Online consultations in mental Health at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Cumbria, Northumberland Tyne, and Wear NHS Foundation Trust (CNTW) service-user appointments are mainly carried out face-to-face, with occasional telephone calls depending on the purpose. While a number of service users travel to CNTW sites for their appointments, a number of staff also travel to see service users. It was believed that an online consultation solution that offers virtual appointments would enable a reduction in travel (for either staff or service users), potential to reduce DNAs (did not attend), and give service users greater choice to access clinical services. Out of area treatments would also potentially become much more financially viable.

CNTW introduced a new digital choice for service users to gain access to mental health services.

Situation

Traditionally, access to mental health services was restricted to face-to-face consultations and telephone contacts. The introduction of online consultations aims to make the service more convenient, with greater flexibility around appointments by offering a video call interaction between clinician and service user, rather than being restricted to the conventional methods or a specific location. Using online consultation technology, clinical services could modernise their approach to consultations without losing the patient-centred approach.

As a result of the COVID-19 pandemic, there became an increased requirement for an online solution to allow clinicians to continue to provide care to their service users. As part of this, the use of an online consultation solution would be fundamental to both the clinician and the service user.

The Trust began a pilot of 50 staff in early 2019. During the initial lockdown during the COVID-19 pandemic, due to the flexible cloud-based nature of the solution, the Trust was able to scale this up rapidly to all services. The solution is now used by more than 3,000 staff, for approximately 3,000 consultations per month. Online consultations give service users greater access to mental health services. Staff now have flexibility to meet with service users, while greatly reducing the need for travel.

Aspiration

The Trust aimed to digitally empower service users by increasing service user choice in how their clinical appointments are delivered. With the ability for service users to use their own technology, the requirement to travel to a clinical location is also negated.

Solution and impact

The Trust procured Modality Systems’ OneConsultation product, which leverages functionality with its existing Microsoft Teams and active directory applications.

Modality OneConsultation offers a secure virtual consultation or group consultation room that a clinician can join using Microsoft Teams and a service user can join, through a web browser, on their smartphone, tablet or PC. Internal and external participants can be invited to join the consultation.

It is a fully managed, customisable service that provides a private, intuitive, virtual environment for high-quality video consultations.

Implementing online consultations as a digital option aims to improve service user choice and access to mental health services. Clinical services that adopt online consultations can add a technological solution to the treatment they offer to help them cope with the demand on services.

Leveraging online consultations provides greater flexibility to clinical staff and service users, allowing appointments to be booked as normal. Moreover, if a service user requires treatment outside of their scheduled appointments, online consultations could be used as an ancillary to their care.

Benefits and outcomes include:

• reduction of travel costs and travel time for both clinicians and service users
• increased clinician capacity to offer care, as less time is spent travelling from the clinical base to the service user’s setting
• service users not having to pay for transport and parking to access services
• reduction of CO2 emissions as a result of reduced travel by both clinicians and service users
• an anticipated decrease in DNA rates through offering a choice of service provision, benefitting both service users and clinicians
• service users gain faster access to services and are able to balance their treatment with their work commitments and lifestyle
• support for staff and service users’ care during Covid-19 restrictions
• efficient use of existing technology

Certain technical systems needed to be in place prior to implementation:

• web browser and operating systems need to be identified. Modality OneConsultation does not run on Internet Explorer. Compatible web browsers are:
  • Google Chrome
  • Apple Safari
  • Microsoft Edge
  • Mozilla Firefox
  • Opera
• the latest version of Windows operating system should be in place
• an active directory for the authentication process is required
• service users need a device that has video, sound, audio capabilities (for example, laptop, PC, tablet or smartphone) and internet connection. Service users should be advised that if they are not connected to Wi-Fi, then they may incur data charges from their network provider
• clinical staff need appropriate kit - PC or laptop with webcam, mic and speaker, and internet connection (Trust network, Wi-Fi, or own Wi-Fi)
• users need access to the internet through Wi-Fi, 4G or 3G to be able to participate in an online consultation

Functionality

The system is a desktop and mobile software application.

Capabilities

• Virtual consultation service
• Virtual waiting area for service users to wait for the clinician to ‘arrive’
• Services can have multiple waiting areas created
• No confidential information is stored on the application
• Clinicians’ virtual consultations can be joined through Microsoft Teams or Skype for Business
• Supports most web browsers
• Service users do not need to download software to engage with consultations
• Allows group consultations
• Ability to add internal and external participants to the consultation
• Can be set up to enable recording of sessions
• Screen share functionality is available
• Service users can test audio and video settings prior to their consultation

Scope

The system can be used in office and home settings to facilitate consultations where face-to-face is not possible or as an ancillary to care if service users require treatment outside of scheduled appointments.

