If you ask Google Images to show you ‘digital healthcare’ or ‘remote consultations’, you will find pictures of an individual patient (usually a young professional) talking to their doctor over a smartphone video link, with the digital connection working smoothly and all the necessary infrastructure in place. The appearance is one of efficient, personal care through a state-of-the-art link.  

The reality of remote and digital healthcare is often a far cry from this, with most remote services dependent more on telephone than video and featuring breakdowns, glitches, discontinuities and other stressful complexities.

This webinar takes this messy reality as its starting point. We will offer no magic solutions (we all know that ‘muddling through’ is often needed). But we will offer some evidence-based ways of improving the embedding of remote and digital pathways and services, with a focus on access and equity, safe triage, avoidance of inefficiencies (such as double-handling) and staff training and support.  

The presentation draws on our 15 years’ experience studying remote and digital healthcare in both primary and secondary care.

Experts: 

• Trish Greenhalgh, Professor of Primary Care Health Sciences, University of Oxford
• Emma Ladds, Wellcome Trust DPhil Student, University of Oxford, GP Partner, Eynsham Medical Group

Transcription:

My name's Helen Serrana. I'm one of the Associate Editors at BMJ, and I'm delighted to be associated with this program of work, which we're calling Future Health. And there's a big event in November, but before the big event, we're running a series of webinars. And this is webinar  number eight or nine.

And it's about how to make organizational level changes to support and optimize remote consultations. Now, remote consultations came up loads in our research as something that everyone was very excited about on some levels and very nervous about on other levels. And we we thought that this was a great opportunity to get some experts in who've done some really great work.

deep thinking about the best way to make remote consultations work really well. And this isn't for this isn't about how you as a healthcare professional might be talking to a patient over a screen directly. It's about how to get the right systems in place to make that bit of the system work really well.

So I'm delighted to welcome Tricia Greenhouse, who's professor of primary health, Care Health Services at the University of Oxford and Emma Lads, who's a GP partner at the Ancient Medical Group and Wellcome Trust DPhil student at the University of Oxford as well. And they're going to take the screen over and give, start their presentation.

So thanks very much for joining us.  

Thanks very much. Yeah, we're so pleased to have this opportunity to tell you about some of our research and some of the work we've been doing. I'm bringing, I'm a full time academic. I used to be a GP and before that I was a diabetologist actually.

And Emma, who's going to be speaking next brings both the academic perspective, but also very importantly is a frontline.  NHS person who's living and breathing some of the challenges. And I know that a lot of you are thinking, do you guys really know what it's like in the real world?

Maybe I'm a bit less up with that. But Emma's certainly doing that for a couple of days a week, as well as being an academic and doing the research. We were given this title, how to make the organizational changes for remote and digital consultations. So by remote, we mean something that's at a distance when you're not in the same room.

And then there's digital consultations where actually you might not be too far away from each other, but you're interacting through some kind of digital medium. So it's all the things that are not just, Straightforward face to face I don't know whether you're going to be disappointed, but I'm not going to give you a list of if you do this and this everything's going to fall into place because it really isn't like that.

And I want to start off by just a little bit of theory on complexity. If it feels complex, it is complex. Some of you, if you've heard me speak before will know this slide. I use it a lot. Everything in life is either simple, complicated, or complex.  Simple is an example of making a sandwich.

If you put the same things in, into the sandwich every day. Every time you're going to get the same sandwich. It's really straightforward. There's a set of of processes in a particular order. The same thing is actually building a rocket. If you follow the manual and you put things in order, in the right order, as you're told, you'll get the same rocket every time. 

Complex is completely different. Simple and complicated are the same process, but complicated is just more of it. Complex, Such as raising a child is a completely different process. Because of lots of things, but partly because of people, you can't just scale it up. What worked for child one isn't the same, isn't going to work for child two, et cetera, et cetera.

And so  once we start thinking about complex. phenomena, we've got to drop the idea that there is a set of procedures that we can follow which will just make everything fall into place every time. And there's something about when do we muddle through? When do we follow our intuitions? When do we abandon the instructions?

And when do we fall back into following procedure in a kind of mechanical way in the hope that if we do that, things will be all right. You can use this for raising your child if you want or you can use it for implementing remote and digital health services, you can use it for any kind of complex challenge.

And the first thing is, Work out what you want to do. Work out what your values are. Is the most important thing to make sure that nobody gets missed out, or is the most important thing to maximize income, or is the most important, whatever it might be. You need to be quite clear about what you're providing and why what you care about and have that as an important compass.

And you also need to work out the practicalities, the constraints those of you who are working in general practice.  You've got a lot of constraints on who you can hire, for example and how. Those are, those just the reality. So bring those together and set a broad direction of travel. And then model through.

Make sure you're monitoring what you're doing, reflect periodically, change a bit, iterate, that is as good as it's going to get. There is no magic way to implement remote and digital services. It's going to depend a lot on your context et cetera. Okay.  So that's the background. It's complex. I'm now going to, I think I hand over to you now, don't I, Emma?

Yep. You're going to tell us about 

this. 

