Changing the way we work: virtual consultations now and in the future

The situation with coronavirus and COVID-19 has meant that many general practice nurses (GPNs) have needed to change the way in which they interact with patients. But how should we go about virtual consultations?Although not all consultations can switch from face-to-face to virtual, the fast pace of change has meant that many of us have had to work out ways to enable this to happen. In this article, we discuss how to confidently carry out a virtual consultation by email, telephone or by video and explain how this can be an effective way of working not just during this pandemic, but also for the future.

PRINCIPLES OF VIRTUAL CONSULTATIONS

In a virtual consultation, the interaction happens in a way other than the usual face-to-face setting that has been the default mode in general practice for years. While other aspects of life such as banking, shopping, meetings and education, have relied more and more upon the use of information technology (IT), healthcare has, for the most part, still maintained the personal element that comes from the healthcare professional (HCP) and patient being in the same room. When the COVID-19 outbreak began, and face-to-face contact was discouraged, more and more HCPs started to consider how to continue to provide support and information without putting anyone at increased risk from close contact appointments. Personal contact is a feature of many healthcare procedures, including taking blood, carrying out immunisations, performing wound care and checking feet. Some types of interaction lend themselves well to ‘non-contact’ approaches, however, and arguably long term condition reviews are among them.

In my practice, we swiftly began to carry out telephone consultations, and via accuRx, we were able to set up video consultations, too. We are also working with NHS England, which is encouraging HCPs to invest time (the training itself is free) in learning about video clinics, building on the group (or shared) consultation approach and taking it a step further.

It is important to say that while these virtual consultations have a lot to recommend them, there are also disadvantages, so HCPs should consider using a mix and match approach in the future, tailoring each intervention to the individual concerned.

PREPARING FOR ONLINE CONSULTATIONS

An excellent source of information about online consultations can be found here. This is well worth reading through as it covers many of the frequently asked questions about how and why online consultations are so effective.

Ideally, before embarking on a different way of consulting, patients should be aware of this option and be happy to try it. In my practice, when the pandemic began, it was not possible to discuss the fact that we would need to switch to phone appointments rather than face-to-face so it was a case of just doing it, ahead of the allocated appointment time, and checking that this was acceptable to the patient – in other words that they were in a safe environment (not driving, for example) and that they had some privacy to be able to speak freely. On more than one occasion, I had third party involvement, when a spouse might pick up the initial call or join in once it was underway. Obviously, great care has to be taken to ensure that the rules about confidentiality are maintained as far as possible, while at the same time acknowledging that these are far from ideal circumstances, so flexibility is needed. In normal times, a proactive approach can be used to discuss with patients how the system works and ensuring that all permissions and caveats have been addressed before encouraging them to try it out when they phone for a standard appointment.

Online or virtual consultations begin with the patient using their smart phone, tablet or laptop to access the NHS.uk website, the NHS app or by going straight to an online consultation app, depending on the availability in their practice. Systems such as accuRx allow people to take part in video consultations, receive text messages, questionnaires and documents, and engage in two-way conversations. In an online consultation, manual or algorithm-based triage can take place using a questionnaire and the patient will be directed to the relevant person. In some areas eHubs are being set up where online consultations are managed centrally, by clinicians, on behalf of a group of practices.

EMAIL CONSULTATIONS

Email consultations (as opposed to simple email messaging) allow people to ask questions, report (non-urgent) problems, send in readings (home blood pressure readings for example), without having to attend the surgery. Queries can be triaged and responded to appropriately and resources (time and money) used more effectively. Email contact can be saved into the records, ensuring that interactions are carefully documented. Email consultations may not be actioned for a few days, so people need to understand that urgent problems should not be notified to the practice in this way.

TELEPHONE CONSULTATIONS

The easiest way of moving away from the face-to-face consultations I usually carry out was to go to telephone calls instead. I arrived in surgery on the first day after we realised that the COVID-19 situation was getting serious, thinking that I should try to speak to a few more people by phone, but my senior partner intercepted me on the way to my room suggesting that I did just that for as many appointments as possible.

