Virtual consultations, remote consultations, video-telemedicine: whatever you call it, it’s great. Use of digital consultations allows flexibility, reduced travel and healthcare costs, and the ability to offer something where nothing might be the only alternative. In the peak of a global pandemic, offering something is clearly better than nothing—the swift move to embrace digital consultations by the NHS during covid-19 was impressive, welcomed, and certainly needed. It’s hard to believe when you see the progress made in six months that we are the same NHS recently reminded not to purchase fax machines or pagers. [1] To continue to harness the benefits of digital would be ideal. But as lockdown has eased, are we really happy to settle for the screen rather than the real thing?
We could not disagree more with the idea that digital should be the default. [2] Rather it should be an option that is considered with young people and their families where it serves to enhance their experience of healthcare. Young people, who have already been disproportionately affected by the restrictions of lockdown, have said they don’t prefer video to face to face, but quite like telephone consultations, if they already have a trusting relationship with the team or their GP. [3] They are particularly uncertain about disclosing mental health concerns remotely. In primary care, there is concern about the considerable unmet needs of young people who have not consulted in the past few months. Are we really going to not listen to them on this? Where is the patient-centred care in that?
The RCPCH, RCGP, AYPH and the young people’s special interest group (YPHSIG) and the RCGP young people’s group have co-signed a joint statement outlining concerns for adopting a digital by default approach. [4] Highlighting four areas: access, confidentiality, quality of consultation and safeguarding as key risks, the statement explains the trade-off is not small and needs thoughtful consideration. What needs to be asked is what risk are we—collectively and individually—as healthcare providers and young people that use the service, willing to carry?
Clinicians are trained to read the room, not the zoom (apologies for the pun, and other video calling platforms are available). The biggest fear is missing something we would have gleaned from a face-to-face consultation. Not least that this approach runs a real risk of exacerbating the inequalities in access to healthcare services, and affecting our ability to really see and hear from young people in a confidential safe space. The risks to identify safeguarding needs or additional psychosocial and mental health concerns is self-explanatory.
It is a privilege to have space and privacy within a home environment to conduct a confidential discussion. Many young people don’t have space of their own. It is certainly not the same as those designed in a clinic setting. We owe our young people the ability to be heard in a way that suits them and also allows a full clinical assessment to take place, including an examination. This also means having suitable space for clinicians to conduct virtual appointments that reassures the young person that they are not being overheard on our side either.
As a minimum our communication around the parity of virtual consultation to a “real appointment” needs to be planned. Recently families have contacted us to check whether their son or daughter really needs to be present for a virtual appointment. It is not an unreasonable question given the flexibility of the appointment, but means that we are in danger of not hearing the young person’s story. It raises other issues, not just about whether we move to mainly digital, but what does a truly responsive and patient-centred health service really look like. Should we be thinking about where and when young people access their healthcare services?
There are times when the real thing, being able to sit face-to-face (or mask-to-mask) and talk through what matters most is actually what matters most. When that can’t happen the next best thing might be to move on screen, but let’s not move there without really acknowledging the choice we are making.
Emma Parish is a General Paediatric Consultant at Guy’s and St Thomas’ NHS Foundation Trust.
Marian Davis is a GP in Herefordshire.
Competing interests: Emma Parish is a general paediatrician and secretary for the Young Person’s Health Specialist Interest Group (YPHSIG). Marian Davis is Chair of the Adolescent Health Group at RCGP, and a member of the Advisory Council at AYPH.
The young people’s health special interest group (YPHSIG) and the Adolescent Health Group RCGP have co-signed a statement. We are both contributors to that statement.
References:
- Ives L. NHS still reliant on ‘archaic’ fax machines. BBC News. 13 July 2018. Available from https://www.bbc.co.uk/news/health-44805849
- Walker P. All GP consultations should be remote by default, says Matt Hancock. The Guardian. 30 July 2020. Available from https://www.theguardian.com/society/2020/jul/30/all-gp-consultations-should-be-remote-by-default-says-matt-hancock-nhs
- Royal College of Paedaitrics and Child Health. Reimagining the future of paediatric care post-COVID-19. A reflective report of rapid learning from the Paediatrics 2040 project team. June 2020 (accessed at https://www.rcpch.ac.uk/sites/default/files/2020-06/paed2040-post-covid-report-20200626.pdf)
- Young People’s Health Specialist Interest Group (YPHSIG). Joint Statement on Virtual Consultations. September 2020 (accessed at https://www.yphsig.org.uk/resources-1/adolescent-healthcare/communication-skills/joint-statement-on-virtual-consultation)