Key learning points

Training and development

• Develop clinician and service user guides. Clinicians and service users were given short user guides with picture instructions and FAQs. This gives the clinicians and service users a guide to refer to, if they need to, during an online consultation
• Develop an e-learning package. An internet page was created with links to guides and an e-learning package. This provides the clinicians with the ability to refer to if and when required

Piloting and feedback systems

• Test with clinicians and service users. Engage all user groups in the testing phase to give them early sighting of the solution and increase their confidence in its use
• Survey service users. At the end of an online consultation the service user has the option to complete a survey. This provides the Trust with the opportunity to see how well the solution is being received
• Revisit your requirements. It may not always be possible to find a product that fits perfectly for all the requirements that have been gathered

Collaborative working

• Involve the procurement team. Expert knowledge is needed when completing a procurement process

Governance and standard operating procedures

• Provide clear guidance in relation to a clinician’s responsibility when carrying out an online consultation. Clinical judgement should be used when assessing a service user’s suitability for an online appointment
• Standardise the workflow process. During the engagement with clinicians it was clear that not all the clinical teams worked the same way. Standardising the workflow process ensured a streamlined way of working for all clinicians, making it easier to share knowledge and support regardless of service area

Digital inclusion

• Consider alternative processes for service users who do not have access to appropriate kit, such as using Trust kit and space or enabling service users to attend a Trust site to use the online consultation solution

Key figures/quotes

• On average the Trust is having 3,862 consultations per month
• 3,138 staff across the Trust have access to the solution
• By the end of February 2021, 41,887 consultations had taken place since commencing go live (on 6 April 2020)
• One service area is saving between £15,000 and £20,000 per month on renting less office/clinic space

Of 4,905 service users who had completed the OneConsultation survey:

• 96% either strongly agreed or agreed they were satisfied with the overall experience of their consultation call
• 93% were willing to receive future mental health care through online consultations
• 92% either strongly agreed or agreed they felt able to share information the same as is if the clinician was in the room with them

Out of 3,717 consultations in January, there were 504 survey responses (11%). Out of 3,262 consultations in February, there were 422 survey responses (13%).

“Clients like to see me and know what I look like. I am better able to observe their non-verbal behaviours than over the phone (and clients can observe mine). I like that we could speak to anyone throughout the country so could support colleagues with long waiting lists in other areas. Clients not having to travel to centres makes it easier for them.”
Linda Dawson, clinician

“[Benefits include] Reduced DNA rates, reduced patient travel times, greater accessibility for some groups, more flexible for patients to attend, can be undertaken with a clinician at home or in a non-clinical office, so less pressure on room bookings and more flexibility with appointments.”
Michael Shaw, clinician

“[Benefits include] Elimination of driving time, ease of access, ability to achieve physical distancing yet carry on most tasks, continuous contact with the team, overall increased capacity, user-friendly.”
Utpal Goswami, clinician

“[The system] Can help to engage those who may not want to come to clinic or may not want me to come into their homes. Can be a way of getting to know patients in what may feel a safer "space". Can do joint appointments more easily with other staff. I also work with students who may return home, and therefore therapy can continue anyway.”
Nicola Barclay, clinician

“We have been able to carry out assessments to some degree during this time, and been able to be in touch with service users and carers/families more easily and be flexible with times, decrease travel and room booking etc. MDT meetings have been easier to arrange with those out of the trust due to not needing to travel etc so diaries are easier to coordinate in a timely way.”
Fiona Johnstone, clinician

“Most patients are willing to attend and engage. They seem comfortable in familiar surroundings. It saves travel time, not having to use transport, and most patients do not need an escort or support of another person.”
Keshar Shrestha, clinician

The Trust commissioned an academic evaluation of the project. The evaluation used a sample of data from May 2019 to July 2020.

Key findings from the evaluation include:

• 68.4% of users were female and 26.6% of calls were to service users aged 16 or under with a further 31.6% made to service users up to 40 years or older
• more than one third of service users resided in the most deprived quartile of UK postcodes
• video calls were preferable to clinic attendance or home visits
• video calls have the potential to improve DNA rates and save staff around 14 miles and 25 minutes per service user contact
• of the 80.4% of service users who reported a time saving, three quarters saved up to one hour's travel
• on average, consultations lasted 37 minutes, saving service users 20 minutes of travel and £1.75
• service user satisfaction was very high and almost all were willing to receive further videos calls, finding the solution easy to use
• three quarters of staff envisaged continuing to use video consultations with 20% of their caseload

This graph demonstrates the number of online consultation appointments between April 2020 and January 2021. Figures are for all services who have access to the solution.

This pie chart demonstrates service user satisfaction scores from 4,701 service users using the solution. These satisfaction percentages have been measured from May 2020 to January 2021.

4,701 service users responded to the service user survey from 88 service areas and results indicated that 3,834 saved up to 30 minutes or more of travel time.

68% of service users saved money by not travelling.

As a first choice, video calls were preferable to clinic attendance or home visits.

Find out more

Online consultations in mental health (requires login)

Key contact

Dr Jonathan Richardson, Chief Clinical Information Officer, Consultant Old Age Psychiatrist, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Jonathan.Richardson@cntw.nhs.uk

Mike Jones, Associate Chief Clinical Information Officer, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Mike.Jones@cntw.nhs.uk