Video consultations - public and clinician views: consultation report

5 Discussion and conclusions on main findings

The use of Near Me video consulting has changed dramatically since Covid-19 pandemic, both in terms of the scale and types of use. On the1st September 2020, the First Minister in her announcement on Programme for Government 2020/2021commented on how quickly progress had been made and stated:

"So, while we recognise video consultations will not be appropriate for every patient and in or every situation, I can confirm that we intend to move to the position where Near Me is the default option for patient consultation. We also intend to develop the use of Near Me in social care."

While the findings reported here focus specifically on Near Me, the approach and feedback will have wider application across all Technology Enabled Care services, including the development of the social care programme and extension to public services more generally. It also highlights the benefits of co-producing services. It is believed this is the first public engagement carried out at a national level into the use of technology across all health and care settings. Therefore, it is of little surprise that the work has identified some new findings and sheds some challenge on previous assumptions about potential barriers and benefits of video consulting.

While this report is not an academic study the data gathered are being passed to Oxford University team for further analysis as part of their independent evaluation into the rapid scale up of Near Me in response to Covid-19. Their findings will be published later this year.

5.1 Public engagement approach

In recognition of the step-change in use of video appointments, the National Near Me leadership team recognised the need to raise public awareness about the service. Various approaches were considered, and it was decided that a national public engagement exercise using a range of methods would be the most appropriate.

This national pre-engagement work got underway with local and national media in April 2020. This included providing reassurances that video appointments were not new, and the current approach and technology had been co-designed with patients and the public in 2017-19.

Launched on 29^th June, through the public engagement views were sought from across Scotland on a range of factors around current and future use of having a health or care appointment by video technology. Potential use was explored through various perspectives and, if and how, views might change during Covid-19 or post Covid-19.

The approach generally worked well, as evidenced by the variety and the richness of the feedback. There were rightly some concerns raised about the restrictions on engagement methods caused by physical distancing as illustrated in Case Study No.6. All suggestions made to the Near Me team on how to improve engagement through non-digital means were actioned, further demonstrating a commitment to be responsive.

Over 300 organisations were contacted directly including over 25 health and care professional bodies, institutes, and unions. The online public survey received 4,025 responses and the online clinician survey 1,147 responses with an additional 228 responses from other means (total =5,400. Put together, it is believed this is significantly more than any other public engagement or consultation in Scotland in recent times including pre Covid-19.^[17]

However, despite the high number of responses, it is important to acknowledge that the number of responses per se is not the only consideration. For instance, we do not know why most professional bodies did not respond specifically (although a number said they filled in the online survey). Furthermore, the online survey component is not a scientifically rigorous study and there is no attempt to imply otherwise. It represents a self-selecting sample of people choosing to respond and offer their opinion. Self-selection, however, is influenced by awareness of the survey and wider public engagement. We are not aware of any intentional bias in raising awareness. For instance, all local media across Scotland were contacted about the engagement exercise and covered the story. There were also communications across all integrated authorities, local authorities, health boards and national organisations. Furthermore, the interim Chief Medical Officer highlighted the engagement exercise within the First Minister's daily Covid-19 briefing which is televised across Scotland. And the use of Near Me video consultations was covered on various BBC Radio Scotland programme including phone-ins.

Relative to the size of population served by each health board area, people in island boards were more likely to respond, followed by people in the Northern boards. This may reflect greater familiarity of video consulting services in these boards where there had been early adoption to address rurality issues.

The responses received from the online public survey were reasonably representative across a suite of demographic characteristics with two notable exceptions. Firstly, responses were over-represented from females (80% responses of the online public survey v 52% female population in Scotland). While females are typically over-represented in health surveys of this type, this is not usually to the extent we have found here (the Consultation Institute, per comms). Secondly, while the working age group (aged 16-64 years) make up 64% of the population, in this survey they also represented around 80% of respondents. In health services, older people are more likely to respond and it seems likely to reflect that, older people may be likely to respond to online surveys. The number of responses from ethnic groups was also low.

The bias towards women responding was evident early on and prompted some targeted awareness raising on Twitter to male groups such as Men's Shed and others. At this point in time we have no evidence or theories to account for this bias. When we controlled for gender, however, there were little or no differences on the survey results.

