Telepsychiatry is a psychiatric interview conducted by video conferencing (such as FaceTime® or Skype®) between a patient and a clinician, who are in different places. The interview may take place with a patient at one hospital and the clinician at another, or when the patient is at home. It is being run by The Emergency Department Psychiatric Service (EDPS), based at The John Radcliffe (JR) Hospital in Oxford.It is being offered to patients over 18 years who are referred by the Horton Hospital Emergency Department (A&E) to EDPS for assessment of mental health issues. EDPS staff at the Horton may also use it to get a senior second opinion from a consultant psychiatrist based at the JR.
Sometimes patients may be offered follow-up appointments with an EDPS clinician. If this applies, patients will be offered telepsychiatry sessions if thier home device (phone, tablet or computer) can be set up for teleconferencing. A key aim of the project was to improve access to our brief follow-up clinic, which patients often find difficult to attend during office hours. The first patient to ‘attend’ follow-up sessions remotely worked in rural Oxfordshire and was able to have his appointments when he had finished work, without having to travel. He told his clinician that, had it not been for the offer of telepsychiatry, he wouldn’t have attended. Another patient had follow-up appointments arranged after school, and had her last appointment while on holiday abroad. One patient commented: “I saved time and the cost of travel because I work weekdays 9-5”. One of the other drivers of this project is to reduce the amount of time, and expense involved, in clinicians driving between the main and remote hospital.
What makes your service stand out from others?
Despite robust evidence for effectiveness and acceptability of telepsychiatry, it has not been adopted widely in the UK. The most regularly identified barrier to its’ introduction is staff reluctance. The Emergency Department Psychiatric Service (EDPS), based in Oxford, Service provides psychiatric assessments to patients who present in crisis, across all age groups. EDPS also covers a regional Emergency Department (ED) 27 miles away. There are delays in assessing patients at the distant ED due to travel time, and the team struggles to offer convenient times for follow-up appointments. Assessments and follow-up appointments by telepsychiatry (video-link) were introduced to reduce patient waiting times, staff time and travel costs and to increase access to follow-up clinics.
Staffing
Another challenge was staff shortage in our own team which meant that we had fewer clinicians regularly available, which severely affected our ability to accept patients into our follow-up clinics, which affected recruitment into that arm of this project. Our aim is to improve this in the next year as we become fully-staffed.
Who is in your team?
2 Consultant Psychiatrists 1 wte band 8a Team Manager 6 wte band 7 Clinicians 1 wte band 6 Clinician 1 band 4 Admin
Working together
Our main partner in this project was the Emergency Department at the Horton Hospital, part of Oxford University Hospital NHS FT. Our clinical project assistant based herself at the ED and liaised frequently with staff. We refined and agreed protocols with ED staff and found solutions to their most pressing concern: that their workload would actually increase by facilitating these assessments. We installed a printer so our staff could remotely print discharge leaflets and safety plans directly to ED for ED staff to give to the patients, enabled access to the electronic ED notes system to enter clinical notes remotely. Our biggest initial challenge was the stability and reliability of the internet connection but changing to another videoconferencing platform provided a more stable connection. We learned a great deal about finding pragmatic solutions to technological issues, and attempted at all times to use fairly inexpensive and readily-available technology so that other teams could replicate the project easily.
Do you use co-production approaches?
Our project benefitted from input from a patient expert by experience who reviewed our information and protocols and made helpful suggestions about the set-up at the remote hospital. In particular, we were able to adapt our leaflets and patient experience questionnaires to make them much less technical and more easily understandable because of her input. We designed both staff and patient feedback forms and used these throughout the initial testing phase and for the first 3 months of the project, adapting the project where necessary in response to the feedback. We continue to regularly collect patient feedback on all patients, including those seen via telepsychiatry, and these form the basis of team discussions around improvement.
Do you share your work with others?
The team aimed to use low-tech solutions which other teams would be able to replicate easily. All clinicians in the Trust had been provided with iPads, and the team based the project on using these. A relatively inexpensive ligature-free mount was sourced to be installed in the assessment room in the remote ED, and a cheap ipad holder (‘stick’) was found to be ideal for the clinician at the team base at the main hospital. We trialled various video-conferencing platforms, and learned a lot about how to set up iPads so that they can’t be ‘interfered’ with. Towards the end of the project EDPS a larger iPad was installed in the assessment room, and the original one will be put into one of the in-patient wards which serves two rural community teams, and EDPS will be encouraging team members to use the video-link to keep in touch with in-patients and to attend ward round remotely, encouraging more involvement with patients and again reducing clinician time, travel expense and carbon footprint.
Our project was initially funded by the Health Foundation, an independent health charity, and this funding allowed us to produce a video of the project, aimed specifically at persuading other clinicians to ‘give it a go’. Staff reluctance still remains the biggest barrier to introducing this sort of working more widely and the team has produced a plan to visit each community team in the Trust (across all age groups) to provide both emotional and practical support in starting to offer telepsychiatry to patients. We have also had a range of other organisations contact us, such as the local ambulance service, who are interested in our experiences and are using our protocols, leaflets and videos to inform business cases to introduce telehealth solutions.
