Coronavirus (COVID-19) - Near Me video consulting service: evaluation 2020 - main report

Executive Summary

Introduction

Near Me is the public-facing name for the video consulting (VC) service used across health and social care in Scotland. Near Me clinics have been established in both primary and secondary care, in all local territorial NHS boards and in the Golden Jubilee National Hospital (NHS Scotland's National Waiting Times Centre), as well as in a range of Health and Social Care Partnerships,^[1] Local Authorities and third sector organisations.

In June 2020 the Scottish Government commissioned the University of Oxford to conduct an independent evaluation of the Technology Enabled Care (TEC) initiative for the rapid rollout of Near Me video consultations in the context of the COVID-19 pandemic. The field work was conducted during June-October 2020 by a research team based within the Interdisciplinary Research in Health Sciences (IRIHS) unit at the University of Oxford. This builds on a previous evaluation conducted by the IRIHS team in Scotland in 2019, before the COVID-19 pandemic (see [1] for full report of the previous evaluation).

Near Me is the public-facing name used to describe video consulting services provided via the Attend Anywhere platform in Scotland. This name was developed by patients in NHS Highland, and was in near-universal use across Scotland at the time of the fieldwork for this evaluation.

Attend Anywhere is the name of the video consultations platform, purpose-built to meet the needs of the health and care sectors, for which a national licence has been procured for Scotland.

For the purposes of this evaluation report, the term 'Near Me' is generally used, unless research participants referred specifically to 'Attend Anywhere'.

Background

Building on initial work and early adopter sites to pilot video consulting,^[2] in November 2018 Scotland's TEC programme launched a £1.6 million 'scale-up challenge', to support wider rollout of Near Me across all health boards. Near Me runs on the Attend Anywhere platform – a video technology which works via the internet and can be accessed by a member of the public using their own device, be it a laptop, tablet or mobile phone. People use an internet link to access a 'virtual' online waiting area, where service providers meet them and provide the video consultation. This process has been designed to align with the ways in which people usually attend face to face appointments, and with established health and care processes and workflows. This is illustrated in the diagram below.^[3]

Figure description:

Image showing the process for a patient attending an online video consultation with a clinician. It starts on the left with the patient entering the online waiting area, and ends on the right when the patient and clinician meet in the online video consulting room.

In the previous evaluation we found that Near Me was being used for a wide range of conditions and clinical services, though on a relatively small scale and concentrated in a few Health Boards. Three different service models were in use:

• Hub-home: Clinician connects from clinic to patient at home.
• Dyadic hub-spoke: Clinician in specialist 'hub' centre connects to patient in remote 'spoke' health or care site without an additional staff member present (e.g. in an unstaffed kiosk).
• Triadic hub-spoke: Clinician in specialist 'hub' centre connects to patient in remote 'spoke' health or care site with an additional staff member (nurse, GP, healthcare support worker [HSW]) present.

The Scottish Government's Programme for Government (2019-20) featured Near Me, and committed to opening up health and care services to those who may struggle to travel due to their condition, by using technology such as video consultations [2]. In March 2020, the rollout of Near Me was greatly accelerated to help reduce the need for face to face appointments during the COVID-19 pandemic. It forms part of the national remobilisation framework [3], as well as a commitment in the current Programme for Government covering 2020-21 [4].

The aim of this evaluation was to provide timely and robust information on: a) the experience of the rapid implementation and delivery of the rollout programme to scale-up and spread Near Me clinics, in the context of the COVID-19 pandemic, and b) lessons from this experience, including approaches taken; and barriers to and enablers of the accelerated implementation and uptake.

Research Methods

The evaluation was undertaken between July and September 2020. It used mixed methods and collected qualitative and quantitative data. We purposefully selected eight of the 14 local territorial Health Boards for qualitative data collection, in order to analyse data within the organizational context. These boards were selected to explore variations in geography (urban, rural, islands), clinical context, local (NHS territorial health boards) and adoption progress.

Qualitative interviews were conducted via phone/video call with health and social care staff, including doctors, nurses, allied health professionals, healthcare and third sector support workers, clinician and non-clinical service managers, care home managers; and with national stakeholders. The report also incorporates routinely-collected data on uptake of the service in different localities, extracted from the Attend Anywhere system, patient and clinician experience surveys conducted immediately after the consultation, and outcomes from a public engagement project with the general public, clinicians and partner organisations.

