Revitalising mental healthcare after covid-19
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2122 (Published 02 November 2022) Cite this as: BMJ 2022;379:o2122
At the start of the covid-19 pandemic, mental health services needed to maintain access to support while protecting patients and staff from the virus.1 In May 2020, NHS mental health trusts in England opened 24/7 helplines offering advice and support.2 Some trusts created alternatives to emergency departments, with calmer environments for urgent assessment.3
More than two years later, record numbers of people are seeking help. In July 2022 more than 1.6 million people in England contacted NHS mental health services—up 22.7% from April 2020, in the first peak of the pandemic. Open referrals of children and young people are 66% above pre-pandemic levels..4
This may represent just the tip of an iceberg. In a Royal College of Psychiatrists survey in March 2022, a third of people reported worsened mental health owing to the pandemic.5 The Centre for Mental Health charity estimates that 10 million people in England will need mental health support because of the pandemic in the next three to five years, including people with complex grief, trauma, and burnout.6
The past two years have also taken their toll on overstretched mental healthcare staff, with many feeling burnt out and exhausted. A depleted workforce and underinvestment have presented ongoing challenges for the sector, the royal college says.78 Children’s services are also under severe strain.9
Despite the bleak statistics, however, innovation in delivering support, tackling waiting times, and preventing mental health problems from escalating give some cause for optimism.
Patient choice
In the past two years video and telephone consultations have become the norm, “saving time, increasing accessibility, and helping staff deal with the growing numbers of people in need of help,” says Adrian James, president of the Royal College of Psychiatrists. And they seem set to be adopted for the long term.
These approaches have been welcomed by many patients, he tells The BMJ. “They feel more comfortable accepting care from home. If you have paranoia or depression, for example, you naturally have more concerns about getting out and meeting people.”
However, they are not a blanket solution for rising demand.10 James adds, “There are sometimes issues you pick up in the consulting room about people’s emotions that you don’t notice online.”
The charity Mind notes that some service users may find digital offerings unsuitable.11 “People need a choice, so that if a digital offering doesn’t suit them they can get to see a practitioner face to face,” says Paul Spencer, head of health policy and campaigns. However, not everyone who wants an appointment face to face can have one—Spencer says that waits can be as long as a year.
Before the pandemic Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust had offered online video consultations as part of a small pilot scheme carried out for three months in 2019. Use was low, owing to clinician and patient choice. The trust was planning to extend the pilot scheme to other services, but the pandemic hit, and in April 2020 the solution was provided to all community areas. An average of 2500 online video consultations now take place each month.
“Just as effective”
An evaluation of the trust’s scheme by Sheffield Hallam University found that patients tended to prefer video calls to attending clinics or home visits, and 93% of patients wanted to receive future mental healthcare this way.12 Patients who would have attended a clinic typically saved as much as 60 minutes and £6 in travel costs for each consultation. When compared with home visits, staff reported saving 25 minutes per appointment.
The trust’s chief clinical information officer, Jonathan Richardson, says that staff and user engagement depends on digital teams, clinical teams, and service users working closely to shape how technology is used. As part of the pilot scheme the trust engaged with service user groups and held engagement sessions with the pilot teams, working with them and the trust’s Patient Information Centre to develop supporting materials.
Using their clinical judgment, clinicians identify patients to offer an online consultation as another option for receiving care. One service user describes how video online consultations have “given me my life back—it has been just as effective as previous face-to-face appointments.”
More collaboration in the community
Another positive development accelerated by the covid pandemic is a culture change in community mental health services, where healthcare, social care, and the voluntary sector work more collaboratively.
Since 2020, Somerset’s Open Mental Health service has brought together Somerset NHS Foundation Trust, the charity Rethink Mental Illness, and social care, as well as local and national voluntary, community, and social enterprise organisations. Initially funded by NHS England, services are commissioned by Somerset Clinical Commissioning Group, and the partnership aims to avoid repeated referral and reassessment of patients.
Jane Yeandle, the Somerset trust’s service director for mental health and learning disabilities, says that a “no wrong door” approach means that, wherever someone presents, they will always be directed to the help they need. The Open Mental Health service provides not only interventions such as talking therapies but also support regarding wider determinants of mental ill health, such as referral to Citizens Advice for help with benefits and housing.
Open Mental Health has 10 peer support workers who have experience of mental health challenges and are paid. A further five are in training, and four more have been recruited. These “experts by experience said that too often they were ‘bounced around’ a complicated system,” says Yeandle.
Expert by experience
Sue Harbor, an “expert by experience” leader for Open Mental Health who has had major depressive disorders, knows at first hand that it can be a “big struggle” to access services. She waited a year before eventually seeing a psychiatrist and receiving treatment in 2019. “When you’re in crisis this is compounded by the fact you can’t get help—you feel desperate and hopeless,” she says.
Harbor uses her experience of mental health services to support Open Mental Health in engaging with people with serious mental illness, including looking at how to encourage patients to take up physical health checks. She says that Open Mental Health’s approach means that service users are “directed to the right services for them at that time, without them having to tell their story over and over again.”