Survey responses collected over the telephone and by paper, albeit a small number (N=47) were more representative of the population in terms of working age and gender but had a higher number of people with a disability when compared to the population (44% respondents vs 25% Scottish average). Fewer of the phone/paper group had heard about the Near Me service when compared with those who had responded online (41% v 58%) or had prior experience of using it (13% v 25%).

Some targeted work by Greater Glasgow and Clyde found that of the eight interviewees whose first language was not English, none had heard of "Near Me" video service for health and care. Similarly, awareness of the service was low in people with learning disabilities. In another focus group four of the five carers were aware of the service.

5.2 Acceptability by service users and service providers

A key question posed by the engagement exercise was: Should video consulting be offered for health and care appointments?

Overall, 87% of those who responded to the public survey agreed that video consulting should be offered. There was little variation in the response by health board, with respondents agreeing Near Me should be offered ranging from 83% to 89%. The only possible exception was for NHS Shetland where this increased to 96%, though the sample size is low. The analysis was re-run to control for demographic characteristics which showed a slight drop-off in older age groups 65-74 years (82% agreed Near Me should be used) which further reduced in the over 75 years age band to 76%. This may back up the earlier point about fewer people responding the survey people aged 65 and over.

Of those who responded by telephone or hard copy, 81% thought Near Me appointments should be offered.

Turning to health care professionals, of the 1,131 who responded to this question, eight out of ten (81%) had previously consulted using Near Me, and over nine out of ten (94%) agreed that Near Me appointments by video should be offered in the future. This may reflect some bias in who was likely to have participated in the survey.

Other responses from individuals and organisations, almost without exception, described a wide range of scenarios where it was acceptable to use Near Me.

5.3 Public and professional opinions on appointment preferences

An important question to address was people's preference for the type of consultation: whether that was phone, video, or face to face.

As expected, preferences for face to face consultations dropped markedly during periods of physical distancing with less than half (46%) opting for an appointment in this way during Covid-19.

Professionals preferred phone and video (95%) during Covid-19 over face to face consultations (56%), and slightly preferred video (88%) to phone (86%) in a post Covid-19 world. The health profession preference for video over phone was smaller than the public's, and indeed health professionals generally scored the acceptability of phone consulting more highly than patients.

The findings showed that video was preferred to telephone consultations, especially by the public, in both scenarios (during and post physical distancing). Although this is unlikely to be significant, it nevertheless is an important finding since hitherto individual clinicians often report a sense that phone is preferred.

On the other hand, Marie Curie reported that its early findings indicated that telephone consultations were preferred over video throughout the pandemic. The charity believed this was due to patients not having the appropriate technology to facilitate video consultations at home or feeling uncomfortable on camera.

Looking at the feedback from people with learning disabilities, a group commonly cited as not appropriate for video consultations, mixed views were found. It would be fair to say that this group encountered more barriers than the public but nevertheless for some video consulting was a positive option, though this certainly should not be overstated.

More generally, from our analysis thus far, the following quote reflects the most consistent feedback around preferences from responses from individual, professionals and organisations across the piece:

"Services are most accessible when people have a range of different access options."

5.4 Range of uses and clinical appropriateness of video consulting

From a clinical perspective, understanding professional opinions around the use of video consulting is a key component to developing the service.

Health care professionals selected a range of consultation types for which they might use video. The most common were 'advice and support' (88%), 'active management and/ or ongoing treatment' (73%) and 'review of long-term condition management including 'medication' (66%). Around one third felt video was appropriate for 'acute presentations' (33%) and 'assessment before a procedure'. Within such categories, there were nuances which should prompt both service users and providers to be alerted to being hasty in making assumptions. This theme will be explored further by looking at substantial amount of free text comments. What is clear from the analysis to date, however, is that most health professionals who responded to the public engagement were comfortable using video consulting, including for:

• consultations where the needs of the patient were predictable; and
• those where needs were unlikely to include a physical examination.

These survey findings are mirrored by the large expansion in video consulting seen in clinical areas where there is less need for physical examination, for example in mental health.

