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J R Coll Physicians Edinb 2021; 51: 283–7 | doi: 10.4997/JRCPE.2021.318 ORIGINAL RESEARCH PAPER
Abstract
Education
Introduction
Preliminary evidence has suggested that care home residents
are especially vulnerable to COVID-19 exposure and morbidity,
with 57% of all European COVID-19 deaths originating from
care homes.1 It is reported that protective strategies and
personal protective equipment (PPE) were insuffi cient at this
time, as they were perceived challenging for health and social
care professionals to access, thus leaving vulnerable patients
at risk.2 As a result, care providers, both within and outside
of care homes, urgently required safer and more suitable
methods of providing care that were considerate of the frailty,
multimorbidity and disability of care home residents2 without
introducing further risks into the homes. One way of ensuring
these criteria were met was the implementation of video
consulting (VC).3
Initial studies reveal VC is useful in mitigating negative
psychological impacts of isolation (for example, anxiety, stress,
depression and loneliness),3 in that internationally, many long-
stay facilities are rapidly implementing VC into routine practice.
A recent study found that the convenience and fl exibility of VC
resulted in Australian care providers ‘ramping up’ the use of
VC from staff meetings to GP appointments.4 A study prior to
COVID-19 found that VC can be used to increase family contact,
which reduced feelings of social isolation, thus supporting the
mental health and wellbeing of residents.5 The social isolation
periods used to limit the spread of coronavirus have been
linked with increased rates of loneliness and depression, and
therefore it is considered important to understand if there are
methods to limit these negative impacts.6 Early COVID-related
data demonstrate that there is potential for VC to improve
quality of life and reduce loneliness during the pandemic,
concluding that VC could become a permanent feature within
care homes.6 Nevertheless, COVID-19-related data within care
homes are limited, and it is essential that further research
into the use and value of VC is conducted.7
Methods
In March 2020, when the COVID-19 emergency was
announced in Wales, the NHS Wales Video Consulting
(VC) Service provided by Technology Enabled Care (TEC)
Cymru8 was developed to roll out ‘Attend Anywhere’ (AA) VC
appointments across all Welsh NHS services. Interviews with
NHS AA users identifi ed a need to link in with care homes
but reported that many were experiencing diffi culties with
1 Research and Evaluation Lead TEC Cymru; 2Programme Lead TEC Cymru; 3Research Assistant TEC Cymru; 4Research Assistant TEC
Cymru; 5Programme Support Offi cer TEC Cymru; 6Assistant Director of Informatics ABUHB, Senior Responsible Offi cer TEC Cymru; 7Child
and Adolescent Mental Health Psychiatrist ABUHB, Honorary Professor, National Clinical Lead TEC Cymru; all Aneurin Bevan University
Health Board, Technology Enabled Care Cymru, Mamhilad House, Pontypool, Gwent NP4 0YP
Correspondence to:
Gemma Johns
Aneurin Bevan University
Health Board
Technology Enabled Care
Cymru
Mamhilad House
Pontypool
Gwent NP4 0YP
Email:
Gemma.Johns3@wales.
nhs.uk
Background During the COVID-19 pandemic, care home residents and staff
were identi ed as being at risk of infection. Their safety was important, but
equally important was safe delivery of healthcare to those who needed it.
The Welsh Government provided care homes with video consulting (VC) to
deliver safe healthcare to the vulnerable, combat isolation and protect the
residents and staff.
Methods To understand the use, value, bene ts and challenges of using VC in care homes
across Wales, telephone interviews were conducted between September and November 2020.
Results From 101 interviews, ndings suggest that while care homes are responsive to VC,
there is a need for further awareness, better training and support for care home staff.
Conclusions Interestingly, issues around connectivity, lack of equipment and technical literacy
were highlighted as minimal barriers. VC should be encouraged as a long-term service to
support the health and wellbeing of care home staff and residents.
Keywords: care homes, COVID-19, video consulting, NHS Wales, healthcare
Financial and Competing Interests: TEC Cymru and the NHS Wales Video Consultation
(VC) Service is funded by the Welsh Government.
Connecting and connectivity: providing video
consulting in care homes in Wales
Gemma Johns1, Sara Khalil2, Jess Williams3, Morgan Lees4, Lynne Hockey5, Mike Ogonovsky6, Alka Ahuja7
50TH ANNIVERSARY YEAR SEPTEMBER 2021 VOLUME 51 ISSUE 3 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 283
accessing VC, such as poor or no internet connectivity, a
lack of available resources/devices or limited technological
literacy of staff, thus impacting on the uptake of VC.9
Funded by the Welsh Government,10 TEC Cymru is a
multidisciplinary team of clinical, project, technical and
research members, who are collaborating with Digital
Communities Wales11 to roll out the NHS Wales VC Service
with care homes to explore these diffi culties further. TEC
Cymru obtained service evaluation approval from research
and development departments from all health boards to
evaluate patients, families, carers and clinicians (care homes
within the defi nition of NHS patients and carers).
