Attend Anywhere / Near Me video consulting service evaluation 2019-2020: report

4. Discussion

4.1 Evaluating progress, outcomes and cost-effectiveness

The 2018 TEC Data Review and Evaluation Options Study [2] included potential outcomes of a generic VC workstream, drawing on an evidence review and represented in a 'logic model'. Notwithstanding the flawed linearity of logic models for change (which underplay the uncertainty, unpredictability and emergent causality of technology-supported change), it provides a useful summary of initial assumptions and expectations regarding the VC work stream. In Table 6, we reflect on the logic-model's proposed short-term outcomes in relation to our analysis.

Table 6: Reflections on the short-term outcomes from 2018 TEC programme review

Proposed short term outcomes: Commentary

Increased number of patients using VC instead of face to face

There is a clear increase in Attend Anywhere appointment activity. However, frequency should be assessed in the context of use (e.g. video as an alternative to a home visit may have greater significance than as an alternative to an outpatient clinic appointment).

Video has also been used as an alternative to telephone appointments, and so it is important to explore what video consultations are actually replacing.

To date, video appointment activity has been captured using the Attend Anywhere platform. Whilst this provides a useful picture of service engagement, it does not reflect the proportion of video within overall clinic activity. There is also potential for it to capture data in addition to consultation activity (e.g. test calls and piloting during implementation). A more accurate and comprehensive analysis would require data from other sources (i.e. patient administration systems).

Improved access to specialist services

The video option has greatly improved access for patients living in remote areas, where they relied on specialists visiting their home or local clinic, as well as rapid specialist opinion during urgent care situations.

Whilst there has been a lot of policy emphasis on reducing waiting times, it is unclear at this stage how, and to what extent, video will impact on service capacity and waiting times. This will likely depend on the context and service model in which the technology is used, and therefore require a more strategic approach to reaching organisational targets.

Less need to travel

Attend Anywhere has helped reduce travel for patients living in remote and rural areas, and patient travelling from the islands. Participants also highlighted other significant time factors beyond long distance travel (e.g. parking, traffic in/around the hospital, sitting in waiting areas, etc), and so it would be useful to focus further on the potential time saving benefits for urban and semi-urban residents, and how virtual access for these groups could be improved.

Improved management of certain conditions

Many practitioners spoke of how video consulting supported person-centred and holistic care. It allowed them to gain insight into patients' lives at home and with family, and how this related to management of their condition.

They also talked about the value of video over telephone appointments, as non-verbal information supported clinical reasoning and more effective dialogue with patients.

The option for multiple participants on the video call also created possibilities for more multidisciplinary and multi-site working with the patient, as well as opportunities for more effective patient and carer education.

The use of video can help infection control. This was initially highlighted in a small number of high-risk clinical settings (e.g. for a patient with cystic fibrosis), but has since become even more relevant during the COVID-19 pandemic.

We found no evidence to suggest that video appointments had a negative impact on the quality of patient care. However, quality of care and clinical governance remain issues for some clinicians, and so outcomes on quality and safety remain important going forward.

Improved access for hard to reach groups

There were a number of social and clinical circumstances in which video was considered preferable over face to face, and enhanced access for hard to reach groups.

In particular, it improved equity of access for patients experiencing travel and/or mobility problems due to frailty and multi-morbidity and patients with fear or anxiety engaging with clinical services.

But whilst the technology may help engage these groups, the digital medium also risks excluding those with low digital literacy and confidence, and/or limited access to the technology.

Effective ways to address the digital divide included the use of local community venues with 'kiosk' computer facilities and opportunities for remote testing and assistance for patients. This has, however, required substantial logistical and collaborative working, with limited success outside of the NHS Highland region. Ongoing infrastructural development of these sites is needed, including partnerships with other digital literacy initiatives (e.g. mPower, community education/peer support programmes).

There appears to be a strong case for the use of video to connect prisons with health care services. However, progress has been slow in the face of significant logistical, infrastructural and regulatory challenges. A focused quality improvement programme may be needed to address the complex and unique issues associated with this setting.

Reduced professional travel and improved efficiency

Video consultations have allowed greater flexibility for clinicians who have been routinely travelling to the islands and remote locations to run face to face clinics. Similarly, video has reduced need for travel among allied health professionals providing care to patients in the community, as well as specialists on-call for emergency care.

