Remote Mental Health Patient Assessment & Changes to Medication Protocols

nterviewee: Navjot Ahluwalia (RDASH)

There were two main innovations discussed in this interview: remote mental health patient assessments and changes to medication protocols (surplus end of life medication and self-administration).

Mental health assessments are a complex area because of the restrictions in place due to the Mental Health Act and the Mental Capacity Act. The Mental Health Act has a Code of Practice which is statutory guidance, which is a way of interpreting the law and gives a way of implementing the law in practice. They had to interpret the statutory guidance from these and other pieces of extant guidance to arrange a legal, safe and appropriate way of assessing patients when face-to-face assessments might pose an infection risk. The difficulties were that assessments must be done in person, they must be done with another professional (e.g. social worker) and there are certain stipulations about what forms must be signed with a ‘wet signature.’ These were therefore very difficult to do remotely/virtually.

Because of the intricacies of legislation, controlled drug medications are strictly controlled. During the pandemic, there were often reported shortages of end of life medications, which could mean that patients were might die in pain, which is unacceptable. Furthermore, staff were sometimes unable to enter a patient’s home due to social distancing to administer medication. There was therefore a need to see how, even with the constrains of existing legislation, existing unused drugs from recently deceased patients could be reused and how patients could self-administer medication.

Because of the intricacies of legislation, controlled drug medications are strictly controlled. During the pandemic, there were often reported shortages of end of life medications, which could mean that patients were might die in pain, which is unacceptable. Furthermore, staff were sometimes unable to enter a patient’s home due to social distancing to administer medication. There was therefore a need to see how, even with the constrains of existing legislation, existing unused drugs from recently deceased patients could be reused and how patients could self-administer medication.

Because of the intricacies of legislation, controlled drug medications are strictly controlled. During the pandemic, there were often reported shortages of end of life medications, which could mean that patients were might die in pain, which is unacceptable. Furthermore, staff were sometimes unable to enter a patient’s home due to social distancing to administer medication. There was therefore a need to see how, even with the constrains of existing legislation, existing unused drugs from recently deceased patients could be reused and how patients could self-administer medication.

Approach/Methodology

Mental Health Patient Assessment

The team consisted of a Consultant Psychiatrist, a social worker from the local authority and a Mental Health Act manager. At the early stages of the lockdown, this team looked at all the legislation, all the case law, the Human Right Act and other relevant guidance. They used legal advice given to the Local Authority from a previous case that they were allowed to see because they would keep everything in the case confidential. Together, this team in Doncaster wrote a 10-page document in a week which stated that they believed that almost all of the assessment can be done virtually with certain safeguards and that documents can be submitted electronically, to avoid unintended transmission of Covid-19. The social worker still had to deliver documents to a hospital, but they did not have to physically go into the hospital.

Changes to Medication Protocols

Rather than getting rid of medications, they wanted to take back medications in a secure and safe way, hold it in the trust and then, with proper protocols, give out to patients that needed it.

They also enabled protocols for the self-administration of certain medications to be relaxed. Self-administration was only allowed when it was safe and patients/family members had been trained to do so.

This was done by their chief pharmacist writing a huge number of unique protocols. It was done quickly and was rapidly took through the Covid-19 Gold Command in the Trust.

Impact

Mental Health Patient Assessment

The document was taken through their Covid-19 Gold Command, which allowed them to use it locally in Doncaster before being spread to the other areas of the trust (Rotherham and North Lincolnshire).

It meant that mental health assessments could still go ahead throughout the pandemic. Assessments were done via MS Teams and, as long as there was a good view of the patient, a proper assessment was able to take place. Although most practitioners did not use virtual assessments in the end, it meant that one practitioner who had to shield for health reasons was able to continue their work.

National guidance has now been released that now virtually mirrors what they produced locally. This was arrived at separately and did not involve consultation with Doncaster.

The response from patients to virtual assessments was mixed. If patients did not want a virtual assessment they were able to decline and the assessment had to be done in person.

Changes to Medication Protocols

It meant that patients were able to self-administer their medication in a safe way and that they could continue to receive treatment.

Next Steps

Mental Health Patient Assessment

The remote mental health patient assessment is now subject to government review. What is currently in place will only be there for the duration of the pandemic.

Changes to Medication Protocols

Part of the protocol might continue. However, when there is no longer a national emergency, there should be less need anyway for changes such as these. It would also be harder to justify maintaining this process from a risk-benefit viewpoint.

Key Learning Points

• Barriers that are in place can have benefits and drawbacks. During COVID-19, things moved at speed because usual governance barriers were not in place. Speed can galvanise and energise people to achieve more (as happened), but there is still the risk that unsafe decisions will be made. However, in usual times, the NHS has come down too much on the barriers side of this divide, which has come at the expense of moving at pace and making necessary changes quickly. There is a risk that this will re-emerge after COVID-19. There needs to be a celebration of the efficiency that was seen during gold command.
• The offer of remote working was very valuable because of the high amount of BAME staff, who knew that they were disproportionately at risk of COVID-19. It gave them reassurance that they their risk was reduced, it helped staff that were shielding and it also made the issue of BAME COVID-19 vulnerability more visible. It also helped out other at-risk groups (e.g. pregnant staff).
• Remote meetings with other staff has been a big positive. It has increased system working and reduced wasted time/money on travelling.
• Ordinarily, it is best to use new medications rather than reuse a supply prescribed for another person. However, if there are times when it is needed (e.g. a potential second wave or if Brexit causes supply disruptions) it is a valuable option to have.