As a senior paediatric trainee (ST8) in a busy district general hospital I am used to doing regular paediatric outpatient clinics. As the covid-19 pandemic took hold in the UK, the NHS had to rapidly adapt and change to meet the rising demand of cases. Many trusts have had to cancel outpatient work, but we were able to continue running our general paediatric follow up clinics virtually by using telephone consultations. The covid-19 pandemic has brought challenges, but also opportunities for new ways of working, and I wonder now if we should ever go back to the way things were?

During this pandemic, changing to telephone consultations allows us to continue to provide continuity of care for our patients while avoiding face to face contact and minimising the risk of spreading covid-19. Telephone consultations have been, in my experience, shorter than standard clinic appointments and there are time savings outside the consultation (for example, time spent parting unwilling toddlers from the toys in the waiting room). Ongoing provision of outpatient appointments may benefit by reducing emergency department attendance, allowing more capacity of the surge of covid-19 patients. Many parents are understandably anxious about coming to the hospital at this time, and telephone consultations may reduce the number of missed appointments. Parking is limited and many patients arrive late to clinic as a result. Moving to telephone consultations removes this problem and also reduces travel time and costs for families. [1] This may also have a beneficial impact on the carbon footprint by removing pollution from travel.

However, there have also been a number of challenges. Usually paediatric patients have their height and weight measured at every clinic appointment. While for many patients this is not essential, there are a subset of patients for whom having a weight and/or height is necessary for their ongoing management (for example, babies who are not gaining weight, or chronic diseases associated with malnutrition, such as cystic fibrosis). Some parents have recent measurements documented from other health encounters, and others have weighed the child on scales in the house, but for a small number of patients a visit to a healthcare professional for this is necessary. 

Lack of ability to examine the patient is another limitation of telephone consultations but in many chronic conditions this is not as important in follow up consultations. [2] Patients requiring prescriptions also need to attend their GP or the hospital pharmacy to collect them; these account for a small proportion of our patients. A small number of patients will need blood pressure monitoring, blood or urine sample monitoring which will require a visit to a healthcare provider.

Communication over the phone is more challenging with a lack of visual cues being the main limitation. [1,2] While it is possible to speak to the parents and older children over the phone, communication with younger (verbal) children, who I would usually speak to directly, is more difficult over the phone. Video consultations may overcome some of these difficulties by being more engaging for younger children and would enable non-verbal cues to be recognised. [2,3] It would also allow for visualisation of some clinical signs. As a paediatric trainee I have had communication skills training, but no specific telephone consultation skills training. This is not uncommon; a recent Cochrane Review highlights the paradox between the widespread use of telephone consultations and the lack of training for this. [1,2,4,5]

Some useful tips that we have discovered for running successful paediatric telephone clinics include:

1. The call/contact is prearranged with the patient and families by sending usual appointment letters.
2. Good communication skills are essential, including active listening, summarising regularly and offering opportunities to ask questions, as well as providing patient education. [1]
3. Appropriate outcomes are recorded for further management and follow up arranged. 
4. A written clinic letter should be sent to the GP and copied to the families summarising the discussion and management plan. 
5. There should be an attempt to phone all patients three times during clinic time. If they are uncontactable, they are classified as “did not attend” and appropriate follow up should be re-arranged with a letter sent to the GP and patient explaining this.
6. Where there are difficulties in communication (e.g. language barrier or poor phone signal) or the patient needs examination or further tests, a face to face review should be arranged. 

In the future, there is a role for telephone consultations to follow up certain paediatric conditions, and with appropriate training and infrastructure (including the introduction of video consultations) this could save clinician and family time and costs. It will be essential to implement appropriate training for doctors in doing telephone consultations and research into effective training is needed. [4] While my experience is that families seem to find telephone consultations acceptable during the coronavirus pandemic, it will be important to check their satisfaction with this when life returns to normal.  

Elly Thomason is an ST8 paediatric trainee in the North West. 

Satish Hulikere is a paediatric consultant and clinical director of paediatrics at Warrington and Halton Teaching Hospitals NHS Foundation Trust. @SatishHulikere

Competing interests: None declared. 

References:

1. Car J, Sheikh A. Telephone consultations. BMJ 2003;326:966-969.
2. van Galen LS, Car J. Telephone consultations. BMJ 2018;360:k1047.
3. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ 2020;368:m998. 
4. Vaona A, Pappas Y, Grewal RS, Ajaz M, Majeed A, Car J. Training interventions for improving telephone consultations in clinicians (Review). Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD010034.
5. Chaudhry U, Ibison J, Harris T, Rafi I, Johnston M, Fawns T. Experiences of GP trainees in undertaking telephone consultations: a mixed-methods study. BJGP Open 2020; bjgpopen20X101008.