The COVID-19 infection and pandemic has been a dominating narrative in the UK for the majority of 2020. There is no denying that the pandemic has impacted on people from all walks of life. In April 2020, it was suggested that there would be a surge in demand from UK mental health services, as people found it difficult to cope with COVID-19 related stressors (Royal College of Psychiatrists, 2020). There was an influx of new studies examining the impact of COVID-19 on the general population, although only a few focused on people who were already living with mental health problems (Sheridan Rains et al., 2020; The Lancet Psychiatry, 2020).
Mental health services faced many potential pandemic-related challenges, including staff absences/redeployment, limiting face-to-face contact (Mezzina et al., 2020) and encouraging people with high levels of distress or cognitive impairment to adhere to COVID-19 procedures (Kozloff et al., 2020). Also, the pandemic exacerbated existing socio-economic disadvantages, healthcare inequalities and traumas experienced by people with mental health problems (Danese et al., 2020; Allwood and Bell, 2020).
Johnson and colleagues (2020) aimed to gather the perspective and experiences of mental health staff, who were working in both inpatient and community settings in the UK, early on in the COVID-19 pandemic.
Experts have commented on the potential impacts of COVID-19 on service provision, but what are the views and experiences of mental health staff?
Methods
An online survey was used to collect quantitative and qualitative data from mental health staff who were working in the NHS, private, social care and third sector organisations.
The survey was developed using information from a rapid literature review (Sheridan et al., 2020) and consultation with the NIHR Mental Health Policy Research Unit (PRU) working group and the wider PRU Lived Experience working group. Seventeen clinicians then pilot tested the survey and provided feedback.
Participants were recruited through professional networks, social media and relevant mental health professional bodies. The researchers also sought to increase representation of staff from a diverse range of Black, Asian and Mixed/Multiple ethnic groups, by tailoring social media and liaising with researchers from the PRU, who had experience of working on diversity issues.
Frequencies of quantitative data were summarised and qualitative data were analysed using a rapid content analysis.
Results
The sample included 2,180 mental health staff. Themes included:
1. Current challenges at work, service activity and barriers to infection control
Inpatient and residential services
- Lack of activities meant that service users became increasingly bored and agitated, while restrictions on activities created more challenging environments for staff
- Service users had difficulty understanding and following the guidance, which was not helped by the inconsistency and frequent changes to guidance.
Crisis assessment services, community teams and psychological treatment services
- Adapting quickly to new ways of working (i.e. remotely)
- Similar levels of either an increase or decrease in weekly contacts.
Common points across services
- Lack of available community services to refer or discharge to and rely on
- Risk of infection for both staff and service users
- Managers and clinical leads more frequently reported challenges of supporting colleagues with COVID-19 related stressors (51.5%) and an increase in workload (40.6%), than those not in management roles
- Tension between upholding the new guidelines for infection control and providing a good quality and responsive service
- Availability of PPE and layout of ward and office spaces made it difficult to implement physical distancing
- Reduced activity in services (i.e., new referrals/inpatient admissions).
2. Staff views of the difficulties service users and carers face
The majority of staff thought that the main issue for service users was access to their usual social support and that social distancing, self-isolating and/or shielding would make service users feel lonely. Other concerns for service users were the lack of access to mental health, physical health and third sector services, difficulties in engaging with phone or video appointments, anxieties about becoming infected by COVID-19, being at high risk if they were infected, a decline in mental health, difficulties accessing food, money or other basic resources and increased risk from domestic abuse. Staff also discussed their concerns about specific groups of people with mental health problems (see Figure 1).
3. Service change and adaptations
Opening hours were extended to the weekend or restricted. Some services were re-organised and new crisis phone lines and assessment centres established. Furthermore, community staff started providing different types of support, which included practical help (i.e., food deliveries).
Staff were also provided with new or extended support for themselves. For instance, quiet rooms for those who felt overwhelmed, staff specific helplines, wellness check-ins, an increase in supervision and national initiatives to support wellbeing.
