The Benefits of Remote Mental Health Assessments
One of the most significant knock-on effects of the Covid-19 pandemic has undoubtedly been the transition to remote working. This has been the case across almost every industry, and the medical and legal professions have been no exception. In terms of Expert Witness work, one of the most significant ways in which the UK Centre for Medico-Legal Studies has had to adapt its working practices is in transitioning from face-to-face to remote assessments, which we now deliver online, via video link.
Perhaps surprisingly, however, in making this transition, we have found that remote assessments have offered several benefits in comparison with face-to-face consultations. They have allowed us to achieve a level of quality in our work that is at least the same as if not better than before, while increasing convenience and accessibility for clients. In this post, therefore, we reflect on our own and others’ experience of remote assessments, looking back at the history of remote medicine and examining how it might improve psychiatric and medico-legal services.
The history of remote medicine
The use of video-conferencing in mental health services goes back to at least the mid-twentieth century. This practice (which is often referred to as telepsychiatry or telemedicine) was originally trialled in the 1950s and 1960s using closed circuit television. The initial trials were widely praised, but it was not until the rise of online video-conferencing, when telepsychiatry was able to offer live, interactive consultations, that remote assessments really took off.
Since then, investigations into the opportunities offered by telepsychiatry have expanded exponentially. A 2006 study published in the Journal of Psychiatric and Mental Health Nursing found 72 scientific articles related to this field published in just eight years. In its review of this wide body of research, the study noted that mental healthcare in particular seemed to benefit from the possibilities of remote working:
Mental healthcare appears to be particularly well suited for telemedicine as psychiatry utilises mainly audio-visual information as diagnostic and therapeutic tools and there is little need for hands-on procedures or laboratory tests.
In other words, compared to other areas of medicine, psychiatry lends itself to remote assessments because it relies mainly on verbal and vocal cues, as well as on patient histories, all of which can be assessed equally well remotely as they can in person. Although the 2006 study recommended further investigation into the reliability of remote assessments for specific types of mental illness, it noted that, in general, online assessments are “an adequate alternative to in-person consultations.”
This seems to be becoming more and more true as the technology for remote assessments improves. In 2018, a review of the impact of mobile apps, video-conferencing, and online services on healthcare predicted an optimistic future for telemedicine, arguing that:
As we continue to march forward, and technology continues to change, and we address the unmet needs of our patients, telepsychiatry will serve the community well. This will be of great importance and value to the primary care physician.
In fact, even before the Covid-19 pandemic, there seems to have been widespread demand for increased access to online and remote services among patients. According to a study conducted by Healthwatch in January 2019 (more than 12 months prior to the onset of the Covid-19 pandemic in the UK), many patients stated that they wanted the NHS to make better use of digital tools. The study gathered opinions from more than 40,000 people across the UK, and it pointed to the following headline areas with regards to the use of online technologies:
It found that people were frustrated with the slow roll-out of online technologies across the NHS. These people wished, for example, that there were more effective mechanisms for storing and transferring patient information digitally. Patients felt that this would prevent them from having to repeat themselves every time they came into contact with a new healthcare professional.
People expressed demand for more flexibility in hospital appointments and communication methods. They said that they wanted healthcare professionals to communicate with them using the internet and their phones. And they also felt that moving some services online would help free up more time for those patients who required face-to-face consultations.
People from rural communities (who sometimes have to travel long distances to access NHS services, only to be greeted with long wait times) and people with long-term health conditions (who need regular but sometimes only minor check-ups) were particularly interested in the opportunities offered by online technologies.
On the other hand, people also raised the important concern that communicating over the internet might be difficult for certain groups and that it might not always be the right approach. They said that they did not want a gap to develop between people who could use the relevant technologies and people who could not. They hoped that face-to-face care and consultations would always remain available as an option.
This final point is important. When it comes to using digital tools, the point is not to replace face-to-face services, but rather to maximise the ways in which technology can improve patient care. One size does not fit all, and the views garnered by the 2019 Healthwatch study echo more widespread calls for “blended” approaches to healthcare and medico-legal services. Such calls were also heard, for example, in a 2015 investigation into the use of telemedicine to treat patients living with schizophrenia. This study found that remote care “may be complementary to a visit to a doctor in person, but it cannot replace it.” The aim of digital technology, therefore, is not to remove the need for face-to-face visits in daily healthcare, but to refine current practices and help improve the overall experience of assessments, care and treatment.
Contemporary evidence regarding remote assessments
Despite the apparent demand for remote assessments expressed in the 2019 Healthwatch study, relatively few people in the UK had had any direct experience of online consultations prior to the Covid-19 pandemic. As such, there was neither a body of evidence broad enough nor a research sample wide enough to know whether remote assessments were effective. Of course, that all changed with the pandemic and the “lockdown”, which saw, at its peak, as many as 85% of medical consultations taking place remotely, up from just 14% in February 2020.
