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Abstract
Introduction Digital healthcare in the UK was adopted out of necessity rather than choice during the COVID-19 pandemic. However, as we move forward, UK governments and healthcare services have acknowledged its evident benefits for patients, staff and the National Health Service (NHS), and are keen to sustain its improvements in the long term.
Objective To understand the benefits, challenges and sustainability of a future-proof digital healthcare.
Design A semi-structured interview study was conducted.
Setting In NHS services in Wales, UK.
Participants With clinical and non-clinical staff across a mix of clinical specialties.
Outcome measures Semi-structured interviews were conducted to address benefits, challenges and sustainability of a national video consulting (VC) service, and thematically coded using a quantification method of qualitative work.
Results A total of 203 interviews were conducted and 3 dominant domains emerged, with 7 themes and 26 categories.
Limitations It is important to acknowledge that these findings were captured during a pandemic.
Conclusions NHS Wales has demonstrated that currently there are an equal measure of benefits and challenges to a national digital healthcare. However, with ongoing government and service support, improvement and evaluation, it has potential for a sustainable digital future, in which the benefits can outweigh the challenges.
- COVID-19
- QUALITATIVE RESEARCH
- Information technology
- Health informatics
- Telemedicine
Data availability statement
Data are available on reasonable request. The analysed data are published on the TEC Cymru website in the format of a full report of all data for the public to view. To access this report please see https://digitalhealth.wales/tec-cymru. Other data can be requested as a reasonable request to the corresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This is a national study, which is representative of Wales.
This study has a large sample size for qualitative research.
This study provides both narrative and quantification of narrative accounts.
Interviews were with clinical and non-clinical staff, therefore, benefits and challenges are perceived by them only, and not patients.
This study was conducted during the COVID-19 pandemic and update and satisfaction of digital healthcare may have been impacted.
Background
Wales is a country that is part of the UK with a population of 3.1 million across a total area of 20 779 km2. Compared with other parts of the UK, Wales has a high rural environment, the oldest age population (21% over 65), the highest proportion of people with a disability (22%) and is the poorest UK country.1 2 Based on Wales’ rurality and demographic profile, it may be assumed that digital healthcare may not be an equitable option for its general population.3 4 However, there is currently little research and evaluation to support that there may be any health disparities in Wales.
Though, such assumptions have been challenged recently, and suggest otherwise. For example, Welsh data from more than 50 000 National Health Service (NHS) patients and staff demonstrates that regardless of what may be considered limiting factors, for example, age, gender, ethnicity, household income, location, health status and disability, digital healthcare, such as video consulting (VC) platforms, can provide equity of care across all patient and staff groups, appointment types and clinical specialties, which suggests that the same type of digital care can be offered and accepted by all people in Wales, regardless of status.5
In support of this, the Welsh government has recently published a ministerial call for a new digital strategy in Wales, stating that ‘digital change offers us a range of new tools for solving old and novel problems’.6 It is further argued that ‘digital offers the potential to make our experience in the world better, enhancing people’s lives [and] strengthening the delivery of public services’.6 The digital strategy, and other Welsh government policies such as Prudent Healthcare and the Future Generations Act7 8 look to support and enable a strong digital future for NHS Wales. Early research and evaluation have been conducted in Wales, which demonstrate the early successes of the government’s strategy.9–11
The aim of this study was to identify the benefits, challenges and sustainability of a national digital healthcare service from a representative sample of NHS healthcare professionals (clinical and non-clinical). The NHS Wales VC Service was identified as an appropriate service to recruit. A VC platform called ‘Attend Anywhere’ was funded in 2020 by the Welsh Government for use across NHS Wales, to include all primary, secondary and community healthcare. The service included unlimited and free access to the VC platform, and additional training, evaluation and support by the national VC team. Thus, as researchers from the national VC team, the scope of the study is limited to understanding VC via the Attend Anywhere platform only.
We conducted semi-structured interviews with staff to identify the benefits, challenges and sustainability of VC across NHS Wales. An opportunity and convenience sampling approach was taken to recruit NHS staff using VC for an interview. First, sampling involved adding an additional question to the end of the NHS VC Service feedback survey, requesting VC users to take part in an interview (this feedback survey appears at the end of each VC appointment). Second, to ensure that we interviewed all types of VC users, emails were sent to all NHS Wales VC Service contacts. Furthermore, social media platforms and personal/professional networks were used to further recruit.