We analysed data thematically, combining descriptive quantitative data with synthesized qualitative themes. Data synthesis was guided by a multi-level theoretical model (NASSS: Non-adoption, Abandonment and challenges to Scale-up, Spread and Sustainability [5]), developed to explain individual and organisational challenges to sustained adoption of technology-supported programmes in health and social care. The analysis focused on developments since the previous evaluation (prior to the pandemic) and implications for scale-up and sustainability going forward.

Findings

Implementation and Use of Near Me

Backed by the Cabinet Secretary for Health and Sport, in March 2020 the TEC team launched a '12-week scale-up plan' to help rapidly deploy Near Me services. This included targeted support for GP practices, priority secondary care services and care homes, while maintaining platform access and providing technical support for local priority activities. The initiative was grounded in learning from the scale-up programme, focusing on issues related to technical set-up (hardware, connectivity, access to software, etc.); service processes (e.g. how patients will enter and leave the video appointment); and training (developing staff capability to consult with patients by video).

A suite of guidance resources on the implementation of Near Me across different care settings (primary care, outpatients, inpatients, care homes) were developed and a large number of people were drafted in from quality improvement teams across Healthcare Improvement Scotland (HIS), the Scottish Access Collaborative and the Care Inspectorate to support engagement, training and service implementation.

Use of Near Me increased significantly from early March 2020 onwards. Between March and June 2020 there was a 50-fold increase in video consultations, from 330 per week to just under 17,000. Hospital and other community care services constituted a much higher proportion of the Near Me activity (77%) than GP services (23%). Near Me was used for over 50 different specialities. Services related to Psychiatry/Psychology and Community Mental Health services presented a significant proportion of Near Me activity, constituting approximately 27% and 10% of overall Near Me hospital/community care activity, respectively. Physiotherapy was the third highest speciality (constituting 9% of overall Near Me hospital/community care activity), followed by paediatric services (8%).

Post-consultation survey data shows that most patients and professionals perceived video consulting as beneficial, both during the COVID-19 pandemic (i.e. to reduce risk of infection) and longer-term (e.g. by improving access, reducing travel). Overall, patient surveys showed positive outcomes in terms of patient satisfaction and patients' views on how the consultation helped them cope with their condition (as measured by the patient enablement instrument, PEI [6]). Technical performance and quality of the call had a significant impact on these patient-reported outcomes.

A separate public and clinician engagement exercise was commissioned by the TEC programme (June – August 2020) alongside this evaluation [7]. Survey data from this work indicated wide support among the public and healthcare professionals for the use of video during, and beyond, the pandemic. However, they also highlight concerns in relation to digital access and health inequalities, including poor internet connectivity, access to relevant technology, cost of mobile phone data usage, and lack of privacy or other social circumstances within the patient's home.

Hospital and Other Community Care Settings

We heard predominantly positive comments from staff, who described various advantages of using video to maintain some level of service provision during the pandemic. The pandemic produced a strong external pressure on NHS organisations and there was a strong sense that this was a national effort being implemented across all NHS organisations in Scotland.

While there was contextual variation across health boards, the case sites illuminate the importance of Scotland's national-level groundwork around video consulting prior to the pandemic, which helped create the technological infrastructure, workflows and local knowledge to hit the ground running with a scaled-up service.

The main challenges and unintended consequences related to the reworking of clinical and administrative routines, administrative structures to support patient 'entry' into the virtual waiting area, and constraints related to IT and physical infrastructure.

The case sites demonstrate the importance of a quality improvement approach to continual monitoring, adaptation and knowledge sharing, in order to support organisational resilience and respond effectively to the evolving and unanticipated consequences of rapid scale-up.

GP Services

Whilst a few general practices had embraced Near Me before COVID-19 (10 out of 931 practices active by March), most had not. The rapid scale-up initiative saw a significant shift in the uptake and use of video consulting across GP services, with approximately two thirds of GP practices starting to use Near Me. But as lockdown restrictions eased, GP activity fell to around a third of practices continuing its use.

While the majority of clinic activity was conducted via telephone, many GPs talked about the value of video consulting, including 'eyeballing' patients to decide whether they needed urgent assessment or admission, paediatric appointment and out of hours (OOH) care.

There were several reasons for limited use and a fall in usage across GP services. These include the case mix in general practice (straightforward problems in patients well known to the clinician where telephone was sufficient), logistical challenges to using video within appointment workflows (due to high variability in appointments), problems accessing video call technology within this busy and complex work environment, and some difficulties with internet connectivity and local IT helpdesk support.