The rest of the talk, we're going to give you some lessons that we've learned about implementing remote and tech approaches. And these are all gleaned really from a study we've been running called Remote by Default 2. And it's been a two year study.

It's taken a long time. It's been across the whole of the UK. So we've looked at GP practices, 12 of them in Scotland, Wales, and England. And what have we been doing? We've actually had researchers linked to each of those practices. We've been doing something called  ethnography. So this is what Clifford Girtz called informed hanging out.

So they've been lurking around in reception, in the waiting rooms, sitting in with doctors. They've been interviewing people and really just trying to get an understanding of how the practices were using any sort of remote and technology and how that's changed over the couple of years whether they've taken things up, whether they've developed them or actually whether they've just abandoned ideas. 

And alongside that, we've been interviewing elite interviewees, so these might be policy leaders, people in industry, importantly patients, just to try and build some awareness around what the issues are to do with remote and tech, build relationships, and really just to hear where everybody's coming from in this sort of field. 

And as part of that, we identified four areas that we thought were going to be particularly important to add. Access and triage and all the issues with equity linked to that. Quality and safety, obviously fundamental, really important, but sometimes overlooked the sort of issues around workforce and training.

And then, of course,  underpinning everything, the technology and the infrastructure itself. And we ran four workshops looking at those four areas with different kinds of stakeholders who might have a vested interest in it. So Trish, if you move us on Sorry, that's all right. Slow there.

There we are. So of course, there are loads of benefits to do with tech. And I'd be really remiss not to highlight them at the beginning. And I'm going to start off by telling you about one of our patients. So this is a girl called Laura. She's 19. And. I think her case beautifully illustrates some of the real positives and the really beneficial aspects of technology and remote care.

So Laura is a final year student, she's away at university, she's miles from her family, she's miles from her usual GP practice where of course she's still registered she's only a temporary resident in London as a student and actually finals are coming closer and you know the stress is mounting, she's getting anxious, she doesn't really have that much support.

Friends are all busy and she thinks, Oh gosh, actually, I really just need somebody to talk to, or maybe I even need an antidepressant, or I just don't know, I need to speak to somebody. And so she goes on to her practice website and she completes a form. And actually it's quite a simple form, it's a few questions asking her what's wrong, what she'd help with.

Ideally who she'd help with and how she might like it. Would she like it by telephone? Would she like a face to face? What is it that she's needing  and then she Sends it off into the ether. She doesn't really know where it's gone or what's going to happen But maybe a day later, she gets a text message just saying, Hi Laura, thanks for your message.

We'd love you to have a telephone consultation with Dr. So and and actually, she recognizes Dr. So and so's name. Maybe she's seen her before, or maybe she's just heard about it from her family. But there's that familiarity, there's a sense of continuity. And now she's got something in the diary.

It may not be that day. It may not be that week, but it's just a safety net and it's very appropriate for her and she feels reassured. And it can be very effective. And of course, that's a demonstration about the ease of tech, the convenience.  How it's possible to organize care at a distance, so geographically distinct.

It can be efficient, as in this example, and actually it can help achieve some of the values of your organization or or enterprise that you're working for. If continuity is a value that you think is important, Then actually, you can use tech within your systems to make that happen.  Asynchronous messaging, for example, emails or this kind of submission of a request and then hearing back later on, actually, that helps with workload management and workflow within systems.

So it's not all bad. And of course, it has the  capacity to send huge amounts of information easily. So there's a massive educational aspect to it as well, potentially.  

Okay. So now let's talk about some of the, I wouldn't say the negatives. I don't, I'd say that  Emma's just told us some of the great things that can happen, and we've all had good experiences with remote consultations, but I'm not going to tell you about the case of Amir.

By the way, these cases are fictionalized. They're based on people that we've learned about or met in our research, but they're not real people. So Amir is 34. He's a sofa surfer. He doesn't actually have a current home at the moment. He left where he was living because he owed people money and he's now sleeping on the sofa of one of his friends and his inhaler has run out.

Now Amir  isn't that great with tech. He's got this phone. It doesn't work very well. It's what we call a kind of entry level smartphone. It's it, And he's not that good at using it. And he doesn't particularly like to use it because he's got some neurocognitive difficulties. So what he likes to do is go into a surgery and walk up.

So he goes into a new surgery and try.  But the receptionist said we don't do that anymore. You've just got to go out and you've got to contact us on your phone because we're digital access only. But Amir was pretty cross about this. He got a bit annoyed. He was upset. He's a little bit impulsive.

And then the practice decided to mobilize their zero tolerance.  Because he'd raised his voice to a receptionist. So he was thrown out of that practice and then he went back. So his friend said nevermind, you can use my inhaler. I've got asthma too. So he borrowed his friend's inhaler for a while.

And then he went to try and register with another practice. And a similar thing happened. The, actually the receptionist in the second practice said, no, I can register you, but I'm going to have to ask you a load of questions because I'm your digital navigator and I can see you can't use tech very well.

And so in front of everyone in the waiting room, she started asking him, now, can you tell me whether you've had this and what you want? And went through this very structured form thinking she was doing him a favor. But Amir felt very embarrassed. He didn't really want to answer all these questions in front of everybody.