The major adaptation to working practices was remote-working and use of technology to interact with and provide psychotherapy to service users during the COVID-19 pandemic, which is something that has been discussed by the elves too (Bell, 2020; Bentivegna, 2020; Enoch, 2020; Tip, 2020). Views on replacing face-to-face meetings with phone or video calls varied.
| Reported advantages | Reported disadvantages |
| Remote working can be efficient | Inadequate resources |
| Allowing services to continue remotely | Potential impact on communication and establishing and maintaining therapeutic relationships |
| Some clients find it beneficial | Digital exclusion |
| Service user preferences |
4. Future hopes and concerns
Around two-thirds (67.8%) of staff said that they would like to maintain some changes made during the pandemic, for instance, remote working and new service initiatives.
However, many participants reported concerns for the future:
- Lack of resource and staff burnout may prevent services from meeting a significant increase in service demand
- Staff feared that current reduced levels of service provision may inappropriately continue and adaptations made may be used to justify reducing funding
- Extending remote working beyond cases where it was deemed useful
- Staff and service users from a variety of Black, Asian and Mixed/Multiple ethnic backgrounds were disproportionally effected by the pandemic and there could be an increase in racism and xenophobia.
Some staff would like to maintain changes, such as remote working and new service initiatives. However, staff are concerned about what the future holds for levels of service provision, funding and potential for staff burnout.
Conclusions
Overall, this article highlighted the views of mental health staff about the many challenges faced by mental health staff, services, service users and carers during the COVID-19 pandemic. However, in order to manage the impact of the pandemic and new infection control procedures, several adaptations to services were made and extra layers of support were put in place for staff.
How can we ensure that services are adequately funded and resourced, prevent staff burnout and manage the ongoing challenges of the COVID-19 pandemic?
Strengths and limitations
Due to the urgency of the topic, the survey was not previously established or validated. However, the authors should be commended for involving service users and stakeholders in designing the survey. It is also refreshing to see a lived experience commentary on the paper. This very briefly addresses the fact that the survey only collected staff opinions on the impacts of the COVID-19 pandemic. Whilst a staff perspective is important, there is still a need to obtain valuable insights from service user and carer perspectives. The authors also highlight that future studies should systematically investigate the impact on the mental health system.
Despite the authors recruitment efforts, the sample was unrepresentative of all staff who work in mental health care settings. Furthermore, professionals (e.g. GPs, pharmacists, paramedics and A&E doctors and nurses), who come into contact with people with mental health problems were not included. Another concern is the over-representation of White staff, even though the authors made steps to increase the ethnic diversity of the sample. The lack of ethnic diversity in mental health research seems to be a widespread issue.
Researchers should actively make connections with communities from diverse ethnic backgrounds and find out how we can increase ethnic diversity in mental health research.
Implications for practice
One major adaptation for practice, especially in community-based services, has been the use of technology to facilitate appointments with service users and staff meetings. Even though there is a growing evidence-base for digital health and telephone/online psychotherapies, it seems that there are still outstanding questions about who finds these modes of treatment acceptable or not. This study suggests that future research could examine whether a blended service approach could be acceptable and effective going forward, e.g., by giving service users the choice between face-to-face, telephone or video appointments.
Lived experience authors, Rachel Rowan Olive and Tamar Jeynes shared many concerns with staff about the pandemic (more on the MadCovid website). Having a safe space, away from distressing conversations, is important. For many people with mental health problems, their safe space is their home and having remote appointments may feel invasive. This should be considered on an individual basis if remote working continues. Emphasis was placed on the importance of ensuring inpatients are not blamed for spreading the virus when there are difficulties in implementing infection control guidelines. An example of this is in the use of restraint, where, if staff struggle to put PPE on in time to deal with an emergency, both staff and service users could be placed at risk of COVID-19 infection. Mental health services may have adapted quickly, but socio-economic inequalities were highlighted in regards to the ability to engage with remote appointments.
Staff’s very valid concerns about future funding are a symptom of a long-standing issue of mental health services being disproportionately funded and resourced compared to physical health services. That said, and over the last 10 years, several documents have been produced to outline the plan for parity of esteem (e.g., ‘No health without mental health’ and the ‘Five Year Forward View’). However, the UK government have been criticised for neglecting to act on their pledges for parity of esteem and perpetuating structural discrimination toward mental health services. Such structural discrimination has been described as being internalised by people with mental health problems to the point where someone may dismiss their own mental health crisis to free up resources for people with a physical health crisis (Hemming, 2018; Huggett et al., 2018). This could have potentially played a role in reduced help-seeking for mental health problems from services, such as A&E and GPs early on in the pandemic (Ougrin, 2020; Tromans et al., 2020), resulting in staff’s fears of increased demand on services when restrictions started to ease. Future research could explore the role of structural discrimination and internal stigma in mental health help-seeking during the COVID-19 pandemic and the fluctuating government restrictions.
