Skype Video Consultation pilot by Central London NHS GP Practice triggers an interesting debate

Cavendish Health Center Skype Pilot

Pulse’s Caroline Price has triggered an interesting debate in the comments of an article titled “Patients give thumbs up to GP Skype pilot”.

mHealth Insights

Don’t miss the comments thread

The article has already led to some very interesting comments and it’s very revealing that only one of the GP’s who have commented has made himself identifiable (congratulations GP Partner Dr Christopher Stern!). Perhaps the rest haven’t heard about the GMC’s guidance document or they’re all just ignoring it because it’s so out of touch?

I felt the GMC Social Media Guidance was completely out of date when it was issued and two years on I think it’s very telling that the Pulse publication (which bills itself as the UK’s leading medical monthly publication “counting more than 70% of GPs among our regular readers” and loads with a “This site is intended for health professionals only” notice on the top of the page) still makes it possible for the anonymous to comment.

95% of Patients who used the service said they would use it again & ​94% said they were ‘satisfied or better’ that the consultation had met their medical needs

I’m not surprised by this (we see something similar with Patients who have documented consultations with us at 3GDoctor) but I am surprised the author of the article isn’t making more of this as it’s an incredible measure of Patient satisfaction.

To put a little context to this on the opening weekend of sales of the most financially successful product in history ‘only’ 85% of the customers buying an iPhone 6 were repeat customers.

GPs at the practice were also positive, reporting that Skype was better than phone consultation for making a diagnosis. However they found it was less time efficient than phone consultations, taking up 10 instead of five minutes

I think this is interesting because it’s suggesting that GP consults are some discrete interaction. Surely every GP appreciates that it’s completely nonsensical to suggest that a 10 minute consultation is “less time efficient” than a 5 minute consultation?

I also think it’s not ideal to have GPs making this type of self judgement because they’re not in a great position to factor in the other healthcare and social care system costs that their care impacts upon eg. If the extra 5 mins the video is taking up of the GPs time means that the Patient is now better informed perhaps it will prevent them from additionally taking a day off work to visit a Doctor, seeking the advice of the 111 service later that night or over the weekend, turning up unnecessarily at A&E because they couldn’t get time off to attend a GP appointment, etc, etc.

An extra few minutes doesn’t mean a Doctor has been spending their time inefficiently and it’s better for us to appreciate that the Video Call is making the Doctor feel more empathy for their Patient and this is increasing the quality and depth of the GP consultation (something that would of course be a lot easier to measure if the telephone/Skype Video Consultations were being documented in the first place.

However plans to extend the number of GP sessions held via Skype each week from two to five were scrapped due to a lack of demand

I’m not surprised by this as nearly every NHS GP I’ve met has developed a ‘build it and they will come’ understanding of demand from their experience providing services that they don’t directly bill Patients for eg. if they opened from 5am till 10pm 7 days a week or offered 30 minute consultations the behaviour of Patients would adapt and there would be a waiting room full of Patients in their offices to avail of the extension of services.

Perhaps things be different if the GP practice realised they could save a lot on London Locum rates by hiring remotely located GPs to help them manage the Skype consultations?

The leading CCG said a broad mix of patients had used the service including working people and parents of young children. Two-thirds of patients joined the remote consultation from home but more than a quarter – 28% – skyped from their workplace

This mention of a ‘broad mix’ is interesting as NHS Direct only recently revealed that they were not getting this balance right. It would be interesting to review more data on this.

It’s a little surprising that Patients are joining one in four consults from their workplace but perhaps this just reflects the Skype Consult availability (eg. they were only being made available during normal GP working hours)?

​Dr Alice Fraser, the lead GP at the pilot practice Cavendish Health Centre in Westminster, said: ‘The flexibility that remote working offers means clinicians can make more efficient and productive use of time. I live outside of London so I found the use of Skype particularly helpful as I could carry out consultations with my patients from home without having to travel to London, which meant I was able to better balance my work and family commitments

I think the is a very clear reminder of how the NHS will continue to miss the video consulting opportunity if they continue to ignore the opportunity to provide GPs with home working opportunities.

The reality is not every Patient in London needs to have Video consults provided by Doctors who have clinic buildings in Central London (where house prices and living costs are the highest in the UK) and in many cases a Doctor is better placed working remotely eg. they don’t need to battle the congestion of central London, they can consult with Patients with less personal stress if they don’t have worries about the cost of their overheads, etc.