Over an eight-week period between September and November
2020, data were collected from a total of 101 care homes
across Wales. The method of data collection was a structured
telephone call interview, which consisted of the interviewer(s)
randomly calling telephone numbers from a master list of
care homes across Wales. Upon phoning each care home,
the interviewer asked to speak to the manager (or other
staff member if more appropriate). After providing information
about the service evaluation, the interviewer obtained
consent from the respondents to take part in a series of
structured questions regarding their experience of VC. A
mixed-methods approach was used to analyse the data to
capture quantifi able and narrative data.
Ethical approval
Full ethical committee approval and a risk review (SA/1114/20)
were obtained, with additional permissions granted by all local
Welsh Health Boards to undertake evaluation relating to the
NHS Wales VC Service by TEC Cymru.
Results
In total, 101 care homes were interviewed, of which 92%
reported to be using VC. Figures 1 and 2 display the types
of devices and platforms used for VC.
Use and value of video consulting (VC)
To explore the perceptions of ‘use and value’ the responses
were recorded by taking handwritten notes, which were
extracted and analysed to observe any commonalities
between the care homes. Out of the 101 care homes, 89%
of homes reported to be ‘using’ VC for one or more reasons.
VC was used for keeping residents in touch with family
members who were not permitted to visit during the COVID-19
restrictions, which as a substitute for face-to-face meeting
was reported to impact positively on residents’ mental health
and wellbeing.
‘Gives residents a massive lift being able to see and talk
to family members, which has helped with their mental
health.’
‘Amazing for mental health of residents, and for boosting
morale. We now use VC much more than the telephone.’
‘Really helpful … some residents talk in riddles, but they
speak fully coherent to family via VC. It’s brilliant mental
stimulation.’
In addition, 67% of care homes reported to have been offered
VC as a link to NHS services and local authorities. These were
mainly to general practitioners (GPs), mental health teams,
dieticians, speech and language therapists, physiotherapists,
and social workers.
‘Handy for appointments with the psychiatrist, and reduces
waiting times and the amount of people in the home.’
‘Benefi cial for sending pictures e.g. with a rash to a GP
and saves so much time.’
‘Very useful, especially for ward rounds.’
Many stated that they could see the use and value in having
VC links with different NHS services that had not yet offered
them VC, with examples including GPs, mental health, speech
and language, continence, dermatology, neurology, diabetes,
dentistry, optometry and dementia care.
‘We reached out to a dentist, but haven’t heard back
since.’
‘We would like to use VC for extreme circumstances like
for end of life or serious diagnoses … We have asked GP
for this service but they never got back to us.’
The overall perception of the use and value was reported as
positive by respondents (89 responses, 83%).
Figure 1 The usage of the types of devices within the care homes Figure 2 The proportion of platform usage within care homes
284 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 51 ISSUE 3 SEPTEMBER 2021 50TH ANNIVERSARY YEAR
G Johns, S Khalil, J Williams et al.
‘Yes, massive value. Use it with 2–3 local GP surgeries.
Really valuable for clinic rounds with GPs.’
The usage was often associated with being more convenient
for the residents and staff, and therefore valuable in saving
time and the need to travel to face-to-face appointments.
‘Very easy to use platform. Saves time and increases
access to support. Get more advice and guidance, and
increases the speed of treatment such as medication
reviews.’
‘Very valuable … In fact, been more benefi cial than face-
to-face in some instances. There are some things that
would’ve been impossible if not for VC.’
VC was also reported as being used for other purposes
within the care home, such as staff and professional group
meetings.
‘Find it very useful for staff meetings across different
homes.’
‘Good as you can involve the care home manager,
healthcare clinicians, other care providers and the
resident.’
However, 3% of the respondents did not consider VC to offer
them much use or value, and 13% were unsure, or highlighted
its use and value only in specifi c circumstances, such as
during the COVID-19 pandemic.
‘It’s a small home, so limited use.’
‘It’s really good, but staff are unsure.’
Some of the care homes reported VC to have limitations on
its use and value, while others expressed a preference for
telephone calls or face-to-face consultations.
‘Yes [we see the value of VC] but many services i.e. district
nurses or CPNs prefer phone calls still.’
‘They (staff and residents) do see value, but are happier
to just use the telephone.’
Benefi ts of VC
All respondents were asked about the benefi ts of VC. One
important aspect of VC was that it allowed a reduction in the
level of visitors and health professionals entering the homes,
and possibly introducing risks of COVID-19 transmission.