This process lasted for approximately 2 months (September–November 2020) until recruitment received at least a 1% representation of all Welsh VC users. Based on the total of 16 000 healthcare professionals registered and set up with VC in Wales, 10% were approached to take part in interviews (approximately=1600), and a total of 203 semistructured interviews were completed with participants across all health boards in Wales, across a range of specialties. This resulted in a 1.3% representation of all Attend Anywhere VC users in Wales.
The inclusion criteria for an interview were to have prior experience of using the NHS Wales VC service in the 1-year period (March 2020–March 2021). On initial contact, via an introductory email or phone call, all expressions of interest met the inclusion criteria, which was to confirm eligibility using a tick box exercise. Interested respondents were sent an email with study information and a consent form. In addition, a scheduled Microsoft Teams invite for a video interview was arranged, or a contact number was obtained for a telephone interview, or face-to-face interview if preferred. A total of 12 people did not attend the scheduled interview, and no follow-up arrangements were made. With each interview, consent was read out verbally, and this was obtained from all of those in this study.
Each interview lasted approximately 45 min. Interviews were audio recorded and transcribed verbatim. A semi-structured interview guide was constructed and included questions that asked about their experience and opinions of VC (topic guide shown in online supplemental appendix 1). A conversational style of interviewing was adopted to allow a more natural dialogue.
Supplemental material
Following Braun and Clarke’s approach,12 thematic analysis was conducted, using original transcripts. Initial analysis involved listening to the recordings and reading of the transcripts and making notes, which then led into highlighting and coding emergent codes and areas of interest, about experience and opinions of VC, as well as flagging up of common domains, themes and categories. These were reviewed and refined until final conclusions could be drawn.
This process was predominately conducted by five researchers. These include a research officer (BW), a head of research (GJ), a national clinical research lead (AA) and two supporting research assistants (MW and SA). The interviews guide was developed by GJ, SK and AA. The interviews were conducted by GJ, BW, MW and SA. The coding was conducted by BW, MW, SA and consensus of coding by GJ, SK and AA. Analysis and development of domains, themes and categories was conducted by GJ, BW, MW, SA, AA and checked and confirmed by all authors.
To provide a clearer understanding of commonality across domains, themes and categories, and provide a more accurate indication of experience and response, using a quantification method of the qualitative work, the findings were thematically coded, analysed and presented as both quantifiable information based on the number of dominant and sub-dominant coded responses (referenced as n=), these were determined by the number of times an idea or theme emerged, using two full rounds of coding (initial and final). Qualitative data were analysed and presented as direct quotations, which are referenced by respondent’s occupation and health board. Qualitative guidelines, found online via EQUATOR, were used to assist with this process.
Patient and public involvement
No patient or public involvement in the development of this study. However, the interviews were guided by standard research principles.
Results
A total of 203 participants were interviewed including clinical and non-clinical staff across primary, secondary and community care sectors, across all seven Welsh Health Boards in NHS Wales. Participant data collected, include clinical specialty, profession and associated health boards (shown in online supplemental appendix 2). Demographic data collected include age, gender and ethnicity (shown in online supplemental appendix 3).
Supplemental material
Supplemental material
From the thematic analysis of the 203 interviews, a quantification of qualitative work was conducted. In total, 1494 direct codes were identified, which resulted in 3 dominant domains emerging, with 7 themes and 26 categories. These are displayed in table 1.
Dominant domains, themes and categories
Domain 1: Benefits of VC
The dominant domain ‘benefits’ is themed into ‘service benefits’ (NHS Wales), ‘personal benefits’ (NHS staff member) and ‘patient benefits’ (patient, family or patient–clinician relationship). As a quantified total of coded benefits, there were 506 individual responses from the 203 interviews that indicate a defined benefit of VC. Of these, 81 responses (16%) were related to ‘personal benefits’, 157 responses (31%) to ‘service benefits’ and 268 responses (53%) to ‘patient benefits’, which were either direct benefits to the patient or family (n=164) or a benefit to the patient–clinician relationship (n=104).
Service benefits
At the NHS service level, VC was believed to have benefited the NHS service due to decreased appointment waiting times (n=26), fewer missed appointments/‘did not attends’ (DNAs) (n=14), monetary savings on reduced service expenses (n=14) and improved service delivery (n=103).
For example, staff narrative states that patients are now waiting less time for an appointment due to VC and its contribution to ease of access and reduced waiting lists.
If we continue with virtual clinics, it will improve, as we’re not constrained by the physical space anymore with them (Otolaryngologist, SBUHB)
If we didn’t have VC, our waiting list would’ve increase significantly (Mental Health/ASD Nurse, ABUHB).