Care Homes

An engagement exercise by the Care Inspectorate during the COVID-19 pandemic revealed just over half of care homes having internet connectivity throughout the premises, about 39% with partial connectivity (e.g. in management offices, corridors) and 5% with no internet connection [8].

Access to mobile and computing devices, and coordinating shared use of these in residential care facilities, was also a limiting factor for video consulting. A number of national and regional initiatives were instrumental in alleviating this issue, such as the Tech Device Network (a Scottish Care-run initiative for organisations to donate technology).

Since the research was conducted, an initiative has been launched in Scotland to facilitate digital inclusion for residents in care homes – a collaboration with TEC and the Connecting Scotland Programme. This focuses on access to devices, internet connectivity and skills support for staff and residents.

Care staff were generally very positive about the option of Near Me appointments for scheduled and unscheduled consultations, and virtual ward meetings with health professionals. However, they were reliant on it being offered as an option by GP and other health services.

A number of video platforms (including Near Me in some cases) have been used to connect residents with family, which has been seen to be particularly beneficial for some residents' social and mental wellbeing.

Data Synthesis using NASSS

The NASSS framework [5] domains were used to assess the impact of COVID-19 on the use of Near Me and the implications of moving from rapid scale-up to longer term use.

Clinical Appropriateness and Extended Use

a. In the context of COVID-19, and depending on the condition and setting (i.e. more so in secondary care), video consultations became an acceptable alternative to bringing the patient into clinic or conducting the appointment via phone.

b. There has been a significant expansion in areas where little or no formal physical examination is required, but where non-verbal cues and facial expressions are important (e.g. psychiatry, psychology, mental health, respiratory, speech and language therapy). In the context of COVID-19, video was often considered even better than face to face because face coverings and other PPE were not needed.

c. Video has also provided a better alternative than phone for limited visual assessments that do not require physical contact or a high-quality/close up image, for "eyeballing" a child or elderly person to assess whether they were, broadly speaking, ill or well, for assessing the acutely unwell patient and also for routine monitoring of chronic conditions.

d. Extended use of Near Me has involved a high degree of preparatory work and creativity among practitioners, in order to adapt and optimise effectiveness. But not all conditions or circumstances are appropriately managed through a remote video consultation. It is important to harness and share learning about the usefulness and appropriateness of different consultation modes in different clinical contexts and social circumstances of patients.

Technological Benefits and Challenges

a. As found in the previous evaluation, the Near Me technology was, in general, considered dependable and produced high-quality video and audio. The software platform (Attend Anywhere) was initially under significant strain due a sudden increase in volume of users, resulting in a small number of periods of service degradation. These were resolved promptly by the technology supplier, avoiding significant disruption.

b. Alignment with hospital and secondary care services through the 'single point of entry' design facilitated rapid scale-up in outpatient care settings. However, expansion in the number of virtual waiting areas and patient volume increased the risk of patients entering incorrect waiting areas.

c. Managing and monitoring patient access was more challenging for GP practices, due to more complex and unpredictable workflows. Functionality within the Attend Anywhere platform (to send an internet link directly to the patient's phone) has recently been included to help overcome these issues.

d. A major challenge for many services across all sites has been establishing adequate private and technically set-up spaces for a video consultation.

Value of Near Me for Patients, Staff and Services

a. The main benefit of Near Me in the context of the pandemic has been reduced risk of infection and the ability to maintain some service provision in the face of limited clinical space, physical distancing and shielding requirements.

b. While COVID-19 has been stressful in some ways, it also created opportunities for service redesign, with many existing and new adopters intending to continue use in the longer term. The main benefits identified were reduced travel, improved access, lower infection risk, increased service capacity, allowing more flexible working and environmental benefits.

c. While video is likely to remain part of business as usual, there would still be value in a system-wide approach to assess the sustainability and cost-benefits of different Near Me service models, as well as other modes of remote consulting.