And they confused him because actually he had the kind of mild sort of cognitive challenges where he couldn't actually work out which of the five options was the. One that he should pick. So Amir is quite a good example of the kind of patient who might decide that the digital front door is closed in his face.

And some of the research we've done mainly Francesca Dakin, who's another one of my PhD students has done some nice work on this. She said one of the problems with digital and remote service. It's, there's a big burden on the patient. They've got to locate the pet, the services.

They've got to navigate them. They've got to explain and classify their symptoms. They've got to negotiate either directly or online. Now, technologies make a lot of assumptions about the people who are going to use them. 

Bring the phone call a GP surgery or a hospital now to, for that department, and I bet we've all got another relative who just can't do it anymore. He just phones me and can you  get your way through this?  Now, in one of those electronic consultations, the patient is  to create. A digital facsimile of themselves on the record by putting all this stuff into their electronic form. 

They have to package their symptoms in a way that is accurate in a way that is persuasive because the staff are going to be using that to prioritize them. And of course, patients with low digital literacy, low health literacy, low system literacy, people who don't understand how the system works are less able to do that.

Now. Staff these days often use that digital representation of the patient to determine their eligibility for care. For example, if someone's got asthma and there's a pull down menu, did you have a cough in the night? Did you have this? Did you have that? And if the patient hasn't filled that out correctly, and we know that disadvantaged patients often say, yeah, that was all right, that was all right, that was all right, because they don't realize that the staff are going to be using that.

to put them up or down the priority list. So safe triage really depends on the accuracy of this digital facsimile. And sometimes staff can fill in the gaps. Sometimes staff know the patient and think, Oh, that guy's no good at filling out the forms. Let's move him up the list anyway. But that really does depend on whether they know the patient and how experienced they are. 

The other thing that we found is that if patients have these pushbacks at the digital front door, they give up. They just don't engage. And I've got another one of my PhD students, Laiba Hussain, who's just talking to  particularly minority ethnic groups who are quite elderly. They say two years ago I tried and it didn't work, so I've given up type of thing.

So this is a real problem. And we're going to come back hopefully to have a bit of a discussion about access and equity, but I'm now going to hand back to Emma, who's going to tell us about continuity.  

So I already touched on continuity briefly and mentioned how it can be one of the values within your system and this is actually the one exception to our patient narrative.

So this is Jane, obviously not her real name but she was a very real patient. She was one of my patients. And her family are delighted that we can actually try and use her story in research and education to try and illustrate some of the problems that arose with her care. So Trish, if you move us on what you'll see is actually the information provided to my reception staff when her daughter rang on a Monday morning After Jane had been discharged from hospital on Friday, and as you can see this is the sort of information that the reception team will collect in a very standardized format, and this is then presented to the triaging GP to make a decision about exactly who within the practice team might be the best person to deal with this.

And what sort of urgency it might require as you can see Jane's daughter felt it was very urgent for today and she described how her mom had been discharged from hospital for end of life on Friday and the family were not given much information or contact with anyone at all. Now over the weekend they've been trying to contact us.

contact 111 to come and give them some morphine, a painkiller just to try and help keep her comfortable. But she's still becoming quite agitated now and again. They're asking for the district nurses to come out urgently to give some more morphine. And they're asking if we can put the family in touch with the palliative care nurses,  because they haven't heard anything.

else about that side of things yet.  And as you can see, what I've highlighted in green, it's just the number of people, even in this snapshot of just a weekend of care and this interaction with the practice team, just the number of different individuals who've been involved so far. There's been the receptionist, the hospital, secondary care team, 111, the district nurses, the palliative nurses, the daughter, and somehow we have to try and join all of this up.

And increasingly what we're finding within care systems is there's a progressive fragmentation. So this is your task, this is your task, this is your task. And what we're lacking is a sense of integration, of bringing everything together.  And that's as much a problem with technology as it is without it. 

But actually, the way we think about using tech within the system can make it more or less likely that some of that integration can happen. Trish, if you move us on, what we've tried to think about based from some of the data we collected was when we say we're joining things up, we're continuing things, what exactly is it that we're trying to continue?

And some of that is about connection, personal connection. The sort of psychodynamic aspect of care and that's  typically your doctor patient relationship when you've known your doctor from cradle to grave. It's that sort of idea and of course that's idealized now. It doesn't often happen but there is still something about having a personal connection with somebody who knows you, who knows who you are as a person, who's seen your parents die, who's witnessed the birth of your children. 

And that may be idealized, but there are still snippets of connection like that. And for some patients, particularly within palliative care, actually, that can be very important. And then there's something about thinking about we're continuing the episode of care, the illness. So that's about recognizing when something doesn't feel right.

So maybe there's just something funny about this pneumonia that isn't quite following the normal pattern. And  if you see the same person, Maybe they'll pick that up and recognize that actually, oh, it isn't pneumonia, it's lung cancer, and take it forwards from there.  Importantly, a lot of this is about joining up teams, joining up working practices, joining up what everybody's trying to do around the patient.

