COVID-19: Secondary and specialist mental health settings

Page last updated: 19 May

Explore below our guidance for psychiatrists and their colleagues working in secondary and specialist mental health settings.

Specific guidance on supporting patients of all ages who are unwell with COVID-19 in mental health, learning disability, autism, dementia and specialist inpatient facilities has been developed by NHS England/ Improvement in collaboration with Royal College of Psychiatrists, the Royal College of Nursing’s Mental Health Programme, and Unite in Health.

People with mental health needs, a learning disability, autism, or dementia should receive the same protection and support with managing COVID-19 as other members of the population. This will mean providing additional support, including by making reasonable adjustments to care systems and clinical practice.

NHS England has updated their guidance for managing capacity and demand within inpatient and community mental health, learning disability and autism services for all ages (November 2020).

The principles that should inform the mental health/learning disability and autism system response include:

  • People of all ages with mental health needs, a learning disability, autism or both should receive the same degree of protection and support with managing COVID-19 as other members of the population. This may mean providing additional support, including making reasonable adjustments.
  • In responding to COVID-19, staff in mental health/learning disability and autism providers may need to make difficult decisions in the context of reduced capacity and increasing demand. These decisions will need to balance clinical need (both mental and physical), patient, staff and public safety and risk. Decisions should ensure critical services are maintained during the pandemic including those services within the community which can impact significantly on both mental and physical health. Providers should ensure that they have in place a patient panel or an ethics committee to advise on decisions regarding the prioritisation of resources or changes to service delivery. This can be an existing group.
  • When considering plans, providers should consider not just patients’ vulnerability to the physical infection, but their vulnerability stemming from mental health needs, a learning disability, autism or a mixture of these. People of all ages will be at risk of mortality through suicide, injury, self-harm and self-neglect, so changes to services need to have patient safety as the paramount concern, including issues related to safeguarding. Providers should also consider the access to support a patient may receive from informal and formal care and whether this is also impacted by the pandemic.
  • Providers will wish to consider the cumulative impact on the mental and physical well-being of carers of the pandemic, especially family members caring for a person who has additional needs at a time of increased social isolation, reduced access to activities and in some cases where shielding has been advised for an individual, (carer or cared for).
  • Partnership working is crucial, and responses, including prioritisation decisions, will need to be co-produced wherever possible. To both maximise the use of community assets and to draw on the insight and expertise of partners, response plans will need to be developed alongside patients, including children and young people and their families, carers, VCS organisations as well as neighbouring mental health/learning disability and autism providers. This will include planning within an NHS-led provider collaborative, with social care partners (both commissioners and providers), the criminal justice system, commissioners, local authority children’s services and education providers for children and young people (CYP).
  • To respond to government guidelines on social distancing, providers will need to consider carefully their policies and procedure regarding family visits and the benefits to patients of all ages, facilitating face-to-face contacts where safe to do so and where this can be jointly agreed with patients. Digital alternatives should also be used to support continuity of social contact for patients, families and carers. Providers will need to consider their need to make reasonable adjustments in respect of visiting and be aware that individual person-centred decisions should be made for people with a learning disability and for people who are autistic. Visits from family members and loved ones may support recovery and discharge and be vital in enabling staff to understand people with communication difficulties or those whose behaviour challenges.
  • Providers should consider taking a blended approach between face to face and remote delivery when planning for service continuation; taking into consideration both patient choice and the clinical needs of patients to ensure that both COVID secure face-to-face and digital alternatives are available. Providers should ensure that there is adequate support for staff, patients and families to use digital alternatives when accessing and delivering care remotely. A person’s ability to adapt to new approaches to service delivery should be considered as well as their ability to use technology appropriately. Where there are any safeguarding concerns a face to face visit is always recommended.
  • Providers must bear in mind the longer-term impact of the pandemic and associated impacts on the mental health needs of the population. Providers must minimise changes that impact on the capacity and capability of the system long term and, where changes are made, keep these under regular review.
  • It is essential that wellbeing of staff (both mental and physical) is maintained and considered when providers are adapting service provision in response to the COVID-19 outbreak. Providers should be signposting staff to relevant support.

Further information for service-specific considerations is available.

Patients receiving ECT are usually amongst the most psychiatrically unwell and are likely to be severely affected by a halt in treatment. NHSE/I published a statement Continuing to provide ECT during the COVID-19 pandemic encouraging local areas to ensure ECT provision is maintained, in particular ECT for those patients who present with a significant clinical need.

However, we know many areas have reduced their provision of ECT services, mainly because of the required infection control procedures and its impact on treatment capacity.

Following updated guidance on Remobilisation of services within health and care settings: infection prevention and control (IPC) recommendations updated on 21 January 2021, local areas should be able to safely resume their ECT service. The Royal College of Anaesthetists has published advice on Anaesthesia for ECT during the COVID-19 pandemic. This recommends that:

  • only Standard Infection Control Precautions (SICPs) need be used in low-risk patient pathways – comprising: gloves (single use), apron (single use), fluid-resistant surgical mask (extended use possible) and consideration of the use of eye protection. Low-risk patients include: asymptomatic patients with a negative PCR (antigen) test within 72 hours who have self-isolated in accordance with NICE guidance; those who have recovered from COVID-19, have been asymptomatic for >72 hours and have a negative PCR; and patients who are tested regularly and have a negative PCR, including inpatients in areas in which COVID-19 patients are not treated.
  • when patients presenting for ECT are in medium-risk or high-risk pathways, only those necessary for the performance of the procedure be present in the treatment area: the patient, a psychiatrist, a psychiatry nurse, an anaesthetist and an anaesthesia assistant. Trainees in anaesthesia and psychiatry may also be present. Airborne precaution PPE should be worn by all present.

