Tool 4: Virtual consultations

• First published: Tuesday 30 June
• This tool is part of our Recovery of Surgical Services Guidance
• Download this tool as a PDF

1. Introduction
2. When to have a virtual consultation
3. Phone vs video consultations
4. Technical considerations and data protection
5. Virtual consultation process

1. Introduction

Virtual consultations, involving a telephone or video call between surgeon and patient, have been used in several surgical specialties prior to COVID-19. It has, however, played a particularly significant role during the current pandemic which is likely to continue in the post COVID-19 era and in future pandemic planning.

This guide provides practical advice for surgeons and managers for delivering virtual consultations with surgical patients.

For details of the consent process and the consent discussion while COVID-19 is prevalent in society, please see our separate guide.

2. When to have a virtual consultation

Virtual consultations can be used for a wide range of patients and for many follow up appointments, provided that patients are able and willing to communicate via telephone or video and that they do not need physical examinations or tests.

Virtual consultations should generally not be used when:

• Patients have high-risk conditions which may need a physical examination or when a close visual examination of an area may be appropriate.
• An internal examination (e.g. colonoscopy) is required.
• The patient’s mental state is unsuitable for a virtual consultation eg dementia
• Patients are unable to use remote technology to communicate, and they cannot be supported to do so by a carer.
• There are safeguarding concerns.

Even in these cases however, remote triage can be arranged before the face to face consultation.

For patients with disability or sensory loss, consideration should be given as to whether their needs can be met through a virtual consultation (e.g. by using assistive technology and software developed for people with sensory impairments.

It is possible to undertake a limited physical examination via video, especially if the patient has equipment at home and is confident in using it. However, such examinations may place an added burden on patients, who may need to take measurements or ensure that the surgeon is able to see that they are doing the examination correctly, so this should be taken into account in the decision to proceed with a virtual consultation.

In all cases, local criteria should be established for carrying out virtual consultations including an agreed risk assessment process that takes into account the patient’s individual needs and service demands, ensuring that virtual consultations are only used when there is low risk on patient safety and outcome.

3. Phone vs video consultations

Some patients may prefer the familiarity of the phone rather than video and for many routine cases video will not be necessary.

However, video can provide additional visual information and diagnostic clues so it would be preferable for sicker patients, those with comorbidities, and those who are anxious and might feel reassured by making visual contact with their surgeon.

Patients who are hard of hearing may also prefer video to telephone.

4. Technical considerations and data protection

4a. Technology for surgeons and patients

Each hospital should ideally adopt a uniform software platform of sufficient quality for video consultations with appropriate hardware equipment and training for staff. Hospitals should also produce information for patients on what technology they need to participate in a virtual consultation (e.g. whether they need to download specific software and how to do so) and how to access and use it.

During the pandemic, NHS Improvement has procured 12-month licences for one video platform, Attend Anywhere, free of charge to all NHS secondary care providers, although hospitals may choose another solution if it works for them and is secure. Independent sector hospitals may use other platforms. Consideration needs to be given to the accessibility of such platforms remotely, by staff who may have to work from home (e.g. in cases of self-isolation).

It is important that there is technical and internet connection is high-quality (at least 11 Mbps but ideally between 11 to 50 Mbps) in which case clinicians and patients can communicate in much the same way as in a face-to-face consultation. Minor technical breakdowns (e.g. difficulty establishing an audio connection before getting started, or temporary freezing of the picture) will likely not cause major disruption to the clinical interaction. Major breakdowns, however, disrupt the quality of the remote consultation and the expected standard of the surgeon/patient communication. A back up telephone number should be available in case of technical problems to allow conclusion of the consultation

4b. Data protection

During the COVID-19 pandemic, many countries are formally relaxing privacy and data protection regulations for video and other communications technologies. However, a remote consultation must be treated as any other consultation in which sensitive or confidential information is safeguarded / take all possible steps to reduce risk to patient confidentiality.

When exchanging information with the patient via email, it should also be noted that personal email accounts held by the general public are not secure and so could be open to breaches in their personal information. This should be explained to the patient and the patient should confirm that they are comfortable using their personal email account to receive communications from their hospital for the purposes of their virtual consultation and consent to treatment.

Although video consultations are securely encrypted it is the patient’s responsibility to ensure that they have adequate anti-spyware and anti-virus protection on their devices. If patients are using a mobile phone, they must be made aware that it can only be as secure as any other phone call on that mobile network. Patients should also be informed that the consultation will not be digitally recorded without their prior consent but clinical outcomes from the consultation will be recorded and stored on the patient record.

