Benefits and limitations
A virtual consultation is a video or telephone appointment, which allows patients to speak to their clinicians without the need to travel to the hospital. Virtual consultations have played a particularly significant role during the current pandemic which is likely to continue in the post COVID-19 era.
Virtual consultations has enabled the continuity of services, for those with longer term conditions, and patients who are unable to travel (e.g. those in high risk groups), and has allowed shielded staff and those in quarantine to conduct outpatient work from home.1 This has demonstrated that there are several benefits of using virtual consultations.
However, virtual consulting presents particular challenges for young people aged 10 – 25 and carries potential risks, such as safeguarding, confidentiality,2 and digital exclusion due to socio-economic status and access to technology.3
The principles described in this guidance aim to support clinicians who are consulting virtually with patients to provide care in a way that is in the best interests of children and young people, whilst protecting both from the risks associated with virtual consultations.
There will be implications for how paediatricians work, so it will be important to factor in job planning in a robust way.
Preparing for the virtual appointment - what children and young people say
The RCPCH &Us team with a group of young people, identified six key areas on what doctors need to think about to help make virtual health appointments work.4
- Reassure us about how it will work
- Give us choice of how to talk with you
- Help us to keep it private when we are at home
- Help us to prepare for our virtual appointment
- Make it easy for people without good WiFi access
- Make it clear and simple about how we get help when we need it
They have also created a poster for staff to support their thinking on Virtual Health Services.5
Arranging a virtual consultation
Patient choice and patient consent
Although the COVID-19 pandemic has accelerated the adoption and utilisation of virtual consultations as part of core clinical practice, where possible, this should be driven by patients’ choice and patients ‘consent:
- Where a young person under 16 years old has requested a virtual consultation, the approach should be the same as it would be for a face to face interaction, assessing their safety and their ability to make the decision using the principles of Gillick Competence.6
- Clinicians should determine whether the patient is capable of giving informed consent to medical treatment without the knowledge or permission of their parents and whether this is in their best interests.7 Follow the principles set out by the GMC when assessing a young person’s competence to consent and for shared decision making.8
- If the child/young person does have the competence to consent to a virtual consultation, then confirm whether they would like either a video or telephone consultation.
- Be flexible when arranging a virtual consultation, as some children and young people may request an initial face to face appointment but are happy with a virtual follow up. Most paediatricians find that virtual consultations work better when the first consultation is face to face. Young people have also shared their appreciation of being able to access health services in person, on the phone or online, and would like this choice to be carried forward post COVID-19.9
- There should be flexibility around timing to ensure the child/young person is in an appropriate setting. For instance, this might mean not offering appointments during school hours, where privacy might be a challenge and ensuring that the child/young person is alone and in a safe space before starting any confidential discussion.
- Provide information to patients that is clear, easy to read and accessible. For instance, a video or graphic that explains how virtual appointments work, aimed at younger patients to watch prior to the consultation. For children and young people whose first language is not English and/or have difficulty reading, you should convert the virtual consultation to a face-to-face assessment as they often struggle to safely and privately access virtual consulting.
Supporting children and young people at the virtual front door
Three sessions have taken place to look at prompts that could be used to support young people/young adults making independent phone calls to NHS Services. The aim of these focus groups were for participants to share what their health needs are, in order to be able to support the phone triage needs of services working through COVID-19. Suggestions are:
- Provide a clear, 2 sentence, plain English statement that reassures children and young people that they are not being treated differently from anybody else e.g.
“I’m going to ask you a few questions that we ask everybody, so that we know who the best person is to help you. We won’t share them with anyone who doesn’t need to know”
- Have two very simple, yes/no questions to start with to establish the context e.g.
Young people have said that at times it can be hard explaining to a receptionist or phone triage what is going on for them because other people are listening, or they can’t see the person so are not able to pick up visual cues, or because it might be hard telling someone what is really going on straight away. They identified that having yes / no answers might make it easier to start with, backed up with a local working protocol or checklist to support these conversations.
Access to technology
Arranging a virtual consultation presents some barriers which need to be thought through. Poverty and other inequalities can impact on ability to access care digitally as not all families have equal access to technology. The 2020 Consumer Digital index revealed that approximately 16% of people in the UK cannot undertake basic digital activities such as turning on a device, connecting to Wi-Fi or opening an app.
The report also showed that it is the most vulnerable and disadvantaged who are most likely to be digitally excluded.10 It is important to ensure that there are accessible routes to virtual consultations for all children and young people regardless of their socio-economic status. Additionally, some systems do not currently allow those under eighteen to book an appointment without parental involvement.11 Before you start, it is advisable to check:
- The child/young person/family has internet or WiFi at home and is confident using a smart phone, tablet or PC.
- Their device has a working webcam and speakers/microphone.
- All contact details (home, mobile number and email) are up to date so that the patient can be contacted in the event of any technical difficulties.
- If there are data concerns which might need to be worked through, e.g. by accessing grant funds to support purchasing a data bundle for data heavy services like Attend Anywhere, or switching to a phone call.
