As you might have experienced yourself when contacting your GP or consultant, the only tide that unfortunately has been turned so far is the NHS going fully digital. This means that I and all other Bart-MS consultants have been relying heavily – as in 99% of our clinic encounters – on virtual clinics to reach out to our MS patients since March 2020. People with MS are invited with an appointment letter (obviously delivered by the Royal Mail) to reserve a time slot in their agenda for a virtual clinic moment. This virtual clinic can be a telephone call or – less likely – a video clinic. The extent of this digital healthcare transition is huge, and it has become the new normal in every tier of the healthcare system.
Imagine you are a person manifesting with symptoms suggestive of multiple sclerosis. Let’s say you noticed one week ago that you had a little bit less strength in your left leg while doing your weekly yoga class. The symptoms have evolved, and now you have difficulties doing stairs and your leg feels heavy all the time. You are really worried about this, and look for medical advice. The following scenario might be very common:
- You contact your GP who decides the symptoms are mild and already ongoing for more than a week. Your symptoms will be evaluated through a telephone clinic and, if interpreted correctly, you will be referred to the local neurology department.
- You get a virtual appointment with a general neurology consultant in a couple of weeks/months. This consultant arranges a brain scan (MRI) and follow-up meeting.
- You come in to the hospital or MRI facility to have a brain scan.
- You get a new virtual appointment with the general neurology consultant who discusses the MRI findings and makes a referral to an MS consultant for a definite diagnosis/treatment.
- You get a virtual appointment with the MS consultant who decides the symptoms and MRI imaging findings are indeed compatible with multiple sclerosis.
- The MS consultant arranges for you to have one or more of the following:
- Bloods: done at your GP surgery or phlebotomy service of the hospital. Lab requests are made electronically.
- Lumbar puncture: done at the hospital by a younger doctor.
- Physiotherapy: not possible or potentially organised through a video-portal.
- Symptomatic treatments: you contact your GP surgery by phone and the drug is added to your chronic prescription.
- A virtual encounter with an MS nurse to discuss about MS treatment options.
- Treatment delivered at your home or administered at the infusion unit of the hospital.
- A virtual follow-up appointment with the MS consultant/nurse in six/twelve months time.
In the COVID-19 epoch, you can thus be diagnosed with MS and treated for the condition without ever seeing an MS consultant or nurse in real-life. Admittedly, the diagnosis of MS is heavily reliant on the findings on MRI imaging and in the majority of the cases this is very indicative. However, this scenario also applies to other diseases such as Parkinson’s disease or dementia in which the role of MRI is much more modest.
The benefits of this policy are apparent and very quantifiable:
- Clinics can continue safely during COVID-19. No risk of COVID-19 transmission.
- Remote clinics are much more flexible and can happen anytime/anywhere independent of room reservations and presence/absence of other staff members. A beach in Morocco? An alpine hut (with good internet)? Neurologists and patients can essentially be digital nomads.
- Avoiding (unnecessary) transport of the patient (and consultant) on the tube/bus/car. Especially in the context of follow-up clinics in which case you already had a chance to get to know the patient, this is very true. Admittedly, healthcare systems around the world have been too reliant on face-to-face evaluations and familiarity with remote clinics opens up the possibility to reach out remote areas with no neurology coverage at the moment. A spin-off MS service in Wales, Isle of Wright, South-Africa?
- No (unnecessary) absence of work for the patient and employer.
- Cost-reduction in terms of NHS infrastructure (less clinic rooms, less parking facilities, less computers, less paper being printed, less energy use).
- Cost-reduction in terms of NHS staff (less counter staff, less people involved in patient logistics, less phlebotomists, less cleaning staff, .. ).
Before you join “team remote”, some additional reflections. The disadvantages are namely less tangible and would require qualitative research:
- No clinical examination is possible. This implies that a diagnosis or management advice is mainly built on the medical history and the result of technical examinations. For a clinician, this feels like sitting on a chair with three legs.
- An unsatisfactory feeling after a virtual clinic for patients and clinicians. People are after all social animals, and there is a reason that for every group of mammals there is a specific term: flock, herd, school, drove, etc.
- Progressively considering coming into the hospital as dangerous and cumbersome. (Would it not be better to skip that next MRI …? Does the patient really needs to come in for this extra blood test?) Common and understandable logic might be: If your consultant not even sees you face-to-face, the hospital must be a real COVID-19 hotspot, better avoid it at all costs..
- Apathy on both the consultant and the patient’s end. To which charity do you donate and why? Is it ALS because your cousin was diagnosed with it? Is it breast cancer because your sister died from it a young age? You relate to somebody’s faith because you have been confronted with the consequences. The possibility to – unconsciously – ignore an individual’s faith is intrinsically related to a ‘remote’ setting.
For all these reasons I am convinced that a healthcare system that is largely reliant on virtual clinics is detrimental to a nation’s health status. I am convinced that when this ‘new’ normal lands as the future standard-of-care in NHS, we will see a decrease in life expectancy 20 to 30 years from now. The problem is that in 20 to 30 years from now, we will have forgotten about the ‘old’ normal and the link between the switch from face-to-face to remote virtual clinics will not be that clear. Young bright epidemiologists and statisticians will look into smoking habits, BMI, environmental pollution, virus pandemics etc. as an explanation for the decrease in life expectancy as – again – those are obvious and quantifiable explanations. The same trap has been set for researchers in the United States. For years, researchers tried to explain which policy change (read: Republicans ‘law and order’ vs. Democrats ‘Tender, Love & Care’) might have explained the steep reduction in youth crime in the early nineties. Was it the number of police officers? Was it the severity of the punishment? Was it the money spent on reintegration facilities? In the end, the most solid explanation was the legalisation of abortion twenty years before.
Therefore, I would like to advocate a diversified healthcare system in which virtual clinics exist in a healthy symbiosis with face-to-face clinics, and in which each of them are used because they are complimentary to each other and, most importantly, to the patient’s needs at that specific stage in his/her disease.