It's the socio technical aspect, distributed work. And you see that beautifully in the example of Jane, that actually, There are lots of different people who are going to be doing work for Jane to keep her comfortable and to support her family around the end of life, and somehow we have to join that up.

And technology's been great, phone calls, emails, they have made communication easier between teams. Emailing discharge summaries from hospital is often much quicker, all of that sort of thing. But often it actually requires extra work on the part of the people involved  to really make that joined up ness, that cohesiveness happen. 

And as we'll see later, that can put quite a lot of pressure on different staff.  And then finally, what we're thinking about is a commitment to a community.  And that's often underpinned by values or ethics. So does what we're trying to achieve fit into our overall view on what we think is important?

What really matters to us?  So why do we care about continuity? For fairly obvious and very well proven reasons, actually. Higher continuity has been  associated with increased patient compliance around some medication usage. good examples might be in diabetes care, for example and maintaining much better control of blood sugars.

And that obviously has knock on effects on outcomes. It can also reduce healthcare utilization. That's normally because people are seen by the right person at the right time. And actually you can put things like secondary preventative measures into place, preventing unnecessary admissions, all of those sorts of things.

Patients like it. It's simple. And also it improves the satisfaction of doctors and not just doctors, but other members of the team as well. It's easier. It may, if you know somebody, it's always much easier when you come across that unusual result to know what to do. It's safer because the context of where you're operating and fundamentally, it's just much more satisfying having that kind of connection with patients, that kind of longitudinal knowledge, it's just much nicer. All of those things and more mean that actually increased continuity is associated with reduced mortality. And there was a really lovely systematic review published a few years ago now. Which beautifully demonstrated that and I think that's just a lovely sort of illustration of all of these things coming together for a patient. 

And actually, just to join up this continuity theme, one of the problems with remote and digital care is it's harder to achieve that continuity and I think that example at the beginning of Laura, the university student who was feeling just dreadful.  Was able to achieve the continuity and you can think through how much money that might have saved.

But also, Laura is going to be a lot less unwell because she's able to get that link. And  a lot of the research we've been doing has  tried to unpick the work that teams are doing to achieve continuity, despite the kind of fragmentation of care that occurs with. digitally distributed work.

Okay, so safety. Mrs. Benson, age 76, is a patient at a particular practice and she phones up having suddenly become quite breathless and speaks to a receptionist who's very busy and has got all sorts of things coming thick and fast there's people coming in through the front door there's lights flashing there's other people coming in.

Passing, putting things under her nose. And so she speaks to Mrs. Benson and says, Oh, you sound like you're not very well. Let me just get you onto the urgent list and puts the phone down. And it's then about to put Mrs. Benson on the urgent list for a call back. and then gets distracted by something else and doesn't do it.

Mrs. Benson, a few hours later, is still sitting there waiting for a call back and sadly dies of some kind of acute condition. Now that's a fictionalized version of a real case and I've deliberately chosen the case which Doesn't have very fancy digital stuff. It's merely a telephone call, but we all know that we've all been there when we've been distracted, the telephone is described in the sociological literature as an interruptive technology.

It just goes off, et cetera, et cetera. So we've got problems here. But Mrs. Benson wasn't one of our participants in our In our remote by default to study, because when we followed these 12 GP practices that Emma told you about, we followed them for more than two years, actually nearly two and a half years.

We didn't find anything like this. We didn't find any never events. We didn't find any major safety incidents. And so we had to change our research question rather than say what happens in, in these safety incidents? We wanted to know how these practices were avoiding safety incidents. When they were providing remote care, because Mrs.

Benson came from an add on to this study, where we went looking in national complaints records and closed litigation cases for these very rare examples of problems, serious problems, sometimes deaths and serious harms linked to remote care. And digital care. So let me tell you how practices avoid safety instance.

I'm sure it's the same in secondary care. The first thing is, and you can imagine, I'm just giving a skim of quite an in depth analysis of this. The first thing is that staff are on the side of caution. The clinicians among you, which is most of you,  Someone  rings you up and says my baby's very, I'm really worried about my baby.

You wouldn't carry on with the phone call, would you? You'd say bring the kid in. And that's something that we've been taught as professionals. And receptionists too have a very low threshold for saying that someone needs to be seen in person.  Secondly, what we found in our research was that staff are well supported in general, even though they're busy, even though they're resource constrained, maybe people are off sick or there's not enough stuff.

Nevertheless, if you're a trainee, your trainer is there.  Someone is there to ask. If you're a new receptionist, you can pass stuff up the line. Thirdly, that GP practices do know their vulnerable patients. At least they know most of them. And they sometimes have workarounds for those particular patients or groups of patients.

Fourthly that the duty callback lists are used very flexibly and adaptively, and patients get put onto them and moved up and down and all the rest of it, and there is that.  Flex in the system, where if someone's concerned about a patient, they can do not just the duty doctor, but there's lots of other technology supported processes  that people use creatively with an eye to making sure things are safe.

And the one I like best actually, is that one of the things that makes  remote care safe is staff break the rules. What do I mean by that? Is that staff invent things, they invent processes. They write things down in an exercise book and then that exercise book becomes a guide for new staff or that kind of thing.

