How mental health services are adapting to provide care in the pandemicBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2106 (Published 02 June 2020) Cite this as: BMJ 2020;369:m2106
As the NHS rapidly ramped up critical care capacity to deal with the surge of severely ill covid-19 patients, other specialties quickly had to rethink how to manage routine care while avoiding face-to-face contact with patients when possible. For mental health services this has meant a host of changes, the biggest being the rapid adoption of video and phone consultations— an approach that had rarely been used in a field where relationships and trust between clinicians and patients are vital, and where body language and eye contact are a key part of assessment.
Billy Boland, consultant psychiatrist and deputy medical director at Hertfordshire Partnership University NHS Foundation Trust, says that some therapy is also being done online, and community crisis teams that have always worked to keep people out of hospital are making greater use of technology.
He explains, “Most services have not stopped seeing people face to face completely, but they have definitely tried to adjust. It is more widespread than it has ever been.” Communicating with a patient who is not in the room can be hard, he says.
“When examining a patient you are trying to get a feel for their mental health symptoms, and that assessment includes how they look, how they behave, [and] how they respond to your questions,” says Boland. “It doesn’t mean it can’t be done, but you have to consider the differences.”
Alka Ahuja, consultant child and adolescent psychiatrist and visiting professor at the University of South Wales, believes that “mental health is something that aligns itself very well with telehealth” but that it is a cultural shift for clinicians to use it. She says, however, “with covid the mindset has changed overnight, and people are very keen to give it a try.”
Ahuja had been heading up a project to implement telepsychiatry in child and adolescent mental health services in Gwent. When coronavirus hit she was asked to be the national clinical lead for the Welsh government’s national video consultation programme, and she has produced a toolkit to help people in psychiatry adapt to this new way of working.1 Many health boards in Wales have made mental health a high priority for rolling out video consultation technology, she says.
In Plymouth, Kate Lovett—consultant psychiatrist at Livewell Southwest, an integrated health and social care provider—had already volunteered to trial virtual appointments as part of a local programme of work with a Swedish technology company called Visiba Care. Covid-19 sped up those plans, and she now uses the Livewell Connect app to do video consultations. “It has meant I can see people, and that is a really big part of what we do. It has many advantages,” she says.
The app, which allows for multidisciplinary team meetings with patients, is also being used by the police to get help for people with mental health needs. Lovett explains, “They can use the app to contact the first response team and get virtual face-to-face support so they can get the right help.” The aim is to reduce unnecessary attendances at hospital emergency departments and ease pressure on the NHS.
Patient privacy and preferences
For people working in child and adolescent mental health services, remote working has been about finding the right balance, says Bernadka Dubicka, consultant psychiatrist at Pennine Care NHS Foundation Trust.
“People don’t always want video consultations, particularly young people. They might still be in bed, might not have done their make-up, and they don’t want to be seen face to face,” she says. “There are also issues around privacy, going into people’s homes. Some people are very happy doing a video, but people should be allowed the choice because it is very intrusive.”
Even more difficult is a new referral and trying to get a sense of the patient’s needs. “I would want to see them face to face if I’d not met them before because so much of our work is around observation of the young person and their family,” says Dubicka, who also chairs the Child and Adolescent Faculty at the Royal College of Psychiatrists. “Once you have that relationship established it’s a bit easier.”
Frightened to seek help
For people undergoing a mental health crisis, under normal circumstances emergency departments offer an important safety net. Yet, as with other non-covid emergencies, there is real concern that people will avoid contacting services when they need them.
Alex Thomson, consultant liaison psychiatrist at Northwick Park Hospital in London, says, “One of the things we’re very aware of is that hospitals have become much more frightening places, and it can be very unsettling to see everyone wearing PPE [personal protective equipment], and people are much more reluctant to seek help.
“We know of cases where people have walked up to A&E, seen everyone in PPE, and then walked away. We want to minimise the risk of exposure to anyone who needs mental health assistance, but also we want people to feel confident to ask for help.”
The solution at Northwick Park has been to set up a Mental Health Emergency Centre. This is not the specially built bespoke unit it may sound like, instead comprising a few requisitioned clinic rooms that were not being used. Getting it set up has involved a lot of good will and flexibility, says Thomson, who has been running weekly webinars for others around the country who are experimenting with this type of service.
Centres will differ, for example, on whether they use phone triage or a walk-in service or whether they are co-located with an emergency department. Thomson explains, “The advantage [of the emergency centre] is you can concentrate mental health expertise and skills and getting the right response, and you have much more control over your environment, which can be slightly calmer and less hurried than A&E.”
Infection control complications
For all mental health inpatient services, including dementia wards, introducing infection control measures and restrictions on visitors has prompted concerns about the impact on patients. Dubicka says that the changes forced on inpatient units have been particularly difficult for young people. “Inpatient services are trying to remove the risk of infection as much as possible,” she says, “and that is really challenging for young people who can’t mix together as much as normal. Video calls with your family are not the same as seeing them in person, and that is a very, very difficult balance to get right.”
Teams have had to think particularly carefully, she says, about the needs of young people with eating disorders: they are at increased risk from covid-19 in terms of their physical health and as such are having to self-isolate from their families, with services trying to avoid admission wherever possible.
Changing the risk balance
Substance misuse services have also found themselves rapidly finding new ways to provide services to potentially very vulnerable populations. This includes moving patients from a daily, supervised supply of methadone or buprenorphine to unsupervised prescriptions of longer duration. This is a delicate balance of wanting to protect patients from the risks of covid-19 and keeping people safe from potential harm caused by their medicines—or, conversely, from not having access to those medicines.
Emily Finch, clinical director of addiction psychiatry at South London and Maudsley NHS Foundation Trust, says, “We have changed our risk balance with some of the treatment we provide. We are trying to use more buprenorphine because it is less dangerous [than methadone] in terms of overdose.”
One way in which the risk:benefit calculation may change is around the prolonged release injection of buprenorphine, which some clinicians would like to see used more widely, but its relatively high cost has been a limitation, says Finch. “We would like to use more, but it is expensive, and it is going to be easier to make that case now,” she explains.
“We’re doing various trials of remote interventions. People are being followed up by phone, and generally service users have responded remarkably well,” says Finch, who is also vice chair of the Addictions Faculty of the Royal College of Psychiatrists. Yet she is worried about the most vulnerable of her service users: “If you were already marginalised this is going to make you more marginalised,” she says.
While some aspects of remote working have proved more difficult to implement, such as group therapy, Finch predicts that the telephone triage that has replaced the walk-in aspect of most substance misuse services is probably here to stay.
Likewise, Lovett sees remote working as a “big leap forward” for the way psychiatry services operate. “I can’t see us going back to how it was before,” she says, adding that patients have appreciated the flexibility. “It has to be part of a menu of choices for patients.”
Boland agrees that “a lot of people are hoping some of these changes will be for good.” But he says people recognise that big changes have been made in unusual circumstances, where teams are working with what they have. “There are groups of people for whom remote consultations might not work well,” he says. “People are really keen to do that research and get a sense of what works best.”
Funding will also influence how much any changes persist in the longer term. Thomson explains, “At the moment there is willingness to invest whatever it takes in the NHS to get through [the pandemic], and it has been heartening to see that as well as investment in ventilators and emergency care there has been a willingness to invest in mental health.
“But whether these models will be sustained or embedded will depend on that willingness to invest—and whether that is sustainable in the long term, I don’t know.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer view: Commissioned; not externally peer reviewed.