Velichka AndreevaWebinar: How digital triage reduced waiting lists by 50% at Buckinghamshire Healthcare NHS Trust
Updated: Jun 1
HBSUK held a webinar in conjunction with Buckinghamshire Healthcare NHS Trust to discuss a joint project designed to address the trust’s growing dermatology backlog.
The webinar looked at how Buckinghamshire Healthcare NHS Trust implemented Virtual Lucy, a virtual solution to tackle its dermatology backlog, and will explored how digital transformation can free up capacity within the NHS.
See Professor Stephen Smith, Professor Mark Goodfield, Titus Burwell and Lucy Cassidy discuss feedback and learnings from their experience implementing Virtual Lucy within Buckinghamshire Healthcare NHS Trust.
The webinar explored:
What led to the implementation of Virtual Lucy
How Virtual Lucy supports NHS digital transformation
Virtual Lucy pathway walk through: see how the system works
How Virtual Lucy reduced the trust backlog by 37%
Benefits to patients and sustainability benefits
The future potential
Q&A session addressing audience questions
Watch the full webinar recording here:
FAQs
We have summarised and answered all of your questions, some of which
due to the time limit, we didn't get the chance to answer during the webinar
I learnt from a Consultant Dermatologist recently, of a secure national database where you can store images of lesions w/o data protection issues - but can you help with details about this on-line platform?
The only one I know of is Consultant Connect. You have this on your phone, take pictures or upload pictures through it and they are then stored centrally, but can be imported into the patient record. You need the patient’s NHS number to do the import, but the images are stored and are accessible through your login to Consultant Connect. It works pretty well.
- Mark Goodfield
I've just checked on ORCHA Health's App directory and can't find Virtual Lucy. Is it accredited?
Virtual Lucy™ is fully approved by NHS Digital and part of their exacting DFOCVC Product Catalogue Description (digital.nhs.uk). The platform is also DSPT approved by NHS Digital Organisation Details (dsptoolkit.nhs.uk), exceeding standards. HBSUK are not registered with ORCHA and considering this as an additional approval – a meeting is set for 8th June with ORCHA to review this.
Does this use Health-e-Intent data?
A review of the Cerner HealtheIntent cloud-based, programmable population health management platform is planned for Q3. Whilst the principles are recognised, application benefits are yet to be assessed. Continuum of care is important to HBSUK, hence the evaluation. VL already supports the same benefits to identify, score and predict the risks of individual patients, allowing them to match the right care programs to the right individuals, and helps to improve outcomes and lower costs for health and care.
Does it take only Dermatoscopic images?
No, Virtual Lucy™ can take images uploaded from any digital source e.g. smartphone, digital camera or computer folder (CB)
Important to discuss the GP referral letter historically not been routinely accessed but moving forwards will be?
Early mobilisations of Virtual Lucy™ did not make use of eRS. This was primarily due to the fact referrals had already been made from primary care to secondary care and a data drop of information from PAS was provided from secondary care for input to VL. HBSUK can take eRS referrals which are automatically added to the care record and available to reviewing clinicians. Whilst it is accepted that all information is useful and important, a separate behavioural study undertaken showed that 90% consultants did not think referral letters are useful and many don’t review at all. Further developments on eRS (2-way traffic) are part of VL development plans and will be available later in the year.
How to ensure the photographs are of a quality that allows for a diagnosis? are there any codes for the clinicians to code uncertainty? e.g. possible bcc or scc
We give the patient clear instruction about how to produce a good image or images, ask them to check whether it is in focus and representative of the problem before upload. Occasionally I ring them to talk this through if the image is not good enough (around 2-3% patients). There is no uncertainty code, but the free text element of the VL platform allows us to convey the level of doubt about a diagnosis. - M.G.
Do you require an N3 connection to log in remotely?
No Virtual Lucy™ is not restricted behind an N3 network
How many clinicians do you have working within dermatology?