There was an element of safety felt by many respondents,
in that these risks were signifi cantly reduced due to the
implementation of VC. In addition, VC reduced the need for
residents to leave the home and travel to appointments,
once again limiting the risk of exposure to infection, as well
as saving time that would be taken up by travel.
‘Quicker and safer … Less formal than physical
appointments and reduces the need for excess people
in the home.’
‘Easier to facilitate appointments and saves the nurses
having to leave the home.’
‘Useful for emergency admissions when residents didn’t
have time to talk to family, giving them a chance to discuss
with the family and to keep their spirits high.’
VC was reported as beneficial for specific appointment
types, such as those with mental health teams and GPs.
For these situations, respondents praised the addition of a
visual element to VC that would not have been available when
using the telephone.
‘Reduces strain on the NHS. Much quicker for things like
rashes, and easy for younger staff who are familiar with
using the devices.’
‘A lot faster to diagnose non-fatal aliments.’
‘The visual element of VC is much more benefi cial to
provide clarity on what condition the resident has … very
useful in the peak.’
The use of VC allowed residents to link in with their families,
which was perceived as a signifi cant personal benefi t for
residents, enabling regular contact during times of social
isolation. Examples were reported to include speaking to
families living both locally and abroad; to celebrate birthdays;
meeting a new baby; and to attend a virtual funeral. The
ability to do this was reported to reduce the stress and
anxiety levels of the residents, specifi cally for those who
were suffering from dementia.
‘One woman is non-verbal and is expressionless, but when
she’s using the video chat with her husband, she’s happy,
smiles and interacts.’
‘The residents are loving it, especially for families who
live abroad.’
‘When residents celebrate their birthdays, they host a little
party on VC with families, who get to see residents open
gifts and cards.’
‘One resident has a great-great-grandchild born during
lockdown, so got to meet the baby via VC, which really
boosted morale.’
‘Even allowed a resident to attend a funeral via video.’
In addition, the ability to receive virtual healthcare was
considered to have a calming impact on residents. Some
reported that the residents felt more open to speak on VC
compared with face-to-face, and that sessions were more
private.
50TH ANNIVERSARY YEAR SEPTEMBER 2021 VOLUME 51 ISSUE 3 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 285
Video consulting in care homes in Wales
‘VC has benefi ted anxious or irritated residents with
dementia, and helps calm them.’
‘Increases patient comfort when they may not feel able to
say certain things face-to-face.’
It was also reported that VC services were offered at a much
faster speed compared with other consultations, such as
face-to-face and telephone, which ultimately lowers stress
and anxiety of both staff and residents.
‘Generally, residents really enjoy it. It allows for smaller
ailments to be seen quicker, and in certain instances VC
is much better.’
‘Prior to lockdown, phone calls took up to six hours wait, but
since VC it has reduced waiting times and increased contact
capacity, which prevents the GPs coming into the home.’
Challenges of VC
Overall, 71% of 84 respondents reported some initial
diffi culties with using VC with their residents.
‘Non-communicative patients, so was initially diffi cult to use.’
‘Most can use it fi ne, but dementia patients only manage
it with help from staff.’
‘Older residents were unsure how to use VC at fi rst as it
was completely new to some of them … starting to get
to grips with it now.’
However, the majority of the care homes had positive
responses in terms of resolving these issues, reporting to
be fully equipped and having adequate knowledge and skills
to make this process as easy as possible.
‘Technology is new to the elderly, but the home has
allocated time within the nurses’ shifts to allow for VC.
Nurses are able to teach them how to use it.’
‘Residents with learning disabilities require constant
supervision from care staff, but it is easy to do as it’s
easy to use.’
‘Some residents with hearing difficulties struggle to
understand how to use it, but if the resident wants
someone in the room with them, then we have someone
in there to help them.’
The majority of care homes reported that their staff have the
appropriate skills to use VC, and for others this was achieved
after receiving suffi cient training.
‘Some problems with older staff to start with, but no
issues after they are shown how to use it.’
Nevertheless, a few respondents still expressed a lack of
confi dence in VC, often resulting in confusion and ‘struggles’,
although many still seemed willing to try to use it to help
their residents.
‘Some staff are older and VC is completely new to them,
so it’s a learning curve.’
A total of 45% of 86 respondents reported specifi c issues
with devices and technology. The most common was relating
to Wi-Fi and internet connectivity, with mentions of slow
connection causing lag, and the inability to access Wi-Fi in
every part of the home.
‘Connectivity for us is the biggest concern as it loses its
appeal to staff members when it keeps dropping off.’