These clinicians consider it to be more efficient for the service (running more appointments at times that would otherwise be spent travelling), but also provided greater work satisfaction and improved their own quality of life, which they felt subsequently improved quality of service.

Improved collaboration between professionals and new ways of working

Attend Anywhere has provided the opportunity to redesign services to address gaps in service provision or a safety risk. In particular, the dyadic and triadic models have provided some staff with development opportunities through bespoke training from specialist clinicians.

The local upskilling of less specialist staff through training and development allowed them to undertake extended roles under that supervision, creating new local service capabilities and increasing professional fulfilment.

The 2018 TEC Data Review and Evaluation Options Study also included a preliminary analysis of potential cost-effectiveness measures. These included reductions in hospital admissions, reduced length in hospitals stay, as well as financial savings from reduced travel of patients and clinicians [2].

Whilst this evaluation did not aim to provide an economic analysis of Attend Anywhere, participants' perspectives within the 'value proposition' domain may inform such studies going forward. In addition to the measures highlighted in the 2018 review, our participants also reported potential cost-savings through increased service capacity and efficiency, such as reduced DNA rates and the upskilling of local practitioners to extend their roles.

But the data also revealed that, although there were many examples of such savings, video consultation clinics can also generate considerable additional work for staff in the both the short and long term, and might require additional investment in other parts of the system to support the service model. This includes, for example, the setting up of 'spoke' sites (room allocations, equipment and staffing) for scaling up of the dyadic model, the logistics of prescribing and pharmacy deliveries, as well as administrative and technical support structures.

This highlights the need for a holistic approach to understanding the relative value of different mediums for remote consulting. This will require a consistent and comprehensive approach across multiple interacting dimensions, including clinical and process outcomes, satisfaction and financial cost [21, 22]. More work is needed to develop a theoretically informed framework to measure the relative value of video and face to face consultations, based on a system level perspective of the social and economic impact, and how these relate to economies of scale. The analysis should also take into account the different models of using Attend Anywhere (i.e. hub-home, dyadic, triadic) in relation to the type and extent of resource required as the volume of activity increases.

4.2 Recommendations for scale-up, spread and sustainability

The analytical lens of NASSS was used to surface the process and outcomes of the Attend Anywhere scaling up programme across multiple interacting dimensions. At the time of writing this report (March 2020), the national response to the COVID-19 had just begun, in which remote video consultations could play an important role in the national response. The fieldwork conducted as part of this evaluation preceded these events, and so this is beyond the scope of the evaluation. However, it is likely that subsequent lessons and long-lasting effects will emerge during this time, and so it would be beneficial to monitor these developments across the NASSS domains.^[9]

In summary, Attend Anywhere has been used for a wide range of conditions and clinical services, through the application of three different service models: hub-home, dyadic hub-spoke, and triadic hub-spoke. The Attend Anywhere technology was considered generally dependable and produced high-quality video and audio when the service had invested in high-quality peripherals, such as screens and noise-cancelling microphones. Attend Anyway has been modelled on the workflow of outpatient clinics, with a number of defining characteristics that have contributed to the successful use and scalability. In particular, the 'single point of entry' and 'virtual waiting areas' have been used adaptively by clinical teams to mirror existing workflows and fit the new service model within their local settings. However, problems with wider technical systems, such as configuring patient administration systems for video, still pose challenges to mainstreamed use.

Staff and patients described various advantages of the Attend Anywhere service over conventional outpatient appointments. Main advantages include time and cost saving due to reduced travel by patients and staff, quicker access to specialists and more holistic care. Some clinicians were concerned about video consulting in general, particularly in relation to the quality of the consultation and the logistical barriers to establishing and running the service model.

Organisations which adopted Attend Anywhere most readily tended to have a history of successful innovation, visionary leaders, a clear and positive narrative about the technology, good data systems to monitor the effects of the change, people or money that could be channelled into the change effort and strong senior management and clinician buy-in.

There has been strong national level support and a long established strategic intent to use video for remote consulting, This has contributed to the scale-up effort through the TEC programme, allowing 'slack' resources (people and technology) for service implementation, facilitating inter-organisational learning and helping shape relevant regulatory policies.

