The role of integrated mental and community physical healthcare trusts in responding to the COVID-19 pandemic in the UK.

For several decades, mental health services within the UK's National Health Service were provided by specialist mental health trusts. More recently many of these trusts have integrated community physical health services into their operations. We describe here how two integrated mental health trusts in England were able to make an enhanced response to the COVID-19 pandemic.

The pandemic of COVID-19 has been one of the biggest challenges to global healthcare in a century. This has been felt in the UK, where it has provided the greatest test in the history of its National Health Service (NHS). For nearly 20 years mental health services within the NHS have been provided by specialist mental health trusts. In more recent times these organisations have moved beyond mental health to increasingly include community physical health services.[1] Much has been written on the role and response of NHS providers, and potential consequences for the service, in relation to mental health and COVID-19.[2] However, COVID-19 is primarily a respiratory disease which carries the greatest risk for elderly people and this has created primarily a physical healthcare need in the early phases.[3] In this editorial we describe the vital role of two integrated mental health trusts in England responding to the COVID-19 pandemic and discuss how the integration between mental and physical healthcare has enhanced this response.

Background to the trusts

Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) serves a mixed, though predominantly rural, population of around 1 000 000, including more than 165 000 people over the age of 65. Originally formed as a mental health trust, for the past 5 years it has also been responsible for provision of community physical care for adults and older people in Cambridgeshire. This includes 102 rehabilitation in-patient beds, 3 minor injury units, district nursing, occupational therapy, speech and language therapy, physiotherapy, podiatry, and dietetics, in addition to specialist teams such as respiratory, cardiac, chronic fatigue, neurological rehabilitation, early supported discharge for stroke, epilepsy, Parkinson disease, multiple sclerosis, tissue viability and diabetes. These new services were merged with existing in-patient and community provision for older people's mental health to create an adult and older people's directorate, which includes urgent response to physical and psychiatric presentations in the community.

Oxleas NHS Foundation Trust (OFT) covers the south-east London boroughs of Bromley, Bexley and Greenwich, serving both inner- and outer-London urban populations. The Bexley directorate has an integrated structure – known as ‘Bexleycare’ – incorporating NHS services for both mental health and community physical health with adult social care provided by the local authority. This is run by an integrated management team from health and social care, covering a large range of services for those over the age of 18. It has an in-patient site, Queen Mary's Hospital, that contains beds for both mental healthcare (working age adult, older persons’ and dementia) and step-down intermediate physical care. Community services for the boroughs’ approximately 250 000 residents include mental health services (for adults over >18 years of age), physical health services similar to those described for CPFT and adult social care.

Changes in response to COVID-19

In line with other NHS providers, CPFT entered a critical incident in March 2020 and adopted a command and control structure. This brought immediate changes to our physical and mental health services, including the formation of a county-wide COVID-19 testing service. From the perspective of physical health more generally we focused on the priority of preserving life. We felt we could best contribute to this by supporting discharge from acute trusts to allow patient flow and by treating people both with and without COVID-19 in the community to prevent deterioration and possible need for admission.

We created a single point of access and a telephone line that took 20 000 calls in its first month of operation. We expanded our discharge to assess (DTA) team, which increased the number of patients it was seeing from 10–20 per day to up to 70 and dealt with 810 patients in its first month. Partly as a result of this, our local acute trusts were able to maintain bed availability. For our community teams we followed national guidance in terms of which services continued and which were suspended. A triage function with senior staff was created which acted on the principle of accepting referrals if the patient needed an intervention that would prevent deterioration likely to result in acute admission or was a threat to life. This principle-based approach was preferred to a list of which patients or conditions would be accepted. It required widespread redeployment of staff to enhance the most critical areas of service. For example, in older peoples’ mental health, routine memory assessments were stopped and staff redeployed to in-patient care or crisis teams. We engaged with colleagues across the system to draw up new clinical guidelines. Perhaps the most notable example was with regard to end-of-life care for COVID-19 patients, where our community teams faced significant mortality, particularly among care home residents.

Bexleycare, as part of OFT, had both a trust-level and London-wide COVID-19 command response. Within Bexley, the joint governance under the NHS organisation and the local authority facilitated early work and communication with public health services (which fall under the local authority). Nursing services in the trust took the lead for infection control and testing, with district nursing services delivering this locally. In-patient mental health services were notably reduced, with a 50% reduction in bed base effected by intentional ward closure because of the risks presented to patients and staff. Intermediate physical health and dementia care wards were notable risk sites and, indeed, sadly there were early infections and deaths of patients on these wards. Daily command calls linked the directorate with the trust and local authority, and through this, regional London command.

Benefits of integration of physical and mental health services

Across both trusts we found immediate and direct benefits of integration. Our mental health services have benefited from support from the physical health teams, for example having respiratory specialist nurses and consultant geriatricians to support our older people's mental health wards. Similarly, our physical health teams have benefited from an extensive psychological support package for staff to deal with what have been extreme circumstances at work. This has included a stepped approach to the support given (from advice on self-management, psychological first aid and signposting to one-to-one support and referral to specialist mental health support, if appropriate, for staff requiring additional help), access to a staff support telephone line delivered by psychology staff and the Staff Well-being Service, guidance for managers on looking after their staff's psychological well-being, and ‘team time’ sessions to help clinical teams to reflect on the personal impact of the work they are doing. These initiatives have helped promote compassionate leadership within our services and have been well received by staff. More generally, having a larger organisation has meant that there is a bigger pool of staff to draw from to bolster critical services, a particular advantage when facing potentially high levels of staff sickness. Some potential drawbacks, such as loss of specialism or identity, have been ameliorated by people coming together in a time of crisis.

Conclusions

Combined mental and physical healthcare trusts can change quickly and at scale in response to health emergencies. We have previously described the benefits of integrated trusts in times of normal business.[1] Although integration does not hold all the answers or fully mitigate the current situation with COVID-19, we have seen that there are benefits in times of crisis and that these can have a positive effect on elements of the wider healthcare system.