Diabetes Appointments Online:

the Newham Experience

Care from home –

Logo designed by

Karen O’Leary,

Service User

Our support consultant:

Funded by:

Introducing Newham

Borough of Newham

332,583 (2015)

Approx. 70% from BME groups (South

Asian ethnic groups being 33%)

6thmost deprived borough in England

Approx. 40% aged 25 and under

(compared to 30% for London)

Alarming rise in diabetes in the young,

mainly associated with obesity

Diabetes prevalence 9.4%, 3-4 times

the national average in some parts

The Problem

Newham Diabetes service exemplifies challenges within NHS:

Rising demand on services: estimated rise 13.5% in 2030

Pressure to cut costs/ improve efficiency

Inflexible and inaccessible services

High non attendance rates: e.g. approx 50% in the Young Adult clinic

Poor patient self-management, related to poor engagement with

service and lack of flexibility of services (Local MORI survey ‘09)

Poor health outcomes e.g.

Repeat admissions via the emergency department, particularly for

young adults

Increased complications – cardiac, renal, foot disease

Poor pre-pregnancy care, late booking into antenatal services

The Local Diabetes Service

• Integrated Community Diabetes Service since

2000; Cluster-based Community Diabetes Model

• Multi-disciplinary clinics; near-patient testing

• Telephone clinics, Use of email

• Evening Nurse-led Clinics & walk-in service

• Text reminders

• Widespread use of Bilingual Health Advocates

NHS Choices Pilot

Small proof of concept study Feb 2010 :

Diabetes Unit and NHS Choices used readily available standard

video-conferencing software for web-based consultations:

15 patients:

Established Type 1 and 2 diabetes

Age 18-25 years, both sexes

Range of ethnicity and self management skills

2 consultations per patient followed by online survey for all

patients, and telephone interviews of staff and patients

NHS Choices Pilot - findings

Patients Staff

Convenient: not having to take

time off work/school

Did not need others e.g.. parents to

take them for appointments

Liked being in the comfort of

home/privacy

Felt health professional was giving

them undivided attention and preferred

this to telephone consultations

Reduction in carbon footprint!

Potential to reduce DNAs

and useful in those with poor self

care

Good complement to face to

face but cannot fully replace it - ?

50: 50 split (could replace

telephone consults though)

Consultation tended to be

more focussed

? More useful with younger people

Role in housebound people

Internet Broadband Usage in Newham

2008-2009

Age Broadband usage

16-24 86%

25-34 83%

35-44 73%

45-54 66%

55-64 63%

64+ 21%

Above figures obtained from LBN

National Average (ONS 2009) - 63% have internet broadband

DAWN - Diabetes Appointments via

Webcam in Newham (2011) Aim:

Learn IF and HOW web-based consultations can provide more accessible and cost-

effective care in the diabetes department; using readily available, affordable

technology Scope:

Offer online consultations to all

patients, where clinically

appropriate and where examination

not required, under care of one

consultant and one nurse specialist

(from May 11), within the existing

clinic

Include all ages

Evaluate using quantitative and

qualitative methods

Webcam

DREAMS

Diabetes Review, Engagement And

Management via Skype

January 2014 – December 2015

Web-based Consultations in diabetes: A tool

for improving patient self- management?

• Use Online Consultations to establish contact with

patients labelled “ hard to reach”

• Change the outpatient consultation process – more

flexible, user-led, “ open access” consultations

• Explore the role of social media in improving user

engagement and self-management

• Evaluate the impact on health outcomes, quality of

like and efficiency of care

VOCAL – Virtual Online Consultations:

Advantages and Limitations

NIHR HS & DR grant, commenced March 2015

• Micro Level: examining the dynamics of the

clinician-patient relationship in greater detail

• Meso Level: What is the organisational impact

of increased online contact?

• Macro Level: How do online clinical contacts fit

in with the evolving NHS policy?

Action Research - outputs

For further information:

www.health.org.uk/programmes/shine-2011/projects/web-based-outpatient-consultations-

diabetes

www.vocalproject.co.uk

Outcome data

• DNA rates: 28% versus 13% for the same patients

pre and post-Skype

• Yearly increase in the retention rate 2011 (39%) to

2015 (100%).

• A &E: too small a sample, too many variables,

observational study and not a controlled

experiment

• Average Hba1c pre-Skype 70 mmol/mol; post-

Skype 65 mmol/mol

Feedback from Patient Focus Groups ACCESS

“Skype is ‘great for diabetes’. Previously it meant taking a day off university to come to

clinic.”

POSITIVE SHIFT IN CLINICIAN-PATIENT DYNAMICS

“I don’t think the consultant or the nurses actually realise, their whole attitude

changes when they are in the consultation clinic, they have got the papers in

front of them, they are fiddling with that, they are reading through it, but when

they are on Skype they just look straight at you and they talk at you”

OWNERSHIP

“Skype has helped to change my mind set in terms of management. There’s no excuse for missing appointments now”

LESS ANXIETY

“I feel better controlled since using Skype and less anxious”

General findings

• Many patients value the convenience of Skype

• Benefits included patient-initiated contact, which increased

patient confidence

• Patients were satisfied with the clinical encounter

• Some patients found that the clinicians appeared more

engaged than they were in the face to face encounters

• Most patients want a mix of face-to-face and online rather

than online only

• Some patients will resist online consultations

• Some patients will resist clinical support in any form

Conclusions

1. Patients much preferred webcam appointments & say they are more likely to attend;

generalisable across ages and ethnicity

2. You need time to demonstrate hard quantifiable benefits:

To gather sufficient data to draw conclusions

Transition time as patients move to new system; before they start to rely on it and

use it to it’s full potential

3. Choice of software provider is important - ease of use and reliability of system matters

4. A flexible approach will maximise the potential of webcam consultations e.g. video

phone and ad-hoc consultations may have the greatest impact

5. Efficiency savings:

Quick wins: shorter more focused consultations (increased capacity), savings for

patients

Early findings suggest DNAs and A&E attends will reduce with time, with

associated cost benefits

Greater efficiencies with increasing volume of web-consults, allowing web

appointments to be grouped together with release of clinic infrastructure costs

What next?

Health Foundation Scale Up Award

• National policy attention and interest from other hospitals

• Seek to support the spread of virtual consultation services by:

1. Creating a virtual consultation unit (VCU) to facilitate local

and national roll-out, and sustained improvements

2. Developing a national network, with new sites acting as

local hubs for further spread

3. Working with national-level decision makers to jointly

develop standardised policy (e.g. on tariff, quality

assurance, staff training)

4. Evaluating the work, continually reflecting on mechanisms

for change

The team

Trisha Greenhalgh

University of Oxford

Shanti Vijayaraghavan

Barts Health NHS Trust

Sara Shaw

University of Oxford

Joe Wherton

University of Oxford

Emma Byrne

Queen Mary University of London

Desiree Campbell-Richards

Research Nurse, Barts Health

Jo Morris

Barts Health NHS Trust

Satya Bhattacharya

Barts Health NHS Trust

Philippa Hanson

Barts Health NHS Trust

Isabel Hodgkinson

Tower Hamlets CCG

Charles Gutteridge

Barts Health NHS Trust

Rita Sudra

Diabetes Nurse, ELFT