They do things in a way that breaches the standard operating procedure, but they do that in order to make care safer. And then what happens is that they start to talk about it and reflect on it. on it and say, do you know what? We should formalize this. It's very important. And so then those safety procedures become formalized into the business as usual of the organization.

So those are just some of the ways that staff make remote care safe. But we also found in, I think all the practices that we looked at, which were great practices, they were all really good. Some of them were highly tech, technological, and some of them were very low. But they were all. 

Practice  volunteers for research, they're pretty well the telephone optimally if you're taking a history and doing an exam,  nation of sorts over the telephone, you've got to maximise the use of that low bandwidth modality. In other words, you've got to give the patient plenty of time to tell their story.

You've got to build rapport. You've got to make sure the patient can trust you. You've got to probe. So if the patient says they, they've got a pain somewhere, you've got to ask lots of questions and then give them time to respond. There's a whole set of techniques, which we should be teaching our undergraduates and our  postgraduate  clinicians  and our support staff to use that telephone. 

Some of the most heartbreaking safety incidents were because people didn't ask enough questions over the phone, got more information. Secondly, that practice workflows are often still designed around people walking in and queuing up and waiting physically whereas actually most people are not doing that.

You go into a GP practice. Now it looks empty. That's cause all the stuff's happening in the remote environment. And some of the workflows need to be redesigned to reflect that change.  Thirdly,  while some vulnerable patients have been identified, can you put your hand on your heart and say, yeah, we know every single person who's perhaps got a hidden disability like autism.

Or mental health condition, which isn't emblazoned right across their electronic record. Do we know the patients with limited English? Do we know the refugees? Do we know people who are cautious and have reason not to trust computers for any reason? When I was a GP, a few years ago now, 30 years ago, I had two sisters who had been Holocaust survivors and they wouldn't have their records on the computer.

They just wouldn't have it. We had to have paper records for them. Do we know all those patients? Fourthly,  are your remote working staff. adequately trained and supported. We picked up an awful lot of  unmet training needs and a high level of stress which I think we may be talking about later.

Are the interruptions minimized in busy areas? Have we really had someone come through and say, now, can we optimize the wellbeing of staff the relationships among staff, all that kind of thing? And finally, Is everybody aware of the key clinical conditions and trajectories? In other words, how fast is the patient deteriorating, for example, that are unsuitable for mode?

This is  lady from Google Images with Alzheimer's, you can imagine it's going to be pretty difficult to assess her on the phone. I'm sure you can all come up with lists of the types of individual that you wouldn't be assessing remotely, but does everyone in the practice know those? If you don't know them, I'm going to give you some links later and we've published on this.

So I'm now going to hand back to Emma to talk about workforce and training.  

Thank you. And I'm going to start by picking up on some of the stress that members of the workforce might be put under by a move to more remote and tech approaches by telling you about Brenda. Now, Brenda is 61 and she works in a practice doing a role called a patient care advisor. So she's a receptionist, but she's a receptionist plus. She does lots of sign posting. She helps deal with patient questions about admin issues increasingly about the NHS app and access to records, all of those sorts of things. And she's been a patient care advisor at PCA for 15 years now. She's loved by the team Because she brings in a cake every week.

She's loved by the patients generally because she's just really good with people. She lives in the local community. Her daughter actually works in the primary school. And so she's really embedded. She knows people. All those vulnerable people that Trish was talking about. She's more likely to be able to recognize who they are.

And importantly, she's more able or more likely to recognize when somebody really isn't right. And when somebody really needs something doing.  Now, she's great with people and she's rubbish with computers. She absolutely hates them. She can't type. She's one finger very slowly, finds it increases her stress,  finds it huge amounts of pressure from doing that.

And what she's found over the increasing introduction of technological  systemization within the practice the use of templates, the use of protocols, is that everything's been standardized. Her usual way of doing something, her workarounds, her sort of fudges that Trish was talking about in that previous slide.

Actually, they've gradually been fixed. And she's been encouraged to use the proper processes. There's less opportunity for flexibility, that personal touch.  And that's really where she gets her work satisfaction. So she's being told that she has to work in a particular way. It's a way she finds difficult, stressful.

She's been told that actually the things she enjoys, that people side of things, actually that's not the right way to do it. She should do less of it. And so all the joy that she gets from work is just gradually dissipating.  And actually over time, she becomes increasingly anxious. She loses confidence, her mood dips.

She becomes increasingly ratty with the team. She starts sending, urgent messages saying that this has to be done and that has to be done really because she just feels under pressure and in turn that passes on all of that pressure and stress and then she goes off sick and she goes off on long term sick leave and then she leaves and what have 15 years become?

What a waste.  So  it's really important that we think about the workforce when we're thinking about remote and tech. It's important we think about the workload, so increasing the ease of access, one of those positives I mentioned about technology, actually that can open the floodgates. And many practices have seen that with the introduction of online consultations. 

We see it every day. The number of admin queries that come in where you think, Oh my goodness, actually, that's just a bit of self sorting. That doesn't need a GP or a practice team to be involved in that. It's easy. So people do it. And then there's that real aspect of techno stress that I mentioned just now, I'm sure we've all experienced it.