In order to maximise the use of Near Me for management, and review of ongoing conditions, mixed models of care have been developed in which a patient may access routine physical tests (eg, blood samples, blood pressure check) prior to a review appointment by video: indeed, having the test results available at the appointment can inform decision making within the consultation. GP practice nurses reported using Near Me for long-term condition reviews, such as asthma and diabetes, with some suggestion that patients who previously did not attend asthma reviews in person were more inclined to access Near Me appointments.

Where video consulting was reported as less useful was in situations where a patient was presenting with an unknown diagnosis. In these cases, many clinicians thought the potential need for a physical examination was so high that a video consultation created an additional step. In contrast, some clinicians reported that where telephone triage was being used for all acute undifferentiated presentations, then the option to convert the telephone triage call to a video call instantly was very useful. In such a scenario further work is ongoing.

It says a lot about the changing circumstances brought about through the pandemic that, until recently, most of the focus and discussion has been around clinical appropriateness of video consultations. Both through the Equality Impact Assessment process and this wider public engagement, a light has been shone on the other circumstances which should influence decision making. A crucially important factor reported less widely before the pandemic is an individual's access to a private space for a video consultation. This was well expressed by Waverley Care in its response.

"There should be consideration given to whether people can safely and privately access video consultations at home. Home is not always a safe place for many people, particularly to discuss sexual health or another sensitive health issue.

"Likewise, we support some women who would be at risk of gender-based violence if their partners were aware, they were accessing sexual health or BBV services. Many of the people we work with have not disclosed their HIV status to anyone other than healthcare providers.

"It would therefore be important to ensure that there are local, safe spaces where people could access Near Me consultations if it were not an option to do this at home. To protect privacy, it may be helpful if this could take place in a generic health setting (e.g. GP or dental surgery), so that the person would have an 'excuse' to be attending an appointment."

From the more qualitative feedback wider issues such as loneliness and the importance to wellbeing of getting up and out for an appointment were also touched upon (Case study No.4).

Two sources of feedback specifically mentioned 'touch'. Marie Curie said that staff had commented on the lack of touch due to not being in direct contact with patients. In the UHI feedback they said that this had also come up in discussion with students and staff linked to the impact of relationship building. Nurses and others said that they had not appreciated how much they physically touched patients prior to Covid-19, particularly when patients were emotionally upset. They went onto add "students have talked about the lack of presence when using VC - difficult to describe, but it's something they feel is missing when using VC. Of course, some of these points could also be adjustment to new ways of working."

At the time of the Public Engagement, Near Me is being used for a wide range of conditions, clinical services, settings, and scenarios. An attempt has been made to capture the essence and range of feedback. These views spread across primary and secondary care, community services, third sector organisations and health care education.

Near Me is being used by just about every clinical specialty and different health professionals. It ranges from the midwifery and infant feeding at the start of life (Case study No.8), through to cancer, Alzheimer's, and end of life care.

Case study No. 8 Use of Near Me for Infant feeding

"My initial thoughts when I first heard of the Near Me service was one of doubt and apprehension re change.

As an Infant feeding advisor, I wondered how I would be able to offer women support for feeding using this platform? Now four months on my doubts and apprehensions have been blown away.

I daily am able to dive on the platform and find myself in the living rooms of women who are having challenges with feeding. The dads have been amazing and very clever with the camera work, allowing me safe, close contact with mum and baby. The mums seem very receptive and look far more relaxed in their home environments. I am able to look at eye contact, facial expressions and we have successfully been able to identify issues and sort feeding problems. We are now using it to carry out breast feeding assessments prior to referral for tongue tie division.

The COVID pandemic has brought about a lot of anxiety for staff and mums alike and this platform has enabled both parties to see visually without masks conversations which are supportive and empathetic. The feedback from mums has been positive and hopefully as we move forward, we will continue to use it for the future."

Survey responses were mixed around using Near Me for difficult conversations, such as breaking bad news and trauma therapy. Some health professionals and patients highlighted the risk of using remote consultations, for example:

"Using Near Me for this work risks 'bringing' the past trauma into their safe space at home"

But more widely, patients commented that not having to travel home after receiving bad news would be beneficial. Health professionals have suggested that choice is the most important consideration: explaining to patients that the next consultation may involve bad news or a difficult conversation, and asking where the patient would like to be: at home by Near Me, by telephone, come into the clinic or, potentially, at a Near Me hub close to home (if such facilities exist).