For acute consultations, it is worth considering that, as the old adage goes, history is 80% of the diagnosis, so listening to the story that is being told by the patient will be the most effective way of deducing a likely diagnosis. As far as examination goes, most people have equipment available to take a temperature and many are able to check a pulse with support and explanation. These days, many more people have access to a blood pressure monitor and even a pulse oximeter too, so basic observations can be carried out.

When carrying out telephone reviews for long term conditions, it is possible to ask key questions, such as the Royal College of Physicians 3 questions for asthma,1 or the COPD assessment test (CAT) for people with chronic obstructive pulmonary disease.² In diabetes care, the 15 healthcare essentials checklist can be implemented over the phone, tailoring the areas highlighted in this publication to the individual, much as might happen in a face-to-face consultation.³ Clearly foot checks cannot be carried out virtually but these have been put on hold until the coronavirus pandemic has resolved, along with tests such as the albumin creatinine ratio (ACR). It will be a priority to get these checks carried out at the earliest opportunity post COVID-19.

Careful documentation is important, as always, as are effective consultation skills as non-verbal communication may be missed in a telephone call. When discussing inhaler technique, referral to resources such as the Asthma UK and Rightbreathe inhaler videos will help to support correct technique (see Resources). A positive outcome from this situation might be that people start to use online resources more and that might include making better use of self-management plans, including via apps such as those from my mhealth.

HISTORY TAKING:CASE STUDY

This was discussed in a previous article, Cardiorespiratory conditions in general practice: differential diagnosis (Practice Nurse, December 2019).⁴ Remember that a good model can help people to ensure that all key areas have been covered, including getting more detailed information about any specific symptoms. Take the example given here:

Hilary, age 42 has developed a cough. She is worried about COVID-19.

Taking a history of the current complaint the nurse discovers that Hilary has had this cough for 2 days and has tried some cough medicine but it did not work. She is feeling unwell and hot to the touch. Her past medical history includes childhood asthma which has not bothered her since her teens, and nothing else. Apart from her over the counter cough medicine, Hilary’s drug history reveals that she takes no medication. In terms of her family’s health, her parents are both alive and well and she has one sister who lives abroad and has no medical complaints. Socially, she lives with her partner and their dog and works as a healthcare assistant; hobbies include going to music concerts and the theatre. She also helps at a local Brownie pack. Using the ICE model (ideas, concerns and expectations), the nurse ascertains that Hilary thinks that her cough and temperature are COVID-19-related, is worried that she could have infected others at home and work, and that she expects to have a swab test done and to self-isolate until she gets the results.

If more information were needed about the symptoms, a model such as PQRST, SOCRATES or OLDCART could be used to collect more information.⁴ As a result, the GPN discovers that Hilary’s cough is a barking cough, unlike and worse than any cough she has had before, is present constantly and does not resolve with any treatment. Her temperature is running at around 37.7 degrees, her heart rate is 88 beats per minute and her respiratory rate is 17 breaths per minute; her pulse oximeter shows oxygen saturations of 96%. Using a COVID-19 assessment tool, it is possible to see that there are no red flags and Hilary can stay at home, focus on her fluid intake and temperature management with paracetamol and stay away from other people for 2 weeks. She should also let her workplace and colleagues know by phone.

VIDEO CONSULTATIONS

The concept of video consultations has taken a swift step forward because of the current need to be able to carry out a thorough and holistic assessment of individuals with, or suspected of having, COVID-19. However, in the longer term, this way of working is likely to be taken up more broadly to allow people who might find it difficult to get into the practice to access an equivalent standard of care. This could, in theory, reduce the number of non-attenders and make those who are often difficult to access, easier to contact and communicate with. Video consultations (Skype, accuRx, Microsoft Teams, WhatsApp, Facetime and other platforms can be used for this) can offer a great deal more than telephone consultations as it is possible to see and interact with the person concerned, similar to a face-to-face on-site consultation, meaning that more information-gathering is possible. The patient’s general demeanour is visible; a rash can be shown to the camera; inhaler technique can be observed. Furthermore, a brief view into the patient’s life may help to understand the individual a bit more.