Drawing on the emerging themes, we propose the following recommendations:

Recommendation 1: For each clinical specialty, produce national guidance offering 'rules of thumb' for what is generally safe for video consultations

Some but not all conditions are appropriately managed through a remote video consultation. For the clinic-home model, evidence suggests that suitable conditions include:

• Routine chronic disease check-ups, especially if the patient is stable and has monitoring devices at home.
• Administrative reasons e.g. re-issuing sick notes, repeat medication.
• Counselling and similar services.
• Duty doctor/nurse triage when a telephone call is insufficient.
• Any condition in which the trade-off between attending in person and staying at home favours the latter (e.g. in some frail older patients with multi-morbidity or in terminally ill patients, the advantages of video may outweigh its limitations).

Conditions in which video would not be suitable for the home-clinic model include:

• Assessing patients with potentially serious, high-risk conditions likely to need a physical examination (although in some cases registered nurses in care homes could do this under supervision).
• When an internal examination (e.g. gynaecological, rectal) cannot be deferred.
• Co-morbidities affecting the patient's ability to use the technology (e.g. confusion), or serious anxieties about the technology (unless relatives are on hand to help or care home staff).
• Some deaf and hard-of-hearing patients may find video difficult, but if they can lip-read and/or use the chat function, video may increase accessibility, and use of British Sign Language (BSL) interpreters may be an option for some.

The dyadic and triadic hub-spoke models could also support care of more complex conditions such as chronic pain or cancer. Such models relied on a high degree of trust between the specialist and the local staff member; they seemed to depend on a positive and longstanding personal relationship between them, and (often) individualised training.

Recommendation 2: Basic training and multiple try-out opportunities for staff and patients

The Attend Anywhere technology was, in general, dependable and produced high-quality video and audio. However, it is important to account for digital literacy and confidence of both patients and staff. The hub-home model presents additional challenges to ensuring adequate set-up and call quality. Some clinicians who use the hub-spoke model have expressed reluctance to move to a hub-home model because they would be unable to control the technical quality of the patient's connection and/or were concerned about time required to troubleshoot or resolve technical problems.

Recommendation 3: Develop and disseminate system-level analysis of the growing evidence about significant financial savings from Attend Anywhere

Staff and patients described various advantages of the Attend Anywhere service over face to face appointments. Different organisations and stakeholders held different priorities and motivations for supporting video consultations. In order to gain senior level strategic support, it will be important to highlight and provide evidence for potential efficiency and financial savings across different strategic areas. This includes, for example, less need for travel (including patient and staff) and increasing service capacity.

Recommendation 4: Identify and address clinical and care governance issues

Service developments require local clinical leadership. Some clinicians were opposed to video consultations because they felt it threatened the quality and safety of the clinical consultation. Others were supportive in principle but saw no immediate clinical need to set up and wanted to observe the outcomes of other services within their specialty. Professional bodies and defence societies (nursing as well as medical) have an important role to play in revisiting traditional definitions of good clinical practice and establishing more contemporary ones.

Although less mature in social care settings, equal consideration will be required on care governance issues.

Recommendation 5: Working with professional networks, disseminate stories of up-and-running services

The service model should be championed and positively communicated by respected opinion leaders, with attention paid to the overall narrative or 'organising vision' within which the technology-supported change is framed. Identify and engage existing inter-organisational and professional clinical networks to endorse the service model and promote sharing of knowledge and best practice. Staff may also benefit from being in 'communities of practice' (groups or networks of people who share an interest in something and are trying to get better at it).

Recommendation 6: Communicate the "gaining a service" narrative

It is important to emphasise what the video consulting can bring to local services and communities. Some staff in remote community hospitals expressed concern that the introduction of video clinics would mean "losing" a consultant-led local service (in the sense that a monthly in-person visit would cease), though other staff in the same settings depicted the change in terms of "gaining" a service (in the sense of access to certain specialists who had previously been unavailable).

Recommendation 7: Assign and support local champions

Social learning from clinical 'champions' who are enthusiastic and confident in using the system is crucial for building capacity. It is important to continue resourcing and building capacity of local clinical champions across multiple disciplines and professions, and to cultivate their capabilities in facilitating cross-departmental collaborations, linking frontline practice with senior level management.

