Getting Our Feet Back On Dry Land
In her shortlisted essay for the 2021 John Henahan Prize 2021, Dr Suzannah Bell says COVID-19 will change healthcare delivery and ophthalmologists have a say in how it will change
At the beginning of the COVID-19 pandemic my sixty-eight-year-old father was on a boat near a remote island in the Caribbean. As the virus spread across the globe, travel restrictions were rapidly implemented, preventing his journey home. As a result, he spent the next three and a half months alone at sea.
Many of us have felt a bit ‘lost-at-sea’ during the pandemic – isolated and unclear as to what the journey ahead might hold. Like many, my dad had to change the way he communicated with his loved ones, quickly developing new ‘tech’ skills to keep in contact with us. He got Facebook for the first time ever and joined organised Zooms with our family and friends. It was amazing to see his face on the screen so regularly despite physically being so far away.
User uptake of online communication platforms such as Zoom or Microsoft Teams have increased dramatically since the start of the pandemic. Restrictions have also forced health services to change how they deliver care in the short term through implementation or expansion of existing remote care or “telemedicine” in an attempt to minimise disruption. I helped conduct a study at Moorfields Eye Hospital on the use and acceptability of remote consultations in families with rare genetic eye diseases before and during the pandemic. Preferences for mode of contact changed during this period from telephone to video call, most likely due to increased familiarity with these platforms.
Telemedicine is not a new concept and is already used sporadically in ophthalmology, particularly in eye screening. However, it has the potential to address the biggest issues currently facing global eye health. The recently published Lancet Global health commission on Global Eye Health reports that developments in telemedicine and distance learning could potentially enable eye specialists to delivery high quality care that is more plentiful, equitable and cost-effective. This applies both between and within high- and low-income settings. For example, cross-border initiatives such as Cybersight allow countries with a shortage of skilled eye specialists to communicate with specialists from other countries, share information and advice on cases.
A lack of human resources and geographic isolation are two major barriers to equitable eye care in low resource settings. Patients may have to travel long distances and incur enormous costs to access eyecare. Telemedicine helps eye health providers reach those most affected by poor vision and do more with less. For example, mobile phones are ubiquitous even in areas without access to basic eye care. Technologies such as PEEK (Portable Eye Examination Kit) have taken advantage of this in dozens of low- and middle-income settings to increase access to eye screening in schools. In Rwanda, telemedicine is already being used to improve access to diabetic screening, where it enables more screening with fewer personnel, delivers quicker results and creates integrated pathways for patients with diabetes.
In high resource settings, telemedicine also has the potential to increase access to eye care. Capacity building in health systems is required to meet the needs of an expanding and ageing population. Wider use of telemedicine could help improve access to visually impaired patients who may attend multiple appointments a year. Often, these patients find travelling more difficult. Telemedicine offers the possibility of carrying out more of these patients’ care in their own homes. In our UK study, half of families with rare genetic eye diseases reported that remote consultations increased their access to care.
However, telemedicine also has the potential to increase health inequities. Certain at-risk groups (e.g. older/homeless people) have less access to the internet or internet-enabled devices. Health services need to be aware of this prior to implementation of telemedicine services and tailor remote contact to their local population needs by asking service users about their access and preferred mode of contact. In our study, although families found remote contact acceptable (either by telephone or video), the majority preferred to be seen face-to face at some point during their care.
COVID-19 will change healthcare delivery and we have a say in how it will change. We have a great opportunity to make eye care more accessible and equitable at every population level. Pandemic restrictions have forced us to adapt temporarily but now we must look forward to making sustainable long-term change, ensuring that nobody is left behind. When my dad finally got his feet back on dry land, as an able-bodied man living in a high-income setting, he once again benefited from good access to healthcare. As we hopefully come to the end of this long and unpredictable voyage, we must move consciously into a new way of working with a global mindset to widen healthcare access and get all of our feet firmly back on dry land together.