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A new delivery model for mental health

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By Gill Weatherill


Published 23 February 2021


While the events of 2020 and beyond have turned all aspects of healthcare on their head, few areas have been more drastically impacted than mental health. Gill Weatherill looks at how fears over personal safety, the psychological impact of national lockdowns and lingering uncertainty over job security have conspired to create a new wave of financial and mental wellbeing concerns throughout the population.

There have been calls for caution in defining pandemic-induced anxiety as a mental health issue, including Sean Duggan, Chief Executive of the NHS Confederation’s Mental Health Network, telling the BBC it would be wrong to “medicalise everything” and saying that it is “perfectly normal to feel uneasy and anxious” during this uncertain time. However, the reality is that irrespective of the cause or classification of stress and anxiety, its impact is being keenly felt.

Mental health services were already under pressure pre-pandemic and, while the healthcare workforce has showed drive and ingenuity in response to the unique demands of the crisis when it comes to the practicalities of managing patients, the sector is bracing itself for the coming crisis in mental health.

Despite the likelihood of mental health issues becoming more widespread during a time of global crisis, economic uncertainty, isolation and an increase in alcohol intake, the number of people seeking treatment or assistance actually fell as the pandemic first peaked. This was in spite of a survey of UK households published in The Lancet Psychiatry Journal showing that mental health distress levels rose after the first month of the first lockdown. This rise included a jump from 18.9% (pre-pandemic) to 27.3% in mental distress levels that would be categorised as potentially clinically significant.

The lack of help being sought may have been down to a desire not to occupy health service time with non-virus activity, as well as staying away from treatment centres due to the risk of infection. As some semblance of ‘normality’ briefly returned doctors reported a reversal of that trend, and the number of patients seeking mental health care began to increase. The numbers needing help after the most recent lockdowns could skyrocket.

In early August, NHS England (NHSE) published the next phase of its Covid-19 response, in which it acknowledges that “mental health needs may increase significantly”. Demand may soar as people feel more confident in seeking care, and as the impact of government support schemes is withdrawn and the unemployment picture becomes clearer.

Towards the end of September, the Department of Health & Social Care (DHSC) also announced a £27 million funding boost for the charity ‘Think Ahead’ to support 480 new mental health social workers and help over 10,000 people living with serious mental illness. The funding will help recruit and train a new wave of mental health social workers who DHSC acknowledges will “form a vital part of the response to the coronavirus pandemic”.

With ONS statistics showing that depression among adults has doubled during the pandemic, and credit reporting group TransUnion warning that one in four teenagers (27%) are concerned about their career prospects due to the financial stress imposed by Covid-19, wellbeing is set to be an issue that dominates healthcare for years to come.

Mitigating the impact on the workforce

Recruiting and training new staff members is one part of the puzzle; protecting and supporting existing staff members is another and it is with this in mind that NHSE has also launched a service to assist health workers with mental health and wellbeing issues.

This will be essential when you consider that a Nursing Times survey of 3,500 nurses revealed that half of nursing staff view the current level of support being provided to health and social care staff on mental health and wellbeing as inadequate. The figures make for grim reading: 33% described their overall mental health as ‘bad’ or ‘very bad’ while 87% said they were either ‘a lot’ or ‘a little’ more stressed at work than usual, rising to 90% when they were asked if they felt more anxious than before the outbreak.

At an individual organisation level, charity care provider Greensleeves Care has sought to tackle this issue for staff through increasing communication and engagement. Chief Executive Paul Newman says this was both necessary and beneficial. Elements of the approach will certainly remain.

Recognising the challenges they were facing and thanking them for this was something we wanted to repeatedly reinforce,” says Newman. “We moved from three printed staff newsletters per year to a weekly digital communication and have now settled on monthly. We were keen to show to our staff, residents and relatives that despite the unfolding pandemic, people were still able to enjoy activities and celebrate life, from VE Day to Fathers’ Day and Carers’ Week.”

Greensleeves normally hosts an annual Care Awards ceremony in London for 250+ staff members. Rather than cancel the 2020 event, it made July the Care Awards month, a celebration that included 16 awards being presented digitally across the month.

