Dorset Healthcare University NHS Foundation Trust
What was the problem?
Dorset Healthcare (DHC) provides a range of clinical services operating across Mental Health and Learning Disabilities, Integrated Community Services and Children and Young People Services for the county of Dorset.
One of the trust’s strategic aims is to maximise the use of Information Management & Technology (IM&T) systems to improve patient care and ensure more efficient operation. Both the NHS Five Year Forward View and the NHS Long Term Plan emphasise the need to work with digital technology and advocate the concept of “Digital First”. The trust is promoting the principle of ‘Digital as Usual’.
The trust’s IM&T Smarter Collaboration Project looks to adopt and implement new technologies as a way of providing or supporting remote working and service provision. There are a number of diverse technologies available and in use which would benefit from rationalisation as well as identifying a clear bespoke platform for which clinical consultations with patients could be provided safely and securely to optimise patients’ choice in how they interact with our clinical services.
What was the solution?
In December 2018, DHC signed up for a trial with the video consultation platform provider, Attend Anywhere. Video consultations enable patients to attend their appointments from almost anywhere, without needing to visit a hospital/clinic. Patients are provided with their appointment date and time in the usual way and are asked to drop into an online waiting area on the platform where they are ‘collected’ by their clinician for their appointment.
During December 2018, DHC was satisfied with the platform’s suitability, and safeguards around patient security were in line with recommended guidelines. Adequate governance and data protection were also in place.
DHC first commenced live clinical consultations with patients through our Steps to Wellbeing service in early January 2019. During this period, other services were identified and targeted to pilot the technology where it would be clinically beneficial across our Mental Health, Integrated Community Services and Children and Young People’s services. This was a improving patient choice and optimising staff time.
We began the pilot in a small number of departments where clinical staff were particularly engaged and eager to adopt new ways of working. These early adopters helped us to understand how and when the use of video was most effective.
We found that there are actually very few interventions that cannot take place via video. We encouraged colleagues to consider what was possible and were impressed by the new and innovative ways they found they could use the technology.
The clinician’s point of view
Julian Hart, Hi Intensity Cognitive behavioral therapy (CBT) therapist, Steps to Wellbeing LTHC Service
My experience has been very positive on the whole. I find that it offers a workable therapeutic platform between a telephone session and a face-to-face session. It has the advantage over the telephone that we can see each other and thus read facial and body language cues, and also it negates the need for the patient (or the therapist) to travel. This is an important factor when working – as I do – with patients with long-term physical health conditions.
The patient’s point of view
Ms L lives in a small village near Bridport. She’s been working on pain management with Julian Hart from our Steps to Wellbeing service. But rather than travelling to have consultations in person, Ms L has been having video consultations.
“There’s no face-to-face pain management network in my area, so video consulting has been a complete godsend for me….to attend a pain management clinic in person I’d have to use my carers’ hours so they could take me there, and then they’d be waiting for me during the consultation. But by doing the consultation by video, I don’t need to use up their hours like that.
I’ve done five or six video consultations so far – each about an hour long. The time seems to fly by.”
Given the success of the pilot and the positive feedback from both clinical staff/teams and patients, DHC negotiated a full year contract with the provider in May 2019 to allow us to fully expand use of the platform across all our clinical services. We wanted to be able to demonstrate its scope and benefits to our wider Integrated Care System colleagues, including all three acute trusts and our Local Authority Partners to provide a truly system-wide solution to benefit the population we serve. The expanded offer included 1:1 consultations with clients and carers, drop in clinics, staff supervision, multi-disciplinary team (MDT) meetings and small team meetings.
This ongoing work meant we were well set up to address future challenges, including challenges of the COVID-19 pandemic. With many of our teams already routinely using video consultations and a lot of learning and experience of the platform within our organisation, we were able to accelerate and scale up its use as part of our business continuity plans in a relatively short time. Between 2 March and 8 May, 3564 video consultations were undertaken.
What were the challenges?
As with any roll out of any new technology, we faced some challenges but none that wer insurmountable. Our key challenges were:
Getting buy in from staff: some staff were initially resistant to change as they struggled to see the benefits of using video consultations and were wary of how to use the technology effectively. We were fortunate to have a number of early adopters whose work we could use to demonstrate the value to both staff and patients. We evaluated their work so that we could share with those who were sceptical. We also offered training to anyone using the platform to ensure they felt comfortable and confident with the technology. The platform we chose is intuitive and easy to use, which made it easier to gain support of staff.
