Specialist teams use video consultations to maintain services

Thousands of OUH patients have been able to continue accessing specialist services during the COVID-19 lockdown without having to attend hospital thanks to a new video consulting platform.

Before the pandemic, very few departments at Oxford University Hospitals (OUH) were using technology to conduct remote consultations with patients. Now, more than 4,000 video consultations have been carried out using the Attend Anywhere (AA) platform, allowing clinical teams from cancer to paediatrics, from haemophilia to antenatal care - to continue delivering vital services to patients.

OUH is a major regional and national centre for many specialties, so its patients often come not just from the wider Thames Valley area, but also beyond. In a time of lockdown, video consulting technology has allowed those patients, as well as those closer to the hospitals, to continue to access vital services.

Ahead of the widespread adoption of AA, the Oxford Sarcoma Service - one of only five National Specialist Bone and Soft Tissue Sarcoma Services in England - carried out a study into the technology.

Significant effect

"Patients often have to travel significant distances for ongoing treatment - as far away as Cornwall and the south coast. The disease process and time away from work for appointments can have a significant effect, as well as being extremely costly, especially for those with malignant disease," said Dr Thomas Cosker, the Consultant Orthopaedic Oncology Surgeon who led the study.

He said patients "appeared extremely happy with video consultation", in particular those who work or are house-bound, noting that it was generally a younger working population who took up the offer.

While the quality of the conference is very dependent on Wi-Fi connection at both ends, and there have been a few failed connections, most patients, according to audits conducted by some services, have been enthusiastic and have found it quick and easy to access the system. Many are keen to continue using remote consultations once lockdown is lifted.

The most frequent users of AA during the COVID-19 emergency have been children's services. Dr Konrad Jacobs, Consultant Clinical Paediatric Psychologist, says this is because engagement and communicating clearly is essential when dealing with young people and their families: "We know that if we don't engage with children and teenagers, we're not going to get anywhere. Using video is immediate, and easier than engaging with them over the phone. Video is not ideal, but it is the next best thing to face-to-face consultations."

Angela Shanly, Consultant Clinical Psychologist and Family Therapist in paediatrics, whose patients include young adults with cancer, says it's important that her consultation involved the family: "Although some patients prefer the telephone, video consultation is usually more effective especially if you want to see more than one person. I was keen to keep seeing families as much as possible - and that includes both parents. With face-to-face consultations, it's often the parent who looks after the child who attends, especially if the other parent is working. Using this there is greater possibility of including both parents."

Timely service

Another area that piloted the use of Attend Anywhere, even before the pandemic happened, was the Oxford Centre for Enablement (OCE), whose specialist rehabilitation teams serve the South East of England and cover as far as Dorset and the Isle of Wight. 

Dr Anton Pick, Clinical Lead at OCE, said it was a strategic priority for the service to hold consultations and deliver rehabilitation interventions remotely, as well as using innovative ways to connect with health partners, such as hospitals across the region from which patients might be referred to OCE.

"Whereas previously clinicians had to travel to places such as Milton Keynes, Swindon, Reading or Winchester to review patients, and relied on phone conversations with clinicians in places further afield, such as Southampton and the Isle of Wight, now we are able to remotely review patients over the platform. It saved significant clinician time and provided a much more timely service to our health partners."

His colleague, Dr Ahmad Saif, a neuro-rehabilitation specialist, said that previously, OCE staff would have to travel to the referring hospital to assess the patient's suitability for admission to OCE; using video consultations had worked well and saved a large amount of time.

"Our patient group have complex disability and find it hard to travel to clinic. Transport can be unpredictable and parking makes the experience difficult. We therefore also introduced outpatient neuro-rehabilitation clinic via video consultation. We have continued to do this through COVID for both spasticity and neuro-rehabilitation and this is working well. Patients have found this extremely useful, and have been overwhelmingly positive," he said.

During the COVID-19 emergency, OCE had been holding medical clinics, delivering physiotherapy, speech and language therapy, neuropsychology and occupational therapy interventions using the platform.

"The pandemic really catapulted us, along with much of the rest of the health service, into a new digital age," Dr Pick said.

Contact with clinicians

Laurence Wright, Senior Occupational Therapist at OCE's Specialist Disability Service, working with patients with conditions such as motor neurone disease and multiple sclerosis, has been using AA to work remotely with carers to set up patients' computers so they can use them to improve the quality of their lives - by using social media, shopping, playing games or writing emails.

"These are patients with very complex needs," he said. "In the final years of a person's life, it's important for them to not only have contact with clinical teams, but also to be able to connect with friends and family. People have reacted well to the fact it's an NHS system - they appreciate that safety has been prioritised."

Like many of the people who've used the system during lockdown, Laurence prefers face-to-face assessments, "but it's better than assessment over the phone, because you need to be able to read people's reactions."

Louise Warnock, a cystic fibrosis physiotherapist, echoes that view: "Given our patients have chronic respiratory disease we are proactively contacting them to identify any concerns early and hopefully avoid the need for admission. 

"Being able to see patients over video makes it much easier to assess how unwell they might be and for me offers the opportunity to observe them performing their physiotherapy. Whilst it is not the same as a treatment in person, I can advise them more confidently how to adjust this - something that would be extremely difficult over the phone. 

"Attend Anywhere has made it much easier to have open honest conversations with patients about how they are coping. Patients have been overwhelmingly appreciative of our calls and are valuing this service. It has allowed me to identify patients that are less well and struggling with doing their treatment.”

Triage tool

Another physiotherapist, Stephanie Taylor in the haemophilia service, started using AA for one-to-one appointments at the start of COVID-19 emergency, although she has been using Microsoft Teams to deliver her regular exercise classes.

Although she prefers face-to-face consultations that allow her to 'lay hands' on patients and make a fuller assessment, the video connection has been important in monitoring the progress her patients are making.

"It has great potential as a triaging tool and could lead to changes in the haemophilia service. It's useful if patients have an acute bleed; it can be assessed rapidly over the video connection and managed remotely. It has been very useful for following up with patients who live a long way away and for reducing footfall at the hospitals.

Kathy Bailey, a Consultant Paediatric Rheumatologist who has been using the technology, believes AA will have an important role to play in future, but cannot replace face-to-face appointments.

"It's been good to be able to access a lot of patients, and we have been able to run most of clinics virtually, but it's not the same as seeing a patient face to face, both in terms of their medical management but also around the relationships that you build and the use of a multidisciplinary team.

"Video consultations have an important part to play - it helps with accessing patients who live a long distance away, with supporting new patients on new treatments and with those patients where you just need regular brief catch-ups, meaning they don't have to take time out of work or school."

Dr Tom Cosker of the Sarcoma service added that it was more common for lifestyle advice to be given during face-to-face consultation and substantially less during video consultation, where the focus was more on the specific treatment relating to their condition, rather than the patient's overall wellbeing.

"We also found that patients and clinicians seem to feel more comfortable with remote consulting when the condition has already been diagnosed and where they already know and have met the specialist," he added.

There are a number of issues that need to be addressed - it is, for example, harder to collect research data via video conferencing - but generally the system has been well received and it looks like being a useful option in the future when restrictions on movement and attending hospitals are eased. 

As Angela Shanley says, "Many of our families are not well off and it's often difficult for them to make a long journey for a potentially short consultation. If there are people who don't need to come into the hospital in person, I think this is a great option."