While COVID-19 is a physical condition this crisis is having a profound impact on the nation’s mental health and across all health and care services and their staff. The ONS has reported a sharp rise in the number of people reporting high levels of anxiety and our survey of our members has found that there has been an increase in the number of urgent and emergency cases seen by psychiatrists.
Our recent surveys of members (15th-17th April and 1st-6th May) have also highlighted significant concerns that psychiatrists are being forced to put themselves and their patients at risk, delivering care without adequate PPE or access to tests for themselves, their families or their patients.
How has demand for mental health services been affected by the pandemic?
Our survey of psychiatrists working in the NHS has found that the COVID-19 crisis has led to an overall increase in emergency and urgent appointments and an overall decrease in the number of patients they have seen for more routine support:
The decrease in non-urgent cases is as concerning as the rise in urgent and emergency cases. It is much harder for mental health teams to deliver routine services while managing social distancing, dealing with an increase in urgent and emergency cases and supporting patients who may have COVID-19.
Members report to us their concern that temporary drop offs in some activity represents a calm before the storm, due to some services being delayed and some patients avoiding contact due to fear of infection or concern that they are being a burden on the NHS. It is critical that people are aware that NHS mental health services are still open. Those who fail to get the help they need now, may become more seriously ill further down the line.
According to our survey psychiatrists working with older adults, they have seen the biggest decrease in regular appointments. Over half of respondents stated that long term appointments have either decreased or significantly decreased since the crisis started. Unfortunately, this is not surprising considering they are the group most at risk from infection and have been advised to take extra precautions around isolating. It may also be that they are the group less able to engage with their mental health team via increasingly adopted methods of remote working such as online video calls. Although it is important not to generalise and assume all older people will be uncomfortable talking to a psychiatrist over the internet.
Our faculty of older adult psychiatry has also reported restrictions on care home admissions. Although, this is for the safety of existing residents our members are concerned for their patients with advanced dementia who need constant support and care but cannot be admitted to a specialist facility.
Our survey found that psychiatrists working in Liaison mental health, and General adult services have had the biggest increase in emergency appointments/interventions.
Members are also reporting a significant drop off rate in regular referrals to child and adolescent mental health services. Far fewer children are being referred from primary care to mental health services or the IAPT programme and fewer people are accessing treatment for eating disorders. This is particularly concerning for patients with mental health conditions which have an increased mortality rate such as eating disorders, bipolar disorder and schizophrenia.
Some of our Forensic Faculty of psychiatrists working in secure NHS facilities and prisons have also expressed significant concerns about their ability to care for patients. They have faced a reduction in referrals and a reduction in the number of hospital patients they've been able to transfer to community services. It is particularly difficult to deliver services in prisons as many of our members have struggled to access patients although we have had reports that this is improving.
Another area where our members have expressed significant concerns is within addiction services. Our Addictions Faculty members have told us that some people with alcohol addictions problem are drinking much more and becoming even more chaotic in their lifestyles as a result of the pandemic. We have had reports of a significant number of people relapsing because of the strains of lock down and being cut off from their friends and families.
How mental health services have adapted to deal with the crisis
Many providers of mental health services reacted quickly to change the way services act in response for the crisis. Our survey found that around a quarter (24%) of members are currently working an 'altered timetable due to reconfiguration of services'.
During the COVID-19 pandemic, it is essential that those who use mental health services continue to get the care they need. Remote consultations, using telephone calls, audio and video to provide care for patients has already become a fundamental part of the way mental health services provide care. As we move beyond the peak of the crisis, this is likely to become more standard practice and there are moves to increase capacity for this in the coming weeks.
Further to this, our survey found that around 17% of Psychiatrists are currently working remotely, showing that services are able to provide flexibility for staff as well as patients.
Those with lack of digital literacy, lacking in confidence using technology or with little or no access to digital platforms must not be disadvantaged. Use of telephone consultations, rather than more complex video platforms may be sufficient for lower risk conversations or to ensure engagement with those who lack digital technology or skills.
The College has published online resources for people with a mental illness and their carers on issues such as medication and how to manage their conditions during the crisis.
Access to PPE
A pair of college surveys found that psychiatrists are being forced to put themselves and their patients at risk, delivering care without adequate PPE or access to tests for themselves, their families or their patients[i].
One psychiatrist surveyed said “There are extreme shortages of PPE and most of us are at risk. Only very limited supply is obtained and most of the time frontline staff are refused risking their lives. Staff are terrified and afraid.”
Our latest survey (in the field from 1-6 May) has shown that a significant proportion of psychiatrists are concerned that they are not able to access the level of PPE set out in the guidance.
The national and regional breakdowns are as follows
Chart 1 - Are you able to access the following PPE kit when you need it (in line with the latest guidance from your organisation)? (NB – don't know responses were excluded)
Some of our members have previously expressed concerns about the potential impact the lack of adequate PPE is likely to have. Some of the most concerning responses to our first member survey (in the field from 15-17 April) included members saying that:
Access to testing
The other major concern raised by our members is that a significant proportion are unable to access tests for themselves, their families or their patients if they have concerns if they have COVID-19. The current Government guidance states that any NHS worker or their family member with suspected COVID-19 should be able to access testing and that tests should be given to any new patient entering an inpatient setting.
When our members across the UK were surveyed (1-6 May) we found that:
These findings match the research by NHS Providers who found that mental health leaders felt that they were significantly disadvantaged in the process of accessing tests[ii].
Infection control and prevention
The majority of mental health units in the UK were never designed to contain a highly contagious illness. Potential environmental risks include aged estates with a significant proportion of dormitory style accommodation, small shared offices, shared computers, shared patient facilities, sitting or dining rooms, shared toilets, poor ventilation and air-conditioning. Particularly worryingly last year there were 1,176 patients having to share mixed dormitories[iii].