Concerns Raised by Patients and Staff

a. In our previous evaluation, the concerns we heard were not about the specific video technology, but about the concept of video consulting in general or the logistics of the service. The survey and interview data in this current evaluation indicate growing support for the use of Near Me, both during and beyond the pandemic. However, staff and patients raised a number of concerns about moving from rapid scale-up to longer-term use.

b. Concerns were raised about implications for care quality and safety, as services move from rapid deployment to longer-term use of video consulting, and the need for clarity on information and clinical governance going forward.

c. Patients and staff highlighted issues related to digital access and health inequalities. They included technical barriers (e.g. connectivity, access to devices, mobile data), IT literacy, lack of private space at home and communication/language barriers.

d. Some staff raised concern about potential negative impact of remote working and remote consulting on workforce management, staff wellbeing, reduced supervision, isolation, anxiety and cognitive demand.

Organisational Issues

a. Most participants felt that the pandemic helped bring about a more conducive set of organisational conditions to accelerate the use of Near Me, including a positive narrative about the technology (to minimise risk of infection), slack (available) resources (redirecting staff/equipment) and senior management and clinician buy-in (with national directive and reporting mechanisms).

b. The pandemic brought further (and evolving) organisational challenges related to significant reworking of routines and workflows across the different care settings. This included processes associated with changes to triaging and appointment booking procedures, a significant shift from a predominant hub-spoke (dyadic and triadic) to hub-home model activity in rural and remote settings, and working/consulting from home.

c. Rapid rollout also put considerable pressure on the administrative structures supporting Near Me appointments, including the administrative resources and mechanisms to offer the video option and managing patient entry into the virtual waiting areas.

d. A quality improvement approach to continual monitoring, adaptation and knowledge exchange was needed to respond to the evolving and unanticipated consequences. The scaling-up programme undertaken prior to the pandemic meant that existing local knowledge and infrastructure was already established; though more so within hospital and other community care settings than GP and care home settings.

Wider Contextual Issues

a. There was already strong policy-level support for Near Me before the pandemic. The rapid scale-up initiative was able to build on (and strengthen) the national profile, inter-organisational collaborations and policy-level support over the course of the pandemic.

b. The Near Me programme continues to form a key part of the national remobilisation strategy, as well as further expansion into social care.

c. Recent events illuminate considerable infrastructural challenges in some regions, which have a bearing on equity of access, including geographical variations (e.g. connectivity), inequalities (e.g. financial hardship) and care homes (e.g. significant variations in local infrastructure).

d. Rapid scale-up and service remobilisation creates implications for the sustainability of the 'hub-spoke' (dyadic/triadic) model, as they require various kinds of double-handling (e.g. appointments needed to be made, rooms booked, and staff members made available, at two sites). Effective communication and collaboration between Health Boards is needed to modify the hub-spoke model for sustainability, and also support the hub-home model across boards when clinically appropriate.

Opportunities going forward

a. The pandemic has dramatically altered the 'relative advantage' (benefits over existing solutions) for video consulting because of infection control pressures. As the pandemic wanes, the relative advantage of video compared to face to face will change. But there was still broad consensus that the pandemic has prompted a long-term shift regarding the role for video in the 'new normal'.

b. Going forward, it will be important to understand how the extended use of Near Me (as well as other remote forms of consulting) for the purposes of infection control could be fit-for-purpose longer term.

c. The Near Me platform facilitated opportunities to try-out and adapt the use of video consulting practices. However, there are still some key infrastructural issues to be worked out with regard to IT and physical infrastructures needed to support wider use.

d. Future work should focus on addressing digital inequalities (related to IT literacy/confidence, financial hardship and internet connectivity) and workforce issues (staff wellbeing, mental health and supervision).

e. There is scope to build on recent achievement and lessons across GP settings to cultivate communities of practice for shared learning and help embed video consulting more effectively.

f. Beyond the pandemic, attention should be paid to the overall narrative or "organising vision" (clear and consistent vision among stakeholders as to what will be achieved) within which the change is framed, informed by continued inter-stakeholder dialogue.

Recommendations

In the previous evaluation of the Near Me programme up to March 2020, we proposed ten recommendations to support scale-up and sustainability of the service model, which were subsequently built into the Near Me work plan. Drawing on the most recent evaluation findings in the context of COVID-19, we have reviewed progress against and updated those ten recommendations. We have also added four new recommendations, based on research undertaken during the pandemic. These are summarised below: for full details, refer to the full Recommendations section of this report.

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

Significant progress has been made in developing guidance across different specialities, including psychiatry, psychological therapies, maternity, pharmacy and paediatrics.

In order to further increase adoption of Near Me and inform best practice, efforts should be made to maintain shared learning and peer support across specialities.

