The coronavirus pandemic has changed many aspects of everyday life, including healthcare. In this Digital Health Special Report, Andrea Downey, explores what impact Covid-19 has had on the development of virtual care.

It’s been two years since the Covid-19 pandemic struck and drastically changed the way the NHS delivers care.

Services that previously would have been delivered face-to-face were forced to go virtual as the country entered it’s first lockdown and patients were told to stay home to prevent the spread of the virus.

Now, as the country adapts to the government’s living with Covid policy, technology has become a focal point of NHS services – virtual care is here to stay.

For Craig Oates, managing director of digital physical health provider Doctrin, virtual care holds the possibility to “completely overhaul” patient pathways by providing more flexibility to patients and freeing up valuable time for clinicians.

“Technology allows us to think outside the box about how we can deliver care differently, while still providing face-to-face care for patients who need it. It’s about providing tailored options,” he says.

NHS England has confirmed virtual care is set to become a permanent fixture of the NHS, with an “aim to be able to offer these models of care to any patient across the NHS who could benefit”.

Virtually unavoidable

Before the pandemic, patients viewed face-to-face appointments as the best way to approach healthcare. For example, around 80% of GP appointments were carried out in person before Covid-19 hit.

“The shift to considering a ‘digital first’ approach has now happened, so the focus needs to be on adapting and expanding the digital model of care to provide streamlined services for patients,” Oats explains.

“Virtual care is essential to creating a sustainable NHS, as well as tackling the elective backlog and demands in primary care. But if it is implemented in the wrong way, it has the potential to create more work.”

Moving forward, the focus needs to be on equipping NHS providers with the capabilities to provide virtual care, as well as the understanding to select the best technology for patients and clinicians, he says.

NHS England has taken steps towards embedding best practice in virtual care throughout the health service.

A spokesperson said the benefits of virtual care for a variety of patients throughout the pandemic have been “striking”.

“For instance, in care homes in North London using digital vital sign tools for their residents, ambulance conveyances to hospital have dropped by almost one third, compared to care homes that don’t yet have access to this technology,” they said.

But it’s important teams advancing technology in the health service “learn as much as possible from others to avoid reinventing the wheel”, they added.

Virtual wards formed a major part of NHS England’s operational and planning guidance for 2022-23, including a £450million investment over two years to reach a national ambition of 40-50 virtual beds per 100,000 people by December 2023.

There are currently more than 53 virtual wards providing more than 2,500 beds nation-wide.

“These plans should be developed across systems and provider collaboratives, rather than individual institutions, based on partnership between secondary, community, primary and mental health services,” the planning guidance states.

Alongside that, more than 300,000 people with long-term conditions have benefitted from other forms of digital home care through the Supporting People at Home programme over the past 15 months alone, according to NHS England.

Health and social care secretary Sajid Javid is keen to continue that momentum, setting out his tech agenda last month which includes a target for 75% of adults in England to use the NHS App as a “front door” to the NHS by March 2024.

“The NHS is already working on new features, including how we can show estimated waiting times and the results of blood tests within the app,” he said.

Virtual care in practice

Over the last two years, some 50% of patients at Barts Health NHS Trust have received virtual based follow-up care using telephone services or through the trust’s partnership with Attend Anywhere.

Charles Gutteridge, chief clinical information officer at the trust, said: “We have continued to use SMS messaging to help support patients by providing reminders of imminent appointments and in some cases to provide patients with the results of laboratory tests.

“The Covid pandemic has driven a transfer to virtual consultation at pace with many solutions now available. The focus has been in providing care to vulnerable patients, particularly those with chronic conditions requiring immunosuppressive therapy which include severe asthma, inflammatory bowel disease, rheumatological disease, multiple sclerosis and cancer patients.”

There has also been an uptake in patient-facing apps that allow users to upload information about their long-term conditions, putting care back in the hands of patients from the comfort of their own home.

But, as with all technology, there have been barriers. Gutteridge lists four areas where improvement is needed in virtual care:

1. Development and adoption of information standards for messaging and electronic health records (EHRs)
2. Use of single patient portals where a patient can find everything required for holistic care
3. Education and training programmes for digital literacy for health professionals, patients and the wider public
4. The development of tools that ‘translate’ the complex language of modern medicine into something easier to understand for patients

It’s a list Oates agrees with. He believes there are three things that need to happen in the NHS to foster the successful provision of virtual care.

Firstly, there needs to be an improvement around patient and clinician understanding of technology.

“We need to make clear that virtual care provides the same high-quality care as face-to-face, as well as providing new benefits such as flexibility and reduced referral-to-treatment times,” he explains.

“This needs to be done while recognising that virtual care isn’t the right route for some patients.”

The second element is an understanding from providers that technology can be used to change care models, but it needs to be implemented in ways that work for the provider and the patient.

Thirdly, virtual care needs to be implemented across all health systems to provide a “seamless journey”.

“We have to avoid making healthcare inequalities worse with virtual care, and a blended model of care is key to achieving this,” Oates says.

A blended approach

As we move towards endemic and NHS services begin to return to normal, the health service is faced with a new problem – a backlog of almost six million patients waiting for care.

As Oates explained, virtual care is essential in tackling the backlog and increasing access to care, but he warns it’s “not the answer for every service challenge”.

“The key is implementing it in a way that compliments face-to-face care, rather than hindering it,” he says.

“The right blend of digi-physical care can transform care experience and patient outcomes, as well as improve NHS staff roles and responsibilities, and can help patients who just need to renew a prescription through to those with long-term chronic conditions who need care more regularly.

“Patient Initiated Follow-Ups are a shining example of this – outpatients book in their follow up appointments virtually if and when they need them, rather than being automatically booked in for something they might not need.”

Gutteridge agrees a blended approach is best.

“In general, there are no specific limits to virtual care for outpatients but the need to physically examine a patient, take tissue samples, develop patient confidence and trust all may need face-to-face attendance,” he says.

“The opportunities for virtual care for inpatients are in supporting early discharge and patient supervision remotely using a range of tools. Longer term care for specific conditions can also be successfully managed in a virtual environment.”

At Barts Health, the majority of remote care currently provided is through telephone and online consultations. But Gutteridge warns a vital component of the success of digital services is understanding that they don’t work for everyone.

“In east London, it is still the case that 5-10% of the population do not have simple access to the internet and depend on phone services for communication. The use of apps is also currently nearly exclusively carried out in English,” he explains.

“Language interpreters and advocacy is still used in virtual consultations but adds further complexity to connectivity for each episode.”

NHS England reassures that the option for face-to-face care will continue to exist.

“The most important aspect is that care is personalised to meet the needs of the individual and that is likely to mean a mix of virtual and face-to-face care,” a spokesperson said.

Looking to the future

It’s clear that virtual care is here to stay. NHS England has cemented virtual wards as part of its agenda over the coming years and the health and social care secretary is aiming to put care back in patients’ hands through the NHS App.

More personalised, easier to access, digitally delivered health and care has been placed at the forefront of the health service.

But, while technology has proved vital over the past two years, it’s crucial that technology suppliers and NHS providers do not lose site of patients who cannot use digital tools. Face-to-face appointments can never be fully replaced by virtual solutions.