…Kiran Chauhan, deputy managing director at NHS Central London CCG, said… ‘Long term, the service can help to increase patients’ access to appointments as it enables practices to provide additional appointments without requiring more clinical space or the associated overheads. This can also alleviate pressure on limited consulting room space, which is a particular problem in central London where estate is at a premium, as GPs can see their patients from any private location’…

I think this is very revealing as it suggests the CCG thinks the focus is access to appointments. We need to move on from thinking that visits are the only way we can serve the healthcare needs and I think the CCG could learn a lot from the pioneering work of Dr John Bachman MD, Professor of Primary Care at the Mayo Clinic.

He has clearly shown that you don’t need to remotely consult with every Patient when you provide Patients/Carers with tools that help them communicate with you online before you decide on how best to proceed eg. is this healthcare need best managed with information, a referral to a Pharmacist, a referral to your Practice Nurse, a referral to your GP colleague with a particular Special Interest, a telephone call from a nurse, a telephone call or Video Consultation with their GP:

Comment from ‘Anonymous GP Partner’: What do the indemnity organisiations think of Skype consultations and any fallout there of?I think it is unsafe and there gets a thumbs down from me!

As with Telephone Calls on it’s own a Skype Video Consult can be very challenging from a medical indemnity point of view and I’m very surprised that the GPs involved in the pilot actually managed to get insurance coverage without first providing documentation of the care because it’s very easy for Patients to forget to mention something or Doctors to miss something being shared within a brief video consultation where there are time constraints.

Comment from ‘Anonymous Sessional/Locum GP’: The big advantage of telephone consultations over Skype consultations is one of logistics. If a patient phones in and asks for a telephone consultation he or she can then get on with their life and be contactable by mobile phone when the GP phones back after up to 2 hours. At the moment very few people have the ability to be immediately contactable through Skype on their mobile phones. Consequently a Skype consultation needs to be booked at a specific time as opposed to telephone consultations. Eventually when mobile video consultations are as commonplace as telephone it should be possible to use this technology in the same way that one uses telephone consultations

This comment highlights the need for Healthcare Professionals who are designing remote services to be familiar with the latest mobile technology and it’s distribution amongst Patients/Carers.

I cannot understand why the CCG is offering telephone consults OR Skype video consultations. Why haven’t they just offered mobile consults eg. a medical history taking questionnaire taken by the Patient could let Patients select their preference by simply asking a ‘how would you like to be contacted?’ question:

Between 3-4pm on Tuesday the Doctor would like to consult with you. Please select from the following ways that you would like the Doctor to contact you?

[ ] Via a call to your Home phone (Insert#FromPatientRecord)
[ ] Via a call to your Mobile phone (Insert#FromPatientRecord)
[ ] Via a 3G video call to your Mobile phone (Insert#FromPatientRecord)
[ ] Via a FaceTime video call to your Apple iPhone/iPod/iPad (Insert#FromPatientRecord)
[ ] Via a Skype call (Insert@SkypeNameFromPatientRecord)
[ ] Other

Comment from ‘Anonymous’: I disagree, if you have any smartphone from circa 2009 onwards you can run skype. as long as you have a data package or wi fi a patient can be consulted in the street if they so wish. I’m not sure Skype is clinically robust enough as a bit of techonology and secondly opens a can of worms as is very hackable by even high school kids. I wouldn’t use it if I was a patient

This comment is presumably made by a US Doctor (he refers to ‘high school kids’) so perhaps it’s a cultural difference but I think it expresses a very odd ‘them and us’ way of thinking about Patients which surprises me as I know lots of Patients (who are also registered practising Doctors) who use video to get help and advice from their Doctors.

I’m also unsure why there are security standard doubts about Skype when the vast majority of NHS Doctors use Microsoft software on their creaking old desktop computers.

Why would anyone think modern video calls are less secure than the telephone calls that the NHS use day in day out? Would there have been hacking concerns expressed if this had been a pilot trialling Apple’s FaceTime or Mobile Network Operator handled 3G Video Calls?

Comment from ‘Anonymous Sessional/Locum GP’: It ain’t safe….anyone thinks making a medical diagnosis using the equivalent of a pair of binoculars and a wilkie talkie is as good as meeting someone in the flesh is kidding themselves. And to those who say…”it can help in some circumstances” and “it’s more efficient and cheaper” …I say – “Pay my increased medical indemnity costs!” Thing is they won’t hey…we as a profession will be carrying this cost, no one else. It’s poor medicine and a bad idea. This is driven by eccomonics and funding issues not best practice and medical excellence. It sucks

This GP has a good understanding of the medical indemnity issues. For me there’s an even more fundament issue here: undocumented video consults fail my “mother test”.

Remote Voice/Video Calls on their own aren’t a safe solution unless you have a very close relationship with your Patient (eg. like Michael Seres clearly has with his Transplant Surgeon). For the rest of us trying to provide remote care it’s key that we bundle it together with clinically validated medical history gathering tools and effective documentation – watch this excellent Royal Society of Medicine lecture from FIVE YEARS AGO to better appreciate this.