In response, in June 2020, a rapid, qualitative study was undertaken to try and understand patients’ experiences of this shift to remote assessments during the pandemic. The study was conducted by National Voices, the coalition of health and social care charities in England, in collaboration with Traverse and Healthwatch. The study questioned 49 people across all age groups about their experience of remote assessments, focusing on every aspect of the process, from arranging an appointment online through to the appointment itself and any follow-ups.
Overall, the study found that, for the vast majority of patients, remote assessments and consultations proved to be an effective and convenient alternative to face-to-face appointments. Specifically, patients appreciated being able to have quicker and more efficient access to healthcare professionals, not having to travel, and being able to fit their appointments flexibly around their schedule. They found that, in most cases, they received the same quality of communication from healthcare professionals. They also specifically valued being able to communicate in different ways, namely by phone, video, text, and email. They also appreciated that remote assessments were treated with the same level of seriousness as face-to-face assessments; healthcare professionals made active efforts to ensure that they gave the same level of care and administrative attention to their online appointments as to their regular appointments. In everything, therefore, this suggests that remote assessments can be just as effective as face-to-face assessments, as long as they are treated with the same kind of attention and dedication.
To guarantee this, the study gave the following advice for healthcare professionals to help ensure that remote consultations are as effective as possible:
Healthcare professionals should provide a precise time window for a remote assessment, and they should stick to it as best as possible. They should treat the appointment with the same level of seriousness as a face-to-face appointment.
They should communicate as much as possible with the patient in advance of the consultation, ensuring that they understand the process and what will be required. They should also ensure that the patient has access to a private environment and the necessary technology prior to the consultation.
They should be adaptable and recognize that people have different levels of confidence with technology. They should be understanding and check in frequently with the patient to make sure they are OK, ensuring that the patient remains confident throughout the process.
What has the UKCMLS’ initial experience of remote assessments been?
Our own initial experience of remote mental health assessments has been similar to that reported by patients and healthcare professionals in the 2020 study above. While the transition to remote working certainly required us to be inventive and proactive, we have found that our remote services have been as good as, if not better than, our face-to-face assessments. Firstly, as the majority of our assessments do not require a physical examination, we have not lost anything by working remotely. Secondly, we have found that, at a time when in-person assessments would require the use of face masks and personal protective equipment, we have been much better able to assess patients online when such equipment is unnecessary.
Furthermore, our experience has also correlated with previous studies’ suggestions that patients benefit from the flexibility and ease of being assessed at home. Remote assessments have particularly helped us to deal with patient anxiety because it is generally much less nerve-wracking for a patient to be assessed remotely, in their own home, than to have to travel to a clinic, a hospital, or somewhere similar.
We have found that the initial feedback from patients has been positive, and we think that this is because we ensure that they are as informed as possible throughout the assessment process. In advance of an assessment, we send the patient a full outline of what to expect in the consultation, including information about the entire process and the kinds of questions involved. We also make sure that the patient understands their rights regarding confidentiality, complaints and appeals.
Furthermore, we have done our best to mitigate one of the main risks that patients often mention in relation to remote assessments, which is data security. In fact, one thing that emerged from the 2019 Healthwatch study, mentioned above, was that young people in particular are concerned about the security of their healthcare data. We use secure data transfer technologies that are fully compliant with the European Union’s General Data Protection Regulation, ensuring that sensitive information remains secure and is not shared with anyone who does not need to access it.
Finally, we have found that, by remaining adaptable in our approach to technology, we have been able to mitigate any technical difficulties that have emerged or any problems related to technological literacy. As with face-to-face assessments, sometimes problems occur that cause either an assessment or a court report to be interrupted, but by working calmly, efficiently, and flexibly, we have found that this has never been an obstacle to delivering an effective assessment.
While we continue to evaluate each particular assessment on its merits, considering the relative benefits of remote versus in-person consultations, we feel that remote assessments have helped us improve our services during the Covid-19 pandemic. Moreover, we feel that they will continue to offer considerable advantages for medico-legal assessments in the future.
This post is provided for general information purposes and is not intended to cover every aspect of the topics with which it deals. It does not constitute medical, legal, or professional advice, nor is it necessarily an endorsement of the views of Professor Elliott, the U.K. Centre for Medico-Legal Studies, its employees, or its affiliates. Though we aim to ensure that all information is accurate at the time of posting, we make no representations, warranties or guarantees, whether express or implied, that the content in the post is complete or up to date.