Qualitative investigation of patients’experience of a glaucoma virtual clinicin a specialist ophthalmic hospital inLondon, UK

Aachal Kotecha, Karen Bonstein, Richard Cable, Jocelyn Cammack, Jane Clipston,

Paul Foster

To cite: Kotecha A,Bonstein K, Cable R, et al.Qualitative investigation ofpatients’ experience of aglaucoma virtual clinic in aspecialist ophthalmic hospitalin London, UK. BMJ Open2015;5:e009463.doi:10.1136/bmjopen-2015-009463

▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2015-009463).

Received 20 July 2015Revised 28 September 2015Accepted 17 November 2015

NIHR Biomedical ResearchCentre for Ophthalmology atMoorfields Eye Hospital NHSFoundation Trust and UCLInstitute of Ophthalmology,London, UK

Correspondence toAachal Kotecha;aachal.kotecha@ucl.ac.uk

ABSTRACTObjectives: To explore how patients felt aboutdelivery of care in a novel technician-delivered virtualclinic compared with delivery of care in a doctor-delivered model.Design: A qualitative investigation using one-to-oneinterviews before and after patients’ appointments ateither the standard outpatient glaucoma clinic or thenew technician-delivered virtual glaucoma clinic(Glaucoma Screening and Stable Monitoring Service,GSMS).Setting: A glaucoma clinic based in a tertiaryophthalmic specialist hospital in London.Participants: 43 patients (38 Caucasian, 5 African/Afro-Caribbean) were interviewed prior to theirglaucoma appointment; 38 patients were interviewedbetween 4 and 6 weeks after their appointment.Consecutive patients were identified from patientreception lists and telephoned prior to theirappointment inviting them to participate.Results: Trust in the patient–provider relationshipemerged as a key theme in patients’ acceptance of notbeing seen in a traditional doctor-delivered service.Patients who were well informed regarding theirglaucoma status and low risk of progression to sightloss were more accepting of the GSMS. Patients valuedthe reassurance received through effectivecommunication with their healthcare practitioner at thetime of their appointment.Conclusions: This study suggests that patients areaccepting of moving to a model of service deliverywhereby the doctor is removed from the consultationas long as they are informed about the status of theircondition and reassured by the interaction with staffthey meet. This study highlights the importance ofpatient engagement when introducing new models ofservice delivery.

BACKGROUNDGlaucoma is the leading cause of irreversibleblindness in the developed world, andincreases in prevalence with advancing age.1

It is a chronic condition which requires life-long monitoring once diagnosed. Thenumber of new glaucoma suspect referralsinto the hospital eye service (HES) is increas-ing, partly due to the advances in diagnostictechnologies used by primary eye care provi-ders.2 This, combined with the increasinglyageing population, has led to some hospitaleye departments to predict capacity problemsin meeting demand for ophthalmology out-patient services.3–5

An approach to meeting increasingdemands for services is to remove theface-to-face doctor consultation and imple-ment a ‘virtual clinic’ within the secondarycare setting, whereby nurses or ophthalmictechnicians collect data from the patient fora consultant ophthalmologist to review at alater time. Glaucoma lends itself to such amodel of care as the disease is usually moni-tored using digital imaging and functionaltesting devices6 that may be administered by

Strengths and limitations of this study

▪ This is the first qualitative interview-based studyobtaining views from patients regarding howtheir glaucoma care is delivered, and how theyfeel about the move to non-doctor-deliveredservices.

▪ Interviews were performed on a one-to-one basisbefore and 1 month after patients’ appointments.

▪ All patients participating in the study had Englishas their first language and were predominantly ofCaucasian ethnicity; thus, they may not reflectthe views of the wider glaucoma patientpopulation.

▪ The study was performed at a single tertiaryreferral ophthalmic centre in London; thus, geo-graphical differences in patient opinion still needto be explored.