The computer says no, or the printer won't work. Suddenly, those are the most stressful moments of your day that they're the hard things, which when you're under a lot of pressure because of an increasing workload, actually, those are sometimes the things those are sometimes the straws that break the camel.

And I think increasingly, given the stress that people are under, Those sort of technological glitches are having much more significant impacts on their well being than actually the kind of scale of the problem would warrant.  And I already touched on this issue of confidence with Brenda, and we see this across all kinds of staff levels and grades.

It's not just admin staff, it's nurses, it's doctors.  Actually, if you're trained in a particular way, or you aren't trained to do something, when you are put in that particular role and you can't do it, it just knocks your confidence again and again.  So what can we do about it? It's,  yeah, go on Trish, do you want to take this one or shall I? 

No, you've got it. Sorry, we missed the baton there. No, it's fine. Should I have gone forward or do you want to go back? No, that's 

perfect. I'll take this forward.  

It's simple, but it's not simple. So we've got to think about the roles that people are doing and not just the roles that we think they're doing, but the roles that they're actually doing.

And as Trish mentioned, a lot of people are working above and beyond. And around the system to try and make things work for patients to try and get that continuity to try and get that safety. And so when we're thinking about training, actually, we should be considering the actual activities that people are doing, not just their idealized role.

There's often this thought that if you just put a piece of technology into a system, into a role, People will use it in the way it's designed. It doesn't work like that. It's not plug and play. People develop their own ways of interacting with technology and we need to be training people for those realities, not that idealized version.

That's the tricky bit. That's the complex bit. So we need to be working out how people are using tech. How should they be using tech to do it safely and that will change according to the particular role and the level of seniority as well, the level of experience.  And we've shown this here in this example between GP trainees and experienced GPs, but it would apply for admin staff and for all of your different roles. 

So trainees need to think about how they're going to use a piece of equipment, how it's going to be done safely. And importantly for them, one of their overriding thoughts is how do I avoid getting sued if it all goes wrong? Whereas experienced GPs are thinking in a much more nuanced way about, okay how do I optimize things with this?

How do I make it really good? How do I manage those aspects of uncertainty? And increasingly, how do I use remote approaches to supervise and coordinate other people? And that's not something any of us have had any sort of undergraduate or postgraduate really training about until the pandemic hit and suddenly it becomes an enormous part of the GP and actually secondary care and consultant's role to be the overarching figure within this remote network. 

So let's finish with some conclusions. Trish, I'm going to pass it on to you.  

Yeah, so some take home messages before we open up for discussion. I hope we've persuaded you that  technologies are complex interventions. Remember what I said about complexity with the example of raising a child. It's that kind of complexity.

They're complex interventions in complex systems, which involve people. We call it socio technical.  If you're going to achieve a change in such a system I suggested you might Start off with by agreeing your values, your priorities, setting a broad direction, and then monitoring and iterating and muddling through, rather than have some kind of rigid implementation plan that is inflexible and un nuanced and doesn't allow staff to do the kind of  adjusting of frontline work that is really necessary. 

Thirdly, as a take home, remember your vulnerable patients and particularly the patient with low health literacy, low digital literacy, and low system literacy.  Now, I gave you the example of Amir, and actually with the picture of him, he looked fine, didn't he? But actually, Amir had all those things. So make sure you're, you've got approaches in place to identify the amirs of this world and to do something about it.

Fourthly, I hope we've persuaded you that fragmentation  of care is a risk in remote and digital care. It's just happens because everything is distributed on the digital system. Lots of people are touching that patient at at some point in the illness journey, not literally touching, but continuity as Emma has said is very important, but it will take effort. Fifthly, that remote care. is usually safe, but that's because staff are on the ball. Make sure that you resource and reward the creativity of staff in make, pulling it all together and making care safe for patients. And finally remote care is more stressful and often it's more novel for staff to the extent that some of them just Don't want to have anything to do with it anymore.

But with most staff, if you train and support them, they will come around to it. They will get good at it. They will start using their own initiative to make it better. And of course, as already, they are your most valuable asset.  So I spent a lot of time over the weekend producing these  QR codes.

So the idea is you can take a picture of that. If you want, you save the screen. I'm not sure how it.  might work and then  you  can hold on. 

Or user QR reader academic papers that we've written on this, but we thought you probably didn't want us to take you blow by blow through all those academic papers now, but if you're interested in any of the topics we've been talking about, then do have a go at searching for those.  So thank you for your attention.

That is the end of the presentation. I'll now stop sharing and now we've got about 14 minutes, 15 minutes for questions and comments. 

Yes. Thank you so much, Tricia and Emma. That was really fantastic. Such so many different threads to pull at. And we've got a couple of questions that have come in just to reassure people on the chat, but we will make All these recordings are going to be available to watch again.

And so you'll have access to everything that was on the screen in a couple of days time when it's up on the BMJ Future Health website. So the first question is, we had in was from Gamindu Kulatunga and they ask is individual digital literacy and or ownership of a smartphone  a particularly important factor in the assessment of the take up of digital health applications by patients? 

Do you know?  