Comment from ‘Harry Longman’: Good debate but look at two key points: 1. For GPs it was less time efficient than telephone, 10 mins instead of 5, ie similar to face to face. No saving. 2. Demand was less than expected, so patients, though “happy” are not flocking to it. Skype may have its place but unless the technology is a big benefit to both parties, it won’t take off.

Harry’s very smart and has a great understanding of the NHS GP access issues – check out AskMyGP – but I’m surprised he’s missing the point about how nonsensical it is to judge the efficiency of a GP consult based on whether it was 5 or 10 minutes in duration.

With the clinically validated interactive Patient History Taking tools that AskMyGP make available to Patients on the secure website of their own NHS GP you can have much more efficient consultations but this isn’t because they are longer but because information is shared more effectively eg. the Doctor has more information about their Patients needs BEFORE they even begin a Consultation.

I also think Harry is placing too much importance on the lack of demand for this pilot. The poor design alone probably accounts for the lack of demand:

> To book a Skype appointment Patients were told to “please telephone us on 0207 487 5244 or pop in and see our reception team“. I think this is a very basic user experience design failing eg. you need to pick up a telephone and get through to a receptionist to book a consult that you will carry out with a remote Doctor on your computer. I wonder if a Doctor trialling Alexander Bell’s invention ever required Patients to send a carrier pigeon if they wanted to book a telephone consult?

> Who wants to consider whether or not to be involved in a “NHS pilot” when they’re ill especially one that comes with caveats about being potentially insecure?

> The lack of an asynchronous information sharing opportunity prior to the consultation has undermined the value of the remote link. For example if you wanted to discuss online content (eg. a Patient Community discussion thread, an online video, etc) apart from the ease of sharing a URL through Skype’s IM this isn’t made much easier by a live Skype consultation but it would be made a whole lot easier if Patients could share this information with the Doctor before the consultation.

> More than half the Patients that these Video Consults might’ve appealed to probably had iPads/iPhones/Macs and were simply put off by the Doctors’ choice of Skype. Similarly if they’d made it a Google Hangout Pilot there would probably have been even less traction simply because more people are aware of Skype than Google’s video call platform.

Comment from ‘Anonymous GP Partner’: “1. For GPs it was less time efficient than telephone, 10 mins instead of 5, ie similar to face to face. No saving.” This is a short-termist approach. Patients who are more satisfied with their consultations may be less likely to return for the same issue. Why not invest 10 quality minutes at the outset rather than waste many rushed 5 minute telephone (or longer face to face) consults for the same issue?

This GP has it spot on. The 2,000 year old model of healthcare is broken forever and Patients don’t need the time of Doctors they need their attention.

Comment from ‘Anonymous Sessional/Locum GP’: You assume everyone who consults needs to be examined. There are many people with LTCs who may need to converse about a disease-related issue without the need for any exam (as they have already been diagnosed/monitored/examined in clinic). They may prefer skype over phone. Nobody’s saying all your consults have to be done via Skype – just that the study showed that patients who did use Skype were satisfied and so apparently were the clinicians

I agree and am surprised more Doctors don’t hold this opinion as clearly Patients want to go in this direction eg. Roy Lilley’s mother, Paramedic Rachel Graham who has paid out of pocket for an expensive medical device that needed to be hacked, etc.

The completely daft alternative is that the NHS continues to hand the most important triage roles to school leavers reading computer screens down the telephone.

Comment from ‘Anonymous GP Partner’: ‘You assume everyone who consults needs to be examined’: The problem you are missing is very often you don’t know wether you need to examine them until AFTER you’ve talked to them. In a Skype consultation there is no choice …this issue is pre-determined before the consultation can’t examine them physically…end of

This comment highlights exactly why we don’t need to think about Skype Video Consults as some stand alone solution but rather as a complement to a well designed, efficient and safe interaction between Doctor and Patient – much like the one that Dr Amir Hannan has began using in his NHS GP Practice (Note: I place a lot of weight on the opinions of Dr Hannan as he’s not the type to just be randomly piloting new tech for the sake of it eg. he has been providing his Patients with online access to their notes for the last 10 years).

Comment from ‘Anonymous Nurse’: ‘So Skype can be used as an adjunct, not a total replacement of face to face consultations. Can’t see anything wrong in that. It’s a generational issue, and it will become more used as time advances, not overnight.

An age old truth: Want to make sense of something? Ask a Nurse.

Related: Check out this talk I gave at last year’s Doctor 2.0 & You Conference in Paris on the topic of Video Consulting best practice:

Leave a Reply

Fill in your details below or click an icon to log in:

Gravatar Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s