Outcomes and evaluation
Staff feedback (n=50) after clinicians had used telepsychiatry with patients showed that 92% would be willing to use the technology again. More importantly, once the team started to use telepsychiatry, we were surprised by how positive the feedback from patients was. 90% of new assessment and 100% of follow-up patients in the project data collection period rated their overall experience of telepsychiatry as ‘excellent’ or ‘good’. Patient comments included: • It’s brilliant that there is no travel or expense involved. I was nervous as to how this would be but I was really surprised as to how effective it was and how you almost forget that the other person isn’t in the same room as you. • Just that it was a great new experience! • Was generally ‘good’ & image & audio were both clear. • I found this extremely useful, convenient and actually enjoyed my session. Thank you. • Communication was clear • It really helped me cope with my emotions better A key aim of the project was to improve access to our brief follow-up clinic, which patients often find difficult to attend during office hours. The first patient to ‘attend’ follow-up sessions remotely worked in rural Oxfordshire and was able to have his appointments when he had finished work, without having to travel. He told his clinician that, had it not been for the offer of telepsychiatry, he wouldn’t have attended. Another patient had follow-up appointments arranged after school, and had her last appointment while on holiday abroad. One patient commented: “I saved time and the cost of travel because I work weekdays 9-5”. Based on the 12 weeks of data in the initial trial period, we continued to see a similar rate of patients at the remote hospital via telepsychiatry we saved 444 hours of clinician time, £4,924 in travel expenses and approximately 3.80 tonnes of CO2e.
Has your service been evaluated (by peer or academic review)?
We collected data on our project for 12 weeks and the responses to our surveys and estimated savings is reported above. Our project has also been chosen to be presented at the King’s Fund Digital Health Congress (oral presentation) and at the Royal College of Psychiatrists International Congress (poster and oral presentation).
Development and sustainability
The ‘offer’ of telepsychiatry has become embedded in our team and we continue to see roughly 30 patients a month for new assessments, via telepsychiatry. We hope to expand our follow-up appointment provision greatly in the coming year. The ease and perceived benefits for both staff and patients mean that it is unlikely not to continue. We have seen a rate between 96% and 98%over the period of 3 months in 2018 of all patients seen within the time frame of 1 hour for patients at the John Radcliffe psychiatric liaison service and 1 1/2 hours at the liaison service at the Horton Hospital.
Access
How many people do you see?
Number of Referrals assessed by EDPS. First figure shows the referrals to the John Radcliffe hopsital and second figure referrals to the Horton hospital in teh past 9 months. August 2017 – 176 and 34 September 2017 – 170 and 30 October 2017 – 191 and 28 November 2017 – 179 and 30 December 2017 – 183 and 34 January 2018 – 205 and 44 February 2018 – 173 and 29 March 18 – 183 and 45 April 2018 – 183 and 46
How do people access the service?
We offer this to all patients who are referred to EDPS from the Horton when staff experienced in telepsychiatry are available.
How long do people wait to start receiving care?
The waiting times for the referrals are dependent upon the area they are referred from; in the A&E department at the JR, the wait time is 1 hour whilst for the Horton A&E it is 1.5 hours.
How do you ensure you provide timely access?
A patient can expect to receive the same standard of care they would receive with a face-to-face interview. Patients can invite a family member to the consultation and/or ask for an interpreter to be present if needed. Patients will be asked to give consent before beginning the session. Patients can choose to be seen face-to-face if they would prefer. If, during the consultation, the patient decides they do not want to carry on with videoconferencing the patient can ask for the session to be stopped and a face-to-face assessment can be arranged. If the link breaks down and can be rapidly fixed the session will continue, but if not, an alternative will be offered, either face-to face contact or another telepsychiatry session depending on the need, urgency and patient preference.
NCCMH mental health care pathways
Have you implemented any of the mental health care pathways developed by the NCCMH (on behalf of NHS England)?
Liaison Mental Health Services for Adults and Older Adults
If you have implemented any of the above, what were the benefits and challenges?
The project also aimed to improve prevention in two ways – by reducing waiting time in ED so that more patients are assessed, and by increasing access to our self-harm follow-up clinic. • There is evidence that providing a psychosocial assessment to patients who present to ED with self-harm reduces the rate of re-presentation. Effective assessment of patients with all presentations is also likely to identify psychiatric illness early and appropriate signposting should improve patient outcomes. One of the difficulties identified prior to starting this project was that patients often did not want to wait for a clinician to arrive to undertake an assessment, and so would self-discharge without being seen. Through this project EDPS staff have not only been able to see patients much more quickly at the remote hospital, but due to the travel time saved, have also been able to see other patients more quickly. • NICE guidance includes the recommendation that patients presenting with self-harm should be offered brief intervention in a follow-up clinic, and there is evidence that this reduces the rate of self-harm and re-presentation to ED. EDPS has offered this sort of follow-up for some time, but patients rarely attend – the cost and time of travel to an out-patient appointment may be off-putting, and finding out-patient rooms has also been difficult. As we expand this availability we hope to be able to demonstrate an increased uptake into the clinic, particularly of patients who otherwise would not have attended.
Further Information
Hours the service operates
24 hours 7 days a week
Population details
Brief description of population (e.g. urban, age, socioeconomic status):
The population treated by this service is people between the ages of 13 onwards who present at either Emergency Department within Oxfordshire with concerns around any mental illness.
Oxfordshire with a population of 690k
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
Oxfordshire CCG
Provided by (e.g. name of NHS trust) or your organisation: *
Oxford Health NHS FT