Furthermore, reductions in missed appointments/DNAs are believed to be associated with the increased use of VC.
There’s a massive decline in the DNA’s. With my clinics, because they are so in-depth, I book in one-hour slots. Usually, if there was a DNA then I would be waiting over an hour for the next patient, and if two DNA’d then that would be a massive waste of my time. Whereas now, I can carry on with other referrals or other phone calls (Stroke Nurse, SBUHB)
It has drastically reduced DNAs because there’s less excuse now…so it has reduced that, and some people forget about appointments and you can now ring them, and they can quickly join whereas that wouldn’t happen if they had to physically get to the appointment (Psychological Therapist, SBUHB)
The NHS service also benefited from direct monetary savings in reduced service expenses such as staff or patient travel expenses being claimed back, or costs such as clinic room bookings.
It’s got to be saving the health board money, as the elderly patients always need transport (paid by the NHS) to get to hospital (Vascular Surgeon, ABUHB)
Massive reduction in our travel, before I was averaging about £200 a month in expenses and now it’s barely £20 a monthly (Occupational Therapist, ABUHB)
It must have saved us (the NHS) a fortune in booking rooms based in the community. The cost implications are massive (Physiotherapist, SBUHB)
VC has also improved service efficacies due to its avoidance of waste on clinical time and resource. This benefit highlights how VC is considered an extra tool in clinical ‘tool boxes’.
I work with nurses, radiographers, paramedics, and we’ve basically, innovated a new service, the VC has helped us to do that (Physiotherapist, SBUHB)
The NHS spaces are so overloaded, and a lot of that is inappropriate… so as an alternative VC allows patients to access services (Mental Health Therapist, CTMUHB)
…VC is another resource that people can use and it’s a tool (Learning Disabilities Therapist, ABUHB)
It’s just another tool really isn’t it…the more tools you have and the more ability you have to offer alternatives, and the more likely you are to be able to absorb the patients that we have (Physiotherapist, SBUHB)
Personal benefits
As a direct personal benefit of VC, the NHS staff report a reduction in their own travel and parking (n=49) and improved flexibility in their working day (n=32), which is said to improve staff well-being.
It saves time in my travel time, because I can literally sit in the office do the appointment, write the notes up onto the next one. (Speech & Language Therapist, BCUHB)
This is transformative for me in terms of travel and how I manage my diary and book people in (Speech & Language Therapist, CAVUHB)
We have more flexibility as when we do our appointments, doesn’t have to be when a room is available, which I think has been good for staff wellbeing (Neuromuscular Carer, SBUHB)
Although these are personal benefits to NHS staff members, they ultimately feed into patient or service benefits as well, as less travel equals more time for other clinical work, and improved flexibility allows more flexible care for patients.
Patient benefits
From the perspective of the NHS staff, there are a wide range of direct patient and family benefits such as the reduction in travel and parking, and improved flexibility (n=113).
VC saves patients travelling. We used to get people in quite regularly just for a check, where now we might not necessarily have to (Podiatrist, CAVUHB)
The parking really stresses people out in our hospital… so now it works really well that patients can have something offered to them like VC (Physiotherapist, SBUHB)
It should have been like this before, we’re a really rural country so our area would have been ideal for VC as people have to travel so far (Counsellor, PTHB)
Parents with children have busy lifestyles and a lot going on, so it’s easier for them… more flexibility (Speech & Language Therapist, PTHB)
My patients who are working age, they are doing VC in their work, in a private room (Neurologist, CTMUHB)
Furthermore, the virtual environment within the patient’s home can encourage family involvement, and positively promote independence and improved patient-centred care (n=52).
It’s almost the next best thing they’re on their sofa their dog is on their lap and they’re chatting away… in their own home is actually quite nice (Speech & Language Therapist, CTMUHB)
Since using VC, we've been working with the families a bit more and on modifying the home environment rather than working with the child specifically (Speech & Language Therapist, ABUHB)
I don’t think in the majority of cases it has negatively affected anybody’s care. It has probably done the opposite in promoting self-management and self-efficacy and like the patients’ treatments. People take the control more and they actually do the exercises… (Physiotherapist, SBUHB)
VC is also seen to positively enhance communication and improve cues between clinicians and patients, ultimately balancing out the healthcare power dynamics (n=85). Participants suggested that this improvement may have been due to patients feeling more comfortable in their home environment.
