Digital - COVID-19 guidance for clinicians in Wales

We'll keep this page updated as new guidance is developed. You can find the latest guidance from Welsh Government here.

*This guidance is consistent with UK-wide RCPsych COVID-19 Guidance for clinicians with the addition:

  • Welsh signposting and referencing
  • Further detail regarding the rapid large scale rollout of video consultations

Mae'r wybodaeth hon hefyd ar gael yn Gymraeg, ar ochr dde'r sgrin.

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).   

Welsh Government has approved the national roll-out of video health consultations, as part of the response to the coronavirus outbreak. Extending the use of this digital technology, which already plays an important role in the NHS in Wales aims to reduce pressure on frontline NHS services.

In many areas of Wales, primary and secondary care provision is being rolled out in parallel.

The technology is being rolled out as part of the Welsh Government's £50m Digital Priorities Investment Fund, which supports the delivery of digital services in the Welsh NHS and is managed by the Technology Enabled Care Programme (TEC Cymru). A successful pilot was driven by a CAMHS service in Aneurin Bevan University Health Board, the CWTCH Project, and has been operational since 2018.

The CWTCH Project is endorsed by RCPsych Wales, and you can find specific guidance written by the CWTCH project team in the accordion below.

Further Information

Information for GPs regarding the rapid large scale rollout of Video Consultation

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.

The use of remote access of NHS and essential services (via telephone of the internet) for anyone over the age of 70, anyone with an underlying health condition and pregnant women) has been strongly advised by Public Health bodies.

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 not confident 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.   

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. 

The Royal College of Psychiatrists Wales has recently endorsed the CWTCH project, funded by the Health Foundation and developed in Aneurin Bevan UHB. CWTCH utilises video consultation in assessment in Child & Adolescent Mental Health Services.

The CWTCH project team have issued guidance in offering video consultation during COVID-19. The guidance compliments the considerations given in the above accordion.

 

"We're delighted to endorse the CWTCH project; the innovation has led to savings in efficiency, economy and environment, whilst maintaining quality in patient engagement. The innovation exemplifies Welsh Governments aspirations around health transformation and technology, as identified within 'A Healthier Wales', and we're excited to support it's development and timely application."

Royal College of Psychiatrists Wales (March 2020)

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