In 2019, the NHS Long Term Plan set objectives to redesign outpatient services. The aim was to avoid up to 30 million face-to-face outpatient visits a year, providing specialist advice on diagnosis and ongoing patient care via remote consultation. This approach seeks to support the ever-increasing demand for outpatient appointments, relieving pressure on local infrastructure and using technology to support a more efficient way of supporting patients.
Prior to the COVID-19 pandemic this aim appeared ambitious. In February 2020 just 4% of outpatient attendances were via telephone or telemedicine, however, the countrywide lockdown and ever present need to care for patients led to an almost overnight transition to remote consultations, where at its peak in April 2020, 35% of appointments were remote, before flattening to 25% in September 2020[1].
While the pandemic provided incentive to quickly redesign outpatient services, it also shone a light on existing health inequalities, with those younger than 65 in the poorest 10% of areas in England almost four times more likely to die from COVID-19 than those in the wealthiest areas[2]. Amidst the urgency of the pandemic the rapid upscaling of remote consultations left little time to consider and support those without access to digital devices, but we now need to ensure we are looking at how these delivery models might further exacerbate health inequalities.
In early 2022 we partnered with Traverse Ltd to gain a clearer picture of how rehabilitation support was being delivered remotely and the impact on health inequalities. This work was commissioned by The East of England Rehabilitation Network and the East of England Trauma Network and had three aims:
The key outputs from this work were a rapid evidence review of current guidelines for using digital services in rehabilitation; a service provider survey; a set of case studies highlighting the patient and provider perspective; and quality improvement recommendations.
The rapid evidence review (available for download) highlighted the lack of evidence-based clinical guidelines covering the use of digital services for rehabilitation. Inclusiveness of services is considered broadly through the provision of different models of delivery, however specific recommendation for patient populations and inequalities are not defined. If we hope to mitigate health inequalities, prevent duplication of effort, and enable the patient voice to guide service design and delivery, we consider that specific professional guidelines are required.
A survey was distributed to service providers across multiple rehabilitation pathways in the East of England to understand what digital and remote rehabilitation services are currently being offered, as well as the level of understanding and engagement with health inequalities. 19 responses were received, and whilst not representative of all services, this provided a snapshot of current practice and local knowledge. Unsurprisingly the survey showed that use of both telephone and video services increased significantly as a result of the COVID-19 pandemic. It also highlighted that further support is required to enable practitioners to identify, monitor and support individual patients experiencing health inequalities.
A set of six case studies were developed which provide detailed examples of the barriers, enablers and what works and doesn’t work for digital rehabilitation from both a patient and practitioner perspective. Both acknowledge that there are benefits to digital rehabilitation services, mainly centred around flexibility, convenience and the potential to reduce waiting lists. However, some patients interviewed had negative experiences of digital services, with both practitioners and patients feeling that face-to-face rehabilitation was preferable for particular cases, such as physical examinations.
To provide actionable insights from the case studies and service user scenarios, a set of quality improvement recommendations were developed within our review. These could be applied in different rehabilitation settings, and fall into three categories:
Ensuring those who experience health inequalities are supported to access and engage with health and social care services has a benefit to the whole population. We hope this investigative work continues to be built upon and recommendations followed to improve patients experience with digital rehabilitation across the region.
On 2 March 2023 we presented our findings to 46 rehabilitation and health inequalities professionals and facilitated discussions on how we can best embed the report’s recommendations in services across our region.
If you are interested in finding out more or accessing the recording, please contact amy.miller@healthinnovationeast.co.uk.
References
[1] The Health Foundation & The Nuffield Trust (2020) The remote care revolution during Covid-19. Available from: https://www.nuffieldtrust.org.uk/files/2020-12/QWAS/digital-and-remote-care-in-covid-19.html#1 [Accessed 14th February 2023].
[2] The Health Foundation (2021) Unequal pandemic, fairer recovery. The COVID-19 impact inquiry report. Available from: https://www.health.org.uk/publications/reports/unequal-pandemic-fairer-recovery [Accessed 14th February 2023].
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