It is evident that parity of esteem is needed and structural discrimination toward mental health services is a potential issue. But how can we achieve parity of esteem during a pandemic and going forward?
Statement of interests
None.
Links
Primary paper
Johnson S, Dalton-Locke C, Vera San Juan. et al (2020) Impact on mental health care and on mental health service users of the COVID-19 pandemic: a mixed methods survey of UK mental health care staff. Soc Psychiatry Psychiatr Epidemiol 2020.
Other references
Allwood L, Bell A. (2020) Covid-19: understanding inequalities in mental health during the pandemic. Centre for Mental Health, 18 Jun 2020.
Bell I. (2020) Therapy over the telephone: how does it compare to face-to-face? The answer might surprise you… The Mental Elf, 29 Jun 2020.
Baker C, & Gheera M. (2020) Mental health: Achieving ‘parity of esteem’. The House of Commons Library, last accessed 31 Oct 2020.
Bentivegna F. (2020) CBT for health anxiety: should it be delivered in person or online? The Mental Elf, 27 Jul 2020.
Campbell, D. (2020) NHS bosses accuse Boris Johnson of ‘structural discrimination’ against mental health. The Guardian, last accessed 31 Oct 2020.
Danese A, Bauld L, Greenberg N. et al. (2020) Expert reaction to new advice to support mental health during the COVID-19 outbreak. Science Media Centre, last accessed 24 Oct 2020.
Enoch D. (2020) Online psychotherapy for COVID era: digital healthcare with insights from Auschwitz? The Mental Elf, 5 June 2020.
Hemming L. A hierarchy of stigma based on mental health diagnosis? The Mental Elf, 5 Apr 2018.
HM G. (2011). No health without mental health: a cross-government mental health outcomes strategy for people of all ages. London: Department of Health.
Huggett C, Birtel MD, Awenat YF, et al (2018) A qualitative study: experiences of stigma by people with mental health problems. Psychology and Psychotherapy: Theory, research and practice 2018 91(3) 380-397.
Kozloff N, Mulsant BH, Stergiopoulos V. et al. (2020) The COVID-19 global pandemic: implications for people with schizophrenia and related disorders. Schizophr Bull 2020 46(4) 752-757.
Mezzina R, Sashidharan SP, Rosen A. et al (2020) Mental health at the age of coronavirus: time for change. Social Psychiatry and Psychiatric Epidemiology 2020.
NHS England (2014) Five Year Forward View. NHS England website, last accessed 31 Oct 2020.
Ougrin D. (2020) Debate: Emergency mental health presentations of young people during the COVID-19 lockdown. Child and Adolescent Mental Health 2020 25(3) 171-172.
Pitman A, Johnson S, & Bloomfield M. (2020) Mental health scientists stand up to COVID-19. The Mental Elf, 27 Apr 2020.
Royal College of Psychiatrists (2020) Psychiatrists see alarming rise in patients needing urgent and emergency care and forecast a ‘tsunami’ of mental illness. Royal College of Psychiatrists website, last accessed 24 Oct 2020.
Samuels EA, Clark SA, Wunsch C. et al. (2020) Innovation during COVID-19: improving addiction treatment access. J Addict Med 2020 14(4) e8-e9.
Sheridan Rains, L., Johnson, S., Barnett, P. et al. (2020) Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses. Soc Psychiatry Psychiatr Epidemiol 2020.
The Lancet Psychiatry (2020) Mental health and COVID-19: change the conversation. The Lancet Psychiatry 7(6) 463.
Tip L. (2020) Guidance for online therapy during COVID-19. The Mental Elf, 4 May 2020.
Tromans S, Chester V, Harrison H. et al (2020) Patterns of use of secondary mental health services before and during COVID-19 lockdown: observational study. BJPsych Open 2020 6 e117 1-6.
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