Moving to an online service
Researchers who are looking into how to transition their face-to-face service into an online version should look at the NHS Digital's Digital Inclusion Guide or the similar digital exclusion/widening participation literature. Beyond the technical issues, it is an acknowledged fact that these transitions may result in particular groups being excluded from services – typically patients who are not technology users, or in itinerant population groups. Alternatively, the opposite can also occur, whereby a new set of service users can access care, particularly those who are physically immobile or reluctant to engage with clinicians in person, pregnant mothers or those with childcare responsibilities. Patients who are not technologically enabled will not necessarily be excluded from services, but rather staff may have to consider ways to support them, or encourage their carers/family to support activities. For example, a carer can book in a video consultation for a patient.
A second point to consider is that new technology necessitates new workflows in care pathways. This often means new roles for reception staff and others in the triage process. If possible, co-producing and iteratively refining these processes with colleagues is the best way to get them to work. Peer learning is also important, and it would be advisable to identify staff members with expertise in digital health who can teach/provide leadership.
The exclusion issue can have effects beyond those with low levels of digital literacy, who typically can struggle to access services. For example, research in Cornwall from the EPIC project shows that when trying to provide digital services for care homes, not all homes had good internet access. Slow speeds made video-calls impossible for some. Furthermore, care homes that did have internet connections may not have them throughout the building but typically only in communal areas.
While there is a current and pressing need for digital healthcare, it not always possible to offer services due to these sorts of pragmatic limitations. The first step in trying to transition any service to an online version is to assess what implementation issues might arise, who might be excluded as a result, and what can be done to mitigate these issues. For example, not all NHS-issued computers have webcams, meaning that if a member of staff wanted to conduct a video consultation they would have to provide their own (although the NHS is working hard to provide all with webcams). Staff should also identify the essential features required for their intervention (e.g. internet connection or webcam) and not worry about over complicating the solution. Choosing a complex process will frequently result in user dissatisfaction or disengagement; it is much easier to click on a link to start a video conference than it is to download and install software.
Solutions do not have to be overly technical in nature, and often simple implementation issues are the ones that prevent effective roll- out. Staff should have a mind-set of Quality Improvement, whereby the technology is facilitating staff to support patients, rather than being the central focus.
If you feel that you might be slower delivering an online consultation, spend more time familiarising yourself with the patient's record or issue the patient forms to complete before the call to obtain basic clinical information. In short, some of the limitations of digital services can be mitigated with small amounts of planning, and scaffolding.