It’s opened up communication for us…It’s never been so good…I always know everything that is going on, I’m always involved in all the decisions. (Learning Disabilities Nurse, ABUHB)
It has been invaluable. You can actually see the patient, you’re looking for the subtle changes on them so you see if they’re being looked after (Neurologist, CTMUHB)
You get the added thing that you’re seeing them in their home so you’re getting cues from what you see behind them (Primary Mental Health Assessor, SBUHB)
VC is a real levelle3r. It’s not a power situation, it’s much more about you and I doing this piece of work… the therapeutic relationship has started off on a better foot. (Administrator, PTHB)
When they come into the hospital, things are very structured and professional. That professionalism gets in the way…, but having contact through VC makes the patient seem a lot more relaxed. (Acute Adult Psychiatrist, ABUHB)
The narrative also suggests that there are specific types of patients and families that VC add an additional level of benefit to. For example, hard to reach families (n=18) whereby VC can remove many of the challenges associated to access of care.
With hard to reach families or families that don’t have transport… (Speech & Language Therapist, ABUHB)
It’s enabled me to work with people I wouldn’t have been able to see face-to-face (Mental Health Therapist, ABUHB)
Domain 2: Challenges
As a quantified total of coded challenges, there were 584 individual responses from the 203 interviews that indicate a defined challenge of VC. The dominant domain ‘challenges’ (n=584) is themed into two sections: as ‘clinical decisions’ (n=451) and ‘technical restraints’ (n=133). The theme ‘clinical decisions’ is subcategorised as ‘risk and privacy’ (n=149), ‘confidence’ (n=60), ‘takes more time’ (n=57), ‘engagement and cues’ (n=64), ‘organisation’ (n=39) and ‘well-being and isolation’ (n=82). The theme ‘technical restraints’ is subcategorised as ‘audio and visuals’ (n=22), ‘Internet and bandwidth’ (n=72) and ‘platform incompatibility’ (n=39).
Clinical decisions
The narrative on challenges relating to clinical decisions were associated to concerns surrounding VC’s delivery of clinical care, particularly what participants felt may be clinically missed, may take more clinical time, or affect clinicians themselves.
Participants commented on the ‘risk’ surrounding VC as a cause for concern for some people in certain specialities, regarding missing certain aspects of an appointment that may be better seen or identified face to face, for example, being able to physically examine a patient.
VCs not a one-stop shop, sometimes you want to check blood and do blood pressure, so it doesn’t do that (Paediatric Consultant, ABUHB)
You may miss things because you haven’t got that ‘hands on’, and that is a worry. But, if you think, right I couldn’t see everything that I needed to, but that’s where your clinical reasoning comes in, and you go out to see that child (Physiotherapist, CTMUHB)
In addition, the challenge around ‘privacy’ was predominately discussed by participants in mental health services, and generally associated to specific types of patients, such as those with a history of abuse or currently living in a domestic abuse household.
They might not be able to speak freely, on a laptop, you don’t know who else is going to be hidden in the room (Clinical Psychologist, ABUHB)
For some clients it’s just not safe for them to do therapy in their own home, they may have children, they may have partners, they may have abusive partners and no privacy so that’s one side of it. The other side of it, some patients don’t want their childhood trauma beamed across their living room which is their safe space (Clinical Psychologist, PTHB)
Some of the participants discussed ‘confidence’ around VC and the required technology was portrayed as a challenge for some patients and clinicians. Interestingly, these findings suggested some participants shadow colleagues while learning to use VC, which impacts digital confidence. Some participants felt more comfortable with this ‘copying’ behaviour where this learnt culture helped participants move to VC with growing confidence. This 'copying' has the potential of positive or negative responses, but it is important to acknowledge its presence, particularly when exploring new digital innovations.
Sometimes patients are shy around VC. But are getting more familiar with it. Its personal choice, I guess (Mental Health Nurse, ABUHB)
So, I was quite daunted by it at the beginning, but I feel really positive about it now. Often you feel the anticipation doing a new thing for the first time (Clinical Psychologist, BCUHB)
However, it was stated how it catches on more as the new culture embeds itself.
I think some colleagues think it’s more difficult than it is, they were scared of it, but I’ve shown them and it’s easy to use… It’s so easy to use and it’s a brilliant resource (Community Nurse, SBUHB)
Some are more comfortable with it and others will avoid it, but with practice they’re getting better at it but perhaps more training, that’s more specific to how to do a video call (Physiotherapist, HDUHB)
Some participants felt extra ‘time’ was needed for VC uptake, as opposed to other consultation methods. This challenge was apparent when training was necessary to use the platform or where patients needed additional explanations and support during their VC. A small number of participants also commented on the additional ‘setting-up’ time needed to conduct a VC.