5.5 Benefits and barriers

In the various ways feedback was facilitated, participants were asked for their views on the actual or potential benefits and barriers of video consultations. The majority described both with some also offering their opinions on the benefits and barriers for other groups of people.

5.5.1 Benefits

That Near Me could be used to lower infection risk was common across all feedback and scored as the highest benefit (Table 11).

Table 11 Comparison of benefits of video consultation for the public as scored by the public and professionals

Benefits to patients	Scored by
	Patient	Professional	Benefits to Professional
More convenient	4.0	Not scored	2.9
Saves time	4.0	4.0	3.2
Saves money	3.6	3.8	Not asked
Reduces the need to take time off work	3.6	4.0	Not asked
Reduces time away from usual activities	3.4	3.9	Not asked
Reduces the need to travel	3.9	4.1	3.2
Lower infection risk	4.2	4.4	4.2
Better for the environment	3.9	3.4	3.5
Easier to have a relative or carer attend	3.1	3.7	Not asked
Prefer attending from a location of my choice	3.5	3.8	3.3
Improve access to services	4.1	3.9	3.9

For the public, the highest-ranking benefits (aside from reducing the spread of infection) were: 'improved access to services', 'more convenient', 'saving time' and 'reducing the need to travel'. 'Better for the environment' also scored highly with patients, indeed, more so than 'saving money'. Trends were similar for those who responded by telephone or in writing, and indeed for that group 'better for the environment' scored the highest alongside 'lowers the risk of infection'.

Perhaps more surprising was when clinicians were asked to give their opinion on what they thought would be most beneficial about Near Me for their patients (rather than any benefits for themselves), they generally scored them higher than patients with two notable exceptions: 'improved access' (3.9 v 4.1) and environment benefits (3.4 v 3.9) where their scores were lower that the public views.

This qualitative analysis is backed up by some of the other feedback where a range of benefits were described (Appendix 4). The response on behalf of Hospices across Scotland, for instance, pointed out that virtual outpatient and day services are accessible by a wider audience and they can take referrals from further afield.

5.5.2 Barriers

For some people, for a variety of reasons they were not interested in accessing video appointments under any circumstances even where they were not digitally excluded.

"Systems need to be flexible and not 'one size fits all' to meet individual's needs. A mix of video, face to face and telephone and so patients can choose what works for them."

The online survey also offered the opportunity for the public and professionals to feedback on the barriers to video consulting. Questions were slightly different for audiences but, where appropriate, responses were compared.

This engagement exercise has, for the first time, highlighted the challenge that many people have with a lack of private space in their own homes or indeed have no home. "No one left behind Digital Scotland: Covid-19 Emergency" cited three main barriers to digital connectivity: access to a device, connectivity, and skills to use digital technology. The issue of space, privacy and confidentiality was not described. It was also not identified in the SBAR prepared by Public Health Scotland "Digital exclusion and impact on accessing redesigning health and care services in Scotland." Notably, the health care professionals scored that 'no or limited access to a device' and 'support' to use the system would be the biggest barriers (Table 12).

Table 12 Barriers from the perspective of health care professionals

Barriers to patients	Scored by
	Patient	Professional
No or limited access to a device for video calls	3.4	4.0
Poor internet connectivity	3.6	Not asked
Cost of mobile data	3.2	Not asked
No private space for a call	3.3	Not asked
Not confident with video calls	3.0	Not asked
Do not like video calls	3.1	Not asked
Not appropriate for my circumstances	3.2	Not asked
I would need support to use the system	2.9	3.9

Average scores are calculated and go from 1 (strongly disagree) to 5 (strongly agree)

This suggests that until now, services have largely been focused on the technical barriers to using video consulting, rather than the wider patient and social circumstances. The challenges for many to access services is not new yet there has been no requirement to carry out impact assessments for more traditional methods of consultations. For many, Covid-19 has exposed these difficulties. Barriers were apparent for young people, people in abusive situations, people who are homeless or living in temporary accommodation, and people who do not wish their family to know about their health condition or situation.

