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

4. Discussion

4.1 Summary of findings

This rapid evaluation has identified a number of key findings.

First, and impressively, in many though not all settings, Scotland's national-level groundwork and strategic planning around video consulting between 2018 and early 2020 created the technical infrastructure, service readiness and positive attitudes which allowed services to hit the ground running and transform, at pace and scale, to a remote-first mode of operating as the pandemic took hold. Between March and June 2020 there was a 50-fold increase in video consultations.

Second, video took off in hospital and other community care services much more than in GP settings, mainly because a) in many cases GPs felt that video was not needed because phone would suffice for most appointments conducted remotely, and b) GP consultations were more varied and so there were logistical challenges aligning video consultations with appointment booking workflows, when telephone did not suffice.

Third, the shift to video occurred most smoothly in services that had already been doing some video consultations, where local enthusiasts could spread their learning and champion the approach, and where a reduction in demand (due to COVID-related service restrictions) created some space for thinking, planning and trying out new approaches.

Fourth, not all clinical conditions or patient groups could be accommodated using the video medium, which raises important issues around how the needs of these groups might be met.

Fifth, our data showed that patients from disadvantaged groups or areas had particular barriers to benefiting from video consultations, including lack of internet access, low bandwidth, inability to afford the data connection, and language barriers.

Sixth, technical performance and dependability is a concern among clinicians and has a significant bearing on the patient experience and clinical quality of the consultation. While the technology application is generally dependable and easy to use, wider technical issues (including connectivity and hardware) must also be in place. Clinicians talked about a need for effective reviews regarding the appropriateness of video for individual patients, IT support (for patient set-up and troubleshooting) and the option of video appointments at spoke facilities within the community to minimise risk of technical issues at patients' homes.

Seventh, the main unintended consequences of rapid scale-up (alongside wider reorganisation activities) included a short (quickly resolved) period of technology performance issues during the early phase, difficulties managing patient entry into the correct waiting areas, and limited availability/assurances of technically-equipped spaces. The impact of these was alleviated through structured knowledge transfer pathways at both organisational and national levels.

Finally, while the pandemic has caused significant disruption to staff and patients, it has also demonstrated an effective capacity for intra- and inter-organisational collaboration. An important aspect of the national response has been the ongoing communication and knowledge-sharing between all elements of the innovation process, maintained by the TEC programme leads. The '12 week scale-up' initiative was grounded in years of experience of embedding Near Me within routine clinical practices, structured to promote a quality improvement mindset and transfer knowledge on the key implementation principles (i.e. the 3-step approach, described on p. 25) and the formation of community networks for collective sense-making and shared learning (webinars, case stories, web resources).

4.2 Opportunities going forward

The pandemic has dramatically altered the 'relative advantage' (benefits over existing solutions) [20] for video consulting because of infection control pressures (and indeed public health requirements to quarantine and shield). As the pandemic wanes, the relative advantage of video compared to face to face will undoubtedly change. However, there was broad consensus among interviewees that the pandemic has meant a long-term shift regarding the role and risk-benefit balance for video consulting in the 'new normal'. Going forward, it is important to harness and further support these achievements, while acknowledging concerns about quality, safety and sustainability.

As noted above, the pandemic has seen a significant expansion in the use of Near Me across a range of clinical contexts. These changes have been most prominent 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 and paediatrics). Practitioners' capacity to try-out the technology and adapt clinical practices have been afforded by attributes of the innovation (e.g. because there was a national licence, it was possible for a clinician to try out the medium without committing themselves), as well as slack (available) resources in some settings (e.g. the lull in routine activity). Furthermore, we have seen extended use of other technologies (such as telephone, sending digital photos), which were deemed most practical or clinically appropriate in some situations. Going forward, it will be necessary to understand the extent to which these new practices that have been introduced for infection control during the pandemic are fit-for-purpose in the long term, and how they can be made better and safer.

