Article Text
PDF
Statistics from Altmetric.com
Introduction
In 2018, the English National Health Service Long Term Plan1 proposed significant increases in virtual consultations over the next 5 years, setting out an ambition to deliver a third of all hospital appointments virtually. This was a direct response to the rise in demand over the past decade from 54 to 94 million outpatient appointments, at an estimated cost of £8 billion.
This plan was dramatically accelerated with the declaration of the COVID-19 pandemic in March 2020. In order to eliminate all non-essential face-to-face patient contact, NHS England recommended that virtual consultations were implemented for all secondary care outpatient appointments, except those ‘which meet local defined exception criteria’—and even for those they advised an initial virtual triage appointment.2
Many paediatricians have welcomed this change and feel that the pandemic has broken down many barriers to innovation.3 While children and young people have specific needs and vulnerabilities, this generation of ‘digital natives’ is a potentially perfect candidate for widespread digital healthcare delivery. However, there is limited research in the routine use of virtual consultations among children and young people. While there have been successful pilot programmes that have improved patient experience and engagement and even demonstrated some clinical outcome benefit, most have been limited to specific conditions or adult populations.4 5
This article aims to explore the benefits and risks of the rapid and extensive deployment of virtual consultations for children and young people and explores the implications for planning of healthcare delivery.
What is a ‘virtual consultation’?
‘Virtual consultation’ is a broad term that can be used to describe different scenarios. For clarity, this article focuses on the definition used by NHS England—‘synchronous, non face-to-face consultations that takes place between a patient and a clinician over the telephone or through video technology’.2 Note that even this tighter definition still encompasses both telephone and video consultations, which can have very different characteristics, challenges and opportunities.
What are the benefits of virtual paediatric consultations?
There is increasing recognition that the traditional model of outpatient care is outdated, inflexible and does not hold the patient at its centre.6 Virtual appointments cause less disruption to patients and their carers’ lives (e.g. impact on carers’ work commitments; school attendance; travel time and/or cost; childcare arrangements; access to car parking; mobility issues).4
A virtual consultation can be less intimidating than a visit to the hospital environment, enabling the clinician to observe the child or young person’s behaviour and family interactions in their home setting.7
For clinicians, the widespread adoption of virtual consultation technology has the potential to dramatically simplify the practicalities of holding multidisciplinary appointments and case conferences, freeing teams from the logistics of coordinating physical space and the travel arrangements of multiple professionals. The reduced need for travel also enables greater flexibility in professionals’ working patterns.
For the health service, virtual consultations can improve efficiency and reduce cost. There is reduced demand for the hospital infrastructure (clinic rooms, support staff, waiting areas, parking), while some studies have shown reduced rate of non-attendance.4 5 There may be wider societal benefits too, such as preventing the loss of income for working parents/carers attending a hospital appointment and reducing the carbon emissions associated with travel to hospital.7
Beyond this, virtual consultations have the potential to disrupt the traditional outpatient clinical pathway. The referral-to-appointment time can be used to make an initial virtual contact (either for triage or to initiate investigations), and the follow-up management can be adjusted—potentially enabling short, more frequent follow-up virtual consultations to monitor progress.
As we develop these models in paediatrics, we should adapt any learning from the experiences of those further along the virtual consultation journey—such as those involved in the management of chronic diseases or to facilitate care delivery to geographically remote populations.4 7 8
Challenges of virtual consultations
For the clinician, the inability to undertake physical examination can be disconcerting, requiring them to adapt to a different style of patient assessment, which depends heavily on the history and acknowledges that the referring health professional might have also not physically seen the patient. With the reduction in non-verbal communication in a virtual consultation, building rapport and having sensitive discussions can be more challenging.7 9 When there is a language barrier requiring the use of a translator, this can magnify the difficulties and the logistical challenge in terms of shared digital access.
From a health service perspective, potential cost savings may be offset by other factors. There is emerging evidence that widespread use of video consultation as the first appointment (whether for triage or full assessment) may actually increase overall workload due to duplication of appointments and missed diagnoses.8 Furthermore, short-term licensing agreements made between the NHS and external vendors of virtual consultation platforms (eg, ‘Attend Anywhere’ or Microsoft Teams) are likely to be subject to renegotiation beyond the pandemic and incur further cost.