Yeah, it's an interesting one. In some senses, clearly, it must be.  And  in the old days, which was about six years ago there used to be this big Kind of thing called the digital divide and the way we measured whether someone was able to connect with digital services and this is not just health, this is digital government.

The way we measured it was asking things like, do you have broadband, do you have access to broadband and do you own a smartphone and things like that. Now, one of the reasons why Amir does have a smartphone is because research that's been done in the last few years suggests that data on possession of devices and very basic digital skills, because Amir can use his smartphone in some things, but he's just not good enough at using it to access health care.

So yes, we need to assess.  patient's digital literacy. And yes, we need to work out whether they've got a device, but actually  you can see that if you engage with the story, you can see that this isn't helping Amir because whatever device he's got and whatever skills he's got, he's not able to use them in the high stress, power charged social situation of negotiating access to care.

Yes, is the answer, but I would caution, there's an awful lot of people who we think are digitally connected, who actually are not. And if anyone's ever given their parent or grandparent a digital device for Christmas and then found it still in its box at Easter, you know what I'm talking about.

Emma, do you have anything to add to that? 

I'm going to be devil's advocate slightly on the other side, that actually it works both ways as well. So some people whom you assume aren't going to be digitally literate actually really are and I went to see a 92 year old lady, the other day who's dying and She showed me pictures over whatsapp.

In fact, she showed me videos over whatsapp on her smartphone of her daughter in new zealand So these sorts of people that you think are might not be able to engage with the sorts of approaches we're taking. Sometimes they really surprise you. So so the assumption is both ways but the other thing I would say is that digital literacy is not a static thing either So people can be trained and supported.

To develop the ability to engage and the nhs app has been a really good example of that So for example, people can check their blood test results You taken from their GP practice using this app on their smartphone. And initially there was a lot of pushback, a lot of resistance about it. But gradually over time we've educated our patients about the existence of this checking function.

And so in some ways their digital literacy and ability to self care and self manage has increased. So it isn't just a one off snapshot. And I can give you one last example that actually. Sometimes despite the example Trish gave about people who will try once and then not not find it a positive experience and so give up using technology, actually the reverse is also true, that sometimes people are resistant to change, and so avoid trying it for a reason, and then try it, have a very positive encounter, and actually suddenly become much more not digitally enabled, but digitally keen in, in some ways that they're actually much more prepared to engage with those kinds of approaches.

So I think it's actually quite a difficult thing to categorically say one way or the other, and it's not static 

and very flexible. And actually, let me add one more thing is another massive issue with digital literacy and digital  kind of. Ability to access is people's social networks, people's family networks.

I've already mentioned I have a relative who just can't even use a telephone has got mild learning difficulties and, but he's all right because I'm his sister, that's fine. I can really navigate my way through. The people who really suffer are the ones who don't have family and who are socially isolated.

And they're, they are really problematic but, sometimes particularly the old elderly have often got a relative who's perfectly happy to do things for them. So long as they're allowed to that's we've given you enough on that question. I think so. No, 

I think that's that was really helpful.

I was going to give an anecdote of my parents crossed the Rubicon of giving the GP surgery, their phone number. yesterday because it enabled my father to get a prescription that he would otherwise have to go out for.  But he's now on the NHS app and using it. So it's very dynamic. And I think I never thought I'd see the day, but here we are.

So next question is back on actually about the telephone, which I think is really interesting question from Mamie Thompson is asking that Telephones are increasingly not used as a means of verbal communication. And a lot of people are not used to having conversations on the telephone with anxiety and hesitancy making phone calls.

Yet, GPs and NHS 111, especially in the UK, are still very phone based. What's the future of the telephone call?  

I'm going to let Emma start this one because I'd started the last one. I suppose 

I'm going to speak about it from my own sort of personal experience, really, as a jobbing GP in a practice where we have a mixture of remote, be it telephone or just asynchronous  text messaging sometimes, if that's sufficient, and face to face appointments.

And again, I think it's about giving people flexibility and choice. And that's both patient and clinician. So when a patient phones our practice, for example, we're asking them. We ask them what sort of modality of consultation they would prefer, and they can submit that information online, they don't have to do that over the phone, and again on the online form it will ask them what they are looking for, a telephone call, so  You can ask the patient, but there are considerations around the resource allocation and the capacity to meet the demands.

It may not be possible to give every single patient who wants a phone call. And sometimes it's about balancing what your capacity is with your demand. And then there's the issue around appropriateness and how do you ensure safety. and often, we will ask patients, Do you think it's urgent for today?

And a lot of the time it's probably not. But there are some times when they say, Oh, no, I think it can wait. Where actually you think, actually, I don't think as the clinician that it can wait, because there is this.  rare thing or this potentially serious thing, and you may not know about it as the patient, may not be able to contextualize it, but I can and I think it is urgent.

In the same way there are things where actually I do need to see you face to face, even though you might think I don't need to see you face to face, because actually having had six years plus of medical school, there are things that I know I will only be reassured about for myself, for you, if I can see you, if I can lay hands on you and examine you.

