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5 Pandemic Planning in Different Mental Health Settings
Community
5.1 A large proportion of mental health care is provided within primary care and in the community. During a pandemic, provision of primary care will be restricted. This will also have an impact on the level of service provided to mental health services users.
5.2 There is a mixture of people in the community with mental health needs and not all their mental health needs are principally met by primary care. Some are maintained in the community by mental health teams or through shared care packages. There is a risk that these users may be overlooked or be assumed to be the responsibility of primary care during a pandemic as all patients, except in a very small number of cases, are registered with a GP,
5.3 When planning in advance of a pandemic, it is necessary to identify clearly those individuals who are at risk of their care being disrupted during a pandemic and who could, potentially increase their demand for services when services are strained. Identifying individuals rather than groups is recommended for best outcomes. Robust risk assessments with set criteria for individuals may need developed.
5.4 Some intervention or support may be needed in cases where the individuals are having difficulty using the National Flu Line or lack a family member or friend to collect antiviral drugs on their behalf. Community mental health teams should be alerted to helping such clients with access to the flu line and antivirals. Guidance on planning for vulnerable groups
5.5 Mental health services within the community are co-ordinated by community mental health teams, crisis teams and outreach teams. During a pandemic, they will have an enhanced role in ensuring that essential health and support services are provided and in place for service users. There may be additional workload requirements. These can be due to a number of factors including:
- the earlier discharge (where safe to do so) of service users from inpatient and residential settings and the corresponding additional support needs of those services users;
- supporting A&E Departments in assessing patients requiring mental health support who present at A& E Departments; and
- working closely with local GPs to identify the long-term support requirements of those caught up in the pandemic, their family and friends and arranging for onward referral into mainstream services if needed.
5.6 There is a risk that anyone with mental health needs will be referred back to mental health services from other services despite a physical health need. Community health teams should act as facilitators for people with mental health problems to have proper access to physical health care within primary care.
5.7 Community mental health teams may need to prioritise casework within the team according to demand and staff availability. Flexibility in work and practices may be needed. Where community psychiatric nurses have systems to share information on caseloads and priorities, the robustness of these systems should be tested in pandemic simulations.
5.8 As far as possible, teams should try to ensure that care packages continue during the pandemic despite staff sickness in the different agencies involved. Teams should work with social care teams in identifying any vulnerable patient group who may not receive a service during any pandemic situation. Information on the different services and agencies involved in meeting each person's needs should be communicated between the organisations.
5.9 This will help identify those who are vulnerable to services being reduced or staff absences. Joint work and collaboration between social care and other mental health services and supports is needed, particularly communication between frontline staff on whether or not a home is a flu environment or not. Sickness among carers will leave vulnerable people without their normal care support at home. Teams will need to be clear on the level of support within the home.
5.10 Should community mental health teams become overwhelmed, particularly in terms of staff absences, the teams may have to consider delivering services in different ways, merging teams and whether all service users require home visits. For example, it may be possible to do assessments over the phone for non-priority cases or where a service user is known to have the flu virus. Self-help materials may have to be provided in lieu of personal visits. Planning could also explore the possibilities of social care services and voluntary groups supporting delivery of care. Community mental health teams may be able to aid vulnerable people in taking appropriate precautions against infection and provide advice on self-care, should they develop influenza.
In patient care
5.11 There are two main challenges facing forensic and other in-patient services: preventing the virus from entering the premises and stopping the virus from spreading widely once it is introduced. The influenza virus tends to spread rapidly in closed communities such as secure units and residential settings. The flu virus will enter the wards via incubating or asymptomatic staff, visitors or patients and by the time the symptoms manifest, many on the ward will have already been exposed. Infection control measures are of utmost importance, especially when it is not possible to move those with significantly disturbed behaviours to other settings.
5.12 In many units, patients have their own rooms and decisions to instigate further isolation may need to be taken. Separation of influenza patients from non-influenza patients should be arranged as far as possible. Admissions during a pandemic may also have to be restricted to essential admissions (i.e. those on MHA section or considered to be at high risk). There should be visiting policies designed to contain spread of the virus. Visiting should be for those where a visit is essential
5.13 Staff will require access to personal protective equipment and training in hygiene matters. Collaboration between NHS Boards, mental health services acute facilities, local authorities and other partners will be necessary. Personal protective equipment, such as surgical masks, should be provided if occupational risk assessments have indicated that to be necessary and staff should be trained in its correct wear, limitations and use (where required). Healthcare staff will also have access to pre-pandemic vaccine.
5.14 Enhanced general nursing and physical health skills will be required of staff. This should be addressed prior to a pandemic. Plans should include allocating someone with physical health skills to each ward during the pandemic. Where staff capacity is reduced due to staff absence other staff may have to be redeployed, flexible rotas and changes to staff shifts introduced and workload prioritised. When required, non-emergency activities could be suspended in order to free capacity and staff time.
