Nuwan Dissanayaka, Leeds and York Partnership Foundation Trust
The pandemic has rendered life unrecognisable. We don our masks and gloves as if pulling on our overcoats to protect us from the elements and the comfort of contact with others we once took for granted has given way to stilted smiles on our laptop screens. As for patient care, we were assured that we were on the verge of a brave new world, one where telehealth promised a brighter, more efficient future. But in our Assertive Outreach Team things haven’t quite gone according to that plan.
The inconvenient truth for the evangelists of digital health is that many of the people with complex psychosis that we support were already struggling to keep pace with digital revolution and in addition to life’s basics of food warmth and shelter, health care is something they need support with face to face. And offering that support, which stretches far beyond their psychological needs, is why Assertive Outreach exists. We take the social determinants of mental health seriously and try our best to help people navigate the labyrinthine processes of the housing and benefits systems which are increasingly only accessible online. If anything, the pandemic has brought the systemic marginalisation of those with severe mental illness into even sharper relief.
The Marmot Review clearly highlighted the social determinants of health. But what is understated is that, whether we are talking about adverse childhood experiences, educational disadvantage, poverty or financial instability, we see a massive intersectionality with severe mental illness. Depressingly, our daily experience is congruent with Marmot’s finding in his “10 years on” report that these health inequalities are getting worse.
The vaccination programme reflects this marginalisation and resultant unmet need. In March 2020 it was recommended that patients with a severe mental illness, defined in the UK Government’s Green Book as “Schizophrenia, Bipolar Disorder or any mental illness that causes severe functional impairment”, were to be offered the vaccine alongside those with a range of long-term conditions that put them at a higher risk from the virus.
But it was clear from the outset that in order to protect the people we support we needed to do things differently. They were very unlikely to take up the offer of a vaccine from their GP, the plea having been made predominantly online and therefore of little value to those who are digitally excluded.
So, we decided to approach everyone we support to offer them the vaccines ourselves. It was fortuitous that one of our nurses had been redeployed to our Trust’s vaccination hub. She knew many of the patients on our caseload already and that trust and understanding would prove to be critical. Excluding those patients currently in hospital, in out of area placements and a small number who were stuck abroad due to travel restrictions, everyone on our caseload was approached. Very few had responded to the calls from their GP and, in many cases, it took several conversations with well trusted members of our team to help them to reach a position of being able to make an informed choice. The level of mistrust in the vaccines was exaggerated by a general mistrust of health services and interventions. This was often compounded by psychotic experiences, raising further issues of decision-making capacity. In addition, we saw a greater level of mistrust in those from minority ethnic heritage, who are overrepresented on our caseload, and we were able in several cases to address their concerns. Of the 113 people approached, 66 accepted the vaccine and the arrangements for the administration of 54 of these were made within our team. Due to the pandemic restrictions, many of these were given at our Trust’s vaccination hub but a significant minority would only accept a vaccine at home. The most striking statistic is that only 12 people, less than 20% of those accepting it, received their vaccination via their GP.
It is hard to be certain about why our approach was so successful, but my own view is that there is something within the therapeutic relationship that we forge, sometimes over many years, which helps us to support people through our Assertive Outreach Team with all areas of their life. Trust, listening and flexibility all matter too. Despite the contrary way that services have evolved over the last couple of decades it remains hard to argue against the fact that long-term conditions often need long-term support. In a period of yet another community mental health service reconfiguration it is vitally important that we don’t forget the groups that have no voice. Because, as we have seen, having the right level of support is literally lifesaving.