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trained technical staff. There are a number of NationalHealth Services (NHS) departments around the UK(personal communication: Simon Longstaff, ConsultantOphthalmologist Royal Hallamshire Hospital, Sheffield,January 2014; Jane Kingett, Advanced OphthalmicPractitioner—Glaucoma Service Lead, West of EnglandEye Unit, February 2014),7–9 and independent sectorproviders10 who use this model.The key factor in the ‘virtual clinic’ is that it removes

the ophthalmologist from the face-to-face patient con-sultation. The rationale for their implementation withinhospitals is that they both improve the patient journeyand improve clinic capacity (personal communication,Simon Longstaff, Consultant, Royal HallamshireHospital, Sheffield, January 2014).The Glaucoma Service at Moorfields Eye Hospital,

London, opened a virtual clinic (the GlaucomaScreening and Stable Monitoring Service, GSMS) inMarch 2014. The purpose of this qualitative interview-based study was to explore how patients felt about theircare delivery, and their impressions on moving awayfrom a doctor-delivered care model where they hadexperience of both. Patients attending both the trad-itional consultant-delivered outpatient clinics as well asthose attending the GSMS were interviewed. For somepatients, it was their first visit to the hospital for assess-ment (whether at GSMS or in a consultant-deliveredclinic) following a referral by an optometrist or generalpractitioner.

METHODSThe GSMS was suitable for low-to-moderate risk,new glaucoma suspect patients, or patients withlow-to-moderate stage stable existing glaucoma at lowrisk of progression, as deemed by their consultant. Fornew patients, ‘low-to-moderate’ risk was defined ashaving up to two of the following risk factors for devel-oping glaucoma: raised intraocular pressure, suspiciouslooking optic nerves, suspicious visual fields, positivefamily history. For existing patients, ‘low’ and ‘moderate’disease stages were defined using a modified version ofthe Canadian Glaucoma Society disease staging guide-lines.11 The GSMS opened in March 2014. Figure 1shows a flow diagram describing the new and existingpatient journeys through both the GSMS and the glau-coma outpatient clinic.Semistructured interviews were conducted in the

Outpatient Department at Moorfields Eye Hospital NHSFoundation Trust, London, UK, between August andNovember 2014. Four patient groups were identified:1. Those attending a new patient appointment in the

GSMS,2. Those attending a new patient appointment in the

consultant-delivered glaucoma outpatient service,3. Those attending a follow-up appointment in the

GSMS, and4. Those attending a follow-up appointment in the

consultant-delivered glaucoma outpatient service.

Figure 1 Flow charts illustrating (A) new patient and (B) stable patient journey. GP, general practitioner; GSMS, Glaucoma

Screening and Stable Monitoring Service; EPR, electronic patient record.

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A sample size of 10–12 patients from each group wasproposed as being likely to represent a range of viewswhile also being practical for researchers to analyse.12

The sample size fits well with other qualitative researchprojects into glaucoma patient perceptions.13–15

Patients attending the consultant-delivered glaucomaoutpatient clinics and the technician-delivered GSMSwere invited to participate via a telephone call madebetween 1 and 5 days prior to their scheduledappointment.The patient selection process was as follows: reception

lists for both types of clinic were printed off in advance.For those attending the GSMS, consecutive patients weretelephoned and invited to participate. For those attend-ing a consultant-delivered outpatient appointment, con-secutive scheduled patients had their hospital recordsexamined by a clinician (AK) to establish that they wereof a similar disease stage/risk as those attending theGSMS. Once identified, patients were telephoned andinvited to participate. All invitations were made by thesame clinician (AK). Patients were advised that thepurpose of the interviews was for a service evaluationproject and that they would be interviewed immediatelybefore their clinic appointment and interviewed againapproximately 1 month later via telephone. All patientsattending the GSMS were new to the clinic—that is, anyreturning patients had previously attended the regularconsultant-delivered outpatient clinic and had no previ-ous experience of the new GSMS clinic.The project conformed to the tenets of the

Declaration of Helsinki and informed consent was takenprior to the start of each interview. Interviews were con-ducted by one of four people (KB, RC, JCl, JCa) using apredetermined topic guide (figure 2). The topic guidewas developed based on some of the common free-textresponses to an in-house patient satisfaction feedbackform given to patients attending the GSMS in the pre-ceding months, as well as the service managers’ interestinto how the service was being perceived.Preappointment interviews took place in a quiet waiting

area in the hospital that was out of the earshot of otherpatients and staff. Patients were advised that the interviewerwould take verbatim notes regarding their statements andthat all responses would be anonymised. Once notes hadbeen taken, the interviewer would read back their notes tothe patient to confirm that they had captured the patient’sresponses to questions asked. Postappointment interviewswere conducted via telephone at a time convenient to thepatient. A half hour slot was given for each interview,although interviews were terminated when the end of thetopic guide had been reached and/or patients hadnothing further to add. The team involved in conductingthe interviews was not part of the patients’ clinical careteam and did not work in the hospital’s glaucoma depart-ment. All researchers were part of the University CollegeLondon Biomedical Research Centre (Ophthalmology)Public and Patient Involvement team and were involvedand experienced in qualitative research exercises.

