Pre COVID-19, the NHS 10-year Long Term Plan highlighted digital working as a priority1 and although this technology is not new, it has taken a global pandemic to break down the barriers to make its use common place. The way in which we communicate with patients has changed significantly and rapidly, with many consultations now taking place via telephone or video with email and text messaging support. Although this concept was previously familiar to some, for others, it was completely new. Support and training therefore will continue to be important moving forward to ensure healthcare professionals are able to deliver safe and effective care using the new models.
Changes to ways of working
COVID-19 has changed how we work and has as a result led to some more efficient ways of working. For example the concept of using data to ‘risk stratify’ patients more proactively is now becoming much more mainstream. Granted, this data was available prior to the pandemic but as part of having to work more efficiently, we are now seeing things in a different light. We can prioritise reviews and target care by searching and picking up on patients that are at higher risk and are likely to have poorer outcomes through data such as emergency admissions, prescriptions for oral corticosteroids and reliever inhalers. A report published by Asthma UK; Digital Asthma: Re-Imagining Primary Care2 highlights how the NHS can better use data to transform asthma management and it highlights the importance of improving data sharing. Hopefully this will be widely used and moving forward, that new and proven models of care will be shared across the country as we continue to adapt. I think we are almost certain, never to go back to the ‘old normal’.
Hesitancy towards remote consultations
Understandably there was some hesitancy around digital consultations. It is no secret that as human beings we can be averse to change, but the pandemic gave us little choice. At the beginning I wondered how I would be able to deliver the best possible care to patients remotely, and this was something I had many a discussion with my colleagues about. However, now delivering remote consultations myself, I can see how many aspects of an effective review CAN be delivered remotely. Video consultations have many advantages over telephone consultations, although both have their pros and cons. One of these advantages is the ability to check and demonstrate inhaler technique: a fundamental component of good disease management. Being able to see the patient, and for them to be able to see you, can provide reassurance for the patient. The addition of visual cues can also make it much easier to build a rapport.
Not all patients will have access to video consultations, so it is important we take this into consideration and use accessible means of contact for our all our patients. A recent survey from Asthma UK found that that 77.9% of people with lung conditions, would be happy to have their care managed remotely in the future3 which largely echoes the feedback that I hear from patients in my own clinical practice. It is important to highlight that remote consultations are not for everyone and that not everything can be done remotely. Face to face consultations still need to be available for those who need them, and this may be determined as part of a triage process.
Using remote consultations for the annual review
Whether it be a telephone or video consultation, gathering some information in advance of a scheduled appointment can help to free up time during the consultation. Information such as the Asthma Control Test (ACT), COPD Assessment Test (CAT), MRC score and so on can be sent out prior to appointments through an NHS approved digital platform or e-consultation system. In addition to this, reviewing the patients notes to look at previous appointments, management plans, prescribed medications and number of issues prior to the appointment will help to better prepare you for the consultation and allow more time to focus on the patient’s ideas, concerns and expectations. It will also help free up time to develop a supported self-management plan in collaboration with the patient.
The importance of written personalised management plans is well documented for both asthma and COPD4,5,6. One of the positive things to come from the pandemic is that there seems to be a much greater focus on supported self-management. This has been a time where patients have had to self-manage perhaps more than they may ever have done before and as healthcare professionals, we are able to give them the information and tools to be able to do this with confidence. There is more awareness and utilisation of the online resources available such as inhaler technique videos7,8 and the information on websites such as asthma UK and the British Lung Foundation (BLF). All these tools can be shared remotely via links and can be referred to in between reviews.
Now is as good a time as any, if not better, to discuss smoking cessation. The BLF highlighted that a smoker is 5 times more likely to get a viral infection and twice as likely to get pneumonia9. While many patients who have been shielding or having to isolate may have smoked more due to boredom and anxiety, my experience has been that many more have engaged with us for a quit attempt. The Very Brief Advice intervention10 can be delivered remotely and it is important to know what smoking cessation services you have in your area; many may not be operating with face to face appointments but will be running a remote service.
I have found that going through breathing techniques over video or telephone consultations to help with anxiety and COPD related breathlessness11 has been really effective. In the absence of face to face pulmonary rehabilitation programmes, where virtual programmes aren’t in place as an alternative, I have been signposting to resources such as the BLF’s stay active and stay well videos12, as these can be done in the comfort of the patients own home. When collaborating with the patient on their management plan, where possible I get the patient to fill it out during the remote consultation with me or I document the plan using as many of their words and ideas as possible and share a copy digitally or by post it if the patient doesn’t have access to a smart phone or email. These are examples of just a few of the components of a respiratory review that can be done effectively remotely.
We have come a long way since the beginning of the pandemic and although it has been challenging, we have made some important changes in the ways that we work. Moving forward, we need to continue to embrace new ways of working to deliver the best care that we can to our patients to improve their outcomes and their overall experience.
For more information on how to conducting reviews remotely please see our other articles.