One year on: What do front-line staff think of telehealth?

Twelve months after the first Covid-19 lockdown, clinicians discuss the digital revolution of treatment and services.

Since the first UK lockdown one year ago, Covid-19 has catalysed the adoption of telehealth. Last year, a report by Deloitte found that, as a result of the pandemic, 78 per cent of UK clinical organisations had increased their use of digital technologies to assist staff. Eighty per cent had implemented tech in order to boost remote patient engagement. “We’re basically witnessing ten years of change in one week,” Dr. Sam Wessely, a general practitioner based in London, told the New York Times last April.

The scope of telehealth is massive, spanning physical and mental health services. Some treatments are wellsuited to remote arrangements, and there can be cost or time savings for both the healthcare provider and the patient who no longer has to travel to an appointment.

A 2019 study by Massachusetts General Hospital on the introduction of patient video visits for follow-up care found that 70.5 per cent of clinicians said they were better than office visits in terms of “timely scheduling”, and 52.5 per cent rated them better for efficiency. But there are drawbacks, too, when it comes to accuracy of diagnosis, patient satisfaction, and variations in the tech-savviness of patients and those treating them.

For Dr. Sreedhar Krishna, a consultant dermatologist based in London who works for both the NHS and in the private sector for the app Skindoc, the pandemic has created significant upheaval. “In my NHS practice, we have sought to limit footfall within the hospital,” he said in an email. “We have tried to make diagnoses based on telephone calls, where patients tell us the symptoms, as well as [via] video consultations.”

But the NHS systems that are used, Krishna says, are “outdated” and unable to replicate the insights afforded by an in-person visit. “Diagnosing a skin lesion as benign or malignant requires a high-quality still image rather than the blurred look that I can obtain via webcam,” he says.

Skindoc, an app which Krishna co-founded, uses the increasingly highdefinition cameras attached to more modern smartphones. Users upload an image of their particular skin ailment to the app, and it is then assessed by one of several clinical experts. “We review the image alongside the patient information provided and send medication through,” says Krishna. “We can [also] discuss the provided images via a video consultation and arrange for the medication to be delivered to the patient’s home.” He says Skindoc is being offered to the NHS departments to help “ease pressure” on over-burdened systems.

For all this innovation, though, Krishna is acutely aware of differing levels of technological know-how: “Many older people are not computerliterate, which has resulted in significant delays in both diagnosis and treatment.”

There is a “delicate balance to be struck”, he warns, between the need to maintain social-distancing protocols, accurately diagnose problems, and give effective treatment. Krishna expects telehealth is here to stay. “Patients like the fact that they are able to obtain a quick diagnosis and receive medications to their home without disrupting their entire day,” he says. But there will be some conditions or circumstances that will “always require face-to-face visits”.

Ali, a physiotherapist based in Manchester, says the pandemic has made his job more challenging: “You are limited to essentially [giving] advice, education and [recommending] exercise.” Although, he admits, around “80 per cent of what we do is advice and education anyway”.

The challenge, Ali says, is not necessarily in identifying injuries via telehealth, but rather in assessing the “extent” of the problem. He uses the example of differentiating between a sprain and a tear of someone’s Achilles tendon. There are “four different levels of sprain”, Ali explains, from mild to “complete rupture”. Grade 4 “would be quite obvious because somebody’s foot would be hanging down. You’d know the Achilles had completely snapped.”

Ali says that while the difference between grades 1 and 4 may be clear, the difference between 2 and 3 is less so. Remote treatments, he notes, will not necessarily give a physio a rounded picture of exactly how much putting certain pressures on the injury hurts. And again, performing small exercises via Zoom is limited by camera quality, a person’s tech-savviness, or the reliability of an internet connection.

Nevertheless, Ali says telehealth “definitely” has a role to play in “triaging” patients. He notes the opportunity to see more patients digitally over the course of a day, discerning “which ones need emergency treatment, which ones need further investigation”. Some people, he says, will be invited in for a physical appointment if necessary, while those who do not require immediate treatment will not have to worry about disruption to their day.

Mental health services, specifically talking therapies, arguably lend themselves most conveniently to telehealth. But as with physical services there are problems, too. John-Paul Davies, a psychotherapist based in Surrey, currently sees 25 clients a week over Zoom and Teams calls. What he misses are physical cues. “Eighty to 90 per cent of communication is non-verbal,” he says.

Although he does not think the overall quality of the therapy sessions has diminished to the point where they are not helpful, Davies says you can tell a lot from “just the way somebody sits, the way they move in their chair”.

Prior to the pandemic, Davies only offered remote options to a handful of clients, some of whom had moved away and wanted to continue in his care. Postlockdown he intends to return to faceto-face appointments as soon as possible, but he wants to retain the remote option for flexibility. “The people that come and see me, they may have half-an-hour drives,” he says. “Sometimes they enjoy the drive, they can think about whatever we’re talking about in therapy on the way there, or on the way back. And then other people, if they’ve got something else they would like to do, then they would rather just do it online that day.”

For Davies, the “main advantage” of telehealth has been the ability to continue seeing clients and start with new ones at a particularly challenging time for people’s mental health. Continuity of treatment during lockdown, he says, has been vitally important.

Davies also appreciates the market opportunities that remote therapy offers. Different treatments are now available to a wider range of people in many different areas. “We’re not limited by geography any more,” Davies says, as he notes that a client can seek out specialists according to their specific needs. “So for somebody to be able to speak to a therapist who is an hour and a half away, or even longer… I think that’s definitely going to be a thing that happens a lot more in the future.”

Choice and balance are the watchwords for telehealth. Technology has made treatment continuity possible at a time when it was really needed – people have not stopped suffering from other illnesses or injuries simply because of Covid-19 – but there are certain cases in which it is not a substitute.

Telehealth may be helpful in widening the range of treatments available and managing patient flow, but healthcare policymakers and practitioners will also need to be honest about the limits of virtual care.

This article originally appeared in the Spotlight report on healthcare. You can download the full edition here.