In the latest of an ongoing series of articles on how mental health services are meeting their clients’ pre-existing and emerging needs during the COVID-19 pandemic, Sebastian Rosenberg takes us to the UK’s coronavirus epicentre in London.
The UK’s outbreak has been swift and terrifying, but there are many lessons here, on how being community and client focussed is a valuable asset, even in the worst of crises.
Sebastian Rosenberg writes:
This is a short report summarising the third in a series of e-presentations about the international impact of COVID-19 on mental health, jointly hosted by The Centre for Mental Health Research (CMHR) at the Australian National University and ConNetica Consulting. There were more than 100 participants in the webinar.
This webinar focused on the situation in London and was presented by Professor Helen Killaspy, Professor of Rehabilitation Psychiatry at the University College London, and Honorary Consultant at the Camden and Islington NHS Foundation Trust in London.
Killaspy began by explaining that the UK Government’s position on COVID-19 had shifted over critical weeks, from their initial policy aimed at containing the virus, then to delay and finally to suppression.
Modelling showing a severe potential impact of COVID-19 was published by Imperial College. However, as late as 19 March, government information on social distancing was provided to the population as ‘strong advice’.
This strong advice was tested on the weekend of 21-22 March when fine weather saw Brits flood beaches and outdoor spaces.
As a result, March 23 saw the Government impose the kind of social isolation ‘lockdown’ measures in place now in Australia.
At the time of the Webinar, London had 40 percent of all COVID-19 cases in the UK (51,500 cases – now in excess of 84,000) and more than 1,000 deaths (now more than 10,000).
The National Health Service opened a new ‘field hospital’ in London, NHS Nightingale, with more than 4,000 ventilated beds.
Killaspy stated that the virus had caused significant changes to the way her Trust (service) responds to mental illness. First, the Trust had invoked “Gold Command” – a system of strategic decision-making in a crisis which creates centralises and elevates decision-making authority.
The Camden and Islington Trust directs 97 percent of its effort towards community-based mental health services. The virus has disrupted the usual work of the crisis, early intervention, rehabilitation, alcohol and drug and other community mental health teams.
In response to COVID-19, face-to-face service provision has been minimised wherever possible, to reduce the risk to both clients and service providers. Of 450 mental health clients in the Trust, 27 had been recorded as having COVID-19, with 20 of these inpatients and 7 community clients.
Killaspy was not aware of any data yet demonstrating the relative vulnerability of mental health clients to COVID-19 in comparison to other clients.
Gold Command issued guidance to workers so they could understand how self-isolation, hygiene and social distancing needed to work, how to report cases, how to work from home, how to access e-health records and teleconferencing.
It was also important to identify clients particularly at risk from COVID-19 who may need ‘shielding’ – this included older people and people with chronic comorbidities.
Killaspy stated that mental health workers – and all workers – faced an ‘avalanche of guidance’ about how to respond to COVID-19. While this guidance was critical, so too was the responsibility to properly interpret and apply this guidance to suit local needs and context.
Forums were set up to engage mental health staff to discuss experiences and consider how best to apply sensible guidance locally. A key question was what to do when a service user was simply unable to follow guidance.
How to manage medication from two metres? How should social workers and others use this guidance? These forums worked to discuss these issues and feed them back into centralised decision-making about COVID-19 guidance, to improve their usefulness on the ground.
For people with severe mental illness, understanding guidance about new social distancing rules could be challenging, understanding why and remembering to wash hands and so on.
People with severe mental illness could see the news, see increased police presence, people in masks and shops enforcing distancing rules. This was intimidating and authoritarian for some clients. Hard won self-management skills were at risk, undermining rehabilitation.
The Service response
One of the Trust’s recovery centres was transformed into a psychiatric assessment centre. This created a new mechanism to permit mental health assessment, outside the accident and emergency department of the local hospital, in anticipation of needing to accommodate COVID-19 patients.
However, access to mental health services by new clients was very difficult and really required assessment under the Mental Health Act to proceed. In other words, the service prioritised meeting the needs of existing clients.
Presentations to Accident and Emergency have halved during the COVID-19 crisis, from 40 to 20 a week. By Australian standards in a major metropolitan area, these numbers are very small and reflect the longstanding predominant effort of the Trust to deliver non-hospital mental health care in the community.
The rate of involuntary admissions has increased from 75% to 90% of total psychiatric admissions. Inpatient mental health services have become COVID-19 wards, with nearly all admitted patients also suffering from the virus.
Information about social distancing and training in the use of personal protective equipment (PPE) and other measures has been provided to the community rehabilitation teams and across the different levels of support housing.
This is where the local interpretation of central guidance has been important. Home visits were minimised, even for the crisis team. People needing longer term access to medication were given supplies to last longer than normal. Medication reviews were undertaken to support and manage this process.
There was an increased emphasis on smoking cessation. Service providers also challenged unhelpful decisions from other services; for example, in relation to housing evictions or undesirable admissions to hospital.
In relation to the latter, with hospitals a focus of COVID-19 infection, the decision to admit a person became an ethical dilemma balancing concerns for their physical and mental health.
Telehealth mental health services have become an important part of service delivery though again, for people with severe mental illness, this has not been straightforward. It is not possible to move every mental health service online for this client group.
Private sector services often operate in tandem with public mental health services in the UK. In this sense, while the Trust was engaged in the COVID-19 response, there was no new or additional capacity to be added into the system overall.
A team WhatsApp group has been established to provide real-time support and communication. Daily briefings are provided to discuss staffing, adjust rosters, set tasks and provide a forum for conversation.
Of the Trust’s 2,200 staff, 23 percent are absent from work due to COVID-19, either personally affected or in the care of a loved one.
This does not necessarily mean they are not working, just that they are absent. But the overall impact on staffing and rosters is considerable.
Universities are all closed, and research has paused, at least into all non-COVID-19 research. No new grant funding for research is available.
The Department of Health is interested in researching the psychiatric impact of COVID-19. Processes to evaluate the impact of cognitive behavioural therapy services have been shifted online.
Impact on the Service
The Camden and Islington Trust has developed one of the most sophisticated supported accommodation responses to mental illness in the world. COVID-19 has challenged them to continue to provide this service while maintaining the usual concern for quality care and individual client respect.
The Gold Command system of decision-making needed to be considered and amended to suit local conditions.
The investment in a predominantly community-based mental health service offered the prospect of some capacity to flex and adapt at times of crisis, in a way that hospital-focused services would find difficult.
Nobody in the UK is yet talking about any kind of recovery or next phase. Service providers remain focused on getting through this crisis.
Dr Sebastian Rosenberg was a public servant for 16 years, working in health in state and federal governments. He was Deputy CEO of the Mental Health Council of Australia from 2005-2009. He is Head of the Mental Health Policy Unit at the Centre for Mental Health Research at ANU and holds a position as Senior Lecturer at the Brain and Mind Centre, University of Sydney.
The virtual meeting described above is one of a series of meetings that The Centre for Mental Health Research at the Australian National University and ConNetica Consulting are jointly hosting with mental health leaders around the world to better understand responses to COVID-19. A recording of the presentations and discussions will be available from either the ConNetica or CMHR websites.