For guidance on clinical practice relating to COVID-19 in Psychiatric Intensive Care Units, please refer to the following resources:

Patients with suspected or actual infection who go to hospital for treatment in an intensive care environment may experience their situation as traumatic. These experiences may have profound, and at times lasting, psychological and emotional repercussions even after the patient’s recovery from the physical illness.

  • Providers should adopt a trauma-informed approach, with particular consideration of the effects of staff in personal protective equipment (PPE) providing care and support to individuals, recognising the overall aim of reducing trauma.
  • Consider what can be done to make the environment less threatening and more familiar for the patient and provide them with as much reassurance as is feasible given the situation. It is also noteworthy that having a loved one in intensive care, is likely to be extremely anxiety-provoking or distressing for patients and their relatives. Where a patient dies, family members may suffer traumatic stress symptoms related to what happened to their loved one or indeed what they imagined happened to them.
  • For both patients, and their families, it is appropriate to make sure that they are actively monitored, in accordance with NICE guidelines, for a month or so after the patient recovers to ensure that their mental health is stable. Where someone is suspected of having a trauma-related mental health problem, they should undergo a thorough assessment and where necessary provided with evidence based care in accordance with NICE.
  • Trusts should be mindful that healthcare staff, family and carers may experience traumatic stress and/or grief due to deaths that occur. Active monitoring of these individuals should also occur and where such difficulties are severe and/or persistent, a full assessment and where necessary evidence based treatment should be provided.

Relevant papers on coping with traumatic stress in health settings can be found below:

Where possible, and in line with national and regional government guidelines, IAPT services should offer face-to-face appointments for those for whom the clinical need is indicated and/or they would fail to receive appropriate interventions remotely.

Services should utilise their local risk assessment processes to enable the use of COVID-19 secure accommodation for patients requiring face-to-face appointments.

More detail on approaches to communications and care planning are set out in the IAPT guide for delivering treatments remotely during the coronavirus pandemic.

During the Coronavirus pandemic, many services continue to be under stress. Work in some psychological therapies services has moved to a remote delivery model, temporarily suspended, and staff redeployed to cover absent colleagues. Face-to-face meetings with trainees have ceased in many places, at the very time that support and space to think is at a premium.

We appreciate the enormous challenges clinicians are facing as they grapple with the threat from COVID-19 and the great work being done to adapt and support your teams, colleagues and trainees.

The Faculty of Medical Psychotherapy has compiled the following guidance for members:

  1. Psychotherapeutic services should not necessarily stop seeing patients. There may be local pressures that make continuing services remotely impossible, and psychotherapy services may be viewed as less essential than other mental health services, but the needs of the patients in treatment should always be weighed against needs elsewhere.
  2. As psychiatrists, medical psychotherapists should be willing to take on additional tasks within their competence as required by the local situation, whilst not neglecting their core service.
  3. The way that patients are assessed and treated, and staff support/supervision is delivered, may need to change, but in many cases, these activities can continue with appropriate adjustments.
  4. Clinicians should consider carefully whether the aims of treatment can be delivered remotely, such as by phone or Teams, and in some cases, psychotherapy will need to be more supportive and less challenging when carried out remotely rather than in person.
  5. Case discussion (Balint) groups are particularly important at the moment, as trainees are having to negotiate unfamiliar clinical situations, and may be required to exercise their ethical and clinical judgement in more unfamiliar situations. These group meetings should be held remotely.
  6. Consideration will need to be given to replacing lost experience in psychological therapies for trainees who are redeployed during the crisis.
  7. Staff support is more necessary during times of high stress and constrained resources. Existing staff support groups should continue remotely, and medical psychotherapists should take an active role in providing additional resources. The College has produced a list of messages for supporting healthcare staff during the epidemic.
  8. Other RCPsych guidance on COVID-19 includes ethical considerations and guidance on remote consultations.  
  9. A group of organisations involved in psychological therapies has drafted guidance for psychological professionals during the outbreak which members may find useful.
  10. Training: There is a new ARCP outcome 10 in response to the pandemic impact on trainee progression assessments which states: ‘Achieving progress and the development of competencies/capabilities at the expected rate but the acquisition of some capabilities delayed by impact of COVID 19. Can progress to next stage of training as overall progress may be satisfactory. Any additional training time will be reviewed at the next ARCP.’
  11. The GMC and COPMeD have advised that Covid-19 derogations remain in place where applicable while the pandemic is ongoing. In most cases the derogations will be required in exceptional circumstances and trainees should be able to progress in the normal way. However, GMC and COPMeD are keen to ensure that trainees still have the flexibility to progress if they are still impacted by the pandemic. HEE have therefore updated the ARCP decision tree.
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