You’re doing a lot explaining of how to use the camera etc., which takes away from actually assessing them (GP, BCUHB)
There’s a training element that’s taken a little bit of time out of my diary, workload overall (Counselling Psychologist, ABUHB)
We just go into clinic a bit beforehand and make sure everything is set up (Paediatric Nurse, SBUHB)
For some participants, there were challenges surrounding ‘engagement’ with patients via VC, particularly with the lack of visible body language and trying to get ‘cues’. For example, several participants found it difficult to achieve the same level of engagement with new patients or younger patients. While facial cues can be picked up well during VC, a number of participants found this more demanding during their virtual consultations.
…The key thing is you have to know the patient. If you’re talking to new patients you haven’t met before you don’t know what to expect of them, or them of you, there’s no relationship there and it tends to go on and on. Whereas with patients you know it is a quick consultation, straight to the point …you both have confidence in what you’re saying to each other (Cardiologist, SBUHB)
Video feels less personal, it’s difficult to strike up a rapport (Occupational Therapist, ABUHB)
You don’t get to pick up on those cultural non-verbal cues from VC patients (Neurologist, SBUHB)
Some participants reported that VC appointments within their services have increased the amount of ‘organisation’ required surrounding appointment setup and consultation. For example, some services struggled to have a streamlined booking process in place, while others found it difficult to manage the sheer number of virtual waiting rooms for their patients.
It’s just managing the waiting room which is tricky for us. We have multiple doctors, multiple nurses running clinics at different times of the weeks. (Administrator, SBUHB)
It’s going well—it works really well actually. The software works brilliantly, it’s the organisation around it that works less well—but that’s not the fault of the software (Infectious Disease Consultant, CAVUHB)
A further challenge that participants reported was the impact that VC had on their own well-being. Some participants reported a greater increase in workload due to the use of VC. This was often paired with feelings of isolation for some participants who were conducting VC from home and not seeing work colleagues as often as before.
My work load has definitely increased and I do feel a lot more tired at the end of the day, and I think that has a lot to do with just sitting in front of the screen (Speech & Language Therapist, PTHB)
You just don’t have the contact with your colleagues or patients, that physical contact, communication (Physiotherapist, PTHB)
Technical restraints
The narrative on challenges relating to technological restraints were discussed predominately regarding ‘audio and visual’ difficulties when using the VC platform, ‘internet and bandwidth’ issues or ‘poor quality or incompatibility’ problems for participants to use as a consultation method.
For a number of participants, audio and visual impacted on the quality of their VC calls. For example, the audio at times could be robotic and the picture quality of the video could be blurred. This was a challenge for many participants as it could negatively impact appointments and damage rapport and conversations with patients if this arose mid-call, particularly when discussing sensitive or emotional information.
When the quality of the video is poor, it’s very unpleasant… It’s not that it impacts the session as such. It’s not as good as other face-to-face platforms so I don’t understand why that would be. It’s more comfortable when the picture is clear (Health Psychologist, SBUHB)
A very minor gripe is that the quality is not as good as other formats. Although, this could be due to peoples phones or the laptops they are using. (Physiotherapist, SBUHB)
Linked with poor audio and visuals is the internet and bandwidth connections that participants had when using VC. For some, their internet allowed them to use VC as intended with no connectivity interruptions. However, for others with poorer connectivity caused issues. Participant narrative suggested that in some services, they were nervous to attempt to use VC following connectivity problems that disrupted the call with a patient.
If people’s internet isn’t stable, there’s a huge delay which makes it really hard (Clinical Psychologist, PTHB)
One couple we tried, we had to give up because the technology wasn’t good enough. It causes huge amounts of stress. It has an impact on the assessment and the therapeutic relationship (Psychotherapist, ABUHB)
In some instances, the participant narrative suggests that at times, the quality of the VC platform is too poor for consultation use. For some, patients were unable to access the VC platform. Some participants found the technology aspect of VC incredibly stressful. For some services, this has had a negative impact on their views of VC and how this would fit in with their consultation methods.
There are some issues, but it’s been the technology stress that has actually put on me more than anything else… It’s nobody’s fault- it’s just the way it is… but technology is definitely the biggest stressor and that’s why I feel sorry for our patients (Physiotherapist, CAVUHB)
For the most part it is very good, I think it’s on the side of the client sometimes they struggle to get on to the system but that could be due to them delaying their appointment as well, might not always be technology. (Administrator, PTHB)
Domain 3: Sustainability
The dominant domain ‘sustainability’ counted for 404 responses and is themed into two sections: ‘future use’ (n=244) and ‘future improvements’ (n=160). Having a blended approach (n=105), patient choice (n=71), favour for face to face (n=10) and VC as a useful tool (n=58) have been sub-categorised within ‘future use’ with their total of codes relating to sustainability. For ‘future improvements’, improved support, training and resource (n=88), awareness and digital champions (n=23) and technical advancements (n=49) are subcategorised.
