Digital - COVID-19 guidance for clinicians

During the COVID-19 pandemic, in which everyone, including clinicians and patients, is being asked to minimise their contact with others, it is important that those who use mental health services continue to get the care they need. Remote consultations will be required to become far more widespread and there are moves to exponentially increase capacity for this in the coming weeks.

Remote consultations include psychiatric assessments or follow-up interviews conducted using telephone calls, audio and video digital platforms (sometimes known as telepsychiatry).

Existing guidance

A qualified doctor is required to deliver safe, ethical care to patients, wherever they may be. The standards expected of doctors by the GMC apply equally to digital and conventional consultation settings.

Consideration should be given to any potential limitations of the medium used and meeting the obligations in Good Medical Practice within such constraints. A doctor MUST satisfy her/himself that they can undertake an adequate assessment, establish dialogue with the patient and obtain the patient’s consent, including consent to the remote consultation process.

NHSX has published pragmatic guidance on information governance since the outbreak of the COVID-19 pandemic. This includes the following advice on platforms for video consultations and consent:

‘We encourage the use of videoconferencing to carry out consultations with patients and service users. This could help to reduce the spread of COVID 19. It is fine to use video conferencing tools such as Skype, WhatsApp, Facetime as well as commercial products designed specifically for this purpose.

The consent of the patient or service user is implied by them accepting the invite and entering the consultation. But you should safeguard personal/confidential patient information in the same way you would with any other consultation.

Public Health England strongly advise the use of remote access of NHS and essential services (via telephone or the internet) for anyone over the age of 70, anyone with an underlying health condition and pregnant women).  

Further guidance from NHSE on maximising use of digital technologies:

• As far as possible, clinical teams should seek to discuss with patients and families/carers in advance about suitability and willingness to engage via technology.

• Providers may consider stratifying patients where there is highest risk of losing contact and agreeing how contact will be retained.

• Where patients and carers live at a significant distance or are in isolation, it may be appropriate to offer access to ‘virtual ward rounds.’

• The information Commissioner’s office has published a statement and Q&As to complement a joint statement from the health regulators. Further questions can be directed to the NHSX IG Policy team via email.

College recommendation  

During the COVID-19 pandemic, remote consultations should be encouraged where safe and appropriate to avoid unnecessary travel and face-to-face contact.  Though ideally remote consultation should be an adjunct to, rather than substitute for, face-to-face consultation, this may not be possible in the current climate.

For initial consultations (where the patient and clinician are unknown to each other), remote consultations may be even more challenging. Despite this, the alternative of no consultation at all is not preferable and we recommend that initial remote consultations go ahead where possible.

However, the clinicians and professionals initiating the consultation will be expected to show sensitivity to patient's comfort level with technology and determine early in the consultation what objectives of an initial assessment or screening can be achieved reliably.

It remains the case that these consultations are limited and those with lack of digital literacy or no access to digital platforms must not be disadvantaged, nor should those who are unconfident about using the technology. Use of telephone consultations, rather than more complex video platforms may be sufficient for lower risk conversations or to ensure engagement with those who lack digital technology or skills.  

Further resources on remote consultations

NHS England have produced guidance on how to deliver IAPT therapies remotely during the COVID-19 outbreak.

RCPsych in Wales has endorser the CWTCH project, which offers innovative video consultation to patients and clinician.

Digital neurodevelopmental resources.

Operational issues for those undertaking remote consultations

In considering which patients to offer video consultations to, consider the following:

• Ensure the patient has access to the technology they require, including internet access, as well as the skills to use it – if any administrator is setting up the call this could be something they check. Has the patient done video calls before with family members, do they order shopping online, book holidays online, or use internet banking?

• Consider any problems with accessibility, in terms of hearing loss or difficulties with dexterity due to coordination problems or arthritis – if you have a choice of platform you can offer, pick the one that addresses these difficulties as best as possible. Patients using a headset may help but may not depending on their needs.

• Do they have a carer who can facilitate the video consultation where they may have difficulties with the aspect above?

• Be aware of any generalisation about any specific group in terms of whether video consultation may or may not be suitable, so consider on a case by case, using your current understanding of the patient’s needs and circumstances.

• Professionals may find it useful to address the following 6 “C’s” in their own approach and development when considering video consultations. Specific guidance on the platform available to you in your organisation should be available to you through your internal website or the IT training team. Please make use of this resource in conjunction with the advice below.

Competence

Take time to develop enough competence in the platform you intend to use:

• Familiarise yourself with the video consultation platform available to you, and ensure you understand what all the "buttons" or options do.

• Test the use of the platform and its features with a colleague - there will be many working from home at the moment who are in the same position.

• Make a note of the features you might want to use and have a crib sheet available to you in case you need to refer to it quickly.

