An uncomfortable truth: digital isn’t perfect, but neither is face-to-face

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Unprecedented – there’s that word again , the word of 2020, a word I have never seen, read or used more than I have during the first nine months of 2020. Despite the risk of a pandemic having been a topic of discussion for several years (and even the plot for Hollywood blockbusters), the world has found itself ill prepared to respond to unprecedented challenges of the novel Coronavirus (Covid-19).

After years of talking about the potential of digital health and care the system suddenly shifted in a matter of days, with digital technology filling the gap when face to face appointments were no longer possible. But the technology is not particularly new, for example video calls first became widely available in 2003 with the launch of Skype and became more widespread with the use of smartphones. It’s not technology but the environment that has changed. A combination of the challenges created by the pandemic and system changes, including additional funding to cover rapid purchasing of solutions, permissive environments so frontline staff can make changes to continue to deliver care, and simplification of information governance, enabled the rapid change.

'After years of talking about the potential of digital health and care the system suddenly shifted in a matter of days'

Digital tools have fast become the norm for care provision during the pandemic. Perhaps the most hyped are video consultations, but telephone appointments, electronic messaging and triage systems account for the majority of the remote care exchange. Telephone consultations are easier to use, more convenient (negating the need for travel) and not plagued by reliability issues. Electronic messaging enables both the patient and health care professional to respond to non-urgent simple care needs in short bursts when convenient, which helps avoid appointments for more simple transactional engagements such as repeat prescriptions. Triaging typically uses a sequence of questions to ascertain which healthcare professional would be able to address the care needs of the patient. This improves matching patient need against available expertise. Triage and electronic messaging are arguably the real digital innovations shaping care, as both can save time and improve the response to a patient’s need .

Digital technology provides benefits for many patients and staff, as well as the system as a whole; this includes greater flexibility, better availability of clinical time, improved morale, more effective recruitment and greater ease of access (especially important for underserved patients, such as those with autism, or have anxiety disorders).

As we look to the future of health and care, a decision will need to be made on how much of the digital transformation is here to stay. We want to ensure the best quality care provision that doesn’t exacerbate or create new inequalities. Many of the most vulnerable members of society may struggle to access care digitally for reasons relating to cost, the devices needed and literacy skills. If we trade traditional care provision for digital we risk exacerbating inequalities. The quality of digitally delivered care when measured by clinical indicators is possibly inferior to the quality of traditional delivery methods. But quality means different things to staff, patients and carers; focusing on clinical indicators ignores convenience, ease of access, flexibility, cost and many other factors that are important to patients and carers.

'As we look to the future of health and care, a decision will need to be made on how much of the digital transformation is here to stay. We want to ensure the best quality care provision that doesn’t exacerbate or create new inequalities.'

The quality of digital care can be improved through a combination of training and making best use of the unique digital capabilities. A rapid transition would means users (both staff and patients) are less familiar with new tools. For example, reading visual cues face to face is second nature for clinicians but when the usual cues are no longer visible it can be concerning, what if something important is missed? But on video calls, there can also new visual clues to read and interpret: the patient’s environment, behaviour and the people around them indicate their wellbeing and general situation. Similarly, if staff are unfamiliar with digital tools they can’t support and guide patients effectively and with confidence. On-going training improves both how information unique to remote care is incorporated into clinical decision-making and staff confidence to help patients and bring them along. Where digital creates problems it also enables potential solutions, now experienced staff can join colleagues on consultations remotely to provide peer support, supervision, on-going training and learning. In addition to improving quality this peer support could improve team dynamics and morale.

We often focus on the differences, but there are more similarities between face-to-face and digital delivery than we acknowledge. Digital tools can be difficult to navigate but equally patients do find it stressful to negotiate traffic, find parking (which costs money) and navigate to a GP surgery or hospital waiting room. Connectivity costs money, but so do most forms of transportation.

The reality is face-to-face and digital both have benefits, and neither is perfect.

Terms like ‘digital-first’ and ‘remote by default’ are misnomers that can over-simplify digital transformation. Digital is important but it should be considered alongside traditional care not instead of traditional care. The problem we need to solve is how to strike the right balance for communities and what other changes (to legislation, for example) are required for transformation to stick. We need to ensure the pace of change brings staff and patients on board and merge care approaches around both patients and staff. We should not close doors in order to launch apps but have open doors and accessible apps.

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Comments

Rachel Jerram

Position
Programme Manager,
Organisation
University Hospitals of Derby and Burton
Comment date
30 September 2020

Great article - very balanced and accurately reflects our experiences over the last few months, thank you

Isabel Ho

Comment date
06 October 2020

Great article providing pros and cons of traditional and digital care, so important to have the capability and capacity for both, not only improve care experience of patients but staff too. We all need a constant reminder to focus on similarities rather than differences and this is essential for collaboration and engagement.

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