For health professionals, the biggest barriers for using video consulting were risk of poor-quality sound or image (4.0), 'worried about missing something on the video' (3.7) and preferring to seeing patients in person (3.7).

A small number describe conducting video calls as 'stressful' or were not confident using video calls for consultations, which in part may link in with feelings of 'stress'. Although this was only identified by a small proportion of respondents, the free text comments would be worthy of further analysis. Many health professionals described their progress in using video consulting from early doubts to growing confidence, and some of the comments may reflect people at different stages of this journey. But as mentioned in feedback from the public, staff not being confident in delivering the service makes for a bad experience for patients.

These results were borne out by the wide range of other feedback with digital exclusion in all its guises and lack of social space and other circumstances featuring as barriers (Appendix 4). Throughout, the feedback was peppered with some technical difficulties experienced and these have been collated in Appendix 5.

'I found the video consultant really good. There was very little to no waiting time. The letter was very clear in its instructions and it was very easy to set up. The audio was very clear, and the picture was good quality. The only issue was the last 5 minutes the video froze. The doctor's internet was not as good as mine but the audio was still clear so he could still hear me and vice-versa. Overall, I found it to be a good experience although I do not know how I would have felt if I was having to show them something instead of just a conversation.

Poor internet connectivity and costs were also barriers, but these are not new findings and have been described including across accessing health and other services.

5.3 Improvements

The development of Near Me from its inception has taken a co-design and quality improvement approach. One of the objectives of the public engagement exercise was to identify improvements and it was successful in this regard.

Addressing some of the issues raised in relation to IT, equipment and infrastructure will certainly bring improvements. One of the issues quite commonly raised by clinicians is a need to improve the functionality of being able to move easily between a phone call and a video. Other suggestions ranged from needing to raise awareness of the service in general, improving accessibility, testing loaning devices and having local hubs, such as in Highland, where the service can be accessed from (Appendix 6). Some of the feedback highlighted it was important to support and equip professional and patients with the skills and confidence with how to conduct a good consultation on video.

More specifically, the existing functionality of Near Me is not being fully utilised including some health care professionals not being aware of the existence of functions such as three-way calling and sharing screens. Yet despite this, there was support for additional functionality. Strongest support from professionals was for sending patient information which could be downloaded during the consultation and for patient group sessions. Notably, these were seldom raised by the public with the need for accessible information a higher priority.

In the opinion of one consultant: "The biggest barriers are clinicians' unfamiliarity and patient access to appropriate technology. Community hospital Near Me hubs, as undertaken in Highland, could be a solution for patients who don't have / can't cope with the technology."

Factors that would enable video consulting identified by a high percentage of health professionals are somewhat surprising and worthy of further consideration (Table 13). Patients asking for a video appointment' (86%) were more likely to influence a health care professional to offer Near Me appointments than best practice guidance from professional bodies (71%). This backs up an earlier point about raising awareness so that patients know what choices are available.

Perhaps surprisingly, only just over half of professionals (55%) thought peer support from others with expertise would make it more likely that they would use video consultations: although this might indicate responses from professionals who are already experienced in using video and are less inclined to use it for other reasons.

Table 13 Factors that might make use of video consultations more likely

(Factors: Support)

Interventions to improve digital access, to make it easier for all patients to use video: 86%

If my patients' ask for appointments by video: 86%

Ability to provide mixed clinics combining video with face to face consultations, instead of all video: 79%

Improved internet connection where I want to make video calls: 72%

Best practice guidance from professional bodies: 71%

Improved organisational processes to use video consulting, eg, clinic scheduling, appointment booking: 60%

Video calling device in my normal consulting room / location: 59%

Peer support from others who have expertise in using video consulting: 55%

More support from my organisation / employer: 50%

Support with test appointments so I am more confident in the system: 28%

Being set up with an account to use video consulting / currently waiting to be set up: 19%

5.4 Environmental

One of the objectives of Near Me is to help to addresses some environmental imperatives including by reducing travel.

Based on the responses from the online survey the public appear to be bought into this to some extent and it was included in their top five benefits. This was seen to be less important to healthcare professionals but one consultant who wrote in commented:

"I don't understand why any treatment modality which will save the health service thousands of pounds and will be better for the environment is even a point of debate."