Future use
Many participants reported that they would like VC embedded into NHS practice for the long term, but as a ‘blended approach’, with a mix of face to face and virtual appointments adopted where clinically appropriate. However, ‘patient choice’ was seen to be just as important.
I am definitely using VC the most, but quite a few people are on a blended approach… I think that blended approach is useful (Paediatric Consultant, ABUHB)
In the future maybe clinic settings could have a mixture of everything (Neurology Nurse, CTMUHB)
I would love to keep using VC. There’s always going to be a time for face-to-face in clinics, but I think together they will work really well (Occupational Therapist, CTMUHB)
It was felt that a combination would ensure the best possible care for the patient, and that clinicians are confident in making these clinical judgement calls. However, regardless of clinicians making these clinical calls, many participants expressed their awareness that decisions surrounding the future use of VC are made above them among managerial staff and specific to health boards.
…it just depends on what our Health Board says (Health Visitor, SBUHB)
I think there is reluctance in other areas and it’s what the NHS is all about, the culture … the chain management. I [as a Manager] have sold it to my team and very much this is how you solve things (Manager, ABUHB)
But there was, however, a strong sense of ‘want’ for VC to continue being part of NHS Wales, with discussions within services on how VC will be best integrated.
Overall it has been really positive for clinicians and patients, and we are looking to take it forward and make it a bigger part of our service (Neuromuscular Doctor, SBUHB)
…we’ve started having conversations about how we can integrate VC into the working diary (Speech & Language Therapist, SBUHB)
But a small few still wish to return to traditional means of face to face.
I hope it gets back to normal soon I’m not doing this job for another 20 years over the screen (Child Development Nurse, ABUHB)
The gold star is face-to-face. (Child & Adolescent Mental Health Nurse, ABUHB)
When looking at the future of VC, participants expressed that they want to be able to give the patient a choice when deciding on their mode of consultation. This emphasises the focus participants put on patient-centred care.
At present, the majority of participants believe this choice to be a ‘service choice’ due to the demands of the service during the pandemic and the need to limit face-to-face contact. Similarly, it is the service choice for many participants to use face-to-face where they see that face-to-face contact is more appropriate.
Past the pandemic, VC will undoubtedly be something which will be incorporated into the system. It is definitely going to be some sort of hybrid system where patients are offered the choice (Physiotherapist, SBUHB)
We wanted to keep choice for our clients… not everybody has the technology or doesn’t know how or use it, and it’s about client safety (Counsellor, CAVUHB)
A number of participants within the findings reported a preference for face to face; as time has gone on they have become ‘fed up’ of only using VC. This emphasises that at present, the use of VC depends on the need of the service and what that specific service and health board have decided, despite a number of participants focusing on patient involvement and choice with VC.
We’re getting fed up and want to be back face-to-face (Physiotherapist, SBUHB)
I think for us front line hands on workers we very much want to get back to that hands on and seeing our patients face-to-face (Child Development Nurse, ABUHB)
A large proportion of the narrative involved the value of VC. Many participants could perceive VC becoming a valuable asset to take forward within their services and being added as a ‘tool’ for professionals to reach for with patients.
I definitely think it should stay and be added to our skills, definitely (Health Visitor, SBUHB)
I would be very disappointed if this was withdrawn from us as a service (Renal Medicine Nurse, BCUHB)
Future improvements
Many of the participants expanded their thinking into future improvements for VC that were considered vital in moving forward with its use and ensuring its sustainability long term. These improvements include ‘increased support and training’, VC ‘awareness’ and digital champions’ and ‘technical advancements’.
While VC has been used across a large range of services, several participants commented on areas that needed further work such as improved levels of support and training which would enable participants to keep using VC. For example, having technical support would increase confidence using VC among participants as well as additional training sessions to consolidate learning and add to VC knowledge and skills. A number of participants also felt as though VC drop-in sessions for any questions would be beneficial and an opportunity to fit in around schedules.
