Making changes within the NHS can feel complex and lumbering. The COVID-19 pandemic has accelerated change, with specialist units needing to demonstrate agility and innovation in ensuring patient access to services. Whilst doctors and patients alike may have found the pace of change hard to navigate, it is important to take stock and evaluate whether there are lessons to be learned in service delivery that can lead to long-term improvement for patients.

There is little more satisfying than seeing a familiar patient in clinic for follow-up. The rapport that is built over time makes shared management of chronic conditions so rewarding. Whilst it is difficult to replicate this over the telephone, these encounters are also often easier when we can put a face to a name¹. However, new patient contact, and in particular explaining a new condition to a patient whose only interaction with the service may have been via telemedicine, is a challenge. Furthermore, the loss of non-verbal communication with patients who might be inclined to minimise the impact of their symptoms on their wellbeing is a potential disadvantage. Whilst many doctors have embraced the delivery of telemedicine, patients have had a more mixed response. A UK-based survey of telephone clinics in the IBD setting found that only half of patients preferred a face-to-face (F2F) appointment, with most healthcare professionals reporting greater satisfaction and intending to use a blended approach of F2F and virtual consultations in the future². Patients understandably were more likely to feel comfortable with a virtual appointment being offered as part of routine clinical follow up than in the context of acute symptoms or a flare.

In some settings, the use of telephone clinics has been shown to improve management of chronic conditions. A prospective study of 125 patients with coeliac disease found that the implementation of a personalised telephone clinic improved adherence to a gluten-free diet³. It should be noted, however, that the average length of the telephone intervention in this study was 49 minutes – significantly longer than the average NHS gastroenterology outpatient appointment allocation⁴. It is also important to ensure that there is adequate infrastructure around the provision of telephone clinics such that the burden of testing and results follow-up does not lead to additional pressure on our colleagues in primary care.

There is little doubt that telephone clinics are here to stay, particularly with the British Society of Gastroenterology recommending ongoing telemedicine delivery through the COVID-19 recovery phase and beyond⁵. Patient selection will clearly be key in successful implementation, with telemedicine perhaps better suited to patients needing routine follow-up and to those comfortable with the use of technology. Flexibility in delivery should also be maintained wherever possible, to ensure that patients can be signposted to F2F services where there are concerns about the adequacy of virtual assessment or deteriorating symptoms.

Authors: Jennie Clough, Oliver Tavabie

References:

1. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ. 2020;368. doi:10.1136/bmj.m998
2. Kumar A, Quraishi MN, De Silva S, et al. Insight from patients and healthcare professionals on the implementation of virtual clinics in patients with inflammatory bowel disease. Frontline Gastroenterol. February 2021. doi:10.1136/flgastro-2020-101714
3. Muhammad H, Reeves S, Ishaq S, Mayberry JF, Jeanes YM. Telephone clinic improves gluten-free dietary adherence in adults with coeliac disease: Sustained at 6 months. Frontline Gastroenterol. 2020;0:1-7. doi:10.1136/flgastro-2020-101643
4. Vokes L, Fitzpatrick M. Call me maybe? Telephone clinics for coeliac disease dietetic services. Frontline Gastroenterol. 2021. doi:10.1136/flgastro-2020-101694
5. McKinlay A. British Society of Gastroenterology Guidance Rebooting Gastroenterology and Hepatology Outpatients in the Wake of COVID-19: Renewal, Redesign and Establishing the “New Norm” Executive Summary.
6. Rej A, Buckle RL, Shaw CC, et al. National survey evaluating the provision of gastroenterology dietetic services in England. Frontline Gastroenterol. June 2020. doi:10.1136/flgastro-2020-101493