Technology has been increasingly integrated into diabetes education and care in modern times, for example, through apps, computer-based or web-based education, and telemedicine [14]. The NHS (National Health Service) long-term plan set out to increase digitalization within NHS programs [15,16]. This included roll-out of virtual or non–face-to-face clinics, with the aim of reducing face-to-face appointments by one third over the next 5 years [16]. This non–face-to-face activity may be synchronous or asynchronous, meaning a direct or indirect line of communication with an HCP, respectively [17,18]. Synchronous activity would be a video or telephone consultation, whereas asynchronous may involve monitoring an email or tracking system and responding to patients’ questions through these platforms. The benefits of non–face-to-face appointments are multifactorial and include the opportunity for better care and more connected patient care pathways, as well as cost savings and a reduced environmental impact.

Studies evaluating virtual clinics prior to the COVID-19 pandemic have demonstrated feasibility, accessibility, safety, and effectiveness comparable to in-person consultations [19]. A multicenter mixed methods study evaluating video consultations in diabetes care showed that video consultations were shorter in duration and people with diabetes did relatively more talking than the HCP [20,21]. Although from a management perspective, video consultations were favored, there were significant barriers to uptake from the teams implementing them because of the significant changes introduced to their usual way of working and the care processes, systems, and pathways [21]. A Cochrane review analyzed 21 low-to-high-quality studies comparing telemedicine to usual care in people with diabetes and found that improvement in glycemic control was variable, but low-density lipoprotein (LDL) levels and blood pressure were more effectively lowered by telemedicine approaches compared to usual care [22]. Further studies have evaluated virtual clinics for diabetes care in type 1 and type 2 diabetes and have reported improved biochemical parameters, including glycated hemoglobin (HbA_1c) [23]. However, many of these studies combined interventions, such as synchronous and asynchronous programs, rendering it difficult to delineate the efficacy of the individual interventions [23]. Studies focusing on synchronous video consultations have been of short duration with a limited sample size [24]. Additionally, how these findings relate to virtual clinics being implemented during and due to a global pandemic must be considered.

During the COVID-19 pandemic, telemedicine has been widely adopted globally in order to reduce exposure and need for people with diabetes to come into a hospital, while maintaining care standards for people with chronic conditions. For example, virtual consultations have been implemented to triage patients suspected of COVID-19 in primary care and to initiate a hospital visit [25-27]. There have been other examples of successful virtual care adoption for people with newly diagnosed type 1 diabetes [28], and for people with long-standing type 1 diabetes. A small Italian study showed that for people with type 1 diabetes who were not working during the pandemic and using continuous glucose monitoring, their time in range significantly improved from 54% to 65%, and this was attributed to decreased hyperglycemia [11]. Blood glucose variability and average glucose readings from continuous glucose monitoring also significantly improved in this study. In contrast to patients who continued working, there was no difference in glycemic control [11]. Early reports suggest that virtual clinics are feasible, with some centers increasing virtual clinic consultations from 1% of all consultations prior to COVID-19 to 70% afterwards, and it is technology that has made this rapid transformation possible [29-31].

A recent linguistic ethnographic study has shown that video consultations among people with a long-term condition and their clinician was found to be effective [26]. When patients experienced technical or operational issues with their video equipment or internet connection, they generally found a solution to resolve the problem. Familiarity and experience with technology helped in situations like these. Technical interruptions and delays of connectivity either on patient or clinician device were clearly evident in the study; nevertheless, remote physical examinations were conducted, allowing the patient and/or carer to take an active role in the consultation [26].

Elements of the routine diabetes clinic (eg, checking blood pressure, sampling the urine, HbA_1c, spot checks, and physical examination) are not possible in the same way in a virtual consultation. However, given the importance of these methods to screen for diabetes complications, alternative strategies can be developed to make them possible. For example, people with diabetes can have their own blood pressure monitor. This may lead to more accurate readings, with the absence of white coat hypertension. Also, urine samples can be delivered locally to general practices and examination can still be performed via video consultation. For example, diabetes foot disease can be screened for and people with diabetes can be triaged to determine need for further assessment.

Anecdotally, in our experience virtual clinics have been feasible and accessible, with high patient satisfaction. Virtual clinical consultations offer a different kind of benefit compared to conventional face-to-face appointments, particularly around convenience, logistics, cost-effectiveness, and clinician-patient dynamic/relationship [26]. However, we must acknowledge the pitfalls of these new modes of communication and the challenges that may lie ahead with the clinical quality and safety of appointments.

Building on these developments, we are looking to make virtual clinics sustainable for the long term. This is in line with the NHS long-term plan to make better use of data and digital technology in the next 5 years [15,16]. In a time of a pandemic, individualized care is more important than ever and virtual clinics provide a readily accessible solution to facilitate this. Having applied virtual clinics in our setting for the last 2 months, lessons we have learned include: (a) the importance of integrating multiple members of the MDT into the one virtual consultation; (b) avoiding the checklist approach and instead focusing on an individualized, person-centered consultation; (c) and acknowledging that video consultation may be preferred to telephone because of the additional benefits of human contact, body language, and the opportunity to gain better insight into the lifestyle and livelihood of people with diabetes in order to tailor medical support accordingly. In our experience, virtual clinics may be better suited to individuals with longstanding diabetes and where possible should be performed by a professional with whom they have already built a strong rapport.

Although virtual clinics can be an alternative option, there are key elements that must be considered to make the consultation as efficient as possible. Firstly, even though virtual consultations would require less resources compared to a face-to-face visit, organizational factors prior to the virtual consultation would still be required in order to book and record a clinic appointment. Secondly, logistical and administrative factors must be integrated within the NHS system, a system which for so many years has been based on delivering face-to-face patient services. We are programmed to deliver our outpatient services in a “traditional” way, and therefore would anticipate a colossal challenge adapting this existing pathway to a more digital-focused platform.

By acknowledging the complexity of integrating virtual consultations, we also acknowledge the challenges that may come with technology, in terms of the security and safety of every patient and HCP. Data protection and privacy is of critical importance; the technology, software, and programs used in virtual clinics must be encrypted and adhere to the General Data Protection Regulation and information governance standards to maintain patient confidentiality at all times. We acknowledge that virtual consultations are not for everyone; however, providing options to people enables them to choose an approach that is tailored to their diabetes needs and lifestyle demands, with the aim of reducing the burden of treatment that so many people with diabetes may be experiencing. We aim to not only prepare our patients to attend virtual consultations, by creating a safe environment and respecting their safety (Figure 3), but to also create a digital platform that would integrate within the current NHS system.