There is an increasing body of information online about carrying out virtual consultations, such as the NHSE tool, mentioned previously, and for those starting out in this area, it is well worth reading through this advice before starting out, as there is a planning tool and advice on how to take a ‘whole team’ approach to making the change. For many clinicians, the concept of working with new information technology can be intimidating and should not be underestimated as a barrier to change. The Online Consultations in Primary Care Toolkit gives a clear explanation as to how to get started with this type of appointment for people who have not had previous experience of doing so. The recommendations align closely with the views published by digitalnhs.uk in a prescient article written by lead nurse Anne Cooper.⁵ This piece, written in 2018, states that nurses should develop the skills and capabilities required to deal with the fast-paced digital world and to support people who want to communicate digitally and access modern digital resources. To gain a further insight into the NHS’s plans for digitalisation, there is also an NHS health technology blog which can be accessed here: https://healthtech.blog.gov.uk/

GROUP VIDEO CLINICS

The use of video consultations extends beyond one-to-one appointments, however. In a previous article, (Group consultations: the why and the how. Practice Nurse April 2019) the benefits of this approach were spelled out: longer appointment times for attendees, getting the benefit of sharing information with others who were living with the same condition, better use of resources, limiting repetitive contacts and information sharing, and so on.⁶ NHS England (NHSE) sees group video clinics as an excellent way of doing all of these things in way which many people will feel is more convenient and appropriate for the 21st century and as such is funding training in video group clinics via Experience Led Care (ELC) training (see Resources). Although some people may feel that now is not the time to be investing time in training (it takes just 2 hours), this could be a case of ‘a stitch in time saves nine’ in that time spent setting up this service now will actually support practices to function better during the next few months and beyond. Once group consultations have been set up, they can be used in a range of different conditions and situations. Clinicians do not even have to be in the practice to facilitate a group video clinic, as long as confidentiality and privacy is maintained.

SUMMARY

Digitalisation of NHS services has been on the agenda for several years, but the COVID-19 pandemic has meant that many practices have had to embrace the change sooner than anticipated to help to manage workload, particularly when face-to-face consultations are being discouraged. Virtual consultations can take place using email, telephone, or via video platforms. Each method has its advantages and disadvantages, but maintaining confidentiality, taking care to gather as much information as possible and ensuring that documentation is detailed and precise are all important aspects to consider in virtual appointments. National guidance and support, including free training, is available to practices that are keen to move forward with virtual consultations. General practice nurses should consider the advantages of implementing the change to different ways of working beyond the COVID-19 pandemic. Early adopters are likely to gain the most benefits now and in the future. Develop an action plan to change practice for the period of the pandemic and beyond.

REFERENCES

1. Pearson MG, Bucknall CE. Measuring Clinical Outcome in Asthma; a patient-focused approach.1999; London: Royal College of Physicians

2. Jones PW, Harding G, Berry P, et al. Development and first validation of the COPD Assessment Test. Eur Respir J 2009;34:648–654.

3. Diabetes UK. Your 15 diabetes healthcare essentials; 2018. https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/15-healthcare-essentials

4. Bostock-Cox B. Cardio-respiratory conditions in general practice: differential diagnosis Practice Nurse 2019;49(12):32-36

5. Cooper A. Why making every nurse an e-nurse matters now more than ever; 2018 https://digital.nhs.uk/about-nhs-digital/nursing-and-nhs-digital/why-making-every-nurse-an-e-nurse-matters-now-more-than-ever

6. Bostock-Cox B. Group consultations: the why and the how. Practice Nurse 2019;49(4):34-37