5.15 Disruption of transport links may inhibit staff's travel to work but it may also prevent staff from returning home. It may be necessary to provide areas of rest and facilities for refreshment. When planning, geographical areas where staff reside should be identified and where possible, accommodation should be identified for any staff who are unable to travel to and from work.
5.16 It may not be possible to acquire agency staff during a pandemic. Discussions with agencies in regard to the agencies' business continuity and pandemic flu plans should be conducted in advance of a pandemic.
5.17 Measures need to be in place to keep hospital patients safe and secure at all times. Patients may need to be shown images of people with protective clothing and equipment in advance so that they are familiarised.
5.18 Service continuity plans will also have to consider that current reliance on emergency services in crisis situations may be affected during a pandemic and alternative agreements sought. The issuing of death certificates may have to be conducted in -house.
Death Certification
5.19 Guidance on changes in death certification procedures in a pandemic has already been issued to all medical practitioners about the certification of deaths from pandemic influenza. The letter gives examples of situations and outlines all circumstances that can be legitimately considered for certification. This will encourage and give confidence to practitioners to certify appropriately.
5.20 Forensic services (low, medium and high security) will have an additional management issue in that patients are under restriction orders. Court procedures may be affected.
5.21 Where in-patient psychiatry beds are housed in hospitals, mental health services should link with acute services to address the particular needs of this group of patients. For example, there may be an issue of providing secure accommodation. Also acute services may be under pressure to close a ward to use the beds for other patients.
5.22 The safe discharge of patients from general psychiatric wards to the community may be difficult during a flu pandemic. It will be necessary to evaluate the risks to the patient and others of discharge compared with the flu risks of remaining an inpatient. This would include assessing the level of support at home for those who are ready to be discharged and the capability of community services in providing care when workloads have been increased by the pandemic.
5.23 Those in Prison may develop mental illness and may need to be moved to a secure NHS services for a period. There could be an issue with repatriation if flu has later broken out in the Prison or the individual has developed flu like symptoms. NHS Boards should link with local Prisons in deciding an appropriate course of action should this situation arise.
Additional Services
5.24 While all mental health services face general challenges and many of the issues specified in the sections on community care and in-patient care are common to all, there are specialist services for specific needs or circumstances. These include:
- General Psychiatry
- Learning Disability Services
- Alcohol and Drug Services
- Psychotherapy Services
- Eating Disorders Services
- Rehabilitation and Recovery
- Day and Emergency Care
- Mother and Baby Services
- Child and Adolescent Services
- Older Adult Services
5.25 All service responses should be included in the contingency plans. There is a risk that these services could be the most vulnerable to closure and it is urged that NHS Boards develop continuity plans for each which address proportionate response to the pandemic. Joint working and integrated planning with all partners are necessary to ensure that care continuity is ensured. However, there should be recognition that some services may need to be scaled back or stopped to free up capacity. Above all, decision-making should reflect the local needs of the population and the impact upon healthcare staff workload elsewhere in the community.
5.26 There are specific issues for specialised services, including:
Learning Disability Services
5.27 People with learning disabilities often have severe physical abilities, cared for in hospital, within the community or in care homes. There is significant input from informal carers- the potential impact on both aspects is covered previously in this document.
Alcohol and Drug Services
5.1 It is important that alternative arrangements are developed to prevent patients relapsing in the event of staff absences affecting delivery of treatments. Access and availability of services may need to be restricted to a limited number of sites. In respect of drug treatment services, there are likely to be particular issues around continuing the safe prescribing, dispensing and supervised consumption of methadone or other opiate substitutes that services will need to consider. Changes outlined in the proposed Medicines and Associated Legislation Changes for Pandemic Influenza document ( UK) will, if agreed, introduce more flexible arrangements for controlled drugs
Eating Disorders Services
5.2 Special considerations also apply for those referred to care but where that referral puts people at risk of pandemic flu. To remain at home will not address their care needs to the same extent and this balance of risk needs to be thought through and explained clearly to the patient and, if appropriate, their carer.
Rehabilitation and Recovery
5.3 Rehabilitation and recovery services may need to restrict their care to those already being treated.
Day and Emergency Care
5.4 As for all other services, NHS Boards and mental health services will have to discuss with partners the potential impact of restricting or closing day care facilities. It is not advised to close day care services which incorporate out-patient care.
5.5 As before, there is likely to be an increased demand for ambulance, emergency and crisis care coinciding with a strain on services due to staff absence. Contingency planning for these eventualities should, like all other aspects be a key consideration.
Mother and baby Services
5.6 The aim should remain, in the context of exposure to infection, to care for the mothers and their babies in a safe and caring environment. Continuation of this care and access to this care should be considered paramount.
Older Adult Services
5.7 Services, such as Home Care and Day Care (see above) may be affected by a shortfall in staffing. Changes to services (e.g. provision of sandwiches instead of serving hot meals) would need to be considered. Voluntary groups who specialise in helping the elderly should routinely be included in local planning.
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