Virtual clinics: An opportunity for integrated diabetes care

In line with Welsh Assembly Government (WAG) policy to improve communication and cooperation between primary and secondary care, and to manage chronic medical conditions closer to individual’s homes where appropriate (Primary & Community Services Assurance Board, 2009), the South Wrexham Locality (SWL) pilot site was set up in 2007.

One of several projects conceived and explored was that of the virtual clinic (VC), in which a consultant endocrinologist or diabetologist would visit participating practices to discuss their more difficult cases in the hope of improving care for those people and also of avoiding likely referrals to the outpatient clinics at the hospital. The individuals would not be present at the clinics and education would be delivered around the cases discussed.

This article explains the methodology and presents the formal evaluation of the pilot.

The aims of the VC were:

• To break down real and perceived boundaries between primary and secondary care.
• To facilitate discussion about existing secondary care patients in between their appointments. 
• To provide educational input to practices.
• To increase secondary care knowledge of the workings and personnel involved in local primary care.
• To facilitate the provision of care to people with diabetes continuing in primary care for as long as it remained practical and safe.
• To rationalise and triage referrals from primary into secondary care.

Methods
Four practices in SWL were recruited to take part. Funding for the consultant’s time was provided by Wrexham Local Health Board (WLHB) at a cost of one session per VC and each participating practice received two visits, 4 months apart. Any members of the healthcare team within the practices were invited to attend and to submit cases for discussion. Discussion was on an anonymous basis unless the individual was already known to the consultant. It was anticipated that the majority of cases discussed would be regarding diabetes management and this proved correct, although endocrine or potential endocrine cases were also welcomed. The consultant could also take along cases that would benefit from discussion between appointments in his clinic but these cases did not appear in the final analysis. Each practice could request a subject update presentation in advance to take place at the end of the VC if they thought it would be of benefit.

For governance purposes, responsibility for acting or not acting on the advice given at a VC was retained by the GP unless a formal referral to the outpatient clinic ensued. This was agreed at the start of the project. 

Evaluation of the project was in three parts: 

1. To explore whether the VC would help avoid or create referrals.
2. To explore the usefulness of the VC as a communication and educational tool to participating professionals.
3. To explore the time efficiency of VCs.

Evaluation forms were formulated and filled in by each healthcare professional attending the meetings. 

To evaluate how many referrals were created or avoided, the forms contained anonymised data about the advice given for each patient and this was to be filled in by the person responsible for submitting that individual to the VC. Each patient discussed was also “graded” on a scale of 1–5 by the GP for the likelihood that they would have been formally referred to the outpatient clinic had the VC not occurred (1 = referral was extremely unlikely; 5 = referral was otherwise certain). 

Data were also collected on whether referral had actually taken place in order that a reasonable assessment could be made on the number of referrals avoided by the VC and also the number created. Individuals scoring 4 or 5 – not subsequently referred as a result of their discussion at the VC – were classed as “referrals avoided”. Those scoring 3 or below who were subsequently referred were classed as “referrals created”. It was not known at the start of the project if more referrals would be created or avoided.

Usefulness to the participating professionals was assessed by the use of simple analogue scores on level of agreement with certain statements about the project. There was also the opportunity on the evaluation form to write free-text comments. 

The consultant kept a careful time log for each VC to evaluate the efficiency of this way of working. 

Results
Exploration of whether VCs avoided or created referrals, and their time efficiency, are summarised in Table 1 and Box 1, respectively.

Exploration of usefulness of VCs as a communication and educational forum 
For questions 1–3 (below) only the responses of the practice staff have been analysed (1 = complete non-agreement; 5 = total agreement).

• Question 1: This VC has helped me to break down real and perceived barriers between primary and secondary care. Number of people answering this question, 25; mean score, 4.6 (out of 5).
• Question 2: This VC has facilitated better communication between primary and secondary care practitioners. Number answering, 25; mean score, 4.6.
• Question 3: This VC has improved my knowledge of this particular disease area. Number answering, 20; mean score, 4.5.
• Question 4 (visiting consultant only): This VC has improved my knowledge of the management of people within this disease area in primary care. Number of answers, eight (one answer for each VC attended); mean score,  4.5.

Discussion
This small pilot study has demonstrated a number of things. Most easy to conclude is the fact that healthcare professionals enjoy and benefit from close communication across traditional boundaries. The question about “real and perceived” boundaries was carefully worded to allow the participants to put their own subjective boundaries to this test of strength given this new way of working. Also, although not directly measured in this project, it is likely that diabetes care benefits from this enhanced cooperation, at least in the short term. 

Education during the VCs was extremely valued. Each case had an educational point which could be expended on at length as appropriate. Typical subjects for discussion were new diabetes therapies, the treatment of obesity, mechanisms of insulin resistance, diagnosis of diabetes and insulin regimens.

Each practice was offered an educational update talk by the consultant at the end of each VC but only one offer was taken up (Surgery B, visit 2) due to the low number of cases identified for discussion. Only a small number of patients were discussed at the first visit to Surgery C, as the practice staff had not fully understood the nature of the visit. Each was discussed at length to form the basis of five impromptu educational sessions on various points regarding diabetes management. 

Efficiency is harder to quantify. This format clearly allows discussion and decision-making for a large number of people quickly, whether they are new to the consultant or already known to them. The numbers of people discussed varied widely between practices (which were all of a similar size), largely due to the participating GPs and practice nurses struggling to identify suitable cases ready for the VC. Discussion with the GPs revealed that this was a combination of them initially not fully appreciating what would be a suitable case and, where the remit was appreciated, actually finding suitable cases to be discussed at that time of the clinic. One GP commented that she was effectively “hanging on” to cases ready for the day so there would be a reasonable number to discuss rather than phoning or emailing or writing for advice earlier.

Travel time is a factor in any service involving expensive staff moving out from their main base, and it is notable that this pilot was carried out in a small rural area with the maximum distance between the local acute trust and the practice being 13 miles. Travel time could be widely different for other practices particularly on this patch of North Wales where some practices are up to 90 minutes from the consultant’s base.