Recommendation 8: Provide set-up support for ready-to-roll sites, paying careful attention to routines between participating sites

There is high interest and a strong economic case for hub and spoke models that allow for remote consulting between health boards (e.g. island to mainland services) and across other organisations (e.g. prisons to hospitals). However, substantial work is needed to align processes across these organisations. Whilst the spoke hospital sites may be remote and small, they are also extremely busy and under-staffed, and so require support to implement logistical and infrastructural arrangements to call into the hub sites.

Recommendation 9: A Quality Improvement Collaborative to maximise inter-site learning

Scaling up video consultations is not merely installing new technology, but introducing and sustaining major changes to a complex system, requiring both national and local strategic leads. A structured approach to identifying, training and bringing together quality improvement leads, and helping them align and monitor their local activities with wider strategic goals, would help accelerate progress to scale-up and spread.

Recommendation 10: Strengthen national branding

Maintain consistent branding of NHS Near Me across all health boards, ensuring the messaging is consistently applied across multiple dissemination and communication channels targeting patients and staff. Raise awareness through public-facing media to reinforce the identity of the new service model and build familiarity and trust.

4.3 Limitations of the evaluation and recommendations for the future

This study provides a socio-technical (people and technology) perspective that links different levels of data collection and analysis across the NASSS dimensions. One of the advantages to this study was the level of detail achieved, with the support of project managers and service staff (hosting researcher visits, arranging interviews, meetings and site visits, suggesting and introducing other colleagues and stakeholders) and the sharing of local evaluation data and reports (e.g. activity data, surveys).

It is important to acknowledge that the fieldwork was conducted within a sub-set of health boards and services. Whilst sites were selected to include variations in geography (urban and rural), clinical context, regional (NHS territorial health boards) and adoption progress, the findings should not be seen as an exhaustive account. However, the key themes and lessons highlighted in the analysis should be relevant and informative to the other sites and the programme as a whole.

The evaluation highlights three different models of use: Hub-home (clinician connects to patient at home on personal device), Dyadic hub-spoke (clinician in 'hub' connects to patient in remote 'spoke' setting without additional staff support), and Triadic hub-spoke (the clinician in a specialist 'hub' centre connects to patient in remote 'spoke' site with an additional staff member). Each model presents different implications with regard to the scope for clinical consulting and the resource requirements for development and sustainability. Therefore, more work should be done to assess the merits of each approach and how they are (and could be) applied across the health boards.

The activity data was captured through the Attend Anywhere platform, which provided useful information on the uptake and use of the system. However, there are limitations to relying on this frequency data alone. For example, some of the key service level outcomes (e.g. proportion of video activity, DNA rates) would be based on data captured through other clinical and administrative systems (e.g. TrakCare, EMIS). The extraction and interpretation of such data would require significant time and resource, especially as different services use different electronic (and paper) systems to manage outpatient activity. Therefore this level of analysis was beyond the scope of this evaluation. However, establishing such processes locally, in order to routinely monitor activity, would be beneficial going forward. This would require close collaborative working between the project and clinical teams, in order to define the areas of analysis that would be meaningful to the local context.

The survey data provided a unique insight into the patient and staff perspective immediately after the consultation, which was instrumental in providing broader perspectives on user experience as part of the mixed-methods approach. As with any self-reporting method, it relies on the willingness of participants to respond, which presents potential sample bias. In this particular study, our analysis was based on 679 patient surveys and 755 staff surveys during a period involving 6719 video consultations (about 10% of patients and 11% of staff). There are also limitations with regard to the type of data that can be captured using this approach. For example, information governance requirements meant that personal level data (demographics, location) could not be captured. Patient administration systems may therefore, play another important role in this regard. In particular, such data could be used to further understand difference in uptake and provision across different regions and patient groups.

In sum, ongoing evaluations should make more use of routinely-captured data through patient administration systems. This approach will require significant time and resource for project teams to work collaboratively with clinical teams, in order to ensure that the data and analysis is relevant and meaningful to the particular setting. Some teams have already conducted (and are continuing to run) preliminary analysis in this way, which helped provide some estimates on activity as part of this report. Applying this approach more widely and systematically would help gain a more detailed understanding of uptake and use nationally. It should be noted, however, that the quantitative data only tells part of the story. In order to inform ongoing scale-up, such data should be used alongside a qualitative and contextual understanding of how the technology is being used and how it can become more embedded within routine practice.