We must ask patients what they think, what they would prefer, and tailor their care accordingly, says Catriona Gilmour Hamilton
The insistence by Matt Hancock, England’s secretary of state for health and social care, that GP consultations should, by default, take place remotely reveals a failure to engage with either the users of healthcare services or the people that provide medical care. If you talk to the recipients of healthcare about remote medicine, it becomes apparent that the situation is a little more nuanced than Mr Hancock suggests, and that—in the interests of patient centred care—people should have a say in the matter.
I want to share lessons from our recent patient experience work in haematology and oncology at Oxford University Hospitals NHS Trust. Our conclusions are consistent with the work of colleagues elsewhere in the NHS, and the work of organisations such as National Voices, suggesting that remote medicine raises similar issues for primary and secondary care, and for patients with different diseases.
Like many other healthcare services, in mid-March this year when the pandemic hit, the oncology and haematology directorate at Oxford University Hospitals NHS Trust implemented an almost overnight turnaround. Previously, approximately 95% of patients were seen face to face, with a few teams regularly reviewing patients via telephone consultations. A small pilot of Attend Anywhere had been launched in January, and a handful of colleagues had participated. But in March this all changed at an exponential pace; the vast majority of patients were switched to telephone consultations, with a few exceptions for people in more challenging circumstances.
Since March, 300 clinical and administrative colleagues have been trained in the use of Attend Anywhere. To try to find out what this was like for the people on the receiving end, I conducted interviews with patients from clinics across the directorate. In partnership with our patient engagement group, we also drafted a questionnaire for users.
The feedback from patients indicates that remote monitoring is, in many instances, a vast improvement on the experience of attending our outpatient department, and not just because of the pandemic. It saves people travel, money, and from a disruption to work and caring responsibilities. It saves the terrible anxiety of being late for want of a parking space, and the day that has to be sacrificed for the process of getting to and from Oxford—often for an appointment of 10 minutes’ duration.
Many people said they can have the same conversation and get the same information as they would if they attended in person. For some, it feels more private to have this conversation from home. We learnt valuable lessons about how patients and clinicians should prepare for a remote consultation: who should be with you, where the call should take place, what documents you want to share, and what questions you want to ask. We learnt that we should train colleagues in the challenges of communicating online or over the phone, and support those for whom remote practice is at odds with years of face to face experience.
But there are some caveats: remote monitoring is not for everyone, and there are times when it is simply not appropriate. Remote consultations can mean sound and image issues that get in the way of a conversation. People can often gain valuable reassurance from physical examinations. This reassurance translates into improved quality of life, while the lack of it sustains anxiety. Some of the people we spoke to described themselves as “more of a face to face person, to be honest,” content for now but keen to return to having clinics in person when it is safe to do so.
Healthcare providers should also be aware of the factors that can strengthen or undermine patients’ trust in remote monitoring. We found, for example, that trust is strengthened by knowing that a clinical nurse specialist is on the end of a line if necessary. People feel safe because they know the team, know we have their back, and that we can and will be flexible. Trust is undermined by myriad letters from different departments that seem to contradict each other. People are immediately troubled if the doctor calling clearly hasn’t read the notes.
The results we had are, in different ways, both surprising and expected. They are surprising because we had, perhaps, anticipated more regret at the loss of face to face appointments and physical examinations. It is uncomfortable to think that we may have persisted in a model that is, for a significant proportion of our patients, inconvenient, expensive, stressful, and outdated. Had we stuck with this way of doing things for so long that we were cultured into the belief that patients chose it and it was beyond our power to change it?
Nonetheless, we were also not surprised by the feedback that there are times when there is no substitute for seeing someone in person. Nor should it amaze us that individuals express a desire to choose the nature and location of their appointment.
We must ask patients what they think, what they would prefer, and tailor their care accordingly. We must reassure them that this particular service development does not signal the demise of face to face consultations; failure to do so will compromise safety and trust in the care we provide. Feeling cared for is a complex construct that is not simply transactional, but reliant on intangibles like feeling heard and being noticed as an individual. The challenge for telemedicine is how to sustain these intangibles in the Zoom era of medicine.
Catriona Gilmour Hamilton began her career as a nurse before moving into the voluntary sector and completing postgraduate research in history of medicine. She is now based at the Churchill Hospital in Oxford where her role is to develop and expand patient and public involvement and patient engagement in haematology at Oxford University Hospitals NHS Trust.
Competing interests: I am funded by the NHS and NIHR but have no other interests to declare.