key: cord-0909551-f5rong2s
authors: Liberati, E.; Richards, N.; Parker, J.; Willars, J.; Scott, D.; Boydell, N.; Pinfold, V.; Martin, G.; Dixon-Woods, M.; Jones, P. B.
title: Remote care for mental health: qualitative study with service users, carers and staff during the COVID-19 pandemic
date: 2021-01-20
journal: nan
DOI: 10.1101/2021.01.18.21250032
sha: a96f42397528e9564a3414b3a26195ae4baf2589
doc_id: 909551
cord_uid: f5rong2s

ABSTRACT Objectives: To explore the experiences of service users, carers and staff seeking or providing secondary mental health services during the COVID-19 pandemic. Design: Qualitative interview study, co-designed with mental health service users and carers. Methods: We conducted semi-structured, telephone or online interviews with a purposively constructed sample; a peer researcher with lived experience conducted and analysed interviews with service users. Analysis was based on the constant comparison method. Setting: NHS secondary mental health services in England between June and August 2020. Participants: Of 65 participants, 20 had either accessed or needed to access English secondary mental healthcare during the pandemic; 10 were carers of people with mental health difficulties; 35 were members of staff working in NHS secondary mental health services during the pandemic. Results: Experiences of remote care were mixed. Some service users valued the convenience of remote methods in the context of maintaining contact with familiar clinicians. Most participants commented that a lack of non-verbal cues and the loss of a therapeutic safe space challenged therapeutic relationship building, assessments, and identification of deteriorating mental wellbeing. Some carers felt excluded from remote meetings and concerned that assessments were incomplete without their input. Like service users, remote methods posed challenges for clinicians who reported uncertainty about technical options and a lack of training. All groups expressed concern about intersectionality exacerbating inequalities and the exclusion of some service user groups if alternatives to remote care are lost. Conclusions: Whilst remote mental healthcare is likely to become increasingly widespread in secondary mental health services, our findings highlight the continued importance of a tailored, personal approach to decisions about remote mental healthcare. Further research should focus on which types of consultations best suit face-to-face interaction, and for whom and why, and which can be provided remotely and by which medium.

Difficulties in mental health are very common; they bring long-term challenges for individuals, families, carers and society. 1 People with significant mental health needs may use secondary health services for specialised healthcare including acute in-patient services and community-based approaches such as early intervention, crisis resolution or specific therapeutic interventions for particular concerns. During the COVID-19 crisis in the United Kingdom (UK) and elsewhere, the number of people in need of mental healthcare increased. Besides those who suffered physically with COVID-19 itself, fear of infection, worry about those unwell and bereavement have been widespread, while measures such as lockdowns and other interventions to reduce transmission increased social isolation, loneliness and domestic strains; all create adverse conditions for mental health. [2] [3] [4] [5] [6] [7] Yet, as need increased, the capacity of mental healthcare provision was severely restricted due to distancing measures, extra hygiene precautions, abrupt changes to care pathways and reduced staff availability 8 . These changes saw provision and use of mental healthcare decrease 4 9 in the face of increased need and risk for service users. 10 In response to these challenges to the entire healthcare system, many services switched to different forms of remote care as a way of increasing capacity and reducing face-to-face contact. Telehealth, where telephone and other technology-based methods are used to provide care, 11 has increased rapidly following years of inertia or slow growth. 12 Accompanying this rise has been a rapid expansion in research, evaluation, guidance and commentary on remote care in a range of fields. This body of literature is largely positive about the potential of telehealth during, and beyond, the pandemic, 13 and is leading some to suggest that it may, at least in part, replace in-person interaction as a mode of healthcare delivery for many service users. 14 The COVID-19 pandemic forced the introduction of remote care across secondary mental health services in a matter of weeks. The bulk of research to date, however, has taken place in primary care and/or physical health. Of 543 papers identified by Doraiswamy et al. in their rapid scoping review of articles relating to telehealth during COVID-19, for example, only 42 focused on psychiatry and related disciplines. 13 Both the advantages and the challenges of remote care delivery in physical healthcare settings may differ substantially from those faced in secondary mental healthcare. The use of remote care in mental health has invited debate for decades. 15 Though some have highlighted the potential of telehealth in addressing mental health difficulties during and beyond the pandemic, 16 remote care may also have important downsides; some are more readily anticipated than others.