Various organisations (public and third sector) with a remit around environmental issues were contacted about the public engagement. They were invited to feedback and support with raising awareness and a good number did. Only RSPB Scotland formally responded: "We can see huge benefits in what is being proposed. It is great to see the links between health and the environment are being recognised more widely."

While there is clearly a carbon benefit in using Near Me (or any virtual appointment system), as it stands, there is not a system to reliable measure carbon associated with patient and staff travel (aside from the occasional ad-hoc studies). For this reason, it is not included in any 'official' figures. There may be some scope to consider this further as part of the work on NHS Scotland Climate Change and Sustainability Strategy.

5.5 Conclusions

The key learning is that use of Near Me video consultations is much more nuanced than often reported, especially around inequalities and wider societal situations and circumstances. The most common finding was that both organisations and individuals generally feedback both benefits and barriers. In other words, Near Me will not exclusively work for some people and conversely not for others: it will often depend upon individual circumstances. Therefore, the findings challenge some of the generalised assumptions that are often made about when video consulting cannot be used. In addition, there were some subtle but important differences in what the public reported was important to them compared with what health professionals' thought would be important. This again highlights the benefit of co-production and engagement, rather than making assumptions, no matter how well intentioned.

The engagement exercise also revealed that four out of ten people were not aware of Near Me including many who felt they would benefit from it. For others, they knew about Near Me, but it was currently not on offer. One reason for this was that the service is not universally available, sometimes because professionals did not have access to sufficient equipment, did not feel comfortable providing a service in this way, or were opposed to it on some other level.

Notably, however, a strong theme to emerge was that almost nine out of ten health care professionals who responded to the online survey said that 'patients asking for the service' would make it more likely that they would wish to provide the service.

From the patient/public perspective, poor internet connectivity was the main barrier. In the future there will be opportunities to expand the service when digital connectivity is overcome. While poor connectivity creates digital exclusion, addressing it is quite different when compared to other facets of digital exclusion.

Two of the most significant findings, compared with previous knowledge about the use of video consulting, has been the key benefit of preventing infection and the key barrier of a lack of private space at home.

The Covid-19 pandemic has been, without doubt, the single most important factor in the rapid scale up of video consulting, despite its potential for reduced infection spread being apparent for some time

However, the issue of privacy at home was a more surprising finding of this engagement exercise. This was quantified both in terms of a suitable space/privacy, and confidentiality considerations and was well described by one CAHMS clinician: "Patients do not always have a quiet private space to have their consultation and in work with young people and families this leads to a number of boundary issue , confidentiality problems and at its most extreme child protection concerns. I have been told by young people after the event that they felt unable to talk because of the presence of other members of the household in the vicinity."

While individual clinicians and services may have been aware of the issue this appears to be the first time it has been described across services accentuated during the pandemic.

One of the tenets of the Near Me Vision was to embrace the principles of Realistic Medicine. The last Realistic Medicine report stated: "NHS Near Me enables us to provide appointments where patients want them, rather than expecting patients to fit their lives around the NHS. It reduces health inequalities related to access and limits the detrimental effects of having to travel for appointments - for frail patients and relatives, it is less exhausting; for others, less time needs to be taken off work or school."

Through this public engagement exercise, there is evidence to demonstrate that use of Near Me is an important option to meet this objective and that significant progress has been made including a better understanding of equality impacts around appointment types.

One clinician who had been using video consultations for some 20 years makes an important observation for their clinical speciality. "There is already a huge amount of evidence showing telepsychology is equivalent to in-person, but most clinicians are unaware of this, and as a result, it is often treated as the poor cousin." The appropriate use of video in the right circumstances is certainly not a 'poor cousin' with evidence to support many benefits.

The findings show that further support would help professionals to overcome some of their barriers and in turn improve the service they can provide through video consultations.

Finally, a consultant neurologist who wrote in with views neatly frames the discussion and where to go from here:

"I have used Near Me a lot and found that patients in general cope well. The question is where it fits into routine practice once we return to normal? How we use it in a pandemic and recovery will necessarily be different."

In conclusion it is hoped that the findings presented here together with the further analysis planned with Oxford University, contribute to the granularity of when best to access health and care appointments and guide further developments and improvements to increase choice.