With a view of containing COVID-19, emphasis on the value of Near Me has shifted from convenience and efficiency (e.g. reducing travel, saving time) to safety and risk management (i.e. reducing risk of infection). Video consulting now forms a key pillar in the healthcare remobilisation plans and will form business as usual in the foreseeable future. But there will still be value in a system-level approach to evaluating the societal and economic impact. The advantages of reduced travel, service capacity and flexible working will remain influential factors in terms of longer-term service redesign. In addition, questions remain regarding long term sustainability for different Near Me models as activity increases (e.g. managing 'spoke' sites, providing support at home), and the cost-benefits of different modes of remote interaction for different clinical contexts (e.g. video, telephone, photo, email).

The analysis highlights a number of unintended consequences that may have been difficult to fully address in a crisis, but should become a focus longer term. This includes problems of digital inequality, related to IT literacy and skills training, financial hardship, poor housing, weak social networks, cognitive and physical capabilities and internet/mobile connectivity. It will require a nationwide effort to improve digital skills and confidence, establish community-based facilities, assist set-up at home and ensure adequate access to equipment and broadband/mobile data. But it is important to appreciate that upskilling and supporting the population in digital access will never fully overcome the structural and social-cultural barriers to access, and so the option of face to face appointments or visits for vulnerable and excluded groups will continue to be needed.

Other unintended consequences to be studied more closely relate to the impact on the healthcare workforce. Remote consulting has been associated with greater cognitive load on staff and loss of personal care for patients, impacting upon professional identity, social and mental wellbeing. Concerns have also been raised for practitioners in training to observe experienced practitioners and gain the tacit knowledge that enables them to manage clinical risk appropriately. The rapid scale-up of Near Me has brought new possibilities and benefits of working remotely. But it should not be assumed that what has been necessary in a crisis represents what clinicians want or need beyond it. It will therefore, be important to engage with clinicians and healthcare staff more widely to identify potential negative impacts and ways to mitigate these.

Analysis across the different organisations revealed that scale-up was most extensive in hospital and other community care settings, where much groundwork for implementation had been done prior to the pandemic. These settings were characterised by a significant presence of clinical champions, pre-existing technical and material infrastructure, and direct links to IT support. GP services tended to default to telephone partly due to limited access to relevant technology (e.g. not all consultations rooms could be technically set up), logistical challenges to aligning video with GP workflows, and because telephone was sufficient for most remote consultations. Further work is needed to understand the role of video in these settings, improve local IT infrastructures and helpdesk support channels, and align video with administrative workflows. Continued efforts should seek to cultivate a community of practice (groups of practitioners who share an interest in something and are trying to get better at it) for shared learning, alongside an iterative and co-adaptive approach to embedding Near Me within local organisational routines and systems; a gradual and resource-intensive approach that was not possible in a crisis, but may lend well longer term.

At a national level, the TEC programme team had taken the formal role in disseminating information and supporting well-planned and funded quality improvement initiatives prior to the pandemic. It is no accident that Scotland's relative success in rapidly scaling-up video consultations during COVID-19 (compared to other countries during the same time period) follows a concerted capacity-building effort, not just in relation to technology implementation, but also more broadly in relation to "bottom-up" service improvement with a focus on buy-in. Going forward, it will be important to maintain this judicious balance between top-down change with firm goals and milestones, and bottom-up, more organic change that is more responsive and contingent. To this end, 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 ongoing inter-stakeholder dialogue, which brings different priorities and accountabilities.

4.3 Recommendations for ongoing scale-up and sustainability

In our previous evaluation of the Near Me programme up to March 2020, we proposed ten recommendations to support the scale-up and sustainability of the service model. These were subsequently built into the Near Me work plan. Drawing on the findings from the current evaluation we have reviewed progress on these previous recommendations and provided four additional recommendations. These are detailed below.

