By Kate Goodman
The NHS has for many years, has been wrestling with increased demand and the impact this has had on bed availability, appointment availability and waiting lists. The NHS has a number of targets that they should meet such as timescales for referrals for suspected cancer, A&E waiting times and operation waiting times. The traditional methods of inpatient appointments do not work for everyone, and most people will be familiar with the long wait, sitting in a packed waiting room with dozens of others, waiting for a clinic or to be called through in A&E. The NHS, even before the challenges of COVID-19, were trying to think of novel, technological solutions to reduce the waits of patients, whilst maximising the time of clinicians in the NHS.
Telephone and Virtual Outpatient Appointments
We are all aware that that since the pandemic, many appointments in the NHS were either cancelled, or rearranged as telephone or virtual, video appointments to avoid even greater backlogs and to try to ensure continuity of patient care, whilst adhering to social distancing or minimising risk of COVID-19.
What many do not appreciate, is that the NHS was already making use of such appointments in some settings. It was not uncommon to speak to GPs by telephone or for more routine hospital appointments to be arranged as a telephone consultation. Such appointments did not work for everyone and still don’t, but for a significant proportion of patients, they avoid the need to travel to the hospital or GP and endure long waits to see a doctor, when a short discussion was all that was necessary. This has saved time for both patient and doctor.
Implementing such appointments as a result of COVID-19 became more a matter of urgency, but many hospitals, and even some GPs, already had the technology to implement such appointments and simply had to expand its use. For many, they have been a positive move and it has kept the NHS functioning.
However, we cannot forget that such appointments do not work for all. Not everyone has the technology to engage in such appointments, and they can deter some patients from engaging in full discussions with their doctor. Clearly a physical examination is impossible with such consultations and more research is needed on whether such appointments help or hinder doctor/patient discussions. They certainly are not appropriate where a physical examination is required, nor for more detailed or complex discussions.
The use of video/telephone appointments by GPs and consultants is therefore a matter of judgment for both the patient and doctors alike. Patients will, however, need to be prepared to speak up if these appointments do not work for them personally. And doctors will need to push back if they feel this from a patient.
How could Emergency Services Benefit from the use of Video?
From the end of June 2021, it became a requirement that all telephone and broadband companies must be able to accommodate a new ‘999 BSL’ service which was subsequently launched in June 2022. This allows people who require a British Sign Language interpreter to speak to the caller, and then relay the message to the 999 operators. This is clearly a very positive innovation for those who require such services as they can now contact 999 without having to worry about how they will effectively communicate with the call handler. NHS 111 also has a similar service now.
But could more be made of this technology? NHS 111 and 999 services have always relied upon a telephone assessment of the injury or illness, and by following certain directions, selecting the correct advice or urgency for which help is required. What if the call handlers had potential access to a video call so they could actually see the patient in real time? One of the criticisms of our current service is whether patients are correctly categorised in terms of the urgency of their needs, and whether they do in fact require immediate medical help or not. It is possible that if the call handler could see the patient’s condition for themselves, then perhaps some (though not all) of the errors that are made could be eliminated.
Some ambulance services and 111 services have partnered with the Good SAM app which allows instant access to video and has been used in life threatening emergency calls. But why limit use of this technology? Surely this could in theory be used for all people contacting 111 or 999 if they are able to use the technology?
How Remote Monitoring Can Help Manage Health Conditions
There has also been a move to use technological advances to allow both patients and clinicians to monitor health conditions more closely.
For example, selective Type 1 and Type 2 Diabetics are to be offered ‘flash glucose monitoring’ which allows continuous glucose monitoring to improve glucose control, and therefore improve their diabetic care.
Other NHS trusts are trialling the use of ‘digital patient monitoring systems’ to improve the management of patients with long term health conditions whilst keeping them at home. Such schemes currently make use of already available health monitoring products such as thermometers, blood pressure machines, O2 and pulse monitors and weighing scales. Most patients or their family can be taught to use this equipment to check the patients’ vital signs and this information can then be communicated to their doctors. Such systems have the potential to improve patient outcomes whilst keeping them out of hospital, both as inpatients and outpatients, thus freeing up beds and clinicians’ time; not to mention the potential to save the NHS considerable sums.
The technology does not end here, however. Many Apps now promote their health monitoring capabilities. Apple and Fitbit, for example, now have built in pulse and O2 monitors in their watches, and this represents the tip of the iceberg of health apps, and inbuilt technology. A number of NHS trusts are trialling use of Apps to collect health data, and AI now has the potential to provide early alerts to doctors where a patient’s condition requires attention. Such technology means clinicians have more information, and perhaps more importantly, more accurate information, about a patients’ condition and they can respond more appropriately to what they are seeing. There is potential to improve patient care, whilst reducing the burden on clinicians by removing the need for unnecessary face to face appointments. If a patient is doing well, do they really need to be seen frequently?
Are Virtual Wards the Future?
Virtual Wards are now being set up by a number of NHS trusts to allow for patients to be treated at home where possible, rather than needing to go to hospital. Many were set up as ‘COVID virtual wards’ so those with COVID-19 could be monitored remotely at home, and only be admitted to hospital where it became absolutely necessary.
Such services are now set to be used for more than just COVID-19 and could, in theory, be used for almost any condition where the patient can be given the necessary equipment to monitor their condition themselves, or with the help of those they live with, though most currently seem to be used for heart and respiratory conditions. But why limit this to just a few conditions when even more patients could benefit?
For example, anecdotal evidence would suggest the number of ‘bed blockers’ has increased since COVID-19, as pressures are felt on all areas of the NHS and social care networks. There simply does not seem that there is enough care to meet everyone’s needs. Stories about A&E waits often quote the number of people medically fit for discharge, but who are unable to go home as the care package has not yet been put in place or there is no one at home to care for the patient. These people at least on the face of it, do seem a good candidate to perhaps attempt a discharge with a remote ward, allowing 24/7 access to medical professionals if they encounter a problem.
Such use of remote wards does have a very real potential to free up bed space, therefore impacting admissions, waiting lists, costs, clinician’s time and patient long term outcomes. The longer a patient is in hospital, the more risks they face such as hospital acquired pneumonia, not to mention the impact on their mobility and general health etc. of longer admissions.
The NHS cannot go on the way it did before COVID-19. COVID-19 has sped up the NHS’s plans for introducing a more virtual existence to cope with increasing demand. Now that technology has made the leaps required to be of use to patients and clinicians, the NHS must learn how to use the technology and make full use of it where appropriate. It cannot, and should not, replace more traditional means of reviewing patients as these will always be of the upmost importance for diagnosis, evaluation, and communication with the patient. But there are now very real alternatives which, whilst not working for all, can be used by a lot of patients and will not only be more convenient to the patient, but also for the clinicians. The technology could be used more so than it is already. As more technology is developed, the NHS needs to keep the momentum in ensuring that they use it, to roll it out to patients as quickly as possible once ensuring it is safe, effective and adheres to legal requirements such as GDPR regulations. The NHS needs to change. It should not be afraid of utilising the technology to do this, but should embrace it.