Across the NHS, individual healthcare organisations have varying degrees of digital maturity and capability. Patients and carers also vary in their digital literacy, access to digital devices and reliable connectivity, potentially exacerbating existing health inequalities. A 20 min video consultation via Attend Anywhere uses between 230 MB and 450 MB of internet data—unaffordable for many low-income families.10
Perhaps the greatest concern for child health professionals is the ability to engage with the child or young person during a virtual consultation. Many virtual consultations are confined to conversations with the parent or carer, as many of our patients have limited capacity to communicate via a telephone or screen. Even when consulting an older child or adolescent, it can be much more challenging to undertake a one-to-one conversation away from carers or to be sure that the remote environment is conducive to their ability to speak freely. There is unease among professionals that, on the backdrop of the COVID-related social isolation, virtual consultations may limit the opportunities to detect potential safeguarding concerns.
Choosing when to undertake a virtual consultation
There will always be situations where a face-to-face consultation remains essential,2 particularly in the assessment of a patient for a potentially high-risk, serious clinical condition or a safeguarding concern.11 The choice of consultation modality must be made in conjunction with young people and families. While box 1 identifies some of the factors to take into account, this will always be incomplete without including young people and their families in decision making.
Factors that may influence choice of consultation modality
Patient/family:
Capacity to engage with consultation: The age and developmental stage of the patient and the ability of their carers to engage with remote consultation should be considered, especially where there are additional communication challenges.
Barriers to access: There are benefits and costs associated with both virtual and face-to-face consultations and these will vary depending on individual patient circumstances. For example, a young person may be assigned to a virtual consultation based on information in their referral letter, but this may need to be changed if they express concerns about privacy in overcrowded accommodation.
Patient/carer preference: Patient and family preference for the mode of assessment should be taken into consideration—appreciating that this may change over time.
Condition/presentation:
New versus follow-up: Not all new referrals will require face-to-face assessment, but some will, especially where there are ‘red flags’ in the referral information or safeguarding issues. Follow-up appointments where there is an established relationship are more likely to be amenable for remote assessment.
Difficult or sensitive conversations: Difficult conversations are more challenging virtually and may benefit from face-to-face interaction.
Physical assessment: Many children will require a physical examination or investigations, and it is logical for these to be associated with a face-to-face appointment.
Clinicians:
Outpatient appointment type: Virtual clinics may facilitate cross-specialty, multidisciplinary, ‘outreach’ or transition clinics more easily than face-to-face appointments.
Clinician digital capability: Remote assessment is a significant change in practice for many clinicians and will be more straightforward for some than others.
Service:
Physical and digital infrastructure: Video conferencing requires adequate digital resources, hardware and software, as well as staff training. Similarly, physical infrastructure (eg, waiting room size, local transport links) will have an influence on the degree to which virtual consultations are accepted as an alternative for face-to-face interactions.
Clinical pathway/model appropriateness: There will need to be flexibility within services to stream individual patients to the most appropriate assessment.
Is the clinic providing a secondary, tertiary or quaternary service?
Is a referral likely to result in a single review and discharge, or a long-term follow-up relationship?
What level of assessment has been performed previously by someone with any paediatric expertise?
Has the child already had a physical examination or other investigation?
What does the future hold?
Virtual consultations are here to stay, even if their current dominance in outpatient activity reduces. From a technological perspective, it will be crucial to tackle variation in broader digital capability and access, for both healthcare providers and patients. The pandemic-related relaxation in information governance and data security will need to be reviewed. Looking ahead, there is potential for further innovation, such as recording of virtual consultations for later viewing and the adjunct of remote monitoring.
For clinicians, there is already a plethora of practical guidance available on how to conduct a virtual consultation, but specific training and education need to be developed and included in undergraduate training curricula. There is also a need to formally appraise the evidence base for virtual consultation use among children and young people. The Royal Colleges Joint Statement emphasises the importance of data collection and gathering feedback both locally and nationally.12
For child health systems as a whole, the challenge is to think critically about how to maximise the potential benefits virtual consultations offer, while working to mitigate the risks they pose for children and young people. Care integration and interprofessional communication must be particularly robust and proactive, given that face-to-face encounters with this potentially vulnerable population will decrease.
Most importantly, the child and young person must remain at the centre of the process. Their needs and preferences must inform the choice of consultation method and must not become subservient to system pressures. The speed of change dictated by COVID-19 denied young people a voice and now we must give them the opportunity to co-design new digital pathways of care and to shape their own healthcare landscape.
Ethics statements
Patient consent for publication
Footnotes
Twitter @cheungronny
Contributors FB wrote the first draft. All three authors contributed equally to the conception of the paper and revision of the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Linked Articles
- Clinical law for clinical practice
- Atoms