5. Virtual consultation process

5a. In advance of the consultation

• The surgeon should confirm that, as far as this can be assessed in advance, a virtual consultation is clinically appropriate for this patient and it meets the locally agreed criteria.
• A link to the appointment slot should be emailed to the patient alongside a guide for virtual appointments. Where appropriate, an advance questionnaire can also be sent to patients at the same time to support assessment of symptoms (including symptoms of COVID-19) and medical history.
• In advance of the first video call it is advisable that a member of the team arrange a test-call to ensure that the patient has sufficient access and understanding of the relevant technology so that the consultation can run smoothly.
• Where possible any reasonable adjustments (e.g. if patient is hard of hearing or if English is a second language) should be considered and arranged in advance of the consultation.

5b. On the day, the surgeon should:

• Check that they have the equipment they need and that the technology is working. If working remotely, they should ensure that home technology and broadband meets the required standard.
• Ensure they have access to the patient’s record, if possible on a second screen so that they can maintain visual contact with the patient.
• Use a quiet, private and well-lit space to have the telephone/video as they would in a face to face consultation.
• Initiate the consultation by calling the patient.

5c. At the beginning of the consultation, the surgeon should:

• Open the conversation by checking that the patient can hear and/or see them and is in a suitable place to talk.
• Introduce himself or herself and any other people in the room and ask the patient to do the same.
• Verify the patient’s identity by checking their name, date of birth and address.
• Obtain consent of the patient for the virtual consultation
• Confirm the patient’s phone number and email address in case the video connection drops.
• Explain what will happen in the virtual appointment and how long it will last.
• Reassure the patient that the consultation will be very similar to a standard one, and that the call is private and confidential like a regular clinic encounter.
• Take and record verbal consent for the consultation to be conducted virtually (this is needed for the first virtual consultation rather than repeatedly).

5d. Discussion with the patient. The surgeon should:

• Have a conversation with the patient to establish their concern or surgical problem, eliciting symptoms and any visible signs as appropriate, and where relevant offer a diagnosis or a management plan, including suggested investigations.
• If a surgical intervention is already planned, then the operating surgeons should have a discussion around consent with the patient in the same way as in a regular face to face meeting, with additional considerations on consent in the context of COVID-19 (see our separate guide on consent)
• Given the length of time that a patient may have been on waiting lists during the pandemic, it is important to take into account possible changes in the condition of the patient to ensure that, based on a balance of risks, the proposed surgical intervention is still the right option for the patient.
• If a visit to the hospital is planned for an intervention or an investigation, an initial assessment should be carried out to exclude possible COVID-19 symptoms. This can include:
  • Recent COVID contact, especially confirmed cases within 1m contact for longer than 30 minutes
  • Anyone else in the immediate family presenting symptoms
  • Recent travel to a known hot spot
  • Persistent temperature of over 38.0 for more than 5 days
  • Persistent dry cough
  • Shortness of breath
  • Loss of taste or smell
• Make written records as in a standard consultation.

5e. Concluding the consultation. The surgeon should:

• Summarise the conversation and any agreed actions from the appointment, ensuring the patient understands these and the relevant timescales.
• Give the patient a chance to ask any final questions.
• If further contact is needed, confirm the patient’s agreement to be contacted remotely and explain how the patient can contact them if they have further questions.
• Arrange follow-on as appropriate.

5f. After the consultation

• The encounter should be documented on the patient’s record including what information has been shared with the patient, what the patient has said and any agreed actions.
• A prompt follow-up letter or email should be sent to the patient after the consultation summarising the call and any action plan and timescales. Any further advice should also be included in the same correspondence, such as patient information leaflets or relevant webpages, alongside advice on further contact if they have any questions.
• Other members of the health care teams should be informed as appropriate of the outcome (eg the patient’s GP).

References

• GMC – Remote consultations
• NHSE / NHSI - Clinical guide for the management of remote consultations and remote working in secondary care during the coronavirus pandemic
• NHSE/NHSI and Surgical Royal Colleges - Clinical guide to surgical prioritisation during the coronavirus pandemic
• RCS Eng – COVID-19: A Guide to Good Practice for Surgeons and Surgical Teams
• RCS Eng – Recovery Plan
• University of Oxford - Video consultations: a guide for practice