Reaching the potential of telemedicine

The shift towards telemedicine is widely seen as inevitable (Royal College of Surgeons, 2018), particularly given the changes necessitated and implemented during the COVID-19 pandemic (Clement et al., 2021). Feedback from patients on using a virtual clinic approach has been positive from many: it reduces time required for travelling and waiting for appointments, streamlines the process, and has allowed continued health provision despite the challenges of COVID-19. It also makes attendance easier for patients living in rural areas or for those with limited access to transportation (NHS England, 2019). The reduced requirement for travel is particularly beneficial for patients with continence issues, and so the option of virtual attendance should be made available in the long term. Communication via email or text messages could also offer options for appointments in satellite locations to improve accessibility for in-person consultations.

The sometimes-embarrassing nature of pelvic floor conditions does not seem to have hindered virtual appointments. In fact, a reduction in non-attendance has been observed in some centres compared with face-to-face visits. Online availability of information may encourage patients to present earlier or even to undertake self-management, both of which could lead to better outcomes with conservative treatments and a reduction in patients requiring surgery. Further, adequate adherence to conservative measures available in primary care is important to ensure these are truly exhausted by the time a patient reaches secondary care; patients may now be more likely to comply with these treatments, such as pelvic floor exercises.

Technology can provide further support to increase efficiencies, for example in obtaining an accurate patient history prior to consultations. Online questionnaires make it possible for patients to answer questions prior to their appointments, saving time during the consultation itself – and in the case of face-to-face consultations, minimising contact time, a desirable outcome in the face of a pandemic.

Patient consultations are not the only elements of care that can benefit from technology. Multidisciplinary team (MDT) meetings can also be conducted virtually, reducing the time commitment for participants and allowing people to join when they are unable to travel or located in different hospitals. Technology can be a key enabler for MDT working. Acceptance of virtual meetings has greatly increased since COVID-19 made this the norm, breaking down reluctance. In fact, in our experience, attendance at virtual MDTs has been improved over previous in-person meetings.

While virtual consultations are a valuable option, they are not suitable for everyone and risk excluding some members of society, for example, through digital exclusion and those with communication difficulties – telemedicine cannot be a one-size-fits-all solution (Clement et al., 2021). It is important that any changes in approach do not exacerbate existing health inequalities (NHS England, 2019). As the first wave of COVID-19 lifted, some patients were quick to request face-to-face consultations again. Further, there are situations where face-to-face appointments are necessary. Examination and assessment are limited in a virtual consultation, and nonverbal cues can be harder to pick up. Communication with patients who require translation services may also be more challenging. Performing a physical examination is essential for pelvic organ prolapse even if further diagnostic tests are planned. However, in some instances (for example, rectal prolapse), the greater adoption of digital self-photography and sharing thereof has reduced the problem of trying to reproduce a prolapse in clinic at the time of examination – though challenges relating to secure electronic sharing of potentially sensitive images must be considered, particularly when treating children.

Where virtual consultations are carried out, it is important to adhere rigorously to recognised treatment algorithms: clinicians will need to resist the temptation to over-investigate to compensate for not seeing their patients in person. As virtual consultations become a more frequent part of medical care, it will be important to incorporate these aspects into training (Clement et al., 2021): trainees should be involved in virtual consultations, to help them to appreciate the nuances of this type of review.

Empowering patients to own their care

Patient empowerment is particularly important post COVID-19, reducing the number of unnecessary outpatient appointments but maintaining the patient’s ability to come into the hospital or clinic when needed, as well as enabling patient-initiated follow-up. Providing information and support online can help to achieve these goals, with better-informed patients better able to undertake self-management.

Some centres are going one step further and providing mobile applications, which offer the added benefit of outcomes data collection – particularly valuable for pelvic floor care, where data are few and far between. These data can then be fed back into services to make further improvements, supporting the global movement towards personalised medicine (Royal College of Surgeons, 2018). Such technology may also empower seldom-heard patient groups to have their voices heard more.

Cost can be a barrier to implementation, particularly with new technology. Partnerships with industry, as seen in Cardiff with the ‘Living with…’ platform, can provide a short-term opportunity to introduce digital innovations, but it is also important to consider the savings and improvements that can be made in the long term. Continence will need to be considered more within spending priorities – this under-recognised patient group deserves, and needs, more investment.

Breaking barriers to learning with remote education

As part of patient empowerment, it is important to ensure patients are informed. Webinars and online courses can be useful, though care needs to be taken to ensure that content is evidence-led, relevant and pitched at the right level. Webinars can be hosted on social media or on mobile applications as well as on purpose-built websites to improve visibility. Whatever the platform, signposts to charities, patient information websites and online support groups (whether UK-based or international; see Appendix) are important to include, as patients often struggle to find resources online. Use of patient-appropriate language and search engine optimisation skills may improve accessibility. A nationally supported continence promotion app, which aims to address this need, is in development and will be included in the NHS apps library.

Finally, technology can also help to improve education among HCPs. Owing to the necessity of online training during COVID-19, health professionals are now more widely accepting of this approach. An example is a certified e-learning programme for catheter training successfully rolled out in Wales. In addition, midwives have access to a peri-partum pelvic floor exercises e-module on the RCM i-learn platform, the result of a collaboration between the Chartered Society of Physiotherapy and the RCM, which was written and updated in 2020 by POGP. This approach provides an opportunity to engage more with HCPs’ education on the pelvic floor and to reach greater numbers, ultimately improving outcomes for patients.