The term ‘virtual health care’ means using communications technology (such as that provided by www.careinnovations.com), so that ‘virtual visits’ can take place between patients and clinicians via video and audio. This enables ‘virtual’ meetings to occur in real time, from any location. This article considers the concept of virtual health care and its potential application for those involved in the care of people with lower limb problems. Drawing on examples of recent experiences from lymphoedema and wound clinics, potential benefits and challenges are highlighted. Learning from the recent necessity to adopt virtual health care very quickly during the COVID-19 pandemic, some broad guidance is suggested for practitioners considering its long-term use.
Background
The NHS is constantly required to adapt and change and the COVID-19 pandemic has accelerated changes. In lower-limb conditions there has been an emphasis on patients self-caring by managing lower-limb wound dressings and compression systems and there has been a need to deliver health interventions in a different way. Many resources supporting self-care have been developed for patients, almost all of which have been on online platforms.
There is no doubt that information technology has transformed the way in which healthcare is delivered. The NHS Five Year Forward View mentioned exploiting the information revolution (NHS England, 2014) and the NHS Long Term Plan (NHS England and NHS Improvement, 2019) suggested that the NHS should offer a ‘digital first’ option for most people, adapting to address the changing population's needs and empowering patients to manage their own health. However, there has also been some resistance and reluctance (Queen's Nursing Institute, 2018).
A document published by NHS England in January set out an implementation toolkit for using online GP consultations (NHS England, 2020). On 13 May 2020 (at 13.10), NHS We are Primary Care used Twitter to celebrate a shift in general practice towards predominantly remote service provision, using video and online consultations; video is available in 97% of practices covering 98% of their population, and online consultations in 75% of practices, covering 77% of the population. They reported that a further 20% of practices were currently implementing an online consultation solution and expected it to be ‘live’ imminently. Despite this shift, there is a significant number of individuals who do not have access to the internet.
A recent article looking at patient education in leg ulceration detailed a patient focus group of individuals over the age of 60 years, 58% of whom did not have access to the internet, a smartphone, laptop, computer or tablet, or a Facebook account (Clarke et al, 2020). This demonstrates the need for virtual services to be equitable and to not exclude any patient groups.
Virtual healthcare lacks standardisation of terminology but is generally accepted as aiming to utilise technology to improve the delivery of patient care and access to services. It may have the potential to enhance outcomes, be more convenient and empowering for patients and families, be more efficient and sustainable. However, it may also be encouraged primarily as a means of addressing frontline clinical shortages (Roxby et al, 2020). The Wounds UK 2018 Best Practice Statement: Improving holistic assessment of chronic wounds (Fletcher and Barrett, 2018) stated that using telecommunications technology has the potential to improve patient care and reduce costs. However, it should be used according to local policy. The document highlighted benefits, particularly for patients living in remote areas. The recommendations for practitioners were to consider the use of telecommunications technology, such as video calling, for wound assessment, monitoring and onward specialist referral. For the patient, the statement suggested engaging with telephone, email or video calls regarding progress and ongoing care.
The challenges of virtual health care are, however, significant. There are multiple online platforms and outdated systems that are not tailored to each individual care delivery setting. This is compounded by poor connectivity and issues around training needs, safety, security and information governance. NHS Employers (2013) recognised the requirement for positive staff engagement, which will only happen if staff feel confident in its use.
Virtual health care in lymphoedema and chronic oedema services
Recently, the British Lymphology Society (BLS) undertook a COVID-19 Impact Survey (due to be published in the society's News & Views in July). The survey identified that a number of services have been affected by COVID-19. Some have been closed completely, with staff redeployed to other areas. Other practitioners have been prevented from treating patients face to face or limited to engaging only with those with urgent or complex needs. It has raised many concerns about the adequacy of care provision. This undoubtedly will have meant that, for some patients, their lymphoedema and quality of life will have deteriorated without the support of the lymphoedema team. It is also suspected that hospital admissions and visits to emergency portals will almost undoubtedly increase (once patients believe it is safe to attend again) for cellulitis and possibly deep-vein thrombosis. Others have suddenly been required to adopt virtual care provision with little preparation.
