Table 1 summarises the perceived benefits of and concerns about the introduction of a digital tool for parents, health visiting professionals, LA colleagues and policy colleagues at DHSC. Stakeholders perceived the benefits of a digital tool to be: possible improvement of the user experience; modernisation of the system; and improved automation and efficiency. Conversely, stakeholders expressed concerns that a digital tool may, in time, replace valued in-person contacts; may exclude certain groups of people; may be impractical; may be incompatible with pre-existing systems; be costly; and require thorough training and staff motivation.

Table 1 Perceived benefits of and concerns about introduction of a digital tool to measure child developmentPerceived benefitsImproving the user experience

A digital offering was perceived by all groups as being able to improve the user experience by constituting part of a broader, centralised online hub wherein all information about children’s health and development, including access to developmental review materials, would be kept.

LA colleagues emphasised the importance of digitisation efforts to “really be a system-wide piece of work rather than, you know, a standalone digital ASQ®−3”. Stakeholders suggested that a digital offering may make the tool more accessible by potentially providing text, video, and aural examples of the questions to aid parents’ understanding of child development. They also highlighted the importance of being able to administer the tool in the parent/carer’s primary languages, and hoped that a digital offering might make this a possibility. Parents and health visiting professionals also noted that a digital hub could provide instant messaging channels that would improve parent/carer engagement with the health visiting service, facilitating easier, more personalised communication between parent/carers and the health visiting service.

Modernisation: a digital tool for a digital world

All groups highlighted the need for modernisation of the services. From LA and policy colleagues’ perspectives, a key consideration was the reputational impact of retaining analogue tools/services; LA and policy colleagues emphasised that providing an online service would fit with government objectives to digitise across all national services. Participants across all groups noted that current reliance on the postal service to distribute key information and materials for the 2–2½ year health and development review is a risky and costly strategy, both in terms of monetary and environmental cost. From a commissioning perspective, LA and policy colleagues at DHSC emphasised that it would be prudent to ensure that any services commissioned in the future are as up-to-date and ‘future-proof’ as possible: “I think it’s unrealistic that we can have no digital system for another 10–15 years. It already feels outdated” [Policy colleague].

Automation and efficiency

A digital tool was perceived as having potential to automate processes, ultimately making the service more efficient. A digital offering was perceived as having potential to save time and money on administration costs, presenting “an alternative to stuffing envelopes with ASQ®−3 questionnaires and posting them out… we’re looking at the capacity of staff it takes to actually send them out” [LA colleague].

Parents felt that a digital offering complete with video examples of each ASQ®−3 item may help them provide more objective and accurate responses. Policy colleagues at DHSC emphasised the urgent need for data management infrastructure to enable automatic inputting of parents’ ASQ®-3 responses into LA systems so they can be “automatically flowing to the back end for any statistical purposes” [Policy colleague]. One LA currently trialling a digital ASQ®−3 confirmed this as a priority as, due to system incompatibility and cost of licencing, their staff had to manually input ASQ®−3 data from the web-based ASQ®−3 data location, to their local data management system, thus effectively doubling the workload.

ConcernsDigital must not replace in-person contacts

Parents, professionals, DHSC policy and LA colleagues took care to emphasise that a digital offering “should not replace the conversation with the health visitor” [Parent]. A digital option was explicitly framed as something that could enhance, not replace, the 2–2½ year health and development review as detailed above, and that time and energy saved on sending and scoring hard copies of the ASQ®−3 could be spent on other crucial aspects of the review, such as health promotion:

“This isn’t a plan to just say ‘just do it online’… even for those families where everything is tickety-boo, there will still be a contact because there are still messages and information to be given at that contact.” [LA colleague]

However, we also heard that in some places, the digital tool was already being seen as a way to target for the ‘universal’ review. One LA colleague reported that they wanted to “see how far [we] can stretch the mandation […], not only with skill mix, but actually with digital options, face-to-face options, questionnaire options”, indicating that a digital option could replace the in-person health and development review for some people (for explanation of ‘skill mix’, see Box 1).

Universal reach

Participants from all groups raised concerns about the extent to which a digital tool may have universal reach. Most commonly, concerns were raised that digital poverty and national inequalities in internet connectivity may exclude certain families. LA and policy colleagues at DHSC acknowledged this and emphasised that “we wouldn’t ever want a digital-only system so as to be able to include families who are not able to get online.” [Policy colleague].

Practicalities of using a digital tool

Parents and professionals observed that the ASQ®−3, particularly in combination with the ASQ®-SE, is very long and so may prove difficult to complete on a laptop/phone in one sitting. A priority for policy colleagues at DHSC was that any digital tool be designed carefully to ensure its fitness for purpose as “if you're having to print it out and go in, do it and upload it… that removes the whole purpose of the digital side of it.” [Policy colleague].

Data management and systems

Policy and LA colleagues raised concerns about the need for a digital tool to integrate effectively with local authorities’ current data management systems. Both acknowledged the potential difficulty of devising a digital format compatible with the various data management systems used across the country (e.g., EMIS, Rio, SystmOne). It was important to health visiting professionals that automatically imported parent-reported data be made available in a way “that we can edit it, rather than it just being what the parent said… that goes on their notes” [Nursery nurse] so that professionals can provide their independent assessment. Health visiting professionals also raised pragmatic concerns that automatically imported ASQ®−3 scores may become out-of-date by the time of their health and development review appointment, as “quite often parents will rebook their appointments” [Nursery nurse].

Cost and licencing

Policy colleagues noted that a lack of a unified data management system could make offering a digital option complicated and costly for LAs. One LA team that had begun the process of negotiating a licence for a digital ASQ®−3 found this complicated and associated with considerable financial risk and ultimately concluded that the risks outweigh the benefits of having a digitally available tool, suggesting that negotiating a digital licence “should be offered nationally” [LA colleague].

Staff training and motivating practitioners

Policy colleagues at DHSC recognised that “a lot of training, a lot of guidance, a lot of encouragement” and reinforcement of existing infrastructure would be needed to ensure health visiting teams deliver and record the results of a digital tool in the intended way. Similarly, LA colleagues stressed that staff will “need to be taught and coached”. A key consideration raised in this group was how the nature of the health visiting role has changed significantly over time, and how a shift to digitalisation would represent further change. Staff buy-in, by providing a clear message on the purpose and correct usage of the digital tool in the context of the health and development reviews, was deemed to be critical:

“There are skills with using this kind of technology that they need to adapt to… their course doesn’t really prep them for working in this way. We really need to bring [health visitors] with us, because we can’t lose any more.” [LA colleague]