Improve remote care to keep patients safer during health crises, says study

New research draws out three key recommendations to improve remote care in the NHS and better prepare it for future health threats.

Published in BMJ Quality and Safety, Imperial researchers in collaboration with the University of Oxford interviewed over 170 participants including clinicians, patients, and NHS 111 call handlers from March to July 2020, during the first wave of the COVID-19 pandemic. 

They asked about participants' experiences and reflections on how care was delivered and the wider healthcare system, during the shift to remote assessment of people with suspected COVID-19.

They found both clinicians and patients felt there was pressure to stay home and protect the NHS, which meant people avoided seeking care when they needed it. Health care was also seen by patients as more difficult to access when delivered remotely. Participants also believed remote care didn’t provide the full picture of a person’s condition because of overreliance on systems that scored people based on their symptoms, at a time when little was known about the full spectrum of symptoms of COVID-19.

“Actionable solutions are needed, as healthcare systems contemplate future uncertainties and risks, from pandemics or other threats." Dr Ana Luisa Neves Institute of Global Health Innovation

To help to address these issues, the researchers developed three key strategies that they say need to be considered for future health crises. These are strengthening the health system’s resilience to deal with the unexpected; creating robust symptoms assessment systems to prioritise testing and treatment; and increasing access to health care for vulnerable groups. Implementing these recommendations would improve care for those with COVID-19 and help the NHS cope in the next crisis, the researchers say.

Dr Ana Luisa Neves from Imperial’s Institute of Global Health Innovation and Associate Director of the NIHR Patient Safety Translational Research Centre said:

“Drawing on lessons from the pandemic, we suggest three key strategies are needed to prevent avoidable deaths and inequalities in the next crisis: strengthen system resilience, develop evidence-based triage and scoring systems, and address social vulnerability.

“While many of the threats to patient and system safety identified in this study have already begun to be addressed, the issue of poor system resilience such as lack of staff and poor resources requires wider recognition. Actionable solutions are needed, as healthcare systems contemplate future uncertainties and risks, from pandemics or other threats.”

A health system underprepared

At the start of the COVID-19 pandemic, GPs in England first assessed patients via the phone or online to reduce the spread of the virus. This research found both patients and GPs thought the NHS was unprepared for this shift and that health staff didn’t have the right tools or processes to deliver remote care safely and effectively. Some interviewers also noted that digital consultations were hard to access for vulnerable groups like the elderly, those who aren’t familiar with the technology, people who didn’t have access to digital devices to book appointments or have language barriers.

The researchers also found that appointments relied on scoring systems that calculate how severe COVID-19 cases are. This meant that people presenting different symptoms may have been missed and not given the care they needed.

Lessons for safer care

The research suggests three priorities that will improve patient and system safety when using remote care during the next health crises:

Strengthen system resilience

In England, the health system was overburdened and under resourced before the pandemic. The study recommends adequate staffing and providing co-designed and patient-centered, compassionate care would help develop services which are fit for purpose.

Adapting and creating support and investment for new tools would allow health systems to deal with unexpected events when they occur. For example, creating information and support for the use of oximeters at home to measure oxygen levels in people with COVID-19 could help the NHS manage people who need urgent care.

“We hope that our research contributes to a more resilient NHS that is better able to preserve patient safety in future crisis.” Dr Sietse Wieringa Nuffield Department of Primary Care Health Sciences,University of Oxford

Developing evidence-based scoring systems

When a new illness emerges, there can be uncertainty about its symptoms. Health care staff used scoring systems early in the pandemic to check for a fever, cough and breathlessness to see how severe each case of COVID-19 was and prioritise people for testing, as testing capacity was scarce at the time.

The study highlighted that research, which is now underway, is needed early on during health crises to develop scoring systems based on the latest evidence.

Address social vulnerability

The researchers highlighted that remote care may have made it difficult for some people like the elderly or those with language barriers to access health care, widening inequality. To address this, the study says that more research is needed into specific tools which would help ensure care access for these groups. Specifically, the researchers say that the use of new software, translation services and 24-hour remote care support should be investigated that could reduce inequalities in care during the next health crisis.

Dr Sietse Wieringa, GP and clinical researcher from University of Oxford’s Interdisciplinary Research in Health Sciences (IRIHS) team at the Nuffield Department of Primary Care Health Sciences said:

“We hope that our research contributes to a more resilient NHS that is better able to preserve patient safety in future crisis.”