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

During the pandemic, there has been a strong incentive to use Near Me as it is perceived as better than the face to face alternatives due to infection control measures. As we previously found, some but not all conditions are appropriately managed through a remote video consultation. However, there has been an extended use of Near Me by a wider range of specialities within the hub-home model. These mainly included consultations involving little or no formal physical examination where non-verbal cues and facial expressions are important (e.g. psychiatry, psychology, mental health, respiratory, speech and language therapy, paediatric care). Significant progress has been made in developing guidance across different specialities, including, psychiatry, psychological therapies, maternity, pharmacy and paediatrics.^[12]

It should not be assumed that guidance alone will drive adoption. Other knowledge transfer mechanisms for shared learning and peer support need to be maintained (e.g. through live and recorded webinars), which should be continually drawn on to inform best practice.

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

The development and dissemination of patient facing materials and staff training resources were underway prior to the pandemic. Online patient information, video resources and test call function are available, which patients can be directed to via their care provider website and information leaflets.^[13] The rapid scale-up initiative also expanded guidance for staff on the setting up and running of video appointments across different care settings (across primary care, outpatients, care homes and prison services), as well as a series of practical webinars and virtual training sessions. This has provided a rich set of legacy learning materials hosted on the TEC website and NES portal. Because there was a national licence, it was possible for a clinician to try out the medium without committing themselves, and explore how to adapt and extend the innovation to better embed it locally.

It will be important to maintain these opportunities for shared learning, support and testing as staff seek to remobilise and redesign services.

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. Remote consulting is now deemed to be part of business as usual, when clinically appropriate, and forms a key strategic pillar for service recovery in the new normal.

While Near Me will continue to be mainstreamed in the foreseeable future, it will be important to undertake a system-level analysis that accounts for the sustainability of Near Me as part of wider service redesign. This should incorporate the (often hidden) infrastructural requirements for remote consulting and the cost-benefit comparisons of different Near Me models (home-hub, hub-spoke), as well as other (synchronous and asynchronous) communication channels.

Recommendation 4: Identify and address clinical and care governance issues

Prior to the pandemic, 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.

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, building on the lessons learnt during the pandemic. Progress has been made in gaining RCGP endorsement of the Near Me guidance for GP practices^[14] but more work needs to be done across different specialities.

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 and supported by case studies and progress report via the TEC website. The national profile and inter-organisational networks around the Near Me programme has further strengthened over the course of the pandemic, including close partnership with the HIS and other national bodies to engage services and disseminate outputs.

Efforts to support inter-stakeholder dialogue should focus on new and emerging ways of working where there are conflicting perspectives, priorities and accountabilities associated with quality, safety and governance (e.g. group clinics, mental health, general practice) and wide gaps in the uptake and use of Near Me between health boards and within specialities.

Recommendation 6: Communicate the "gaining a service" narrative

In the previous evaluation we found that 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 challenges of the pandemic. However, it will be important to remain aware of these differing perspectives and workforce implications during the remobilisation phase, as new service models and remote working practices take form.

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 levels of support to accelerate clinic set-up through the rechannelling of local resources and the 'three step' guiding framework to implementation.

Some key infrastructural issues still need to be fully worked out, including logistics and sustainability of the 'spoke' sites, management of physical hospital/office space, IT infrastructure and helpdesk support mechanisms in some localities.

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

Significant progress had already been made prior to the pandemic with regard to establishing structured approaches to identifying, training and bringing together quality improvement leads, which subsequently became a key facilitating factor for rapid scale-up during the pandemic.

Recent events reveal the importance 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 communities of practices for ongoing monitoring and improvement.

Recommendation 10: Strengthening the national 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 evolve across care settings (e.g. group clinics, virtual visiting, social care), potentially involving other platforms, technology enabled care initiatives and associated platforms.

We have also added four new recommendations, based on research undertaken during the pandemic.

Recommendation 11: Review and address digital inequalities

Review service use and develop digitally-enabled care pathways to increase inclusion, ensuring all patients receive the same level of access and care regardless of their digital preferences, access to technology and IT literacy. This will require a multi-faceted approach through joined-up government working, to address issues such as financial hardship, communication/language barriers, physical/sensory/cognitive capabilities and IT literacy/confidence. Proposed strategies include community-based facilities to access private spaces with adequate technology/connectivity, digital skills training for patients and staff, free public wifi/mobile connectivity and public awareness-raising. Opportunities to assess and support patient set-up/access should also be incorporated in the administrative pathways (e.g. when booking appointments).

