Dr Rakesh Modi is a GP and Primary Care Unit researcher on the landmark NIHR-funded SAFER trial investigating screening to detect an undiagnosed heart condition responsible for one in ten strokes. Here he writes on how the study has launched an additional feasibility study to test the ability to deliver their intervention remotely following the COVID-19 pandemic.
I’m doing one of my first consultations as a GP using remote technology and this is the long silence between myself and my patient.
It is the point at which I want to put my hand on that of my patient. I have to tell her that her symptoms might be cancer. I need to refer her urgently. I can see her face and she can see mine but we can’t bridge the distance.
“Thank you. Thank you.”
Another early consultation. This time it’s with a patient dealing with severe anxiety and caring for her mother who is shielding during the pandemic. I tell her that her medical certificate can be sent quickly by email. Primary care has managed to reach its arms out to someone who would have been left helpless without the new remote systems.
The good and the bad, we weather it all, as we adapt to the new normal. But there is constantly a new normal – change is the real normal. Our biological evolution may have settled but one could argue that we thrive on social evolution. If it’s not pressure exerted from the world, it’s the pressures we exert on it – cars, the internet, smart phones – they have all moulded the phenotype of our interactions, across health care and everywhere. What we don’t yet know is, when all the messy problems get thrown at the wall, what sticks?
As researchers, we too have to adapt to the new normal. Not as passive supplicants, but active questioners, investigating our new state of being and then aiming for its betterment.
Pragmatically, we have all needed to attend to a series of big questions:
Ethics: what does ‘routine care’ look like now, for our control groups?
Safety: how can we target the vulnerable but reduce risks of infections?
Relevance: What is the place of a face-to-face consultation in a culture looking for remote options?
The shape of the research landscape after these rains may be unrecognisable.
Adapting research during the pandemic
The NIHR-funded SAFER trial for which I am researching is moulding to these pressures. Originally, SAFER was a study where people aged 70 and over would be given a handheld device to check for a dangerous but common heart rhythm called atrial fibrillation (AF). Participants would have the screening process and subsequent results explained to them face-to-face by a member of their general practice.
Now, those ‘in person’ consults at the general practice seem unethical, unsafe and irrelevant, despite AF still being a real and present danger. SAFER now emerges in a new shape: all consultations explaining how to perform screening will be remotely performed by video consult or telephone. Simultaneously we will need to check if the device is giving good quality readings.
In the new feasibility study, one practice will arrange their staff to perform remote consultations for this purpose. In the other practices, the trial management team will perform this appointment either as a default, as an option or if the initial readings are of poor quality.
Practical issues will dominate: how to explain a device without physically being there, how to enable internet access for research participants who are all over 70, the mechanics of asking them to return equipment in the post. These questions may seem pedantic but they are likely to become typical challenges for healthcare researchers.
Redrawing the future landscape of healthcare
In addition, while all primary healthcare is moving away from ‘in person’ and towards ‘remote’ models, screening programmes are also sliding on another dimension, between delivery by general practices and delivery by a central management team.
The new version of SAFER will map out these two dimensions to help redraw the future landscape of healthcare. And what we still don’t know is, what sticks?
In 2021, we might have a better idea of the form in which healthcare, primary care and research will emerge. Screening will still be important but how will people feel about taking that risk, even if it’s just the anxiety of risk, of coming into the practice?
How will researchers introduce new care models and what dimensions will we study, against a background of a shifting relationship between patients and staff?
In 2021, the most promising model from the feasibility study of the SAFER trial will be tested in a pilot study. It will be perfect timing to examine how practices and patients adapt the screening programme to suit their new ways of life, and what this means for a national AF screening programme.
I personally think that remote working will leave its footprint on the health system as it can be highly efficient where resources are scarce – I can now conduct 50 consultations in the morning instead of my normal 25. Most people are adapting to it, although who are we leaving behind?
But what this means to us, society and health, after the rains, is the uncharted territory ripe for exploration.
Written by Dr Rakesh Modi, GP at Great Staughton Surgery and Wellcome Trust PhD Fellow, Primary Care Unit, University of Cambridge.
Dr Modi’s blog is also published by NIHR.
More information on the SAFER trial is available on the study’s website.
Queries: please contact Lucy Lloyd, Communications, Primary Care Unit.
Image: Among the Sierra Nevada, Albert Bierstadt, Smithsonian American Art Museum.