Demographic data and medical information pertain-ing to the patient’s diagnosis data was also collected.The study protocol was developed and is reported

according to the Consolidated Criteria for ReportingQualitative Research (COREQ).16

Data analysisAll notes were transcribed to an Excel spreadsheet andanalysed by four of the authors (RC, JCl, JCa, AK) usinga thematic framework approach.17 Transcripts were ini-tially descriptively coded (open-coded) by each memberof the analysis team individually, who then met toperform analytical coding during group discussions untilconsensus agreement was reached. Themes were identi-fied using a thematic analysis approach.17

RESULTSThe demographics of the patient groups are displayedin table 1.Figure 3 illustrates the themes and subthemes that

emerged from the analysis. Six main subthemes wereidentified and these will be explored in greater detail,using patient quotes as examples. Patients have beenidentified as to whether they were new or existingfollow-up (FU) patients, whether they attended thevirtual (GSMS) or consultant-led clinic, and by theirgender (M=male, F=female).

Figure 2 Interview topic guide.

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TrustThe theme that was at the core of most patients’ percep-tions regarding moving from a traditional doctor-ledservice to a ‘virtual clinic’ was their trust and confidencein the systems and processes of their care pathway.Existing patients who trusted their clinical care team

were more open to being moved into the GSMS:

They know when I should see a doctor. I feel if theythink I should see a doctor, they will tell me.—FU GSMS5, F

Not really concerned[if I do not see a doctor today] asmy condition is not currently serious. If I felt conditionwas deteriorating[I] would be more aware of who I wasseeing and would want to see someone correspondinglysenior. I wouldn’t be particularly concerned if I didn’tsee a doctor every time.—FU Consultant 2, F

Patients who were less informed regarding the natureand status of their condition or the care processes were

less trusting of the new clinic. Similarly, some patientsexpressed mistrust about the agenda behind the change.As themes began to emerge from the data it becameevident that trust was the key factor linking all otherthemes and subthemes. These will be discussed infurther detail below.

Prior informationPrior information played a key role in patients’ percep-tions of their eye care within the HES. This was furthersplit into subthemes which pertained to the administra-tive processes within the pathway and the clinical infor-mation they received regarding their condition. Thistheme encompasses communication, in many forms, ofinformation such as: why they were attending theservice, why they had been moved to the GSMS, the sta-bility of their clinical condition in terms of their risk ofsignificant visual loss and the need to see the doctor.As indicated in figure 1, all patients transferred to the

GSMS should have a patient information leaflet

Table 1 Demographics of patients interviewed

GSMS ‘newpatient’ (n=11)

Consultant clinic‘new patient’(n=10)

GSMS ‘follow-uppatient’ (n=11)

Consultant clinic‘follow-up patient’(n=11)

Average age (years) 63 63 66 72

Age range (years) 40–80 39–84 43–78 57–83

Male:female ratio 6:5 6:4 6:5 4:7

Ethnicity 10 Caucasian

1 African/

Afro-Caribbean

10 Caucasian 9 Caucasian

2 African/

Afro-Caribbean

9 Caucasian

2 African/

Afro-Caribbean

Number of patients where no

postappointment interview was

available

1 2 1 1

In total, there were five patients for whom postappointment interviews were not available, due to an inability to contact the patient followingtheir appointment. GSMS, Glaucoma Screening and Stable Monitoring Service.

Figure 3 Themes and

subthemes identified during the

coding process. HCP, healthcare

practitioner.

