Clinics

Virtual clinics, started by necessity during COVID-19, should continue and be a mainstay of the redesign of cardiology outpatients. Physical attendance at clinics should be minimised without compromising either quality of care or patient experience. Phone clinics are technically less complex than video-based clinics and may be suitable for patients who are less able or comfortable with use of technology, but video consultations offer the advantage of mutual visualisation for patient and clinician, the use of images in explanations and potentially the recording of consent. They also facilitate the participation of family members or other patient advocates and open the possibility of multidisciplinary consultations without the need for all clinicians to physically be in the same location.

For a number of patients, there will still be the need to have a face-to-face consultation, for example, to facilitate clinical examination. When this is required, clinics should be conducted in an environment that minimises the possibility of infection transmission.

Device clinics being undertaken by remote follow-up should become the default to minimise the requirement for travel and face-to-face attendance.

Referrals from primary care

In many areas, there is a lack of a ready means for primary care clinicians to contact secondary care for advice about patients, and as a result, referral for an outpatient appointment has become the default. Many problems could be dealt with via ‘advice and guidance’ or by similar mechanisms of direct virtual contact between primary and secondary care without the need for an appointment. Potential interactions between primary and secondary care are summarised in figure 1. All referrals to a cardiology service should be made electronically through a single-triage portal informed by agreed local protocols. Where investigations are requested directly from primary care as part of these pathways, results should be accompanied by a clinically relevant report that provides advice on further management. All referrals should be triaged and allocated to a pathway with care wrapped around the needs of the individual patient. Outcomes from triaging may include advice back to primary care, investigations, virtual clinic or face-to-face clinic.

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Figure 1

Potential interactions between primary and secondary care. AECG, ambulatory ECG; CP, chest pain; CTCA, computed tomography coronary angiography; EHR, electronic health records; EOL, end of life; EP, electrophysiology; GP, general practitioner; GPwSI, general practitioner with specialist interest; GUCH, grown-up congenital heart disease; HF, heart failure; NT-pro BNP, N terminal pro B-type natriuretic peptide; OOH, out of hours; OPD, out patient department; QI, quality improvement; RAAC, rapid access arrhythmia clinic; RACP, rapid access chest pain clinic; RAHF, rapid access heart failure; TLOC, transient loss of consciousness; TTE, transthoracic echocardiogram

Networks/systems of care and community diagnostic hubs

Some trusts have managed to place a proportion of their diagnostic capability within the community pre-COVID-19, but the drive to provide off-site cardiac physiology investigations during the pandemic has accelerated the development of community diagnostic hubs. These should be geographically convenient for patients, facilitate integration across primary and secondary care and, by being remote to acute hospitals, should increase resilience to both second peaks of COVID-19 and new threats.

Acute trusts will need to further develop collaborative working so that facilities, including catheter labs and imaging scanners, are fully used across a region and can remain operational during future crises. This may require redistribution or consolidation of activity across sites. There is a strong case for ‘passporting’, such that clinical staff are able to work freely across secondary/tertiary care, as well as in community diagnostic hubs.

Availability of records

Lack of access to records and investigations from other hospitals and from primary care is a frequent source of delay in patient management and treatment errors. Availability of all patient data, including premorbid state, advanced care plans, medication, ECGs, ambulatory recordings and imaging, is an essential part of a comprehensive electronic record and will greatly facilitate management of patients across institutions.

Integrated prescribing with primary care

Many patients who have outpatient consultations have recommendations for alteration of medication. Redesign of outpatient services allow opportunities for more integrated electronic prescribing with primary care. While non-urgent prescription changes can still be achieved via electronic communication with primary care, urgent prescriptions may need to be addressed by hospital-based electronic prescribing linked to home delivery of dispensed medication or integration with primary care systems.

Virtual multidisciplinary teams (MDTs)

Virtual MDTs have become common in the wake of COVID-19 and should become the norm, both as a means of ensuring that patients can be discussed in a timely manner and to enable the participation of referring clinicians. Where relevant, they also allow the involvement of primary care and of multiple specialities, even if not colocated.

Interhospital referrals

Interhospital referrals are frequently required but can be time-consuming and may be performed on an informal and ad hoc basis with no robust audit trail. Moving forward, electronic systems that enable structured referrals and ensure accountability should be adopted.

Cardiology education

Cardiology education has been transformed by COVID-19. The principal scientific meetings have been cancelled or postponed, and in their place, a multitude of initiatives have been developed. One positive example is the programme of webcasts on BJCA.tv produced initially by London deanery trainees. National meetings are also being hosted on virtual platforms with interactive sessions. Web-based education is more economical, more accessible and more equitable than attendance at fixed meetings. This should be embraced going forward, alongside physical meetings when conditions allow, enabling simulation and networking.

Patient education

The move to online education also provides opportunities for patient education. This could take the form of a programme of national education webinars provided jointly by patient organisations and medical societies. Many patient organisations have already developed virtual patient education events and online materials. Patients and carers could be provided with an electronic suite of information on diagnosis or discharge to facilitate compliance with medication and lifestyle alterations, including in future relevant apps.

Cardiac rehabilitation

Traditional cardiac rehabilitation has been severely curtailed by the pandemic. This has led to the rapid development of home-based rehabilitation facilitated by the use of social media, smartphone apps and wearable activity trackers which have potential in a non-pandemic environment.

In conclusion, cardiology, like other specialties, needs to assimilate and act on the lessons learnt during the pandemic. This will require a restructuring of the way that we all work and deliver clinical services. While many of these changes do not in themselves come with a substantial cost, they will not be achieved without a substantial investment in information technology infrastructure and diagnostic capacity, and the NHS will also need to recognise that clinical staff will in future need to organise their time in different ways and must build this into job planning and contract discussions.