We currently use a central cohort of 6 Dermatologists to review current activity volumes. We have over 20 Dermatologists trained on VL and have a rapid onboarding process for new clinicians. We have strict quality control measures in place, including peer auditing to ensure homogenous delivery of services. We have several other Dermatologists who have shown an interest and will be in our queue to join when we have sufficient volume. Whilst we can provide our Dermatologists, we can also offer a platform only solution whereby the NHS commissioner uses their own Dermatologists, either full or part-time. We will be introducing dermatology specialist nurses to review and treat specific conditions within the next quarter.
Who is completing the case review?
Case reviews are currently 100% completed by Dermatologists.
We are currently exploring and trialling what conditions can be reviewed by specialist dermatology nurses and will be able to offer this functionality in the next quarter. Dermatologists can be provided by ourselves or use local Dermatologists in a full or part time capacity. Typically, we see HBSUK doing a waiting list catch up sprint, using our own Dermatologists, but transitioning to use local Dermatologists once backlogs have been cleared. The most common model forming is for HBSUK to provide a ’top-up’ service, whereby local Dermatologists do the core, with peaks being picked up by HBSUK. HBSUK also offer an ‘insourcing’ service, so having completed the outpatient triage, we can fully manage onward physical treatments with our teams as required.
Is not going back to patient slowing down process and repeating what the referrer has gathered?
Waiting times are not excessive in comparison to the patient waiting for an out-patient appointment! In any case, referral letters are very variable in what information they contain, and the first part of any interaction with a patient we see for the first time is to take a history. That’s what we would do face to face and it is what we do via VL, but virtually. Once the patient has agreed to interact, it is very quick.Going back to patients is all done under 48 hours (often the same day). -M.G.
Can the Virtual Lucy platform provide coded data for research?
Virtual Lucy™ has a very data rich MI (management information) depository. We have our own dedicated MI/BI team so can easily extract data in any form. Our current research is in moving from static to dynamic data and planning to later in the year move to machine learning technology as a pre-cursor to AI. We use our own data to feed into clinical publications and reviews. We would welcome working with the NHS and academics alike on research, analytics and predalytics (predictive analytics).
Who uploads the photo? Is it the patient?
Yes, the patient uploads images and any other supporting information such as medication. As part of our accessibility and inclusion adherence, from Q3 this can be done by proxy representatives.
Would you not need a dermoscopic image?
If we were doing 2 week wait work, then it is a current NHS requirement to have dermoscopy for pigmented lesions, but this is not what we do. In the context of a routine waiting list where melanoma and SCC are not suspected, then dermoscopy is not required and adds little to the assessment of rashes. Should suspicious lesions be seen, and this can happen, we always send for urgent F2F where dermoscopy will happen.
Accepting that the virtual assessment times will differ, what is the average time allowed for the virtual assessment?
There is no allowance of time as such. The actual assessment of information, including anything pulled in from the primary care record and image is quick - a matter of a couple of minutes once you know your way around the system. The delivery of information via free text, and making the response more personalised takes a bit longer, but you will normally be able to get through 4-6 patients in half an hour or so.
How is activity through Virtual Lucy recognised and factored into Job plans?
We provide 3 options (fully managed service, part managed service and platform only). If you are using platform only, you will need to add into your normal job planning process and probably set up virtual clinics within your resource planning. If we are doing part or all the assessments, this would be tempered accordingly. When we complete the discovery workshops and onboarding, we cover how resource allocation will be managed and agree this with you as well as other KPI’s.
Of the 40% have you assessed what % are referred back in again for the same problem?
So far, we have received no indication of any re-referred. There will inevitably be some, since even when offering a series of management options to the GP, there will be some who don’t respond. This is no different from what happens after a F2F appointment. We hope to identify those patients eg with difficult psoriasis who we know will require ongoing management and make sure that they receive a follow up appointment at the hospital, just as one would after F2F.
Is the consultation report linked/saved in the patient's e-records?