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describing the clinic. In addition, patients with existingglaucoma who had been transferred to the GSMS attheir previous appointment should have had the movediscussed with them at their previous visit.Patients who were well informed tended to be more

accepting of the service they received:

I received a letter explaining that I would have tests doneby a technician and that the results would come to myGP in about 2–3 weeks. The technician in the clinic hasalso explained this when she greeted me…I am happywith the information…[I] just expect to see the techni-cian.—New GSMS 1, F

My optician noticed pressure behind the eye and gaveme a letter. I then took the letter to my doctor. I was[sent] a booklet containing directions to the hospital/clinic and information on what to bring and a letter con-firming who my appointment is with. All of the informa-tion was very useful. I expect to see a doctor today but[the letter said] it could be someone else.—NewConsultant 2, M

However, it was clear that some patients did not get asmuch information or received confusing information:

There was nothing in the letter about where to go. Iasked at the general reception when I arrived and theysent me to clinic 2. When I got there, they didn’t think Ishould be there and sent me to clinic 3. They[clinic 2]didn’t think I should be there so I was sent back to clinic2 and then I was sent over here…I’m not anxious aboutmy appointment so it hasn’t been a problem for me butif I had been worried about it, I think it would have beenunnerving…—New Consultant 3, M

[I am] a little disappointed[about not seeing a doctortoday] as I didn’t receive a letter explaining the[virtual]clinic. On arrival, the technician-service was explainedwell but there is still some disappointment.—New GSMS6, M

In cases where patients had not received prior infor-mation regarding the nature of the GSMS, screening‘failure’ added to their anxiety:

I am not happy not seeing a doctor[at the virtual clinicvisit];[I] have a follow-up appointment in Novemberwhich is too long to wait!—New GSMS 6, M

This is despite the fact that the reviewing consultantwould have chosen an appropriate follow-up intervalbased on the results of the screening tests.Prior clinical information pertaining to the reasons

for their referral into the clinic also played a significantpart in patient experiences. The previous experiences ofophthalmic care, and communication from the care pro-vider, coloured their expectations of the service theywould be receiving:

The optician had reported seeing nerve damage and Ihave a family history of glaucoma.[I am] not concerned[if I do not see a doctor] as long as tests are thoroughand promptly evaluated.[I] want to be sure that it is notleft too long if treatment is needed.[I] would like adoctor to explain what the optician said as optician madereferral but just talked about seeing ‘ nerve damage’, and[I] have had no explanation of possible course of condi-tion or cause.—New GSMS 4, F

In cases where ambiguous clinical information regard-ing the reasons for referral were given, the lack of doctorcontact and screening failure also led to greater anxiety:

[The letter had] no information, no outcome, no explan-ation. Just a letter saying I ‘would benefit from a reviewin one of our consultant led clinics’. The appointmentfor this is in 3 months! I am worried in case I need treat-ment and am having to wait this long for it to start. Ihave a family history of glaucoma so am anxious aboutthis and would like to know what they found / what theresults of my tests were.—New GSMS 4, F

Existing patients booked into the GSMS are stablepatients at low risk of progressing to significant visual loss.It might be expected that this would in itself allay patients’concerns about the stability of their condition; however,there were some patients who expressed an anxiety at notseeing a doctor on the day of their GSMS visit:

Would be concerned[if I did not see a doctor] becauseof the nature of why I’m here.[It is] comforting to seethe top person especially for pressure check.—FUConsultant 3, F

I definitely want to see a doctor. That is why you come toa hospital, you come because you have a serious condi-tion.—FU Consultant 5, F.

EngagementAnother major theme that emerged from the data con-cerned the level of engagement patients had with theircondition and their care. This theme linked closely with‘prior information’ since those who were more engagedtended actively to seek out more information, both inde-pendently and through the hospital. Some patientstrusted that their care team had the professional expert-ise to decide what was in their best interests, and as suchdid not wish or feel the need to question the care deci-sions made. Others appeared not to be informed as towhy they were attending for their follow-up appointmentor the nature of their condition, but were happy to ‘takea back seat’ in the process.

All new to me so am just doing as I’m told and have noexpectations. Happy to leave it to the staff here to decidewho I need to see.—New Consultant 1, F

Other patients valued the consultation and wished tobe jointly engaged in discussions of the care decisionsmade:

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[I] didn’t have much explanation of the results.[I] wouldhave preferred to have more information.[I] would likemore information of test results at the next appointment.—FU Consultant 6, F

I saw the consultant and felt that I was in the best handspossible. We both came to a decision on my diagnosisand the treatment.—New Consultant 3, M.

