The LYNC study was undertaken to understand how digital communications might enable better relationships between clinicians and young people (aged 16-24) in order to have a positive impact on health outcomes. The study responded to the fact that there are gaps in the evidence about what and how digital communications may work best in clinical practice, alongside ethical and safety implications.
The objective of the LYNC study was to understand how the use of digital communication between young people with long-term conditions and their NHS clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards. As digital communications become increasingly prevalent in everyday life, this is an increasingly urgent issue for clinical teams to address.
The research team conducted mixed-methods case studies of 20 NHS specialist clinical teams and their practice providing care for young people with a variety of long-term conditions. The case studies included two Child and Adolescent Mental Health Services (CAMHS) and two Early Interventions in Psychosis services (EIP).
In total, the team observed 79 clinical team members and interviewed 165 young people with a long term condition. They also interviewed 173 clinical team members and 16 information governance specialists from the participating NHS Trusts.
A thematic analysis was conducted of how digital communication works alongside analysis of ethics, safety and governance, and annual direct costs.
The study found that young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol (VoIP) (e.g. Skype) to keep in touch.
The study found that digital communications can enable timely access for young people to the right clinician at the time, which can make a positive difference to how they manage their health condition. Digital communications are valued as an addition to traditional clinic appointments and can engage those who would otherwise be disengaged, particularly at times of change for young people. They can enhance patient autonomy, empowerment and activation. Whilst they challenge the nature and boundaries of therapeutic relationships, the study showed that they can improve trust.
The clinical teams studied had not themselves formally evaluated the impact of their use of digital communications. The study identified a number of risks to digital communications including increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures. These risks were mostly mitigated by young people and clinicians using common-sense strategies through trusted relationships.
The study found that context was salient in determining the most effective method of digital communication. For example, mobile phone calls were used for more urgent issues, text messaging for raising less urgent concerns and reminders, email for more complex information and summaries of discussion in a consultation. Some young people used email or text message to communicate a sensitive issue rather than raise it when meeting face-to-face. The asynchronous nature of these communications enabled each to carefully construct their question and their response respectively. Digitally mediated communications were perceived, by young people and practitioners alike, as a useful adjunct (but not replacement) to face-to-face contact.
Introducing digital communications often raises concerns by staff about increased workload and their capacity to respond. In contrast, digital communications are often assumed to create efficiencies that can result in savings. In this study staff reported that digital communications did not reduce their workload and for several they increased it.
The emergent nature of use of digital communications within the NHS is noted within the study, along with the need to manage expectations for both patients and clinicians. Digital communications can improve patient autonomy but can conversely increase dependency in so far as a practitioner may be more readily available to help with decision making. All of the risks associated with digital communications in the study were common to clinical communication more generally, but the ease and speed of use of digital channels magnifies the risks.
Strengths and limitations
The observational mixed methods study design illuminated the pragmatic issues that health practitioners and young people have when using digital communications.
The study asserts the potential to reduce health care inequalities by engaging young people who are otherwise hard to reach. However, the implications of digital exclusion for young people with long term conditions may be a limiting factor. Recent analysis of variable digital access and skills can be found in Ofcom’s Children and Parents: media use and attitudes report (Ofcom, 2016). This is an area that requires more research as the potential to increase inequality through use of digital communications should be taken into account.
The generic nature of analysis of the 20 case studies did not allow for any condition-specific data to be surfaced. It would have been illuminating to understand if a number of themes, such as the use of asynchronous digital communications to facilitate discussion of sensitive issues, are specific to conditions where there are issues of stigma, such as mental health.
Implications for practice
The report shows how practitioners and young people are navigating the use of digital communications as an adjunct to face-to-face communications in everyday practice. As digital communications become increasingly prevalent it is helpful that research such as the LYNC study enables us to consider the implications in detail. The study shines a light on the emergent nature of the use of digital communications and the extent to which their use is based on trusted relationships between patients and clinicians rather than through organisational policy.
The absence of quantifiable savings identified in the report suggests that services implementing digital communications should be motivated by quality and patient experience and should recognise that workload may be increased. Even offsetting potential savings from reduced adverse events and enhanced long-term outcomes will not generally accrue to the service facing increased initial costs. Given that the dominant narrative of digital technologies in the NHS is one of efficiencies, the fact that digital communications may increase costs should be recognised from the outset.
The absence of formal ethical or safety appraisals of use of digital communications is a concern for clinical practice and should be addressed by teams during implementation. This should include a privacy and equality impact assessment in additional to a clinical safety assessment. In this way teams can identify hazards and mitigate them as appropriate.
A ‘multi-channel communications in CAMHS’ project currently being undertaken by the mHabitat team in Leeds has found that even modest introduction of digital communications in NHS services can have significant implications in terms of infrastructure, interoperability and information governance. There needs to be increased sharing of these issues, and how NHS Trusts are addressing them, to remove barriers and speed up adoption.
Conflicts of interest
Victoria Betton is currently writing a book aimed at practitioners about the use of the internet by young people with mental health problems.
Griffiths F, Bryce C, Cave J, Dritsaki M, Fraser J, Hamilton K, Huxley C, Ignatowicz A, Kim SW, Kimani PK, Madan J, Slowther AM, Sujan M, Sturt J. (2017) Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People: A Mixed-Methods Study (The LYNC Study). J Med Internet Res 2017;19(4):e102 DOI: 10.2196/jmir.7154
Ofcom (2016) Children and parents: media use and attitudes report (PDF).