In addition, it is often the case that some patients may be unable to follow advice on containment, isolation and testing, which presents a further clear infection risk to be considered and managed.
We welcome the recently published NHSE guidance Supporting patients of all ages who are unwell with coronavirus (COVID-19) in mental health, learning disability, autism, dementia and specialist inpatient facilities which includes a range of infection prevention and control measures. But we are concerned that some NHS mental health estates are unsuitable, making it very hard to follow guidance. The guidance includes recommendations that all new patients coming into a mental health, learning disability, autism, dementia or specialist inpatient facility are tested for COVID-19, including asymptomatic patients, and kept separate from other patients until they get their results back.
As shown above many of our members have expressed significant concerns that they are currently unable to access testing for their patients. To date it has been very difficult to effectively cohort due to lack of adequate access to testing, therefore it is important that effective delivery of this change in testing policy in mental health settings is monitored and not overlooked.
Many sites also lack the space to keep patients separate especially those with mixed dormitories. Consideration is needed on how mental health trusts can be supported to undertake the complex task of cohorting effectively within their estates, both in the immediate term and looking to the medium and longer term.
On admission, space is needed for confirmed COVID cases, a second space for patients confirmed via testing to be COVID negative and a third space patients whose COVID status is unconfirmed while test results awaited. In addition, patients who need shielding should be kept away from those with confirmed COVID.
It is important to understand the extent to which local areas are able to follow this guidance, and this is monitored, and additional support is offered to those areas that are struggling to follow them.
How we can we support the mental health of NHS staff?
At this time, NHS staff may feel stressed for many reasons such as having to make difficult decisions about patients’ care, the amount of work, being uncertain about the future, worrying about taking the virus home with them and infecting others, and/or less contact with family and friends.
The role of NHS team leaders, managers and supervisors is crucial to ensure NHS staff have the mental health support they need. NHS leaders need to have frank discussions with staff about the challenges that lie ahead, not to sugar coat them but also not to overstate the trauma they are likely to face. These discussions should address the difficult decisions that staff may have to make.
We also recommend supervisors speak with their teams using structured forums similar to the ones provided by Schwartz Rounds. Such forums enable staff to come together with their leader after their shift and talk honestly about what did and didn’t go right, the difficulties they faced and the associated emotional reactions. While staff will have limited time to be involved in such discussions, this approach is likely to reduce the potentially damaging mental health impacts of working on a stressful hospital ward. This should be done during staff’s normal working hours.
For further information, we have published a range of resources for team leaders and supervisors as part of our COVID-19 guidance. We have also developed specific resources for psychiatrists on taking care of themselves as well as helping other healthcare professionals.
Despite the challenges they face during the pandemic, most NHS workers will not suffer from a mental illness. With good leadership, as well as properly preparing and supporting NHS staff, most will avoid developing longer-term difficulties.
For those who do need help, we should provide evidence-based care both in the short term to help NHS staff get back to work and in the long term. The available evidence strongly suggests that the support given to NHS staff members as the crisis begins to recede is of critical importance in determining whether they will experience psychological growth, develop a mental health disorder or neither.
Supporting the health and wellbeing of NHS workers following the first COVID-19 outbreak is likely to be even more critical. To this end, the NHS must give its staff members - who have been working intensively in arduous circumstances - sufficient time to ‘reset’ before they embark on their usual work.
This time will be crucial for them to access the social support they need, and to readjust to the ‘new normal’ without being under too much pressure while trying to recover. Should there be second wave of coronavirus this rest period will be even more crucial
We have developed some concrete elements that we believe should be put in place for staff in every NHS Trust, including:
How we can we support people’s mental health after the initial peak?
It seems inevitable that once the pandemic is past its peak, there will be an increase in demand for mental health services. This may be because of pent up demand caused by the current fall in referrals, the consequences of lockdown, economic uncertainty and the trauma of contracting or losing loved ones to COVID-19.
The recent ONS wellbeing survey found that between 20 March and 30 March 2020 almost half of the population of Great Britain (49.6%) reported high levels of anxiety. This compares to 21% of people who said the same last year[iv].
A significant economic downturn following the crisis is widely predicted and there is strong evidence of a link between economic difficulties and higher rates of mental health problems [v]. We have already seen from the recent ONS survey that people who had experienced a reduction in household finances because of COVID-19 reported 16% higher anxiety on average[vi].
Mental health services, which are overstretched at the best of times, will come under even more pressure. One of the biggest causes of this is a lack of trained staff. To meet the promises already made to expand mental health services, and to meet the government’s recruitment target, reduce NHS staff vacancies and cover retirements, we need an additional 4,370 consultant psychiatrists by 2029. The most recent census by the Royal College of Psychiatrists showed the rate of unfilled NHS consultant psychiatrist posts in England has doubled in the last six years.
It is important that the commitments made in the Five Year Forward View for Mental Health and the NHS Long Term Plan are not forgotten. Between them they promised significant increased investment in mental health services which would make a big impact on the lives of many patients. While some targets might need to be altered for this year as services struggle to cope with COVID-19, we will need to redouble our efforts to make sure that mental health services are able to get back on track to delivering the ambitious programme of progress towards parity for mental illness.
[i] The Royal College of Psychiatrists issued a survey to its members working in the National Health Service across the United Kingdom. It was in the field from Wednesday 15 April until the morning of Friday 17 April. 1,685 completed responses were received out from across the UK of a total available sample of c12,900, which equates to a response rate of 13%. This includes 1,384 from among members based in England.