‘The Wi-Fi is poor and doesn’t provide strong enough
connection throughout the home.’
However, the remainder of homes reported no diffi culties, or
that they had installed (or planned to install) Wi-Fi boosters to
increase access to the internet and usability of the platforms
and devices.
‘Wi-Fi is a bit slow, but it is better now we have purchased
“boosters”.’
‘No Wi-Fi in the home, so we use 4G. But we are making
headway on Wi-Fi installation.’
Although VC was viewed positively overall, respondents still
reported concerns and limitations separate to technological
diffi culties; for example, issues with accuracy in diagnoses.
‘Nurses are concerned about the accuracy of VC when
diagnosing and reviewing more serious illness – but often
due to picture quality.’
Others expressed a preference for face-to-face.
‘No substitute, as soon as face-to-face visits are allowed,
we will be back to that.’
‘My concern is it needs to be reduced a bit to ensure
residents have a good relationship with their GPs, but
also keen to increase use when needed for convenience.’
Another concern was the need for staff to support residents
using VC, thus increasing the time taken ‘off the fl oor’.
‘Using VC takes the staff off the fl oor in order for them
to supervise.’
‘VC does withhold who would otherwise be available on
the fl oor, and then we have to call in extra staff to do more
hours to cover.’
Furthermore, some respondents reported a lack of VC
training, or expressed concerns regarding the multitude of
platforms on offer, introducing diffi culty and confusion.
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G Johns, S Khalil, J Williams et al.
‘Not had any training on how to use it, so it’s confusing
for us.’
‘Too many platforms, so confusing, so we need prior notice
to prepare to use different ones.’
Finally, care homes were asked if they would continue to
use VC post-COVID. Of 87 responses, 74% stated that they
would use VC once COVID-19 had passed, although some
stated that it would be used in specifi c circumstances or
only when necessary.
Discussion
A large proportion of care homes perceived the ‘use and value’
of VC as positive. VC allowed a reduction of visitors entering
the care homes, ultimately minimising the risk of COVID-19
transmission. This made attending NHS appointments more
convenient by reducing both travel and appointment time for
residents and staff. In addition, VC can allow residents to stay
in contact with their families, improving their overall mental
health and wellbeing. Issues with the ability of some residents
to use VC were reported, although with staff support, this was
generally successful. Concerns were reported when using VC
for specifi c pathologies that require physical examinations in
circumstances where residents have limited communication
abilities. It was reported that VC added to the demand of
staff time, in that additional support was needed. Regardless
of the diffi culties, the majority of care homes reported they
would continue to use VC post-COVID-19. Thus, overall, VC
seems to be accepted by many care homes in Wales.
Based on this data, care homes are clearly very responsive
to using VC, with very little concern of signifi cant diffi culties
with accessing devices or technology, nor did they express
any unwillingness to improve their internet connectivity.
Furthermore, technical literacy and the ability to put solutions
in place to support residents were also evident. Rather than
assuming that care homes are not able to use VC, more
urgent work is needed to ensure that better communication
and awareness are readily available to limit the ‘noise’
surrounding the myths, and to work more closely with care
homes to ensure they are getting the best use of VC.
Nevertheless, there are still clear gaps that emerged as
barriers for some care homes to use VC. For example, there
is a lack of awareness regarding VC in that some respondents
were unsure of the name of the ‘GP link’ (9%) they were using.
Also, the majority of care homes were using a large number of
different platforms at one time, potentially contributing to the
confusion about VC not only for residents and staff, but also
for their relationships with external VC users such as NHS
clinicians and local authorities. It is therefore recommended
that further awareness about the NHS Wales VC Service is
needed to ensure that a better and more consistent line
of communication is offered to care homes. This will be to
provide support and training regarding the most appropriate
and accessible platform to use, in order to take advantage of
the NHS services that are available to them, which many seem
to be currently unaware of. Thus, a clear messaging about
the NHS Wales VC Service platform is needed, along with a
single method of training and support to ensure that all NHS
and local authority services are made aware of the uptake of
VC within their local care homes, and to encourage a more
collaborative approach between all services. Furthermore, it
would also be recommended to encourage future uptake on
a long-term basis to support the mental health and wellbeing
of staff and residents beyond COVID-19.
At the time of data collection, there were limited logistics
or protocols in place for using VC in care homes. This is
likely to be due to the nature of the pandemic, and VC being
adopted as an emergency. However, as Wales looks to come
out of pandemic, TEC Cymru and the Welsh Government are
making recommendations for the sustainable use of VC in
care homes. Further research is also under way, such as
observational studies. Further work is looking at linking
up care homes and a wider range of services, such as
healthcare, social care and third sector agencies, to get the
best out of VC in the future.
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