There is a copy of the assessment report and any other information eg fact sheets within Virtual Lucy. Local clinicians are granted access to the platform to allow viewing of such information. The patient has their own portal and access to all information. A copy of the outcome and report is also sent by email to the GP. Whilst we have full connectivity to primary care records via GP Connect, we are awaiting NHS digital to enable such functionality back into GP care records. Currently we send a .pdf file, which is then appended to the patient’s records. Once GP connect phase 2 (NHS digital pending) is available, report information can be added directly to patient’s records. We have a HL7 interface able to connect with secondary care EPR systems and directly interface with hospital PAS systems.
I'd be interested in knowing what were the local administrative challenges that stopped referrals?
It was a mix of various staff turnover (admin, and service management)within the local NHS and transitions between teams took longer than would have been preferred due to training and priorities.
What is the cost to implementing Virtual Lucy services in a foundation trust or a health board?
There are a number of options and models that can be selected. SAAS only (supported platform), SAAS plus admin support, SAAS plus service (full or part), physical treatments service (insourcing). The preferred model used to date is a Trust or CCG requests support to reduce a backlog, HBSUK provide the platform and all the support from an outpatient perspective or including treatment (insourcing service, providing teams to manage secondary care services from surgery to phototherapy and isotretinoin). Local connectivity to PAS systems is hospital dependent and discovery sessions can be done in 2-5 days.
For an individual quote, please contact the service team on 07973 287751 – Chris Birch chris.birch@hbsuk.co.uk
My concerns with these efficacy measures is that what will be left in our clinics are the complex cases that would require a longer clinic time. Therefore, clinician might be pressurised by management to see the same number of patients historically seen in clinics (having lost all the simpler cases)
This is always identified as a problem whenever pathway redesign happens. The same issue was raised when community clinics arrived. It is of course correct, and is something that should be discussed with local management during any set up process. It is also the case that ‘Consultants should see what only Consultants must see’ (BAD service document). It makes clinics easier to have a mix of easy stuff, but not really great use of consultant time, but it is important to make sure that clinic slots allow for this. We are happy to talk through optimisation of resources during any onboarding process.
It seems like the pilot was successful, is there a plan to expand Virtual Lucy to other Trusts in BOB ICS?
The pilot is on-going, and we continue to evaluate the results. Although the service has primarily been used as a backlog clearance initiative, we are discussing how this might be developed into a wider solution offering a single point of referral across a wider geographical area, building in Advice and Guidance and potentially Patient Initiated Follow Up. Even if the BOB ICS can’t benefit from this, it is hoped that others may learn from our experiences.
What engagement has been done with patients, carers and representative groups? What do patients feel about possibly not being referred to a consultant, etc?
All patients were referred to us for consultant assessments, so everything was done by consultants. We have previously done some equality data analysis to see if certain demographics of patients accessed the service more (e.g. older patients had a little more restrictions in accessing). Whilst Virtual Lucy is 70% compliant with NHS Digital DFOCVC accessibility requirements, this will be 100% from the next release due in August.
How have the GPs responded?
Generally, well. Discussions with LMC representatives indicate that the important issue is good and early communication so that everyone knows what is happening and no-one is surprised. Local rules on guidelines and formulary are important for the VL team to understand when they are providing the service. Having had this experience, this is a standard part of the onboarding process for new clients
How do the patients get from your service to the specialist service in the hospital if required ie are you able to complete the Urgent cancer referral for patients who have SCC/potential melanomas or does the advice go back to the GP to complete the onward referral?
Any identified cancer patients are directly spoken to by one of our Dermatologists who explains the clinical pathway. There is a ‘red flag’ process as part of the system that identifies such cases, and these are clearly flagged to the secondary care provider. The HBSUK contact centre follows up any urgent cases to ensure they have been picked up. There is no need for any referral back to the GP, unless this was mandated via local protocols.
Would this not be similar to electronic referrals and the advice and guidance that consultants can return to GPs
The difference is that the current Advice and Guidance does not include the patient at any stage and in some cases, there have been reports of up to 10 back and forth conversations. Virtual Lucy™ case reviews include both the voice of the GP and the patient ensuring carefully tailored treatment advice with a 0% re-referral rate from the GP and no GP complaints
How many assessment do you think could be completed in an hour?
