Impact of Virtual Clinics on Streamlining NHS Outpatient Waiting Lists and Carbon Emissions

Abstract

Background:

The National Health Service (NHS) outpatient waiting list is growing, affecting specialties like foot and ankle. Delays are due to increasing demand, limited resources, and administrative inefficiencies. Virtual clinics are being explored to reduce physical clinic burdens and provide timely care. This study investigates the effectiveness of virtual clinics in reducing prolonged waiting times in the foot and ankle specialty. Emissions from personal vehicles are a primary driver of climate change, which is a little recognized benefit of virtual clinics.

Methods:

We analyzed outcomes from a virtual elective foot and ankle clinic, overseen by a specialist consultant, for new elective referrals over 4 months. Data for 175 patients were collected from Lorenzo, our electronic health records system. We also assessed the success rate of virtual consultations in terms of accurate diagnoses and effective treatment plans. Measured distance to the hospital based was on patients’ residential address.

Results:

The virtual clinic effectively managed patients. Of the 175 patients, 48.6% completed treatment, and were discharged, and 53.7% were managed without face-to-face consultations. In addition, 66.3% did not need in-person visits; this includes patients treated and discharged and who were referred for investigations. In this clinic, avoiding 1 visit to the hospital by 116 patients saved travel of 1040 miles.

Conclusion:

The widespread adoption of virtual clinics can provide a convenient and cost-effective health care solution for patients and also potentially help reduce carbon emissions contributing to control global warming.

Level of Evidence:

Level IV, retrospective case series.

Background

The COVID-19 pandemic has significantly disrupted trauma and orthopaedic services worldwide, necessitating the exploration of alternative methods to safely conduct orthopaedic services. This disruption has severely affected elective clinics and procedures, resulting in extensive waiting lists. Currently, there are 6 million people on the waiting list, a substantial increase from the 4.4 million recorded before the pandemic. ⁷ Specifically, the average waiting time for the first outpatient appointment at Sandwell Hospital has reached 13 weeks. ⁵

The increase in waitlists during the COVID-19 pandemic can be attributed to several factors that contributed to significant delays in nonurgent care, pushing wait times.

Virtual clinics save time for both patients and physicians. Patients avoid the need for travel to and from the hospital, reducing time spent on commuting. Similarly, physicians can work remotely, eliminating their commute to the hospital, increasing efficiency, and allowing more flexibility in managing appointments. This convenience enhances accessibility and makes health care more efficient for both parties.

In light of these challenges, we sought to investigate the potential of virtual clinics to reduce these prolonged waiting periods. Our focus was on the virtual foot and ankle clinics that had been previously conducted, supporting providers to meet increased demand in particular localities. Virtual clinics present a compelling alternative as they eliminate the need for patients to travel unnecessarily to hospitals, which is both cost-effective and time-saving. ⁸

This is not a new concept for orthopaedics. For instance, Brighton and Sussex University Hospitals NHS Trust implemented a Virtual Fracture Clinic in 2013. ⁹ This initiative aimed to speed up patient access to orthopaedic services and reduce unnecessary outpatient follow-ups. It provided a patient-focused alternative to traditional fracture clinics, where referrals were reviewed by an orthopaedic consultant the next working day after the presentation. Fewer patients needed to be seen in the clinic as many were discharged following a telephone and radiology review, receiving injury-specific advice. Since its launch in August 2013, the Virtual Fracture Clinic reported a 57% reduction in outpatient appointments and increased patient understanding of their rehabilitation.

The health care sector’s transportation activities contribute significantly to carbon emissions, releasing an estimated 3.4 million tons of CO₂ annually, constituting 18% of the sector’s total emissions. The National Health Service (NHS) is a major contributor to road traffic in England, accounting for an estimated 5%. A substantial portion of these journeys involve single occupants and short distances, with 56% of car trips <5 miles and 23% <2 miles. ² In addition to global warming, the widespread use of motor vehicles, including cars, buses, and trucks, has been identified as a significant contributor to air pollution. Numerous studies have highlighted that these on-road vehicles emit a variety of pollutants, including carbon monoxide (CO), nitrogen oxides (NOx), particulate matter (PM), and volatile organic compounds (VOCs). These emissions are a major source of urban air pollution, ¹⁰ particularly in densely populated areas with heavy traffic. The combustion of fossil fuels in vehicle engines releases these pollutants into the atmosphere, which can lead to adverse environmental and health effects, such as respiratory problems, cardiovascular diseases, and environmental degradation.

This study investigates the effectiveness of virtual clinics in reducing prolonged waiting times in the foot and ankle specialty. Additionally, we wished to estimate the potential reduction of travel-related emissions associated with virtual clinics.

Methods

Participants

The study included all new patient referrals to the foot and ankle elective clinics from general practitioners (GPs) and other hospital specialties. A total of 175 patients were involved in the remote consultation process. This cohort comprised 79 male and 96 female patients. The study was carried out within the Sandwell and West Birmingham (SWB) NHS Trust, Birmingham, United Kingdom, providing a representative sample of the local patient population (Table 4).

Study Design

This research is a retrospective study, examining past patient consultations to evaluate the effectiveness and outcomes of remote consultations in foot and ankle clinics. The study was registered with the Clinical Effectiveness department under the registration number 1483 and was subsequently presented during a Quality Improvement half-day meeting, ensuring adherence to ethical standards and clinical governance.

Data Collection

Data were collected over a 4-month period, from July 8, 2020, to November 11, 2020. The data source was Lorenzo, an electronic health records system used by the SWB NHS Trust. The study focused on new elective referrals, ensuring that all included patients were newly referred cases rather than follow-ups or ongoing cases (Table 3).