Recommendation 12: Engage and support GP services

Further work is needed to cultivate communities of practice across GP settings for collective 'sense-making' (asking questions, exchanging different viewpoints, reflecting collectively) and shared learning. Investment is also needed in local IT infrastructure and helpdesk support structures, in order to embed video appointments within the administrative routines and workflows.

Recommendation 13: Supporting set-up in care homes

Targeted support should be provided to care home organisations and their residents. A high degree of variation across care homes (in terms of technical infrastructures, in-house technical skills, and availability of the remote option from local healthcare providers) calls for close collaborative working across sectors to help care home managers and staff devise workable arrangements. Attention will need to be paid to the diverse and unique capabilities (and preferences) of the service users. This work should be aligned with other streams of work to improve digital access and social connectivity within these settings.

Near Me and the pilot vCreate secure video messaging initiative 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

It is important to consider how remote consulting impacts professional identity, mental health and training. The pandemic has brought new possibilities and benefits of working remotely with patients and colleagues. But it is also important to engage with clinicians and healthcare staff more widely to identify potential negative impacts and opportunities to mitigate these.

4.4 Limitations and future research

This study provides a socio-technical (people and technology) perspective that links different levels of data collection and analysis across the NASSS dimensions and illuminates key factors that contributed to raid scale-up. The context of this study presented a number of challenges. This was a rapid evaluation conducted at the height of the pandemic. Interviews were conducted remotely (via phone/video) and many participants were also dealing with and adapting to significant change within their working environments. But with the support of project managers and service staff (facilitating recruitment, participating in interviews/focus groups and providing supporting documents), as well as the TEC team (providing activity data, surveys and reports), the research team were able to build a rich picture of the people's perspectives, experiences and challenges to rapid scale-up in this complex and evolving setting.

It is important to acknowledge that the interviews were conducted within a sub-set of health boards and services, and during a fixed period during the pandemic. Whilst sites were selected to include variations in geography (urban, rural, islands), clinical context, local (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 activity data was captured through the Near Me (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, it cannot provide some of the key service level outcomes, such as video activity as a proportion of all consultations. Given the important role of other technology/systems to support remote consulting (e.g. phone), it would be useful to gain further insight into the relative proportion of appointment types across services. The recording and extraction of such data would require significant time and resource, especially as services had to rapidly restructure administration systems. This level of data would, however, be beneficial for ongoing formative evaluation of remote consulting practices, as services seek to sustain this service model beyond the pandemic.

Patient recruitment for interviews was difficult due to the remote nature of this study, especially for digitally excluded groups. However, the TEC team's public and clinician engagement work employed multiple approaches to access a diverse sample, including online, telephone and written surveys, and proactive engagement with a range of groups. The majority of survey responses were captured via online surveys, which raises potential for sample bias. However, efforts were also made to access participants who may not be able (or willing) to participate online (e.g. via phone/written questionnaires), and to enrol hard to reach groups. Therefore, it has provided a unique and highly informative data set, which has been instrumental for informing our overall analysis. It also illuminates the need to further explore the needs of disadvantaged groups in more detail, and find effective ways of engaging them in the ongoing co-design of Near Me service models.

The post-consultation 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 a large patient sample. But it is important to note that these were reflective of a sub-set of patients using the technology (response rate 15%). There were some limitations with regard to the type of data. For example, information governance requirements meant that personal level data (basic demographics) could not be captured. Patient administration systems may therefore, play another important role in understanding and addressing potential barriers and inequalities across different groups.

Future research needs to focus on how healthcare organisations move forward to the 'new normal'. While much transformation has happened in response to the pandemic, the challenge will be to strategically build on these developments. Key areas to address in this regard include quality of care and patient safety, (including appropriateness of video, conducting physical examinations), health inequalities (including digital access, financial hardship and language/communication), infrastructure (including IT and material aspects) and workforce implications (including staff supervision, training, social and mental wellbeing).