Knowing that people are benefiting from her experience has been “amazing for my confidence,” she says. “I’m in a much better place, and my involvement with Open Mental Health has made me feel listened to and valued.”
Speedier support and cultural change
On average, 3600 contacts a month are seen by Open Mental Health—and promptly: people wait an average of two days from contacting the service for support, while the national standard is four weeks.10
Working in alliance, including local meetings held at least weekly, has been a “huge cultural change for all our staff,” says Yeandle. “It’s been important to learn to trust and work with one another and not work in silos.”
Trusts should “scope their local stakeholders and voluntary organisations, build those relationships, and see what opportunities there are to combine forces . . . listen to the people who use your services, and allow them to develop them,” she advises.
Will Higham, associate director of programme innovation at Rethink Mental Illness, tells The BMJ, “Post pandemic, the community approach is the right approach. In particular, the peer workforce can be a pathway to recovery for people, as well as being crucial to helping solve the workforce shortage, as there simply aren’t the clinical hours to deal with the level of need out there.”
Doctors can be “powerful leaders” for mental health in their communities and can help drive service innovation, says Higham. He explains, “Find willing partners in your community to help meet the wave of need we’re facing. Meet your local mental health charities, find out what ‘transformation plan’ your trust is putting together and feed into that, and look at what resources you can unlock to make a difference in your area.”
To help deal with the huge pressures facing community and specialist services, Andy Bell, deputy chief executive for the Centre for Mental Health, tells The BMJ, “We need to prioritise early intervention—for example, by investing in open access youth advice and counselling services, and by locating more mental health support in GP surgeries.”
Early intervention for under 18s
Since March 2020, NHS Grampian’s Psychological Resilience Hub has offered early support to more than 600 children and their families. This virtual service aims to prevent mental health problems related to the pandemic, such as experiencing anxiety and reaching crisis point, to reduce demand on child and adolescent mental health services and GPs.
Gillian Strachan, a consultant clinical psychologist who manages the hub and helped set it up, tells The BMJ, “Our service uses psychological first aid—an approach designed to support people during or in the aftermath of a serious event—ensuring early intervention, in an easy to reach manner, via online self-referral. This approach removes many barriers to accessing mental health support, such as the need for multiple referrals.
“Helping a young person manage their panic attacks through cognitive behavioural therapy, preventing a more severe disorder down the line, is one example of many interventions this service has made.”
One service user says of the hub’s approach, “My feelings and emotions were validated, and I never felt judged by my struggles during this time. Coping techniques were given, and just having someone to acknowledge and listen helped hugely for me.”
In the past few months the initiative, which was developed as a time limited support in response to the pandemic, has come to a natural end. Referrals to the service began to reduce, and staff supporting the initiative returned to their substantive roles. However, Strachan says that it could be adapted as an early intervention psychological service for children.
Patient case study: phone, video, or face to face
“It’s hugely positive how mental health services have evolved”
Darren McCartney, 40, from the south east of England, found video consultations during the pandemic helpful for continuity of care.
“I’ve experienced mental health problems since I was around 16 years old,” he says. “I have been diagnosed with complex PTSD, OCD, and clinical depression. Talking therapies, as well as EMDR therapy [eye movement, desensitisation, and reprocessing], have helped me get to the root of some of my problems. It’s important to work with a therapist who you can build a rapport with.
“When the pandemic hit, my therapist was very proactive in making the decision to switch our weekly face-to-face appointments to video calls—something I’d never envisaged in a medical context—and the service was adapted very quickly. I was very thankful for every call.
“Having a remote consultation meant I needed to find a private space in my home setting. Video consultations were not the same as a personal visit to my therapist, because I wasn’t able to be as emotionally open and ‘present’: sometimes I would lose concentration in front of the screen. It’s also more difficult to understand the therapy techniques being demonstrated via video than in person.
“But the remote sessions were valuable because they ensured the service was consistent—and when you have mental health issues, consistency is key.”
He adds, “I’ve also called on crisis lines on many occasions. At my lowest points, I’ve picked up the phone to crisis services. But their responsiveness varies, and some ‘emergency’ app services that require you to text can take many hours to reply. I’ve also had phone consultations, which can feel very mechanical.
“During the pandemic, my talking therapy came to a natural end, and I was referred to a trauma based service for specific therapy for my PTSD. However, due to pressures on services because of covid-19, I was on a waiting list for seven months. Since March [2022] I’ve been having weekly face-to-face appointments.
“I believe it’s hugely positive how different mental health services have evolved since the pandemic, particularly the way remote consultations have opened up new ways of communicating with health professionals and are helping with demand on services.
“Post pandemic, a one size service for mental health issues won’t fit all. Services in the future need to continue to be varied, based on individual need. For example, some people may prefer a phone or video call because they find having to make the journey to an appointment hugely stressful. But, however a service is delivered, it must be regular and reliable.”
Footnotes
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Patient consent obtained.
Provenance and peer review: Commissioned; not externally peer reviewed.