I think drop-in sessions would be good for those sort of questions too (Health Visitor, SBUHB)
I would really like another training session now I’ve used it for a few months, um, because I would really like a session to consolidate (Physiotherapist, CAVUHB)
I would maybe need a bit more training, a refresher I suppose if I wanted to go into adding someone else into the call or go into a different call but for the moment just adding one patient and talking to them one-to-one, it is so easy (Physiotherapist, CTMUHB)
There were a number of participants who reported being ‘digital champions’ or ‘super users’ for VC and thus, took the lead role on the roll out of VC within their service. This was considered important for leading the way, especially in encouraging uptake among the less confident or motivated members of their team.
While digital champions are not deemed essential by participants to use VC, having colleagues who were available to go to for support and advice was incredibly useful for participants. Closely linked to participants having the support to use VC among their colleagues is also the needed improvement of raising awareness of VC. Without the support of making VC known within services, participants felt as though it was difficult for those (clinicians) using it to make contact with patients. Participants reported awareness is necessary among patients, clinicians and administrative staff alike.
We have a VC group, a task and finish group, and they’ve looked at some of them who are less confident or looking at a ‘buddying up system’ and how to support therapists who are less confident (Speech & Language Therapist, BCUHB)
I’m a super user. So I’ve been training people up on VC (Psychologist, ABUHB)
More options to share tech with people, borrowing something for a limited time, and have someone go into show them how to work it. Or liaise with other organisations like Age Cymru who have digital coaching (Psychotherapist, ABUHB)
A bigger media presence with it on TV for something and for me it needs to not be medic-people… it needs to be the AHPs, the nurses saying we can do these things this way (Physiotherapist, SBUHB)
While a number of participants had these three levels of awareness in place throughout their service, other participants commented on the noticeable gaps and the need for improvement. A particular issue noted by participants was that if administrative staff are not as well informed about VC as participants hoped; if administrative staff do not offer VC, then patients do not know it is available and the awareness never increases. In turn, participants found this a struggle and emphasised that improvements to appointment setups were needed for a clear and seamless integration through the VC system, as without this, VC is less productive at both the individual level and also service level.
VC is here to stay, but it needs the organisation behind it… to ensure that they have had a practice run, so they come in my call and know what buttons to press (Cardiologist, SBUHB)
I would really push for that seamless integration… but that improves all the time doesn’t it (GP, CAVUHB)
The administrative team did not implement VC. They did not see it as important, they did not see it as a priority (GP-BCUHB)
I’m trying to get my administrative staff to ask patients whether they’d like to be seen face-to-face or virtually. (Paediatric Neurologist, SBUHB)
Appropriate technology and available space to be able to conduct participant VC is considered a much needed future improvement. While the majority of participants felt as though they had been provided with the adequate technology to run VC, there were a small number of participants who felt there had not been a push for VC from their managers and health boards, and so they lacked the equipment and technology as VC was not seen as a priority. For example, many participants noted that they were without correct head sets and devices to run their VCs.
Have to treat them like a normal clinic in terms of needing a room to conduct those VCs privately so I still can’t do those from my shared office (Oncologist, BCUHB)
We don’t really have the equipment, it would be great if we had laptops and better cameras and things (Occupational Therapist, CTMUHB)
There isn’t enough infrastructure in the hospital to support the system. For example, they don’t have enough cameras, they don’t have enough speakers so we have to take our own equipment. (Infectious Disease Consultant, CAVUHB)
Conducting VC from the office and from home, some felt as though equipment was lacking. For the office environment, there is a needed improvement in ensuring there is adequate space to conduct the VCs that is private, to ensure confidentiality. Office environments also need to have the appropriate technology and WIFI connections to ensure VCs can be conducted without disruptions. For participants working from home, there was a consensus that more should be done to ensure they are able to work from home and be provided with equipment.
Equally important to improving the technology access and space is the technical improvements to the VC platform itself. There are noticeable improvements that participants felt would.
I would really push for is high-quality video (GP, CAVUHB)
The expansion of the capacity of VC to do groups would be good (Physiotherapist, PTHB)
The thing a lot of us are screaming out for is an interactive platform where we can get the person on the other side to show us what they are doing (Therapy Assistant, SBUHB)
Discussion
It is important to view these results in their historical context. The period of March 2020−2021 involved the rapid adoption and spread of VC at the beginning of the COVID-19 pandemic across Wales. The use of VC enabled many healthcare services, especially community, mental health and outpatient teams to continue to offer a service to patients when there was limited or no access to face-to-face delivery in clinic or hospital settings. VC represented an immediate and very helpful tool to enable healthcare professionals to provide patient care and to social distance. While greater use of digital technologies and remote monitoring in healthcare have been longstanding NHS objectives, findings from across the UK suggest that ‘The single biggest reported factor reported as enabling an increase in video consulting was the cancellation of non-essential face-to-face appointments. Changes in staff and patient attitudes were also considered important.’13
As such, it is not surprising to have found significant themes in this study about the benefits of using a VC platform for both patients, healthcare staff and services in these circumstances and to have captured some of the technical, organisational and capability issues that such a rapid deployment of a new way of working bring.