This is the first implementation of virtual elective clinics, and we aimed to evaluate their effectiveness. We already have established virtual clinics for trauma and follow-ups. The primary rationale for elective virtual clinics is that most patients are referred by general practitioners and often do not require in-person consultations with a specialist.

All clinics during the study period were conducted by a single consultant, maintaining consistency in patient assessment and management. The consultations were carried out exclusively via telephone, using audio consultations. No video consultations were employed, which may be relevant for interpreting the scope and limitations of the findings. This methodology was chosen in response to the circumstances at the time, likely influenced by the COVID-19 pandemic, which necessitated remote health care delivery to reduce face-to-face interactions.

Patients were contacted based on their referral, and relevant clinical data were extracted retrospectively from the electronic health records. This included patient demographics, the nature of the referral, and any clinical decisions made during the consultation.

Distance from the hospital to patients’ residences was measured by using Google Maps.

Results

Out of the total patients, 116 (66.28%) did not require a visit to the hospital. Many patients were managed and discharged (48.57%), whereas some were referred to other consultants for further management (24.57%).

Performing an hour-long virtual consultation created 0.434 kgCO2e per consultation compared to 5.264 kgCO2e for face-to-face (Table 1). ¹ The average UK petrol car emits 0.28 kgCO2e per mile, and our patients traveled an average of 5.94 miles to attend the foot and ankle clinic, resulting in 3.33 kgCO2e emissions per round trip. By conducting virtual clinics, we eliminated an estimated 1,040.4 miles of patient travel, equivalent to 291.31 kgCO2e over 4 months. ¹² In total, by avoiding face-to-face clinics, 363.22 kgCO2e of emissions were saved (Table 2).

Table 1.

Carbon Emissions for Face-to-Face and Virtual Consultation (kgCO2e).

	Face-to-face	Virtual
The clinic room’s energy consumption	0.065	0.065
Telephone usage	0.039	0.369
Personal protective equipment (gloves etc)	0.152	0
Usage of water	0.008	0
Staff commute	1.68	0
Commute of the patients	3.32	0
Total emissions per consultation	5.264	0.434

Table 2.

Calculations.

Category	Calculation	Result
Total clinics	23 half-day sessions (3 h each)	23 clinics
Average patients per clinic	175 patients / 23 clinics	7.6 patients per clinic
Clinic emissions (total hours)	23 clinics × 3 h	69 h
Clinic CO2 emissions	69 h × 0.434 kgCO2e/h	29.95 kgCO2e
Patient travel emissions avoided	Average distance: 5.94 miles
Round trip distance	5.94 miles × 2	11.89 miles
Emissions per patient trip	11.89 miles × 0.28 kgCO2e/mile	3.33 kgCO2e
Total emissions avoided	1040.4 miles × 0.28 kgCO2e/mile	291.31 kgCO2e
Total emissions avoided from virtual clinics	Summing all patient travel emissions avoided	363.22 kgCO2e

Table 3.

Data Summary.

Category	Count
Total patients managed	175
Male patients	79
Female patients	96
Patients managed and discharged	85
Patients needing time to decide for surgery	4
Referred to other consultants for definitive management	43
Referrals made for face-to-face consultations and listing for operations	Not specified
Unable to contact	4
Reviews	4
Referred for injection under ultrasonographic guidance	9
Referred for investigations	22
Open appointments	3
Awaiting results	1

Table 4.

Key Metrics.

Metric	Count
Patients completing treatment and discharged	85
Referred to other consultants and reviews	47
Descriptive Statistics
Category	Percentage
Gender Distribution
Male	45.14
Female	54.86
Outcome Distribution
Managed and discharged	48.57
Needed time to decide on surgery	2.29
Referred to other consultants	24.57
Unable to contact	2.29
Reviews	2.29
Referred for injection under US guidance	5.14
Referred for investigations	12.57
Open appointments	1.71
Awaiting results	0.57

Discussion

The implementation of remote consultations and targeted referrals for foot and ankle conditions has demonstrated significant benefits in patient management.

Virtual clinics helped reduce the waiting list in several ways. There was no need to arrange additional outpatient clinic staff or physical clinic spaces, which are often difficult to coordinate for extra sessions. A single clinician, equipped with a laptop, was able to conduct the clinic remotely, even from home. This alleviated the pressure on the organization to secure additional outpatient clinic places.

An additional benefit of virtual clinics, beyond helping reduce waiting lists, is their positive impact on controlling global warming. By reducing the need for patient and staff travel, virtual clinics lower carbon emissions, contributing to environmental sustainability. This is especially important given the global effects of climate change and the urgent need to mitigate its dangerous consequences

The NHS is estimated to be responsible for 5% of all road traffic in England, ³ with travel contributing to 18% of the nation’s carbon footprint. ⁶ This presents a significant opportunity for reducing the carbon impact, enhancing sustainability, improving convenience and safety, and saving both time and money. ⁴ Although our department’s contribution may seem small, the broader implementation of such practices across the NHS could lead to a considerable reduction in carbon emissions, underscoring the importance of virtual clinics. These findings highlight the potential for remote health care services to play a pivotal role in delivering efficient, cost-effective, and environmentally responsible care on a national scale.

Conclusion

The widespread adoption of virtual clinics can provide a convenient and cost-effective health care solution for patients and also potentially help reduce carbon emissions contributing to control global warming.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114241305603 – Supplemental material for Impact of Virtual Clinics on Streamlining NHS Outpatient Waiting Lists and Carbon Emissions

Supplemental material, sj-pdf-1-fao-10.1177_24730114241305603 for Impact of Virtual Clinics on Streamlining NHS Outpatient Waiting Lists and Carbon Emissions by Bhaskar Amarnath Bhavanasi and Shrikant Kulkarni in Foot & Ankle Orthopaedics