Patient/healthcare practitioner interactionThis theme revolved around the patient/practitionerrelationship and how patients valued the rapport thatexisted within the traditional doctor/patient consult-ation. Patients viewed the consultation aspect of the visitas a chance to receive ‘reassurance’ regarding their con-dition and progress. Those who did not have time totalk to the doctor, or who were unable to build arapport with the staff they saw at their appointment,were not satisfied with the care they received:

[I had] only a very short time with the consultant. I wasdisappointed because he hadn’t read the notes: he askedabout the drops (I am not on drops), and didn’t tell mewhat the pressure was—I had to ask. He said I wouldhave to see just the nurses next time…but I am worriedabout that.—FU Consultant 8, F

Those who were moved to the virtual clinic wereunsure of the roles and responsibilities of the techni-cian, which led to a degree of uncertainty as to whatthey could or could not ask about their condition:

I did feel safe. My pressure was a bit higher but I wasn’tsure about quizzing the technician. He was good thoughand looked back through the notes to reassure me this hadhappened before. He also explained that I would be calledback if the doctor looking at the results was worried…it wasok…Maybe the technicians could invite the patient to askquestions. Perhaps a bit more interaction with the techni-cians[could be an improvement].—FU GSMS 2, F

I don’t know what a ‘technician’ is or does, in terms of[their] qualifications[and their] authority. I would haveliked information beforehand on what a technician is,because sometimes it can be a derogatory term—‘only atechnician’.—FU GSMS 1, M

The experience in the virtual clinic was very staffdependent, with some technicians clearly outperformingothers in terms of the service they gave:

The staff were very, very professional…They explainedeverything and told me I wouldn’t see a consultant…Theway they were working made me feel safe.—FU GSMS 5, F

There was an explanation of a kind but perhaps it is diffi-cult to explain a technical procedure to a non-technicalperson.[My] only reservation was that there was a slightlanguage barrier as the English was not[the technician’s]first language, so[the interaction was] not quite idiom-atic.—New GSMS 11, M.

Clinical assessment processThere were views on the clinical assessment process thatcovered aspects of waiting times and efficiency, as well asthe terminology used and the move towards moretechnological advances in the assessment process.Overall, patients expected long waiting and journey

times:

Usually takes a long time, there is a long wait at the fieldstest. Then I see a doctor, it usually takes a long time.Sometimes I have to wait for an hour to see the doctorafter the fields test.[This time] there was too long a wait:I was there for 2 hours. And then I only had a very shorttime with the consultant.—FU Consultant 8, F

I had to wait for quite some time[before I was seen]. Ifound it hard to find my way through the hospital. I hadseveral tests and had to wait a long time to be seen ini-tially. My visit lasted over 3 hours…The waiting times aretoo long…It is particularly hard if you are visiting alone.—New Consultant 1, F

Patients moved to the GSMS made positive commentson the organisation of the clinic:

I was happy with more tests being done at this appoint-ment compared with previous appointments with thedoctor.[I] felt like my eyes were tested thoroughly as aresult of this.—FU GSMS 4, M

[There was] nothing that didn’t work well…I was seen ontime…I was told what each[test] was for before they didit.[It was] all laid out like an assembly line, straight fromone[machine] to the other. Very efficient…It was verythorough, I didn’t realise how thorough it would be, itwas very reassuring…Good to know there is a part of theNHS which can look after you like that.—New GSMS 3, M

However, some patients expressed an anxiety as towhether their performance would affect test results,which in turn might affect the clinical decisions madeby the care team:

I felt the visual fields test wasn’t accurate. They ran toomany tests too quickly and didn’t give my eyes enoughtime to adjust. The tests weren’t explained thoroughlybut I was told there was no major worry.—FU Consultant11, M

When I had the peripheral vision test, I wasn’t asked aquestion about my general wellbeing on the day. Generalwellbeing questions are needed before being tested[asthey may affect results].—New Consultant 3, M

Some patients also commented on the modernisationof the hospital, in particular the use of moretechnology:

[There] was a bit of a concern about not seeing a consult-ant. …I have reservations, there is the comfort factor,there is more chance of an error like this…I am

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concerned that the test results won’t reach the consultantand that now more records could be lost.—FU GSMS 3, F.

