Joint Statement on Virtual Consultations
“Digital by default” or digital divide? Virtual healthcare consultations with young people 10 – 25 years
‘Digital by default’ isn’t anything new. These were the words used to sum up the UK Government’s Digital Strategy launched in 20121. Covid-19 has achieved what years of encouragement failed to do, by accelerating the transition to a huge increase in ‘virtual’ consultations in primary and secondary care. NHS England has indicated that they want this to continue into the future, with the aim of 25% of outpatient appointments to be conducted remotely2.
However, remote consulting presents particular challenges for young people aged 10 – 25 and carries potential risks. ‘Default’ should not mean ‘always’. The young people’s special interest groups of RCGP, RCPCH and the AYPH urge those who design and commission services and who create policy to proceed cautiously. We need to consider carefully the impact on young people and their views before advocating a wholesale change to remote consulting and triage.
Based on the professional expertise of our members and a nationwide youth engagement exercise led by the RCPCH3, we have identified four key issues; equality of access to service, protection of confidentiality, the quality of the consultation and ensuring adequate safeguarding.
· Arranging a remote consultation presents new barriers which need to be thought through. Some systems will not currently allow those under eighteen to book an appointment without parental involvement
· Poverty and other inequalities can impact on ability to access care digitally. Not all families have equality of access to technology (internet, broadband, WiFi, data or devices). Some may have additional issues (learning disability, auditory or visual needs). Some may not have English as their first language.
· Digital consulting can make it harder to hear the young person’s story and fully understand their perspective if the parent or carer is always present. Providing the opportunity for young people to be seen alone is an important part of young people’s healthcare. This is more difficult to manage in a remote setting.
· It is more difficult to ensure that a consultation is confidential on both sides of the screen, and the ability to do so is also affected by inequalities such as access to private space.
Quality of consultation
· Health professionals and young people themselves have reported that remote access can prevent young people seeking help for their health and wellbeing concerns.
· Although we assume young people prefer to engage digitally they have told us this is not always the case. Their views need to be taken into account.
· An effective consultation needs a protected space and the full attention of both the clinician and the young person. This can be harder to achieve when people are using the flexibility offered by mobile technology rather than meeting face-to-face.
· Psychosocial evaluation is the bedrock of young people’s care. Remote consultations can make it more difficult to develop a trusting relationship with a young person, pick up on non-verbal cues and create an environment where a young person feels confident to talk about their underlying concerns.
· Transition to adult services can be a particularly complex process for young people with health conditions – if this happens digitally it may be difficult for a young person to build relationships with the adult team with potentially long-lasting effects on outcomes.
· Safety netting can be less robust due to limited rapport, lack of non-verbal cues, inability to pass on physical resources, reliance on verbal recall and technical issues.
· Use of digital consultation can bring additional complexity and raises potential risks associated with virtual examination and the receiving, capturing, storing and the use of images taken for clinical purposes.
· While potentially offering an insight into a young person’s home environment, safeguarding needs can be missed - either because young people do not feel safe to disclose because others are present (including, potentially, someone who is doing them harm), or because of fear of being overheard.
· It can be more difficult in a remote consultation to observe and react to the subtle nonverbal cues e.g. the body language between a young person and the accompanying adult that would alert the clinician to a possible safeguarding issue. Use of digital consultation should be combined with a consistently low threshold for face-to-face consultation if there is any suggestion of a safeguarding concern or need for physical examination.
A number of organisations and agencies are developing good practice models. However, we need to ensure that these are driven by young people’s needs. We are encouraging more data collection on the specific impacts of virtual consulting on this age group, and their viewpoints, to inform new policies and guidance. Digital will not suit all. Retaining choice and control over how to consult will be critical.
If the move to more remote consulting is not done with young people’s needs in mind, there is a risk that it will increase health inequalities. The ‘class of Covid-19’ are already going to be disproportionately disadvantaged by the educational and economic impacts of the pandemic, and their access to healthcare should not do anything to exacerbate this. Indeed it may be part of the solution.
References:1. Department of Health. Digital Strategy: Leading the culture of change in health and care. Dec 2012 (Accessed at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213222/final-report1.pdf)2. NHS England [internet]. Digital First Primary Care [cited 2020 August 6]. Available from https://www.england.nhs.uk/gp/digital-first-primary-care/3. 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)
A PDF version of the statement can be found on the AYPH website here
A related blog in the BMJ is accessible here
A joint statement from:
Young People’s Health Special Interest Group (YPHSIG)
Adolescent Health Group for RCGP
Royal College of Paediatrics & Child Health (RCPCH)
Royal College of General Practitioners (RCGP)
Association for Young People’s Health (AYPH)
With acknowledgement to:
Lorraine Albon, Richard Burack, Neil Davidson, Marian Davis, Dick Churchill, Ann Hagell, Emma Parish, Emma Park, Emma Rigby, Terry Segal, Gill Turner and YPAGne