Rigorous qualitative studies examining the experiences and needs of service users, carers and clinical staff involved in remote mental healthcare are needed to understand its impacts, and guide short and long-term changes to services. This is not only to mitigate problems but also to take advantage of opportunities to address long-standing concerns about access that have been exposed by the pandemic. In this article, we respond to this challenge. We report on a large, interview-based study involving people with direct experience of seeking . CC-BY 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 20, 2021. ; https://doi.org/10.1101/2021.01.18.21250032 doi: medRxiv preprint (including carers) and providing mental healthcare in England during the first wave of the COVID-19 pandemic.

The study was designed and developed with six experts by experience (three service users and three carers) and a peer researcher from the McPin Foundation, a mental health research charity.

Between June and August 2020, we undertook a qualitative study involving remote interviews with 69 adults including:  24 people with mental health difficulties under the care of secondary mental health services in who either accessed support, including inpatient and community mental health services, during the pandemic, or who needed services but did not access them. The interviews (all telephone) of four service users were excluded from this analysis because they did not fulfil the criterion of accessing the English NHS for secondary mental healthcare.  10 carers of people who accessed, or needed to access, secondary mental healthcare during COVID-19.  35 point-of-care staff working in NHS secondary (inpatient and community) mental health servicesparticularly those more likely to be involved in critical and timesensitive decisions. They included psychiatrists (trainees and consultants), care coordinators, mental health nurses, clinical psychologists and psychotherapists; some had managerial as well as clinical roles.

We recruited people with experience of mental health services in England only. We did not include individuals seeking to access mental healthcare for the first time through their general practitioner or staff working in primary mental health services such as GP practices, community pharmacists, and Improving Access to Psychological Therapy (IAPT) services.

To comply with the UK lockdown regulations, all interviews were conducted remotely. Participants could choose between being interviewed over the telephone or using online video-supported secure software:

 19 service users were interviewed over the telephone, 5 were interviewed by videoconference.  8 carers were interviewed over the telephone, 2 carers by video-conference; all cared for a family member with mental health difficulties.  21 members of staff were interviewed over the telephone, 14 by video-conference.

Participants who opted for video conference interviews had the option to turn their camera off. In both cases (video-conference or telephone call) only the audio was recorded, either online or using an encrypted audio recorder for telephone interviews. Interviews lasted between 22 minutes and 95 minutes. Using peer-research methods, 17 a researcher from the McPin Foundation carried out and analysed the service user interviews, drawing on her own experiences of accessing secondary mental healthcare both before and during the study period.

We recruited individuals using online network-based approaches: some participants engaged in response to information circulated through dedicated networks, whilst others became involved as a result of colleagues or friends alerting them to the study (a technique . CC-BY 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Across participant groups, our recruitment strategy was informed by efforts to maximise diversity. We adopted a purposive sampling strategy, 18 aiming to identify a variety of experiences related to our research questions. As data collection and analysis progressed in parallel, the size of the sample was adapted to the variety of experiences captured, in line with the principle of information power. 19 Invitations were circulated through an expression of interest form, and people who wished to take part were asked to indicate their ethnicity, the gender they identified with, and the first half of their postcode. We then prioritised invitations accordingly, seeking to increase the number of those from a minority background, and to achieve balanced gender representation and widespread geographic cover in England (Table 1) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Potential participants were contacted by the researchers via telephone or email, depending on people's preferred contact method. Eligible potential participants were provided with a link to register via Thiscovery, a secure citizen-science platform developed by THIS Institute according to the AA Web Content Accessibility Guidelines that assure accessibility standards. Once registered on Thiscovery, potential participants were given further information and invited to complete the informed consent form. On completion of the consent form, participants were then able to schedule an interview, with the choice of videoconference (on Thiscovery) or a telephone call. Service users and carers were compensated £25 for taking part in an interview. EL, NR, JW and JP conducted semi-structured interviews; JP is a peer researcher with lived experience of accessing secondary mental healthcare before and during the pandemic. The interview topic guide covered a range of themes we sought to explore; the guide was deliberately non-directive to allow participants to discuss areas they perceive as relevant such as feelings of abandonment for service users or moral injury for staff.