- It might be helpful to have a pre- assessment discussion on the telephone with the child/young person and encourage them to make a test call beforehand to better prepare for the virtual appointment.
Starting the virtual consultation
The virtual consultation
- If by video, use a private, well-lit room and ask the child/young person to do the same.
- Some children might be with their parents so it is important to ask the child/young person “who else is with them today?” or “whether they would like someone else with them”. If by telephone, the child/young person may prefer another person in the room with them (or may not) and it is just as important to confirm with the child/young person that they (and you) are alone
- Seek to ensure that everyone on the call is visible on screen rather than having anyone off camera.
- If you don’t know the patient, confirm the details of who you are talking to.
- Reassure the child/young person about how the video consultation will work with clear information and no waffle.
- Confirm the child/young person’s phone number in case the video link fails.
Recording the virtual consultation
- If you need to record the video consultation or take a screenshot, then you will need the consent of the child/young person or someone with the legal authority to act on the child/young person’s behalf for healthcare decisions.
- Many GP surgeries automatically record telephone calls to patients - the reason for this needs to be clarified at the start and whether the patient themselves wishes to record a copy of the consultation so that they can replay it afterwards in case they forget what has been said.
During the virtual consultation
- Keep it straight forward and simple.
- Explain medical terms in plain language and try to match the child/young person’s language and what you perceive to be their knowledge level.
- Proactively involve the child/young person in discussions.
- Give people the time, they need. Appointments should not feel rushed as children/young people need to feel listened to and clinicians must have all the information they need to hand.
- Reflect back on what has been said so that the child/young person feels that you are listening to them.
- Explain silences so they know the line is still working. e.g. sometimes it helps to say things like, ‘let me think about that for a moment’ if you are going to stop and think before responding.
While virtual consultations can potentially offer an insight into children / young person’s home environment, safeguarding needs can be missed - either because children or 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. However, there are a few tips that could be useful:
Safeguarding concerns during a telephone consultation
- Try as much as possible to speak to the child/young person themselves.
- Consider the use of “closed” questions that require a ‘yes/no’ answer when asking about safety as this may help victims of abuse share that they are being harmed. For instance, “Do you feel safe?”
- Listen carefully for whether the conversation is being directed by another person.
Safeguarding concerns during a video consultation
- Check the child/young person’s medical records before the consultation for any safeguarding concerns e.g. whether the patient is known to social care or is a looked-after child/young person and whether a face- to face appointment might be more appropriate.
- Ensure that the child/young person is present and can be seen.
- ‘Examination’ or ‘showing body parts’ should be avoided to protect children and young people from abuse/exploitation but also the normalising of showing a stranger their body on screen.
- Observe the child/young person’s reaction to their carers being present. Is the child/young person looking at the other person before they can have a say? Do they appear guarded or watchful? How are the interactions with their carers?
- Observe the environment for any signs of neglect in the home.
- For patients who are already known to the team and where separate consultations have taken place, it can be useful to agree a ‘safe phrase’ which should alert the team to the need to speak separately and in confidence. For instance: the code phrase could be “I need a glass of water”. On hearing a ‘safe phrase’ the clinician could respond by asking the child/young person if they happy to have a separate conversation without their parents.
- Trust your instincts! If you have safeguarding concerns at any stage, you should convert a virtual consultation to a face-to-face assessment, unless there are compelling reasons why that cannot happen. It might be that social services and the child/young person’s school may need to be involved in any follow up discussions.
- Encourage the child/ young person to have continuous contact with their friends and family who they trust through virtual means e.g. by phone, video chat if they feel isolated and need someone to talk to.
- Virtual consulting can make it harder to hear the child or 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 children and young people’s healthcare. This is more difficult to manage in a remote setting.
- If a child/young person wishes to discuss a matter in the absence of a parent, all the usual principles apply in relation to confidentiality (see the GMC guidance).
Closing the consultation
- Be particularly careful to summarise key points to ensure that nothing was missed.
- Give both the child/young person and the parent (if present) person an opportunity to ask questions.
- Confirm (and record) if the patient is happy to use a virtual consultation again
- Try to ensure that the child/young person is emotionally ok and are aware of how to seek support if they have any concerns or distress.
- Advice how to contact you – or in your absence who to contact, and how.
- End with a friendly sign-off, e.g. ‘I’ve enjoyed talking with you. I hope that’s been helpful.’
- 1RCPCH Paediatrics 2040 Report : www.rcpch.ac.uk/resources/reimagining-future-paediatric-care-post-covid-19-reflective-report-rapid-learning
- 3London Networks good practice guidance to determine suitability of remote consultation, NHS England and Improvement, July 2020, selondonccg.nhs.uk/wp-content/uploads/2020/08/Paper-1b.-Remote-consultation-good-practice-guidance-Draft-v-1.0-for-CAG_.pptx
- 7 childprotection.rcpch.ac.uk/wp-content/uploads/sites/6/2020/10/Key-principles-for-intimate-clinical-assessments-undertaken-remotely-in-response-to-COVID-19-v1-July-2020.pdf