Royal Berkshire NHS Foundation Trust
What was the problem?
Royal Berkshire NHS Foundation Trust (RBFT) provides over 600,000 outpatient appointments in a multi-site model as well as managing condition specific facilities at the Prince Charles Eye Unit, Windsor and the Windsor Dialysis Unit.
Around half a million of these outpatient attendances take place annually at the main Royal Berkshire Hospital site in Reading. This results in congestion on the site, lack of space to develop new services and facilities and sometimes poor patient experience due to the parking difficulties.
In July 2017, RBFT developed its Clinical Service Strategy (CSS) which set out the long-term goal of improving care, developing clinical services and increasing convenience for patients attending outpatient clinics. This was tied to a wider ambition to redesign our estate. The strategy was based on a model of reducing non-value adding activity, maximising use of our other sites and using more virtual modes of delivery.
What was the solution?
The RBFT Outpatient Transformation Programme was set up in 2018 to focus on achieving the ambition of reducing the number of appointments at the Reading site by 50%. The aim was to use innovative delivery models and our estate more effectively to provide care closer to home. The programme involves all partners in the Berkshire West Integrated Care Partnership and a wide range of patient stakeholders.
Through engagement with stakeholders including patients, we developed multiple workstreams including remote monitoring, virtual clinics, patient initiated follow up and pathway redesign with Primary Care Networks (PCN). Each workstream is technology enabled and provides a digital solution to transforming outpatient clinics.
In June 2019, RBFT joined the NHS England and NHS Improvement video consultation pilot, trialling the use of video consultations in outpatient settings, using the Attend Anywhere platform. Using video in this way increases convenience for the patient, reduces travel costs and minimises the need for patients to take time out of their day to attend hospital. It also helps to reduce congestion on the acute site.
Training was provided for clinical teams in the implementation phase. The virtual clinics were rolled out across specialties in the trust and patients were informed.
What were the challenges?
Implementation was slow to start, with 5% use in outpatient attendances in the first six months. Uptake was increased by running workshops, sharing of best practice by colleagues and producing a how to guide to rollout across specialties.
Patients were involved in the design of the process and feedback collected to ensure that the service worked for them. This also helped quickly highlight the benefits of this work, bringing about willingness to transform the way care is delivered.
There was some anxiety and fear from clinicians about patient confidentiality and safety, but these were addressed through the guidance and resources available. Information governance was obtained, and applied to all specialties, reducing delays to implementation. Patients were informed of the virtual clinics and consent obtained before a consultation took place. Pre-clinic information and assessments were sent to patients prior to clinic. Patients were reassured that they would continue to receive care and face to face appointments were still available if clinically appropriate.
The administrative team play a key role, providing system support such as confirming the patient details and setting up the appointment. Some administrative teams also proactively scan future clinics to offer patients who live a significant distance from the hospital the option of a virtual appointment. This is recorded on the electronic patient record (EPR) which improves accuracy in coding and activity data.
Good IT support to was also important, ensuring good network connection, availability of clinical documentation and pathology and radiology results all in one place with a single login. This helped secure clinical buy-in and continued use of virtual clinics.
Systems and process are shared across all specialties. The central core resources and supporting pathways are adapted by specialties according to clinical context. This helps rapid implementation, saving time and avoiding duplication. Examples of best practice in clinical areas are shared and celebrated in line with the trust’s values.
What were the results?
Improved patient experience. Greater convenience and a reduced need to take time out of a patient’s normal routine, as well as a reduction in the associated costs and time to travel and park at the hospital/other site.
One patient said, “The whole thing was really easy – I like being able to speak directly with my consultant and discuss my condition. It would have been a two-hour round trip to have the same conversation in person. I am reassured I will still be able to see my consultant as this is vital for checking measurements, but the more regular check ins via video are really reassuring.”
The digital readiness of our outpatient service meant we were very quickly able to provide virtual clinics in response to the COVID-19 outbreak. We accelerated the deployment of equipment and the software to ensure patients could continue to have their reviews virtually. There was a growth from 5% in January 2020 to 42% of consultations taking place in virtual clinics by April 2020. We are working to ensure that we maintain this level of usage.
Utilising video is now supporting us to clear the backlog of appointments, aiding us in the recovery phase of COVID-19.
In addition to clinician-patient virtual clinics, we have implemented clinician-clinician e.g. Consultant-GP; and patient-relative, using tablets for virtual visits in view of the COVID-19 restrictions. We had 80 virtual visits in the first week of implementation in April 2020. In the same month, we had 990 virtual visits. This has had a positive impact on patients and relatives alike with relatives from all over the world able to keep in contact with loved ones.
What were the learning points?
Our journey in implementing virtual clinics has been positive. Engagement with clinicians was key. This allowed the bridging of new technology and traditional clinical ways of working. In addition, the development of central processes and single points of contact with I.T. made setup more straightforward which reduced barriers to adoption.
COVID-19 has allowed the process and system to be tested. We have gained invaluable insight, learning and feedback that will inform our future delivery of outpatient clinics.
We found many benefits including increased flexibility for clinicians and increased convenience for patients. For the trust, it means the logistical and congestion challenges can be eased.
Next steps and sustainability
As we move to the recovery phase post COVID-19, a digital by default process will be adopted across all RBFT hospital sites. Virtual consultations will be the ‘new normal’ where appropriate. To sustain current levels use we have implemented a total outpatient pathway system that is end to end and patient facing. GPs can refer patients who will be discussed and stream by the clinician. The patient will be offered a virtual clinic and will get a text or electronic invitation for this.
A patient portal is being develop for patients to access their results, complete questionnaires and letters and interact with the clinical team. This will support us to achieve the NHS Long Term Plan ambitions, reduce activity on the main site by 50% as well as improve patient experience and satisfaction.