Interview audio files were securely transferred to a third-party transcription service subject to the University of Cambridge data protection regulations. Anonymised service user, carer and staff interviews were analysed separately. Analysis of anonymised interview transcripts was based on the constant comparative method. 20 The coding scheme was developed based on a subset of initial interviews. The initial codes were revised, expanded and collapsed as analysis progressed, and through whole team discussions. Codes were then were organised into categories in a thematised coding scheme. Data was processed using NVIVO software by five coders (four females and one male, DS). JP and NB analysed service user interviews, EL analysed carer interviews, DS, NB and NR independently analysed staff interviews.

During the process of write up and dissemination, some interview excerpts were edited further to protect the identity of participants.

Ethical approval for the study was obtained from the University of Cambridge Psychology Research Ethics Committee on 15 June 2020. All participants were provided with information about the study and gave consent. We followed the Standards for Reporting Qualitative Research recommendations 21 .

We consulted a panel of mental health service users and carers convened by the McPin Foundation. Members helped us shape the research questions, methods, and risk management plans for the study. We also gathered the views of these experts-byexperience on the study materials, including the research protocol and our participant-facing documents. We shared the study documents with these experts-by-experience requesting their comments and recommendations. We also held a series of online meetings to give participants a further opportunity to share their views and suggestions for improvement, providing individual online meetings or a telephone call according to preference. Experts-byexperience provided advice on how best to include carers in the study and suggestions for . CC-BY 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 20, 2021. ; https://doi.org/10.1101/2021.01.18.21250032 doi: medRxiv preprint specific networks for recruitment. They also guided how best to compensate participants for their time, as well as emphasising the need for an accessible summary of the research to be made widely available.

Our interviews with service users, carers and staff confirmed a widespread move to remote care in response to the pandemic. Telephone consultations were, initially at least, reported to be the most commonly offered form of remote care; setting-up secure video-conferencing systems took time due, in part to uncertainty as to which, if any, platforms and systems were allowed by information governance policies of different trusts, and staff and service users being unfamiliar with how to use them. Initially, it was assumed by service providers that telephone would be the most widely available to service users, with fewer barriers to access than online methods. Towards the end of our recruitment period (August 2020), interviews were beginning to indicate that secure video-supported platforms were in place in various NHS community mental health services across the country.

Service users had mixed experiences. Most reported that remote care was adequate or tolerable, but that face-to-face was much better. Some felt that the use of remote methods made it more likely that appointment times would be altered or not followed through. This often led to a sense of uncertainty and frustration. Several reported that trying to build a therapeutic relationship remotely with a member of staff who they did not know was problematic, and that they preferred being able to build on pre-established rapport.

I suppose if the AttendAnywhere works… actually, it doesn't take as long out of your day. It takes exactly an hour rather than travelling to the appointment. So, it's an option. But I still feel that the face-to-face has it for me. (Service user) I can't deal with uncertainty and inconsistency and I think they literally did…oh, we'll call at 3:00, and then they'll call at 4:00 and it was, yes, we can, no, we can't. Then in the end they discharged me with a letter and then…it was in a way, you know when they discharge you as well, you don't know whether to say, yes, that's a good idea or no because you're worried that actually tomorrow I might have a really bad day (Service user) I think it's a very poor service that make an agreement they'll ring somebody every week, and then suddenly to fall off a cliff like that, I think it's a really bad service, I'm sorry. I think someone should handover and say, well, I've got a vulnerable client that's actually been working with the [service name] as well, and then just to be dumped like that for nearly seven weeks, I'm sorry I think it's really poor. (Service user)

Positive experiences generally came from service users who had a prior relationship with a clinician.