Working with resistance: as is often the case we had a range of experiences with staff from very keen early adopters to people who really struggled to see the value or embrace change. With people who found it more difficult we used early adopters in teams to support them, offered one to one support if needed and also allowed people to access this at their own pace. We also used feedback from both staff and patients to support people in seeing the value, whilst acknowledging that this was not going to work for everyone and was also not suitable for every service. As we continued to evaluate the work and system, we were able to share the positive story of what we were achieving for our staff and patients. Resistance came largely from colleagues rather than from patients. Patients were largely happy to have their appointments over video when offered this an alternative to travelling for a face to face appointment.
Links to clinical systems: The video consultation platform we are using does not and is not intended to link to the Patient Administration System (PAS). For us, that has not been a big issue and in many ways it has been a benefit. We have used our Electronic Patient Record systems to capture appointments in the usual way (national coding means that appointments are recorded as Telemedicine) which means this has a very limited impact on staff time. We were able to record all consultations that took place via video consultation as opposed to face to face in a physical room or over the telephone.
What was clear with all these challenges was the importance of having clinical involvement and senior leadership support from the outset, as well as the importance of effective evaluation and always remaining true to our objectives.
What were the results?
Some of the expected and some unexpected positive outcomes are outlined below:
- Improving patient choice and patient experience: adding video consultations to the range of options we have for delivering patient care improved patient choice. We were able to offer patients more flexible access to their appointments, enabling them, their families and their carers to access appointments in places that were convenient for them, whether from home, a private space in their workplace or at an NHS site closer to their home. This saved patients time and money, and reduced disruption to their day.
- Optimizing staff time: delivering video consultations saved our staff time, particularly time spent travelling between our sites and patient homes and with the video consultation sometimes (for good reason) being more succinct than a face to face appointment. This freed up clinical time to deliver physical face to face appointments for the patients who need them.
- Cost savings: in addition to saving time travelling, there is also a cost saving to reducing travel across the trust as well as the travel cost to the patient including parking costs. In the mental health directorate alone, there is the potential for a 10% cost saving that can be spent on improving patient care.
- Supporting recruitment and retention: the ability to deliver video consultations provides an opportunity for all our staff to work more flexibly, fitting their work around their other commitments and personal circumstances. The option for staff to work in more innovative environments helps us to attract and retain staff, a big challenge in Dorset.
What were the learning points?
The clear benefits for staff and patients as well as national support for rolling out video consultations in secondary care should encourage all providers to use video consultation technology. It is being used effectively at DHC and a multitude of other healthcare services across the world, and we have seen that there are very few scenarios where video cannot be used effectively.
Establishing a strong clinical oversight and senior leadership support early was key to our success. Our team includes a clinical lead, a technical lead, a communications lead and others. Each had an important role to play in gaining the early buy in we needed. We continue to work to embed the use of video consultations across the trust and support colleagues in partner organisations to do the same. Behaviour change takes time and it is important to remember that new practices do not become business as usual straight away. In most instances, however, our early adopters have generally moved to business as usual. It’s important to continually support and encourage uptake and reinforce and share good practice across the provider, system and country.
Next steps and sustainability
The outbreak of Covid-19 spurred colleagues to take up video consultations in an unprecedented way. We are keen to continue to scale up the use of video consultations across the organisation and in our ICS and continue to embed this practice by:
- supporting people with training and Q&A sessions
- sharing waiting areas across organisations to provide better care for patients wherever they live or wherever they are on a pathway
- supporting partners both in the statutory sector and in the third sector with thinking about how they can use video consultations to both support their direct work with DHC clients but also the wider health and social care system in Dorset.
We are exploring further opportunities to work with partners to support and encourage them to use video technology with the people they are caring for. We are exploring these possibilities with our local authority partners in particular to ensure benefits are felt across the local health and social care system.
Want to know more
Contact Sarah Hall, Clinical Lead for Transformation (Mental Health), Dorset Healthcare University NHS Foundation Trust at firstname.lastname@example.org.