At Circle Health Group, Employee Assistance Programmes were updated and existing schemes adapted for remote use. Having seen their impact, with thousands of users joining virtual fitness sessions for example, Karen Prins, CEO, intends to progress many of these programmes. A staff ready, willing and able-ness survey was issued to guide leadership action, and an additional wellbeing support helpline was set up with executives taking turns to field calls from staff directly.

Moves like this may seem small-fry in the grand scheme of a global pandemic, but their impact should not be overlooked.

The fantastic thing about this was that we were able to engage far more staff and residents in the award-giving process thanks to Zoom,” says Newman. “When social-distancing allows, we will host a Winners’ Lunch to thank everyone in person. Due to the much higher levels of staff and resident engagement, we are considering adopting this innovation in the long-term.”

Reimagining regulation

Of course, regulation has had to – and will continue to – evolve in tandem with new working methods. The Care Quality Commission (CQC) was forced to adapt how it regulates and inspects health and social care services mid-pandemic. Newman, like many in the sector, understands and agrees with the decision from CQC to move to the Emergency Support Framework (ESF), but he looks forward to the return to ‘routine’ inspections as a chance to show that standards are being maintained.

During the initial peak of the pandemic, CQC took the right decision and ceased routine inspections. However, I am confident that this was the time that services were focussed on safety and quality like never before and we would have welcomed the opportunity of an inspection to demonstrate this. The ESF worked well but cannot replace a robust, evidence-based inspection.

The temporary switch to the ESF, he points out, will also have been useful in identifying those services that needed legitimate intervention and which will require further support going forward.

The CQC have now published their 5 year strategy consultation, together with what may be the first of many associated consultation processes, which start to put into focus the strategy planned. This begins to reveal some of the detail about how the regulator plans to achieve a more responsive approach to ratings across the health and social care sector and suggests that there may in fact be reduced reliance on site inspections and the use of more alternative information sources for ratings. Whether such an approach will apply to all providers, and if so how, is yet to be seen.

More broadly, there is now a need to update ‘standard’ safety and quality checklists. Regulators and family members alike may be adding crisis preparedness – for instance an organisation’s ability to procure PPE equipment effectively – to the factors they weigh up when assessing care home suitability.

Add to the above the continuous, sector-wide pursuit of technological solutions to boost the functioning of healthcare post-pandemic, and it becomes clear that further regulatory reform is certainly on the cards, as reflected in the CQC regulatory approach which ‘will adapt and respond as the situation changes’. This is likely to accelerate given that, when it comes to technological adoption, years of reluctance and scepticism are being broken down.

In many health services including mental health, there’s always been a resistance to handing over decision-making to what psychiatrists would see as machines,” says Lesley Soden, Programme Director at Health Innovation Network. “But we are seeing a shift. Our innovation grants have also funded a project around simulation labs, where staff test out the digital mental health solution and figure out how it operates, second stage is that actors are used to simulate and test things out in different scenarios that would replicate a patient scenario.”

Training to make staff more comfortable is proving effective, and the public’s willingness to transition to new models is also driving uptake.

This is important to build confidence from clinicians to embrace this technology, especially now the public is more used to this way of working,” adds Anna King, Commercial Director at Health Innovation Network.

At Greensleeves, social media and mobile devices have been critical in facilitating communication between residents and loved ones, but also in demonstrating to those loved ones that activities and events have continued within the homes, while reassuring them that those activities are being done in a safe manner.

In some instances, pre-existing technology has been redeployed for Covid-specific purposes.

Last year, we decided to pilot acoustic monitoring technology to make night care more responsive and take safety to the next level,” says Newman. “We have been able to deploy this technology 24/7 to detect new persistent coughing in residents, one of the chief symptoms of Covid-19.

Global tsunami

Bupa Global’s Executive Wellbeing Index reveals that 78% of business leaders have experienced poor mental health during the pandemic, while the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) describes the situation as a “global tsunami of mental health problems”, so it is clear that the issue must be tackled head-on while we are in an environment that fosters reform and innovation.

It is encouraging, therefore, to see DHSC already showing a willingness to be creative in tackling this tsunami. The wider solution will require new training and recruitment, as well as those new ways of thinking and new support tools. Crucially, there will also need to be an acknowledgement that the same issues facing the public-at-large are also going to be increasingly prevalent among a healthcare workforce that has shown steadfast levels of commitment despite the unique challenge that has faced them.