[The psychiatrist] was really great across the phone… I was quite worried that the phone appointment was going to be terrible because I've always had it in person, but he was really good. It was almost like he was in the same room as me. (Service user) Some service users and carers chose not to receive remote care, particularly for psychological interventions, because they believed that face-to-face consultations would be reintroduced soon. Others did not feel that remote consultations would be as is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Staff expressed concerns that breaks in therapy might negatively affect service users' and families' mental health during the pandemic. They recognised the challenges in providing remote care and understood service users' choices not to engage with it, some offering face-to-face when allowed: Some staff shared the view of many service users that remote care was more suitable for maintaining continuity in existing relationships than for meeting people who were newly referred. Conversely, some clinical psychologists and psychotherapists reported that remote care was more likely to be accepted by service users who had not experienced face-to-face therapy before, because they did not endure the 'shock' of a change in access mode.

The move to remote care helped to maintain some form of connection between service users and services during the pandemic. However, participants reported that remote care changed the character and depth of clinical encounters and, in turn, their relational quality. Uniting the accounts of service users, carers and staff was the loss of the embodied dimension of therapeutic interactions, including the physical space where these used to take place. Many described remote consultations as 'not the same', noting that even where they were able to see someone's facial expressions (in online consultations), not being together in a room meant that building and maintaining a connection was problematic. For example, when eye contact was mediated by a camera, it hampered the reciprocity normally experienced in face-to-face interactions, as did the emphasis of verbal communication over body language. These factors compounded many service users feeling socially isolated during the pandemic, while for others, the loss of a particular, even sacred, therapeutic setting undermined the quality of care: is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The loss of the journey to and from services was another aspect of remote care that required adjustment. Some service users felt they were deprived of the opportunity to process the content of the sessions and gently transition back to their home lives. Similarly, some staff members reported less opportunity to reflect and process after consultations due to back-to-back appointments. Several therapists also emphasised the importance of therapy taking place in a safe and bounded physical space (the therapeutic setting). They saw remote consultations, often being delivered from their homes as removing a boundary between private life and therapeutic work, compromising the safety of these consultations. They found some types of therapeutic work, such as trauma processing, to be so ill-suited to remote care that they paused it. 

A particular area of concern for all participants related to the effectiveness of remote forms of care in conducting assessments and identifying risks. Service users reported that the lack of face-to-face contact made it more challenging for staff to identifyand help them recognise signs that their mental health was changing. This was important when, for example, the nature of their mental health difficulties meant they could transition rapidly from depression to mania, without being able to understand that this was happening and that a crisis requiring inpatient admission might follow. In interviews, service users and carers described video consultations as going some way towards addressing these issues compared with telephone calls, but mostly they saw them as a poor substitute for face-to-face contact:

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Before COVID, probably in face-to-face meetings there [was] more of an opportunity to observe body language and assess mood from the physical presence of somebody that you're sitting with. I don't think that can be really captured over the phone. (Carer) Some carers felt that the shift to remote care exacerbated a pre-pandemic problem of their being excluded from assessments, such that risk may not be assessed properly. One carer felt that the person they supported did not find remote consultations beneficial and tried to end the interactions quickly. Because the carer was not included in the consultations, some issues were not recognised, recorded or addressed:

Staff tended to agree on the inherent limitations of remote consultations for conducting assessments and identifying mental health risksespecially in the context of COVID, where service users presenting to community services were more acutely unwell. It appeared that specific aspects of assessments were particularly compromised by remote contact. For example, staff and carers said remote consultations made it difficult (or, in the case of telephone consultations, impossible) to pick up important non-verbal cues, such as body language and levels of tension. These difficulties were exacerbated for service users who struggled to verbally communicate how they were feeling. Acknowledging the limitations of remote consultations for risk assessment, some services used telephone consultations to evaluate the need for face-to-face contact. Yet sometimes this introduced other problems: delaying fuller assessments, for example:

Other factors that limited the depth and appropriateness of remote assessments included an inability to evaluate service users' home circumstances. Staff had to rely much more on service users' self-report of their mental health without, in addition, picking-up subtle, nonverbal clues that are available during an interview. Staff acknowledged the importance of carers, family members or friends being physically present at the point of assessment, reporting that service users who did not have this support (for example, those living in care homes during the pandemic) may have been particularly disadvantaged. Remote working and lockdown restrictions also meant that service users in compromising home life situations, such as those facing domestic abuse, may not have felt comfortable disclosing how they were coping: is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 

Participants across the service user, carer and staff groups reported multiple concerns about the potential for remote care to have disproportionately negative effects for some groups of service users and carers through intersectionality, thus creating or further amplifying inequities. These groups included those with hearing difficulties and communication impairments; people for whom interacting through a screen or a telephone was particularly challenging (e.g. because of anxiety or autism); people who were unfamiliar with or reluctant to use technology, including some older people and those experiencing paranoia or delusions about technology; people who could not afford devices or internet access; and people who needed support with the English language, often impacting on whole communities ( Table 2 ). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 20, 2021. ; https://doi.org/10.1101/2021.01.18.21250032 doi: medRxiv preprint relaying only upon verbal communication may constitute an obstacle to mutual understanding.

Some participants emphasised the need to identify and address the inequalities created by new, as well as traditional, ways of providing support. One carer noted that in evaluating the appropriateness of remote care, it is important to account for remote consultations that are missed or cancelled as well as those that do take place, to avoid self-selection bias: Conversely, remote care appeared to have some role in addressing some inequalities associated with face-to-face only. For example, during the pandemic, it enabled people who were shielding or particularly vulnerable to the virus to continue accessing services, reducing transport costs and logistical difficulties for service users and carers, and benefitted people with physical impairments who were challenged by having to travel. That said, it did not benefit all.

For a long time, service users asked us 'Do we have to come all the way into a site with no parking, or could you see us by video?' And the answer's always been 'No.' So I think some of them are a little bit annoyed because they've been asking for this for years and never received it, and now we've said 'It is possible, after all -who knew?' So, it'll be funny after to see what people are happy to go back to… My consulting rooms are on the first floor [with no] parking space, which is hideous for older people with mobility problems. So, I think a lot of them would prefer telephone or video rather than having to come in. (Senior clinical psychologist) The future of remote care Service users, carers and staff had varying views on the appropriateness of remote care for secondary mental health services, but generally concurred that shared decision-making about access modes (face-to-face versus remote care) needed negotiation. As the use of remote care became more common during the pandemic, such consultation and shared decision-making became even less commonplace, albeit largely through force of circumstances. Service users, carers and staff, alike, felt strongly that organisations should take a tailored approach to introducing remote care once more flexibility returns to the system. It should take into account the differences between different types of clinical encounter (for example, psychotherapy, psychiatric reviews, monitoring or changing medication, or regular care coordinator encounters) and the range of options for remote contact (including telephone calls, video-supported calls, text messages, emails). They also highlighted that, in the future, mental health services should attempt to acknowledge the . CC-BY 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 20, 2021. ; https://doi.org/10.1101/2021.01.18.21250032 doi: medRxiv preprint unfamiliarity and potential 'strangeness' of accessing services remotely and recognise that people's preferences around remote access may shift in response to their changing circumstances and experiences of mental health:

There wasn't anything about, 'You might find this strange initially; it's going to feel different'… Something like that would have been really nice, like 'It's going to feel different and maybe these are some of the ways that you and your psychiatrist can manage that.' (Service user) Participants described technology-related and connectivity issues as other key factors to consider in relation to remote access. Wi-Fi and signal problems could affect sound and video quality and sometimes prevented consultations from happening altogether. These issues seemed to be more substantial in rural areas, thus disproportionately affecting services in specific geographical locations.