So sometimes there are clinical judgments that, that I think should appropriately play into those decisions. Is the telephone call on the way out? I don't think so. I use it regularly every day and find it very effective, particularly in cases where you know the patient. I think that makes it much more much more user friendly, much safer.

And yeah, much more satisfying as well.  

Thanks so much. And just to come in, I don't think the telephone's on the way out either, but I do hear what you're saying that people actually don't make that many phone calls anymore because there's so many other means of connecting. Now, one of the things about the telephone is that it has very low functionality.

You just pick it up and dial it. Telephones are around even in the olden days when I was born, they've been around for a long time. Everybody knows what a telephone is. And. And they're very dependable and dependability is one of the key things with technology. You can have a flash digital technology, but if it's not dependable, in other words, if it works 95 percent of the time, but not 5 percent of the time, people actually don't want to use it.

It's too risky. So actually the telephone is pretty safe because it's dependable. Very rarely, maybe in 40 years as a doctor, I've picked up the telephone and it hasn't worked. And that actually was a cardiac arrest and it was a ward prayer, but that's another story. It's telephones usually. 

I'm going to add a nuance to that applies to the telephone, but also to most tech, actually, that it's about managing patient expectations as well. So if a patient knows to expect a phone call from the doctor. then actually they are much more likely to pick up the phone to take that call because they're expecting it.

In the same way that if you don't tell them that it's going to be seven days or so before you email them back about something, they will be on the phone the next day to you saying why haven't you sorted this problem out? It's about communication and understanding as with most things in life and managing the expectation around what's going to happen. 

And I have to say one of the things that I've learned a lot about or how I've learned a lot about good telephone consulting is by talking to people who run out of hours services. Because if it's Sunday afternoon and your kid's sick and you ring and you get put through to the out of hours service, it's For years, it's all done by telephone.

They're really good at it, they have good protocols they are, have highly trained staff, but also the patient expectation is that you're going to get a phone call and then if you need a visit or an in patient visit, person, you'll get tracked into that channel whereas within ours, general practice, it took the pandemic to make us realize that actually some interactions can happen perfectly well over the telephone.

So it's a very interesting question. I would say this most research is on video consultations, but most  remote consultations occur by telephone and we need to do more research on how to optimize those consultations.  

Interesting. Thank you. I think we've got time for one more question which is from Nadia Celia, who asks about blood results.

I think Emma, you mentioned it in one of your answers quickly and patients checking blood results over digital platforms can get anxious if they're if they notice abnormalities, which may not be clinically significant, or they don't understand, etc. So what are your views on this? And I guess what's, what are the practicalities that we can?

I think that one's for Emma. 

it's obvious, isn't it? There's real pros and there's real cons. Certainly the way that GP results are released to the patient. A GP must have looked at them first. And again, I think it's about expectation setting by the person who's requesting the results.

So what we typically say to people, is if it's normal, we won't get in touch. If it is, if something needs to be done, then we will contact you. So even if patients notice on their app that something isn't quite right, if they haven't heard from the doctor, but the expectation has been managed at the beginning, then I think you don't have to generate unnecessary anxiety.

I think a lot of anxiety is being generated where doctors don't have access to those results before the patient sees them. And sometimes that's the case with results released from the hospital. And that can be the same for scan results as well. And I can't begin to imagine the kinds of anxiety that could be generated with a patient seeing those sorts of abnormal results.

before they've had any sort of context or expectation setting. So I do think it's all about the context of how it's done. I think generally it's been very positive in helping manage the workload within our practice. We couldn't begin to call everybody to tell them that all of their blood test results were normal and the kind of volume of calls coming in for patients to check that their results are normal is also important.

Just unmanageable, really, given the amount of preventative care blood tests that are done. So it's a practical necessity, but there are ways to make it better.  

And of course, the way we record because if what we're giving is a biomarker result a relative of mine always has just slightly high Billy Rubin levels.

And he's got me to ask, so that's fine. But if you're, if what you get is what your level is. plus the normal range and you're outside that range. I don't blame people for feeling anxious about that, but maybe we shouldn't be recording it from, for the perspective of the patient. We should have a different way of recording it on the record so that. 

Some level of appropriate reassurance or conveying of concern gets gets conveyed to the patient. Similarly with blood pressure results, cholesterol results, all those things that patients quite understandably get bothered by if they're outside the so called normal range. 

All right, I think, thank you so much.

I think we're gonna have to call it a close now. I noticed there are a couple of other questions, but unfortunately we don't have time to get to them. I'm sure Tricia and Emma will be able to answer them in some way at some point. We will be sharing the webinar, as I've said, we'll try and get the QR codes the QR codes that Tricia put up, everyone is very keen to see, they'll be available in a few days and I'd just like to close really by thanking Tricia and Emma very much, and reminding you that registration is now open.

We're running a call for problems, so some of the questions you have asked might count as problems that we can fix at BMJ Future Health, so do have a look at that and consider submitting your problem. You don't need to have a solution, but we want to help people find problems. Thanks for inviting us.

We're both on social media, by the way, so if you want to Ping us a question on what used to be Twitter. We may pick it up there.  

Brilliant. Thank you so much, Tricia and Emma. 

Thanks for inviting us. Bye.