Reason for changePatients were diverse in their opinions on the changes toservice delivery, with some understanding the need forimprovement and appreciating the efficiency of thevirtual clinic, with others concerned about the agendabehind the change:

[I am] not happy with[commercial coffee shop], far tooexpensive…Hospitals shouldn’t be depending on com-mercial money, they should get more governmentfunding. I feel it is important to maintain high standardsof qualified expertise and care in the NHS and this maybe under threat from new initiatives.—FU Consultant 5, F

I would like to know why the change has been made…isit to save money?—FU GSMS 3, F

Technology coming along can be more efficient than‘human frailties’…I am all in favour of improvementsand efficiency, I move with the times.[But] I wouldprefer to see a doctor…I am a doctor myself[and have]worked in the health service for 40 years. I don’t liketaking the doctor out of the appointment process.—FUGSMS 6, M.

DISCUSSIONThe findings of this qualitative interview-based studysuggest that patient acceptance of new pathways fortheir glaucoma care centred around trust, which was pri-marily built through communication between the careprovider and the patient. That said, it was evident thatsome patients implicitly trusted the care teams’ decisionsbased on the reputation of the hospital and the per-ceived professional expertise that they received.New patients attending the service had no preconcep-

tions regarding the care pathway, and so their percep-tions were very much coloured by the prior informationreceived, either from the hospital or their referring prac-titioner. Some new patients seen in the virtual clinicexpressed an anxiety at not seeing a doctor on the dayas they had the perception that their condition wasserious, based on the information received by theirreferring practitioner. Some patients with existing glau-coma felt similar levels of anxiety at removing the doctorfrom the consultation and moving to a virtual clinicpathway, despite the service only being suitable forstable, low-risk patients.Glaucoma comprises a wide spectrum of disease

ranging from very early disease with low risk of progres-sion to significant sight loss, to those at a more advancedstage with a high risk of progressing to advanced visualloss. It has been shown that those presenting to the UKHES with early disease are at a low risk of progressing toblindness.18 Only those patients judged to be at the lowrisk end of the spectrum would be suitable for thevirtual service. Our study revealed that some patients

were better informed than others regarding their risk ofprogression to blindness, and it may be that this lack ofknowledge about disease status and risk is due to failingsin doctor/patient communication. In their qualitativestudy evaluating patient perceptions of the visual fieldtest, Glen et al15 also discuss how effective doctor/patient communication could influence patientresponses to follow-up care. Indeed, in our study, thosepatients who were well informed about their own diseasestatus were very comfortable with the move away fromthe face-to-face consultation, particularly if it resulted ingreater efficiency and less waiting/journey times at theirappointment.It was clear that some patients did not receive suffi-

cient prior information regarding the change to theircare pathway, which led to anxiety on arrival at thevirtual clinic. It is unclear as to whether patients did notreceive or did not read the information sent to them;however, for some there were failings in the administra-tive processes. Informed patients knew what to expectand were more relaxed as a result. Those who did nothave information were much more concerned about thecare they would receive and whether it would be to thesame standard as that of previous consultant-led visits.Since completing this study, we have developed a patienteducation video, available on the hospital website, towhich patients booked into the service are directed, aswell as reiterating to all administrative staff the import-ance of providing patient information leaflets. We havealso emphasised to clinicians working in outpatientclinics the importance of face-to-face communicationduring the doctor/patient consultation regarding a pro-posed move to the stable clinic. It is likely that this lattermethod of communicating change will be the mosteffective at instilling patient trust and alleviating anypatient anxiety with respect to moving from the trad-itional doctor-led delivery of care.Reports by the Picker Institute have shown that

patients wish to be involved in decisions about theircare,19 and it has been shown that patients with chronicdisease who are more informed about their conditionand care needs have better health outcomes.20 For somepatients, the reputation of the hospital and the previousexperience of care within the hospital both contributedto a sense of trust that the decisions made would be inthe patient’s best interest. For others, the perceived pro-fessional expertise of the care providers was enough forthem to trust that they would be in a better position todecide what was best for the patient. However, patientswho wished to be actively involved in care decisions andwho felt that they were not given the opportunity todiscuss things with the doctor were less trusting of thecare they received at their appointment. Patients are allunique and while there are some who value in-depth dis-cussions regarding how to best manage their condition,for some, too much information can be overwhelming.21