I know a lot of people who've had technical and/or IT-related issues with [remote care]largely due to connectivity or lack of. So that seems to have been the biggest barrier.

There was one appointment when we tried and tried to get the AttendAnywhere to work and it just wouldn't, and it was really frustrating because we could see each other but either I could hear my psychologist, or he could hear me, but we couldn't hear each other. So, we gave up in the end… It does rely on you having a good internet connection. (Service user)

When staff were asked about the future of remote care, most saw it as having a role in supplementing face-to-face contact. Its advantages included avoiding unnecessary or burdensome travel, giving healthcare staff more time to maintain regular contact with service users, allowing the flexibility to offer shorter, more frequent sessions, and perhaps enhanced ability to follow up service users who did not attend their scheduled appointments, although this was not the experience of the service users we interviewed. Staff also reported some remote sessions as being more intense than face-to-face so they brought them to a close earlier. Finally, staff emphasised that if remote care was going to be more widely used in the future, they would need specific and tailored training for delivering psychological interventions remotely: is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 

This qualitative study of the accounts of 65 service users, carers and healthcare staff about their experiences of remote care during the COVID-19 pandemic offers much rich learning (Box 1), including indications of how to optimise service provision in the future and where evidence and guidance is needed. Participants reported both advantages and disadvantages to remote care as a means of sustaining capacity and enabling access to secondary mental health services. Some participants, including both service users and service providers, valued the flexibility offered by remote care, particularly in the context of reduced access to face-to-face service provision. 22 Nevertheless, there were significant downsides. Participants found that consultations by telephone and video restricted therapeutic relationships compared with in-person contact, particularly where service users and staff could not build on a bond already formed face-to-face. This finding underscores the limitations of the current evidence on video-based consultations as a substitute for in-person healthcare that, as Greenhalgh and colleagues note, relates almost exclusively to "highly selected samples of hospital outpatients with chronic, stable conditions." 23 Our study further challenges the transferability of the findings of this body of evidence to the mental health context, particularly for service users whose difficulties are fluctuating or who may find themselves in crisis.

Our study has strengths and weaknesses. As a qualitative study, it relies on accounts of behaviours, practices, experiences and opinions as reported by participants, cannot take into account the clinical or personal outcomes of remote care, or infer causal relationships between these and the various features of remote care identified. Furthermore, we did not recruit people attempting to access mental healthcare for the first time. Among the study's strengths are its large and varied sample and its novelty in exploring remote care for mental health during a pandemic from the perspective of service users, service providers and family carers. We acknowledge that the methods of online recruitment and engagement used in the study will have created some barriers for some groups; the approach favoured those to whom we could reach out with information about the study, as well as those with the necessary resource and capacity to decide whether or not to take part in the interview and to complete the informed consent process. For this reason, our findings may underplay the problems. On the other hand, remote methods may also have facilitated involvement of some people who would not have chosen to take part in a face-to-face study. Further strengths include the study's involvement of experts-by-experience and use of peer research methods, which arguably facilitated more authentic understanding of people's views and experiences, valuing the expertise of all those involved while equally valuing difference.