The three domains discussed in this study, and the related themes and categories are, however, of great importance to this area of work, and it provides understanding of the experience or opinions of NHS staff using VC, which for many, was the first time using digital healthcare. For future digital interventions, this evidence is crucial.
Many of the benefits discovered in this study, have potential to continue to bring long-term gains, especially the reduction in miles less travelled for healthcare, better utilisation of buildings and resources, flexible ways of working, reduction in missed appointments and increased patient choice. The challenge now, as we are in the recovery phase of the pandemic, is to reorientate utilisation away from VC being seen as an ‘emergency response’ and to ensure that it becomes a mainstream method of delivering healthcare. As blended delivery models of VC, telephone and face-to-face consultation become possible; this will require health and social care staff, in partnership with patients, to codesign what the ‘new normal’ pattern of consultations looks like for each clinical specialty and service. It is highly likely that differences will emerge between specialities based on clinical need for physical examinations and observations. Key ingredients in the success of this next co-design phase will be incorporating the patient’s choice of method of consultation (VC, telephone and face to face), while balancing service demand and effectiveness, the most appropriate medium for that moment in clinical care and clinician preference.
The challenges the study have highlighted align with wider findings from 'health systems research that disruptive technological innovation, especially in heavily institutionalised environments, is complex, uncertain, challenging and risky. Success is not just about new technologies but also about their clinical safety, how we make them work, and whether NHS infrastructure can accommodate them at speed and scale' 13. This study highlights that while there were many benefits from the rapid deployment of VC across Wales, inevitably the speed of adoption will mean that there are issues to address and a need to continuously improve.14 These include ‘skills and knowledge; motivation and attitudes; user-centred design; ways of working; safety and equity; resources and infrastructure; and culture and leadership…[and they add] It is not difficult to see how rolling out changes during a pandemic may have created challenges in each of these areas.’14 The thematic findings in this study correspond with these key factors, and so potentially illustrate the areas where the next phase of continuous improvement must focus.
It is now important to reflect on the learning we have gained from this period and the potential role for VC in a sustainable healthcare system. The findings from this study highlight the benefits to patients and staff of being able to access and deliver healthcare through VC and provide a helpful lens through which to see where continuous improvement should focus for greatest impact on patient and staff experience and outcomes.
Limitations
Due to this study being conducted during a pandemic, it may influence the update of digital healthcare, as many face-to-face services were unavailable. Furthermore, this study was conducted with NHS staff only, and therefore, patient voices were directly missed. Future research should seek to focus on these gaps.
Conclusion
Overall participant narrative highlights both benefits and challenges from VC use within NHS Wales’ services. Nevertheless, moving forward, the benefits are likely to outweigh the challenges, in that many of the challenges identified in this study are relatively simple fixes, which the Welsh government and TEC Cymru are currently working on, such as improvements in internet connectivity, data integration and VC platform issues. It is also important to consider the ongoing benefits, and sustainability of VC and continue to understand how participants see VC being used in their services, and what they deem necessary for its long-term benefits and success.
Data availability statement
Data are available on reasonable request. The analysed data are published on the TEC Cymru website in the format of a full report of all data for the public to view. To access this report please see https://digitalhealth.wales/tec-cymru. Other data can be requested as a reasonable request to the corresponding author.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by prior to the start of the study, ethical approval was obtained (SA/1114/20) from the Aneurin Bevan University Health Board Ethics and Risk Committee. Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @teccymru
Contributors GJ contributed to the main design of the study and development of the research questions, the main structure and write-up of the paper, and final amendments to the manuscript. GJ, SK, BW, MW and SA conducted the data collection and analysis. GJ, AB, SK and AA discussed and interpreted the data once analysed. AB completed the discussion. SK, MO and AA helped structure the manuscript, and contributed to the programme and clinical understanding of the findings and shaped the conclusions. AA was responsible for overseeing the full development of the study design and data collection, the analysis and development and final sign-off of manuscript from a clinical and programme perspective. All authors contributed to proof-reading and amendments of the final manuscript. AA is the author acting as guarantor.
Funding Technology Enabled Care (TEC) Cymru and the NHS Wales Video Consultation (VC) Service is funded by the Welsh Government. Funding award number N/A.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.