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
All rapid responses
Emma Wilkinson describes some of the clinician experiences that the change from face-to-face to video consultations has brought as a consequence of Covid-19. Sussex Partnership successfully deployed a video consultation platform at this time, such that we are leaders nationally in the numbers of consultations offered this way. CAMHS and primary care services have had significant uptake, but so too have adult community and inpatient services.
It supports families being able to join in consultations from a distance without disrupting their working lives; lead practitioners joining ward reviews from different towns which brings valuable service user insights and ensures service users feel supported; as well as allowing shielding clinicians to remain part of the workforce.
A strong relationship between clinical and digital leadership, to support the socio-technical change that new technology brings, underpins the successful roll out. Early surveys show excellent clinician and service user feedback.
Following the initial drive that comes from a burning platform, there is now time to be more considered in order to ensure further adoption and sustaining change.
Key is the development is of user friendly technical but also clinical guidance, such as how to manage self harm if it presents virtually, or the limits of virtual consultation for trauma related work as patients describe reliving their experiences in their homes impacts the sense of it being a safe space. Beyond this is guidance around managing emotional exhaustion for staff who report back to back video consultation as more tiring than face-to-face work.
Working with groups brings challenges in term of the need to see all attendees on the screen at the same time and introducing new service users to virtual groups, along with new skills such as managing groups virtually. The technical aspects of ensuring attendee's email addresses and phone numbers are not visible requires thought.
Services are taught the NASSS framework (1) so that they have a suitable tool that helps them think through the challenges that embedding technology into established patterns of working will bring. Governance process for non Trust approved platforms are required for when clinical considerations alter the balance with Information Governance concerns.
Equality impact assessments are required to ensure equity of access going forward as we consider digitally excluded groups such as older age, dementia, learning disability and potentially psychosis groups. For cognitive assessments in the older age group, we need to think through how we replace the paper based ACE examinations. Surveying usage to understand the developing requirements and optimising the digital solution is necessary, and should include mechanisms to reach out to the digitally excluded groups.
There is much learning that is happening with this new modality, such that setting up appropriate forums for multi-disciplinary sharing of new learning to avoid silos of knowledge is helpful.
Lastly, structures to support working across organisational boundaries are needed to bring in the possibilities of real transformation in the way service users interact with the health and care system. Involving service users in the redesign from the concept stage is critical. This aims to reap the benefits of integrated system working, namely patient experience and outcomes, and better ways of working for clinicians (2).
There will be some losses and more gains in the transformation, but the genie is truly out of the bottle, and whilst it will need some shaping going forward, there is no possibility of it returning.
1 Greenhalgh T, Wherton J, Papoutsi C, et al. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res. 2017;19(11):e367
2 Baxter, S., Johnson, M., Chambers, D. et al. The effects of integrated care: a systematic review of UK and international evidence. BMC Health Serv Res 18, 350 (2018)
Competing interests: No competing interests
RE: COVID-19 an opportunity for strengthening mental health service delivery in the UK
Emma Wilkinson summarises how mental health services are adapting to provide care in the pandemic (1). COVID-19 offers an extraordinary opportunity to revisit and strengthen mental health services in the UK and long-term service delivery.
The pandemic has stormed through the country at challenging times for the National Health Service (NHS), mental health and social care organisations (2-4). The NHS has responded by shifting resources to tackle the urgency of the situation and create additional capacity within the system. Whilst clinicians have adapted to these difficult times (1), the public has reacted with great sense of solidarity and cohesion, by volunteering within the NHS-COVID-19 effort (https://www.england.nhs.uk/2020/03/250000-nhs-volunteers/).
The next step is to prepare for an increase in demand for mental health services related to COVID-19 in the months to come. This is based on multiple evidence, including the recent Royal College of Psychiatrists’ survey (5) and the knowledge from the psychosocial consequences of the 2002 and 2004 pandemics of the Severe Acute Respiratory Syndrome (SARS), caused by a pathogen similar to COVID-19 (6-8). The two SARS pandemics resulted in a substantial increase in the rates of anxiety and depression lasting beyond the duration of the infection itself (6). The difference between COVID-19 and SARS is in the higher magnitude of COVID-19 transmissibility. Based on COVID-19 versus SARS number of infections in June 2020, the ‘transmissibility ratio’ is currently 853:1 according to data from John Hopkins University and the NHS (6.910.014 vs. 8098 known cases) (7,8).
Mental health services require to prepare in the next few months to meet the need of individuals already known to suffer with mental health conditions and also: 1) patients with COVID-19, 2) those with pre-existing physical conditions other than COVID-19, 3) the general population for new unfolding cases and 4) COVID-19 exposed healthcare professionals. This response to meet the need for increased capacity could constitute the basis to strengthen the delivery of mental health services.
During the pandemic ‘NHS England and Improvement' (https://improvement.nhs.uk) has launched a ‘24/7 all ages mental health support service’ (9). This is a very helpful point of entry into mental health service to reach people in need when a face-to-face assessment is not possible or preferable (9). It is also an efficient and cost effective approach at any point in time in coordination with mental health services, within COVID-19 response and beyond the time of the pandemic.
China showed at the zenith of the infection, that mental health service can shift from clinical interactions to telephonic and on-line consultations (10). This approach is useful to improve efficiency of care delivery in mental health by reaching individuals in quarantine or self-isolation during the pandemic but also offers flexibility and alternatives to those not keen or able to engage in face-to-face consultations for various reasons at any time point (10).
Online self-assessment tools can be used to boost mental health resources during COVID-19 and beyond, to screen for psychopathology, and to help identify patients in need for a more comprehensive assessment which can result in improved time management, better use of resources and could save costs to mental health services.
Around 318,000 health apps are available, 10,000 or more in mental health (11). Already existing or new online services or ‘digital apps’ can provide essential information, and possibly deliver simple interventions to boost resilience during the pandemic (10) and personalise mental health care delivery in the post COVID-19.
COVID-19 is a challenge for health services but also provides an opportunity to utilise the rapidly improving technology infrastructure to adjust future service delivery and expand capacity in mental health infrastructure in the UK.
1) Wilkinson Emma. How mental health services are adapting to provide care in the pandemic BMJ 2020; 369 :m2106
2) Papanicolas I, Mossialos E, Gundersen A, Woskie L, Jha AK. Performance of UK National Health Service compared with other high income countries: observational study. BMJ. 2019; 367: l6326. doi:10.1136/bmj.l6326
3) Iacobucci Gareth. Mental health services: CQC warns of “perfect storm” BMJ 2019; 367 :l6032
6) Tsang HW, Scudds RJ, Chan EY. Psychosocial impact of SARS. Emerg Infect Dis. 2004;10(7):1326‐1327. doi:10.3201/eid1007.040090
11) Marshall JM, Dunsan DA., Bartik W. The Digital Psychiatris: In Search of Evidence-Based Apps for Anxiety and Depression, Frontiers in Psychiatry 2019 10: 831. DOI=10.3389/fpsyt.2019.00831
Competing interests: No competing interests