The study is helpful in identifying the distinctiveness of the mental health context compared with remote care for physical health conditions. Staff and service users alike noted that many features of a consultation that are taken for granted in face-to-face care become problematic in remote consultations. From clinicians' perspectives, the essential non-verbal cues that are important to their questions, assessments and advice were missing. They sometimes doubted whether service users were willing or able to disclose all relevant information. Similarly, service users and carers felt that important aspects of consultations could be missed or misconstrued, especially by telephone, and even during video consultations. Both service providers and service users lamented the loss of the 'sanctity of the consulting room', as a space reserved for highly personal, confidential conversations. Neither the psychological nor the physical features of this space could be replicated in remote consultations. The lack of boundaries between domestic life and the clinical encounter could be immensely stressful, and challenges around privacy that have been noted in relation to physical health may be particularly difficult in remote care for mental health. 24 25 For some service users, aspects relating to their mental health magnified the challenges that have been noted in remote consultations about physical health. 22 26 Sensory difficulties, communication impairments, digital exclusion and aversion to screen-mediated contact . CC-BY 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 20, 2021. ; https://doi.org/10.1101/2021.01.18.21250032 doi: medRxiv preprint made remote care especially problematic for some service users, and might be caused or exacerbated by some mental health difficulties.

Though remote care in secondary mental health services is likely to become increasingly common, perhaps routine, our findings suggest that a blanket approach is not a suitable long-term solution once the exigencies of the COVID-19 pandemic have passed. While enhancing access for some groups, it may impede it for others, and the differential impact of remote care requires careful evaluation, accounting for impacts on those who withdraw from remote care as well those who engage. This also points to the need to develop tailored, personalised approaches to remote care that cater for the preferences and needs of individual service users, as well as for changes in their mental wellbeing. Our data show that many service usersand indeed professionalshad limited influence or choice about how care was provided. Identifying the appropriate balance of in-person and remote support for individuals and for different service user groups requires the input of frontline clinicians, service users and families who may be involved in their care, and the adoption of rigorous co-production methodologies that will take careful development. Future research should aim to provide guidance on exactly which type of clinical consultations best suit in-person presence, and for whom and why, and which can be offered remotely, and through which medium, taking into account intersectional challenges regarding access that contribute to the continuing 'digital divide' in mental health 27 28 . Training and development might focus on enabling staff, service users and carers to make the most of the advantages offered by remote care, while identifying and mitigating its challenges. Equally important is to consider the risks of remote working for members of staff: reduced contact with colleagues in the structured environment of a shared working space may hinder the kind of informal knowledge sharing and mutual monitoring that is key to maintaining safety in healthcare teams. If we can define what good looks like, shared decisions about the option of remote approaches could support a tailored, personal approach to mental healthcare. Box 1: Leaning points for remote care Box 1: Learning points and priorities for improvement for providing remote mental healthcare  While remote consultations allowed secondary mental health services to continue working at a time of unprecedented crisis, refinement is definitely needed in how these will be offered in the future.

 The availability of remote access technologies does not mean that direct substitutions are appropriate.

 Conducting mental health assessments remotely may be particularly problematic and could hinder the identification of risks and use of shared decision-making.

 Training for staff in leading or supervising clinical interventions remotely is needed; this must be targeted to the specific remote platform used and be based upon co-production principles with service users and carers in delivery.

 There is a specific need for guidance on use of remote access mental healthcare, which would be best based upon further research and consultation.

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Do we still have a digital divide in mental health? A five-year survey follow-up

Digital exclusion among mental health service users: qualitative investigation

We are very grateful to the service users, carers and staff who so generously took part in this study, and those who helped us to develop this study. This project was funded by THIS Institute's grant from the Health Foundation. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. All contracted parties contributed to the study under agreements through the same funding. We are grateful to colleagues at THIS Institute for developing and managing the Thiscovery online research platform that facilitated this work, to Joann Leeding for support with public and patient involvement, to Bethan Everson for assistance with governance and data management, and to Kim Cannon-Sell for help with reference management. PBJ is supported by the NIHR Applied Research Collaboration East of England and by RP-PG-0161-20003. Mary Dixon-Woods is an NIHR Senior Investigator (NF-SI-0617-10026). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Elisa Liberati was lead researcher and managed the project with Natalie Richards. Peter Jones, Mary Dixon-Woods, Jennie Parker and Vanessa Pinfold contributed to the design of the study, analysis, and writing-up. EL, NR, JW and JP conducted the interviews. DS, JW and NB contributed to the analysis and writing-up.

The authors declare they have no competing interests.