It will depend on the complexity of the case, but usually somewhere between 8 and 12
Over what period of time were the 1500 patients dealt with?
9 months as driven by patients shared with us from the Trust. We have the capacity to do 6000 patients per month which could be extended to 50000 within 6 months if demand was required.
At what point is the information gathered integrated into patients hospital record?
The clinical summary letter and copy of the patient’s assessment is currently emailed to the hospital and GP immediately when the case review is completed. This can be direct to the HIS if the commissioner wishes to use our HL7 interoperable interface.
What impact does the platform have on the local admin team?
Like most other NHS providers, Bucks has an already stretched admin service. So, as with any capacity generating initiatives (WLI/outsourcing/Insourcing) this can dramatically affect the workload of the admin team as the work required is above and beyond ‘Business As Usual’. NHS providers need to factor this in when planning these initiatives as this can sometimes create a bottleneck.
- Titus Burwell
How important does he think the questionnaire was? Could he make most decisions based on the GP referral letter and the photo?
The questionnaire is fundamental since it mirrors the history taking that we would do F2F. GP referral letters are variable in content - some are detailed and very helpful, others just print out the last consultation which may or may not be helpful, and others (still) unfortunately say ‘This patient has a rash”. The source of the image doesn’t matter, as long as it is usable.As part of deployment, we work with GP communities to feedback learning outcomes and seek improved communications and inter-working.
-Mark Goodfield
30k assessments in total - how many Virtual Lucy Dermatology assessments have you been able to conduct?
By May 31st 2022, we had conducted 2623 Virtual LucyDermatology assessments. The VL service is now fully deployed with the largest Private Healthcare provider in the UK and volumes are growing exponentially on a weekly basis.
Have you struggled with any patients that might be digitally excluded?
As with all virtual services you cannot avoid a degreed of digital exclusion and at the end of the day virtual services are not appropriate for everyone. The things that we have done to encourage digital inclusion are the following:
A dedicated customer service team who can support onboarding
A recent upgrade to ensure WCAG accessibility
A verified reading age of 9 across all platform content
Mobile optimisation and UX design to make the platform simple & intuitive
Proxy logon support consideration
You said that 40% were discharged directly from the system without a need for a hospital appointment. but also said that there was a 30% proportion where there was failure to engage. Was your discharge rate therefore 30%. +40% of the remaining 70%? And do you know what happened with the 30% where there was failure to engage? We’re they rereferred via other routes?
Yes, 70% engaged with the system of which 40% that engaged were returned to the community without need of a hospital appointment. Those that did not engage with Virtual LucyTM we returned to the trust for follow up directly by the trust to follow the original pathway.
So far, we have received no indication of any re-referred. There will inevitably be some, since even when offering a series of management options to the GP, there will be some who don’t respond. This is no different from what happens after a F2F appointment. We hope to identify those patients eg with difficult psoriasis who we know will require ongoing management and make sure that they receive a follow up appointment at the hospital, just as one would after F2F. To be clear, patients referred back to the Trust were directly listed for treatments so there was no requirement for any additional outpatient activity.
Is there room to use GPwER in your Dermatology pathway rather than consultants alone?
There is no reason why not, provided that they have appropriate experience and training. In the non-virtual situation, consultant overview is essential, and personally I would want certainty about the individual concerned is giving the same sort of opinions and advice that I would give. It is the case, though, that having a consultant opinion is very re-assuring if a virtual consultation is the way in which many patients will be managed.We are very happy to debate this further and can discuss in detail as part of any onboarding.
In trusts with limited dermatology consultant capacity, how did they manage with the demand of those that required any surgical intervention.
HBSUK provide physical insourcing services as well as virtual services. Once backlog outpatient lists are stratified, we can deploy full teams to conduct any form of treatment from surgery to phototherapy or isotretinoin. We can manage the entire backlog or new capacity to match the needs of clients.
Request a full Virtual Lucy demo or request a proposal :
Chris Birch, Service Lead (Non Clinical)
07973287751