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Qualitative study of candidacy and access to secondary mental health services during the COVID-19 pandemic

Why it matters

The COVID-19 pandemic forced secondary mental health services to make sudden and extensive changes in the way they operated. At a time when mental health vulnerabilities were heightened, such changes in service delivery were likely to have a significant impact on services users, staff, and carers.

Our approach

The McPin Foundation, the University of Cambridge Department of Psychiatry, and THIS Institute undertook a study to understand the experiences of access to secondary mental healthcare during the COVID-19 pandemic.

We conducted sixty-nine in-depth interviews with service users, mental health staff, and informal carers, and we used the concept of candidacy to interpret our findings. Rather than seeing access as the direct result of the availability of services, this concept puts the emphasis on the efforts and resources demanded of service users to achieve access, as well recognising the systemic structural influences that can tend to disadvantage some more than others, the importance of micro-level interactions between candidate users and services, and the relevance of cultural alignment between users and services.

What we found

During the first wave of the pandemic, some mental health services that were deemed ‘non-essential’ were paused. The criteria for admitting people into inpatient settings were tightened to reduce infection risk. Some services were offered remotely (by telephone or video) and new prioritisation processes were introduced to identify the service users thought to be most in need of regular contact. When services could no longer offer proactive support to service users, people were instructed to contact providers if and when they were ‘in need’.

But many users were uncertain as to what level of distress or illness qualified as a care need during a pandemic – in other words, they struggled to identify their own candidacy. This was particularly true for service users whose mental health difficulties contributed to their feeling like a burden to others. Some carers and service users reported that lack of communication from services led them to assume that mental health support was not available to them during this time. Some people internalised the sense that their mental health difficulties were not seen as deserving of support.

Service users who did try to seek support reported that it was more difficult to navigate services (in candidacy terms, services were less permeable). People with limited access to the necessary technology, Wi-Fi or mobile data, or enough credit on their phones, were particularly disadvantaged.

Staff faced difficult decisions about which service users needed the most support. Many voiced their discomfort with the new prioritisation systems, knowing that reduced support could cause service users categorised as ‘low risk’ to become increasingly unwell. They reported dissatisfaction with the quality of care they were able to offer, sometimes resulting in moral injury – a perceived violation of one’s own professional integrity and values. The pandemic put a spotlight on the fact that, in time of crisis, the preventive and therapeutic functions of mental health services are particularly at risk of being de-prioritised, in favour of risk containment.

The concept of candidacy in mental health is very useful in explaining that access is not simply a matter of supply of services. Also critical are people’s interpretations and behaviours, which are powerfully affected by the way services choose to define and prioritise need. The concept of candidacy also draws attention to some of the painful dilemmas faced by healthcare staff unable to provide the care they think is needed.

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