Where I work in Newham, east London, there are some acute challenges to delivering efficient and effective healthcare. We have a young local population with a high prevalence of diabetes and multiple long term conditions. It is not a wealthy area, and people often find it very difficult to take time off work for hospital appointments. We also see lots of young mothers with caring responsibilities, alongside older patients who rely on family members to accompany them on hospital visits. All of this means that there has traditionally been a low level of engagement with healthcare services.
In 2010, at Newham University Hospital, we decided to see how we could help people become more engaged with their care. We carried out a very small project—with around 30 patients with diabetes—using video conference software to carry out consultations. All the patients loved it and, most importantly, they all kept their online appointments. We were able to develop very useful qualitative feedback, and wanted to see how we could build on this success.
The next year we received further funding through the Health Foundation’s Shine programme to investigate the impact of replacing selected face to face appointments with online consultations.
Unlike remote areas, where distances can be huge, face to face contact is a readily available option in inner city London. We were therefore keen to test the online model, to check if people would still use it in preference to face to face care.
We soon began using a Skype service and this helped our patients to become much more mobile in managing their care—they could now hold consultations using their phones and MP3 devices. Sixty two per cent of people who were offered the service began using it, with an 85% take-up rate among those aged under 40.
We were soon conducting many more consultations online, and by the end of the first year we saw that non-attendance rates were declining, with early data also suggesting an improvement in patients’ overall blood glucose levels.
What were the main reasons for these improvements? Was it purely as a result of convenience for patients, or was a more fundamental change happening? People were telling us that the relationship between patient and healthcare professional was changing dramatically—that it was becoming much more of an equal partnership. Patients were comfortable, and felt much more at ease and in control of the consultation process when talking online in a physical environment of their choice.
Despite this exciting progress, we then wanted to see if we could engage people who were traditionally labelled as “harder to reach”—those who were most disengaged as a result of social isolation and who never turned up to appointments at all. This was part of a wider ambition at Newham to completely change the way we deliver care to ensure that we make it as easy as possible for people to engage with us. We made it clear to these patients that we would hold one scheduled consultation with them each year when we would be able to examine them, and that they could contact us directly in the interim if experiencing any problems managing their diabetes.
Many of the patients traditionally labelled “hard to reach” began getting in touch with us proactively. They welcomed the newfound access that the project and Skype gave them.
In 2012, we received additional funding from the Health Foundation to expand our Skype consultation service. Since this latest project has been in place, non-attendance rates have dropped from 25% to 13%, with non-attendance among Skype users as low as 8%. As well as observing improved levels of blood sugar control among our patients, we have also seen signs that suggest patients using online care are relying less on A&E services, though we do not encourage them to use online contact in an emergency situation. But the most important thing is that they all relish having more control of their outpatient contact.
Because we have shown substantial cost savings, everyone at Newham University Hospital who attends diabetes clinics with me or our specialist nurses who provide the Young Adult Diabetes Service are routinely offered the opportunity for Skype consultations, and our community nurses will all soon start using the service.
We’ve seen remarkable progress but the work doesn’t stop here. We have recently secured funds from the National Institute for Health Research (NIHR) to explore more closely the dynamics of the relationship between patients and healthcare staff when using online contact, and to communicate the benefits of this shift across the healthcare sector so that it can inform decision making.
Shanti Vijayaraghavan is a consultant physician at Newham University Hospital, Barts Health NHS Trust.
I have read and understood BMJ policy on declaration of interests and declare the following interests: The work mentioned in this blog was funded by two research grants from the Health Foundation.