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

There has been broad expansion of patient and staff resources, mechanisms for training and multiple try-out opportunities.

It will be important to maintain these capacity-building resources and pathways, as staff seek to remobilise services beyond the pandemic.

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

The pandemic has meant a significant shift regarding the financial case for Near Me, which now forms a key part of service recovery plans, and is considered as part of business as usual for the foreseeable future.

There would still be value in a system-level cost-benefit analysis that accounts for the sustainability of different Near Me service models, as well as other communication channels; and how Near Me can become efficiently embedded within wider service redesign.

Recommendation 4: Identify and address clinical and care governance issues beyond the pandemic

During the pandemic, there has been a strong incentive to use Near Me as it is perceived as better than face to face alternatives due to infection control measures.

As the pandemic recedes, professional and regulatory bodies will have an important role to play in revisiting traditional definitions of good clinical practice in health and social care. Progress has been made in gaining endorsement from the Royal College of General Practitioners (RCGP) for the Near Me guidance for GP practices. Further work needs to be done to secure endorsement across different specialties.

Recommendation 5: Working with professional networks, disseminate stories of up-and-running services across GP, hospital and other community specialities

There was a strong positive narrative around the technology-supported change during the pandemic, communicated by respected leaders and clinical champions.

Attention should be paid to new and emerging ways of working as part of the new normal, especially where there are complex challenges and potentially conflicting views on quality, safety and governance.

Recommendation 6: Communicate the "gaining a service" narrative

In the previous evaluation, some staff in remote community hospitals were concerned that the introduction of video clinics meant 'losing' a consultant-led service (e.g. monthly in-person visits would cease), although others in the same settings depicted the change as 'gaining a service' (access to certain specialists).

To some extent, these concerns have been overtaken by the pandemic. But it will be important to remain aware of these differing perspectives as services recover.

Recommendation 7: Support local champions

The pandemic saw the importance of organisational learning through local clinical 'champions' (who extol the benefits of an innovation to others, including at board level where decisions are made).

It is important to continue supporting these individuals as services look to incorporate remote consulting practices within long-term service redesign.

Recommendation 8: Provide set-up support for ready-to-roll sites, paying careful attention to routines, IT support and material infrastructure

The pandemic has seen a significant increase in the resource and support to accelerate clinic set-up and the development of a guiding quality improvement framework to implementation.

Some key infrastructural issues need to be fully worked out in some settings, including sustainability of the 'spoke' sites, management of physical hospital/office space and IT infrastructures.

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

Recent events reveal the importance of the work undertaken prior to the pandemic, which helped the establishment of a system-level, quality improvement approach to ensuring ongoing adaptation and organisational resilience.

It will be important to proactively maintain and expand on existing networks and communities of practice that have grown during the pandemic for ongoing monitoring and improvement.

Recommendation 10: Strengthening the national Near Me branding

Efforts in late 2019 to get a single, patient-focused national brand ("Near Me") accepted likely contributed to the success of rapid scale-up, providing a consistent and familiar message to patients and staff.

An important challenge will be managing and maintaining the scope of this national brand as service models continue to evolve.

The following additional recommendations are based on our research undertaken during the pandemic.

Recommendation 11: Review and address digital inequalities

Review service use and develop digitally-enabled care pathways to increase inclusion. This should aim to ensure that all patients receive the same level of access and care regardless of their digital preferences, access to technology and wifi, IT literacy and confidence, and communication and language barriers. This will also require joined-up government working to address underlying issues such as financial hardship.

Recommendation 12: Engage and support GP services

Pursue a dedicated stream of work to cultivate a community of practice across GP settings for collective sense-making, peer learning and investment in the co-evolution of Near Me service models. Investment is also needed in local IT infrastructure and support to embed video appointments within administrative and clinical workflows.

Recommendation 13: Support set-up in Care Homes

Targeted support should be provided to care home organisations and their residents. Support close collaborative working across sectors to help care home staff devise and adapt workable solutions to offer video appointments within local contexts, while also respecting residents' rights to choose preferred modes of consulting. Near Me and the pilot vCreate secure video messaging initiative, which links patients, families and clinicians, should collaborate in order to benefit from shared learning and joined-up working.

Recommendation 14: Monitor the impact of remote consulting on the welfare of the health and care workforce

Continually review the impact of remote consulting on the welfare of the health and care workforce, including their professional identity, mental health and training; and identify how negative impacts might be mitigated.