While the majority of patients had very positive viewsabout the GSMS, some patients missed aspects of the

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doctor/patient consultation, with some being unsure ofthe boundaries of the technician/patient relationship.Rapport between the doctor and patient positivelyimpacts on patient satisfaction and patient outcomes.22 23

In this study, patients who were able to build up arapport with their healthcare professional felt reassuredand, consequently, satisfied with the care they received,even though they did not receive information on theirdisease status at their appointment. It is important toremember that technicians delivering the GSMS are notthere to replace the doctor, and thus cannot commenton the stability or otherwise of the patient’s condition.However, those technicians who were able to effectivelycommunicate with the patient, in terms of what wasexpected of them and what they should expect tohappen, who showed empathy with the patient, as wellas showing skill and competence with testing, inspiredconfidence and trust which contributed to a positivepatient experience. Thus, while the technicians will nothave the same relationship with the patient as thedoctor has had, the way they interact with the patientcan still provide the reassurance that the patient needsfrom the appointment.As with others’ findings,15 some patients made com-

ments with respect to the visual field (VF) test and its‘accuracy’ at detecting change. The variability and valid-ity of the VF test and the influence of patient perform-ance is widely known among glaucoma specialists24–26;thus, results are always interpreted with caution.However, this needs to be communicated to the patient,so that they are reassured that clinicians are fully awareof the impact of patient performance on test results andhow this is taken into account particularly when manage-ment decisions are made remotely.Another aspect that raised concern for some patients

was what was seen as an over-reliance on technologywhich was associated with a greater chance of ‘lost data’.Previous studies have suggested that older persons viewtechnology in healthcare with more suspicion, in partdue to their lack of familiarity with technology.27 Thissuggests that there needs to be better communicationregarding how technology can make healthcare provi-sion more efficient, particularly when moving patients tovirtual services, in order to increase patient acceptanceof these models of service delivery.The agenda behind the change in service delivery was

of some concern to a small number of patients. Ratherthan being seen as a way to deliver services more effi-ciently, there were concerns that it was a cost-cuttingexercise and would result in reducing the quality of carewithin the NHS. One patient in particular was verydefensive about the NHS and viewed any proposedchanges with great suspicion. This view may be in partdue to the political climate at the time the study wasconducted: the study was performed in a UK electionyear, and thus there was much media coverage regardingthe future of the NHS under different governmentadministrations. However, it also reflects a deeper aspect

of how change, as well as the need for change, in servicedelivery is communicated to patients.Limitations to the study include the predominantly

Caucasian sample which was drawn from patients attend-ing a specialist tertiary referral centre; thus, it is notclear how well the findings may translate to otherdepartments. Furthermore, as postappointment inter-views took place approximately 1 month followingattendance, there is a possibility that some aspects of theappointment were not recalled and thus not captured bythe researchers. Further work is required to assess theacceptability of new models of service delivery in differ-ent patient populations.In conclusion, this study suggests that patients are, on

the whole, accepting of moving to a model of servicedelivery whereby the doctor is removed from the con-sultation as long as they are informed about the status oftheir condition and their risk of progression to severesight loss, and they are reassured by the method of datacollection and the interaction with personnel they see attheir appointment. Nonetheless, this study highlightsthe importance of good communication as a way ofbuilding trust between the provider and patient, so thatthey perceive full transparency in how changes willimpact on their care without compromise to quality.

Contributors AK was involved in study design, participant recruitment,thematic coding and manuscript preparation. KB was involved in studydesign, participant interview and manuscript critique. RC, JCa and JCl wereinvolved in participant interview, thematic coding and manuscript critique. PFwas involved in study design and manuscript critique.

Funding This study was supported by the Department of Health NIHRBiomedical Research Centre for Ophthalmology at Moorfields Eye HospitalNHS Foundation Trust and UCL Institute of Ophthalmology.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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