Communication

Consider how to adapt your communication skills to improve the experience:

• Try to allow for as much non-verbal communication to be captured as possible. Including your head, neck, upper body and arms may be better than just your head. Encourage patient do the same.

• Slow the rate of speech to allow for problems with slow connections and pause between sentences longer than you might do face-to-face.

• Use clear language - again this may be shorter than in face to face to ensure clarity of expression across the video call.

• In order to establish eye contact, you need to look at the camera, not at the eyes of the person you are interviewing.

• Use any features, such as a shared “white board” function, you are familiar with to help with sharing of information.

• Lighting and background are important – plain, darker static/uncluttered background with light directly on your face may help, particularly where the connection is of lower quality.

• Where the patient is new to you - take even more time over the introduction and signpost what is going to happen next.

Contingencies

Have a clear understanding of what to do when the consultation is not going well for technical or clinical reasons:

• Have a back-up plan for managing any technical difficulties (e.g. loss of connection) and provide this via email to the patient ahead of the session for example or in the first few minutes of the call. Check you have the right mobile telephone number to call them as a back-up. Agree who will contact whom in the event of a lost connection.

• Brief the patient that if you don't feel able to complete an adequate assessment you will discuss what steps to take next. This will include reviewing the risks of a face to face contact in the current context of recommended social distancing and delay in care that might result.

• Ideally have this process mapped out in front of you until you are familiar with it.

• Practise the "script" that you might want to use for managing contingencies and ensure that the description of how to manage the “what ifs” are clear.

• Make sure the technology (laptop, phone) is charged or plugged in and advise, where possible, the patient does the same. If possible, have a back-up device available.

Confidentiality

• If the patient is new to you, verify they are the right person where possible, and check they are expecting the appointment for their mental health and not another condition or problem.

• Check who is in the room with the patient, ask for them to be introduced to you, and if possible/practical that they remain in view.

• If the patient is in a public place (e.g. on the bus), consider with them whether it is appropriate to continue at that time. If the need to be in a public place to make use of a public connectivity, explore whether they can move to a private room or consider alternative arrangements.

• Manage your own environment. avoid sensitive, personal details in the background. Lock the door to the room you are in, if possible, to avoid disruption.

• Some platforms have a function that will blur the background behind you - be familiar with how to enable this.

• Have a dedicated clinical account, if you use the video platform socially as well as professionally.

• Does the patient have anyone else present in the room (such as a relative/carer/advocate)?  If so, allow them to introduce themselves and clarify the purpose of the interview with them.  

Consent

As with all appointments, it is important to consider the relevant aspects for meaningful consent:

• Be clear with the patient on the limitation of the assessment or review, and whether they have any concerns.

• Ensure that you are clear about the security of the platform you are using and that it is fit for purpose to be used for such an encounter and be able to discuss this with the patient if they require. Your local IT training/support team will help you with this. Please also refer to the Information Governance guidance issued by NHS X in response to the Coronavirus epidemic referred to above.

• Ensure that you discuss with the patient about recording the session - ask about the use of this recording and ideally agree what might be useful for them to be able to take away and that it will only be for private use.

Confidence

In addressing the other “C’s” you can build the critical sense of confidence for you and the patient in using video consultations:

• Being confident about using the technology, having a clear sense of what to do if something goes wrong and what the limitations of the technology are will help you develop a confident approach to using video consultations.

• You need to be confident that you have been able to a do a good enough review or assessment. If you haven't be able to, don't be afraid to say this, and develop a clear plan of what you need to do next with patient - just like you would in a face to face consultation. Whilst under pressure to continue to deliver services against significantly unusually circumstances, this remains the most important factor in safe care and discussing this with that patient is key to them having confidence too.

In response to the COVID-19 pandemic, the Professional Record Standards Body (PRSB) has published guidance for health and care professionals in collaboration with NHS Digital.

The COVID-19 SNOMED CT codes comprise the following groups:

• Risk category
• Isolating/shielding advice
• Encounter and advice
• Exposure
• Signs and symptoms
• Swabbing
• Tests and test results
• Clinical and test result interpretations/disease labels
• Severity assessment
• Complications
• Vaccination

The full list of codes is available on the NHS Digital website.

For further details, please refer to the PRBSB website. 

NHS England/Improvement published Legal guidance for mental health, learning disability and autism, and specialised commissioning services supporting people of all ages during the coronavirus pandemic (PDF)(second version, 19 May) which includes guidance on the application of digital technology to MHA assessments covering the following areas: 

• Minimum standards of technology and environment
• Taking into account a person’s views
• Safeguards and ensuring quality
• Documentation
• Checklist to support decision in line with the minimum standards and safeguards on the application of technology to the MHA assessments
• Specific considerations by setting
• Specific considerations by population