This research looks at evidence regarding vision-based monitoring in inpatient mental health units.
We commissioned SQW to do a rapid evidence review, supported by the King’s Fund Library Service. SQW then wrote the summary and full report.
Purpose of this research
The Care Quality Commission (CQC) makes sure health and adult social care services in England provide people with safe, effective, compassionate, high-quality care.
CQC commissioned SQW to do a rapid evidence review, supported by the King’s Fund Library Service. The review focused on the use and effectiveness of vision based monitoring systems (VBMS) in inpatient mental health units.
This review is intended to inform CQC’s thinking about best practice and consent for the use of VBMS in inpatient mental health units. It is also intended to inform CQC’s thinking about mitigation strategies for potential threats to people’s human rights.
The study reviewed 68 documents. These documents were found through a literature search and a call for evidence. A total of 11 interviews took place to add to the findings.
A lot of the documents and interview feedback had a particular perspective on VBMS. This means much of the evidence comes from stakeholders with a particular viewpoint or perspective regarding VBMS.
The findings were first reported to CQC in March 2024; this report has since been updated to ensure it is accessible.
Findings
Use of vision-based monitoring systems
There was limited evidence on the use of specific types of VBMS in different countries and healthcare settings. One brand of technology appears to be the most used VBMS technology in healthcare in England. There were other examples cited in the literature and from stakeholder interviews.
VBMS technology offers a range of functionalities. These include:
- Location/physical activity monitoring
- Vital signs monitoring
- Automated and/or manual human monitoring of data footage
- Remote or non-remote monitoring of patients.
There was limited evidence on whether VBMS technologies are registered as medical devices. One has been classified as a Class IIa medical device in the UK and Europe since 2018 and received FDA clearance in the USA in 2021. Two were not registered due to this not being applicable for their use. The registration status of others was unclear from the evidence.
The intended uses of VBMS as marketed by developers were only identified for one technology provider. Guidance and marketing materials described the technology as enabling staff to make informed clinical decisions. They also indicated the technology could support staff to intervene in potentially dangerous situations.
These materials highlighted some anticipated benefits. These included:
- Reduced patient sleep disturbance through reduced need for night-time observations
- Reductions in adverse events such as self-harm, assaults and falls
- Improved staff and patient experience.
The materials emphasised that the technology should enhance rather than replace staff care.
More widely, the evidence identified key uses of VBMS. These included:
- Vital signs monitoring
- Location and activity monitoring
- Activity reporting to inform clinical assessments.
The main purposes for use identified included:
- Safety/reduction in adverse events (e.g. self-harm, assaults, falls)
- Reduced use of restraint
- Reduced patient sleep disturbance
- Cost reduction and increased efficiency
- Improved staff and patient experience
- Improved data for clinical decision-making.
Drivers, challenges and risks
Key drivers for the use of VBMS identified included:
- Increasing safety. Monitoring patients that could be a high safety risk. Alerting to activity related to self-harm, violence and aggression
- Other drivers included more general physical health monitoring and improving staff safety
- Reducing disruption. Making observations without disrupting patient sleep or rest
- Reducing staff pressure. Reducing pressures on staff in inpatient mental health services
- Generating evidence and data. The potential for VBMS to generate evidence and data for clinical care
- Economic efficiencies. Financial cost savings.
Key identified challenges or risks for the use of VBMS in mental health services included:
- Privacy and data protection. The evidence highlights that balancing a patient’s right to privacy against their safety is a challenge
- Informed consent. The evidence indicates failure to obtain consent from patients can cause significant distress
- Safeguarding. The evidence refers to a risk of harm and distress for patients. The evidence notes that the use of camera based technologies could risk exacerbating symptoms. This has the potential to result in longer-term trauma
- Person-centred care. VBMS is not intended to replace the therapeutic relationship between care staff and patients. However, the evidence identified risks to person-centred care. In particular, a risk was highlighted that over-reliance on technology could lead to unsafe practices
- Lack of policy and guidance. This also presents an issue in relation to the obtaining of consent
- Functionality and efficacy. There was some discussion in the literature on risks regarding the functionality and efficacy of the VBMS themselves.
The British Institute of Human Rights recognise that the use of cameras and other recording equipment in health and social care settings can be a helpful addition to care for some patients. However, the British Institute of Human Rights also recognises that for others, it can violate their human rights.
Evidence on effectiveness
There is a range of evidence regarding the actual or emerging effectiveness of VBMS in inpatient mental health care. Several studies and interviewees called for further independent research in this space. They cited a lack of clear consensus on the effectiveness and impact of these technologies.
There is limited evidence on the use of VBMS as being effective in reducing the risks of self-harm. The majority of the evidence came from one study. The study found a relative percentage reduction in:
- Bedroom self-harm incidents in observational wards with VBMS in use (-44%)
- Bedroom ligature incidents in observational wards with VBMS in use (-48%).
However, lived experience examples suggested the technology could increase (or alter) the risk of self-harm.
Two studies reported evidence of the effectiveness of VBMS in reducing the use of restrictive practice. One Trust reported a 26% decrease in the use of restraint within four psychiatric intensive care units. Other evidence included views shared by staff members of the potential effectiveness of VBMS in reducing risks of restrictive practices. However, some of the literature and interview data saw the use of VBMS as a form of restrictive practice in itself.
The evidence also highlighted economic benefits regarding the use of VBMS in inpatient mental health services. NHS Trusts using or planning to use VBMS reported expected and/or actual operational efficiencies. This was largely related to staff time savings and the generation of data and evidence.
Alternatives to VBMS
Several examples of alternatives to VBMS were identified. These included:
- Wearable devices
- CCTV
- Body-warn cameras
- Infrared monitoring cameras
- Sensor systems
- Chatbots
- Virtual mental health assistants.
Non-technology based alternatives to VBMS were cited in the literature. These included:
- Continuous observation techniques
- Wider care options such as a call bell or pendant, and regular check-ins or observations.
Considerations and implications for CQC
The findings from this review provide relevant insights for CQC in relation to the use of VBMS in inpatient mental health units.
Guidance and regulation
Implication 1: CQC could expand their Surveillance Policy to clearly encompass VBMS, or develop a separate VBMS policy. This could support settings looking to implement such technologies in line with CQC guidance.
Implication 2: CQC could consider clarifying how it will consider VBMS when carrying out its regulatory duties. This could include detailing the assessment of policies and practices regarding VBMS within settings. Sharing good practice examples with settings may also prove useful.
Implication 3: CQC might want to consider how to raise CQC staff awareness of the different types and uses of VBMS. Awareness raising could also cover CQC's policy and regulatory requirements on VBMS.
Implementation
Implication 4: CQC could use its unique position to coordinate and contribute to conversations regarding VBMS (e.g., with national bodies and other regulators). Conversations could explore the potential benefits and relative risks of the technology. Conversations could complement ongoing work by other key stakeholders such as NHS England.
Evidence base
Implication 5: CQC should be clear on the limitations and risks associated with the evidence base. This should be considered carefully when developing CQC’s position, policy and guidance on VBMS.
Implication 6: This review identified gaps and limitations with the evidence base. CQC could consider how best to support the development of the evidence base further.
Implication 7: CQC could consider engaging patients, service users and family members on an ongoing basis to understand their experience and perceptions of VBMS. This could inform CQC’s position, policy and guidance on VBMS.
Implication 8: CQC might wish to continue to engage with both technology providers and campaign organisations to understand their perspectives on VBMS. This could inform CQC’s position, policy and guidance on VBMS and ensure it considers different perspectives.