Caring for people with lower-limb conditions such as lymphoedema is a very ‘hands-on’ service. Assessment of tissue changes and the degree of fluidity to determine the level and type of compression required involves palpation and clinical judgement. Skill is required to ensure adequate compression is achieved to be clinically effective, having determined any impairment of vascular function. A good fit of any compression garment is essential for a successful outcome and this must be based on accurate measurements (Wounds UK, 2015). Understandably, many practitioners were extremely anxious about the extent to which they would be able to make sound assessments and decisions to effectively manage very complex needs using virtual technology. However, the current crisis necessitated a brave step into the unknown for many practitioners.
The experiences of lymphoedema practitioners in one service
Lymphoedema practitioners in the clinics of one regional service have shared their experiences with the BLS in relation to virtual health care using different technological applications during the COVID-19 pandemic. Overall, there was great relief at how well patients engaged and responded, taking on the challenges of much greater levels of self-care under virtual supervision. Nonetheless, there were issues to overcome. Some 65% of the service's caseload comprises patients over the age of 70 years, who are therefore shielding.
General benefits
Virtual applications used
Telephone consultations and monitoring
This required no new technology and had an 89% success rate in terms of the purpose of the consultation being achieved. It was used to triage patients and prioritise need. It was useful for reviewing medication and liaising with the GP to make any required changes. Education needs were met by posting information materials and encouraging patients to watch videos if they had the means. Reaching out to patients by phone was excellent in allaying their anxiety.
Main and unexpected benefits
Practitioners were able to initiate basic skin care measures, positioning and chair-based exercises immediately. Some cases of oedema were very simply resolved by identifying that patients had been prescribed an oedema-inducing medication such as amlodipine, and arranging an alternative. Other patients could be discharged after telephone follow-up once an initial intervention with skin care, exercise, positioning and elevation and advice on medications was undertaken.
Main limitation
The main limitation was that the patient and practitioner were not able to see each other, so was best for existing patients. It was not possible to visualise skin, tissues or the distribution of swelling to get a full ‘picture’.
Video consultation
Practitioners found the NHS video call service, Attend Anywhere, easy to use. Patients visit the hospital website, click on the Attend Anywhere link, select the community waiting area and enter their name. The practitioner can see them in the waiting area and when ready, click on their name and they are connected. Everyone with internet access has been able to successfully use it and it has been useful for all patient groups, both new patients and those requiring follow-up consultations. Patients could be reviewed within 24 hours of referral.
Main and unexpected benefits
Practitioners thought that joint consultations worked well, bringing specialist centres to the patients for those unable to travel. The ability to offer case conferences in complex cases or get a second opinion was excellent. Patients have managed to measure their limbs over the video consultation and practitioners found teaching simple lymphatic drainage fairly straightforward.
Main limitation
A few patients have not wanted to use video conferencing or do not have the technology, but these have been in a minority.
AccuRx
This is a patient messaging service that is easy to use. The technology is integrated with NHSmail and uses a practitioner's nhs.net account. It securely sources patient contact details from the NHS Spine; it may be used on computers or smartphones because contact details are not shared. It is said to be used and trusted by over 90% of GP practices in England (www.accurx.com).
Main and unexpected benefits
It is possible to send one-way SMS messages to patients to check appointment time suitability. Up to four people may join a call so a patient can choose to have other family members present. It may be used for calls or video consultations.
Points to consider for long-term use of virtual health care in lower limb conditions
Summary
The NHS is changing and practitioners will need to deliver health care in different ways. Digital options have been encouraged because of the potential to reduce costs and empower patients. There are also potential clinical, convenience and cost benefits for the patient. However, it is essential that individual healthcare providers improve their IT systems, offer training opportunities, and partner with patients to provide the best service possible that meets the needs of both parties. All health professionals must be willing to engage with technology and develop the skills and confidence to use it well.
Much reflection is required on how best to align future pathways for lymphoedema services post-COVID-19. But the authors would like to thank every healthcare professional for all they have done to support patients during the pandemic. The recent BLS COVID-19 Impact Survey highlighted frustration and concern that they have been limited in the care they have been able to provide for patients, but it is clear that everyone has done their best to protect patients and maintain service provision, wherever possible during the months of lockdown. The experience of using technology during this period is likely to have encouraged some to explore its use further. Those who have not had the opportunity should be supported to engage with it for future application.