a single clinical service (diabetes) in 2010. We have been gradually extending the service ever since. Our research suggests that video consultations seem to have a more equal dynamic, with patients more at ease in their home environment and more confident to challenge the doctor or nurse.
But despite obvious benefits for the patient (no travel time, no parking costs, no need to navigate hospital corridors or sit in waiting rooms) and the NHS (no need for a fully-equipped outpatient room, less clinician time wasted while patients remove coats and get comfortable, lower heating and laundry bills, potential administrative savings), few readers of this article will have ever experienced a video consultation in the NHS. And for reasons we explain below, it may be a few years before that situation changes significantly.
What holds up change?
For one thing, both patients and staff are wary of change. People with the highest health needs are (on average) older, poorer, less well educated, less tech-savvy, less likely to have fast broadband at home and less likely to speak fluent English than the average person. All these factors are associated with lower willingness to try video consultations.
Patients may feel more secure – and better looked after – if they come to the hospital in person. The power of touch, for example, can be healing in itself. Staff, meanwhile, may be set in their ways, unable or unwilling to adapt their consulting skills to the virtual environment, or concerned about confidentiality (such as hacking) or the legal implications of a technical failure or missed diagnosis.
In addition, establishing video consultations as business as usual in an NHS hospital requires major logistical changes. Outpatient consultations, whether face to face or via video link, don’t just happen. Activities and routines are needed to book appointments, get hold of medical records, line up tests before or after, and send a letter to the patient’s GP. If some or all consultations are happening by video, a new supporting infrastructure is needed, and this takes time to get established. A service that is already financially stretched and working at full capacity may not have the resources, time or energy to shape a new set of routines.
The governance challenges are also substantial. Technologies dealing with sensitive data are subject to legal and regulatory restrictions when used in NHS organisations. Your doctor can download Skype onto his or her personal device without getting permission from anyone, but they can’t do the same on their NHS computer. Malware can spread rapidly through large organisational networks.
Meanwhile, the payment system for hospital-based video consultations in England and Wales is not yet finalised. Whereas there has been an agreed national tariff for face-to-face and telephone consultations for some time, the underpinning economic assessments needed to set a tariff for a video consultation have only recently been completed.
While video consultations may work out slightly cheaper in the long run, the short-term costs of offering such consultations will be high because of the set-up investment (new equipment, staff training and so on) and because the new service will initially be low-volume and run in parallel with the existing, conventional service. And if the tariff is set too low, there will be no incentive for hospitals to start seeing patients virtually.
So introducing video consultations in NHS hospitals, despite well-documented advantages to patients, is not likely to be easy, quick or cheap. The five-year target cited in the new NHS Long-Term Plan seems overly ambitious in the light of other countries’ experiences. Norway, for example, initiated a five-year programme to provide digitally-enabled hospital consultations in 2009. Research published in 2015 showed that despite generous funding and a strong policy push (which led to 75% of hospitals signing up to the initiative), the proportion of outpatient consultations conducted by video link was only 2% by 2013.
In our research, we have documented, and begun to address, the multiple barriers to offering virtual consultations to patients with a range of different medical and surgical conditions and social backgrounds. We have set up a central support unit which provides expertise and templates for set-up planning and progress monitoring.
We are also supporting other hospital trusts around the country to address the challenges of staff and patient resistance, reconfiguration of organisational routines, information governance and payment. At the time of writing, the list of specialities and organisations using or planning to use video consultations is gradually increasing.
Video consultations are, broadly speaking, a good idea. They have the potential to save time and money and make clinical services more accessible (though perhaps not as radically as some policymakers are predicting). But the new staff roles and organisational pathways and processes needed to underpin such a service will not materialise overnight simply by issuing a top-down directive saying that patients must henceforth be “digitally empowered”.
The significant organisational impact of changing traditional outpatient models needs to be recognised and addressed. Video consultations and, more widely, technology-supported change must be adequately resourced, locally owned and aligned with the core principles of the NHS: to provide universal, evidence-based health care to everyone and reduce inequalities of access.