Oral evidence: Progress improving mental health services, HC 1000
Monday 17 April 2023
Ordered by the House of Commons to be published on 17 April 2023.
Members present: Dame Meg Hillier (Chair); Olivia Blake; Sir Geoffrey Clifton-Brown; Mrs Flick Drummond; Anne Marie Morris.
Gareth Davies, Comptroller and Auditor General; Ashley McDougall, Director, National Audit Office; and Marius Gallaher, Alternate Treasury Officer of Accounts, HM Treasury, were in attendance.
Questions 1-63
Witnesses
I: Andy Bell, Chief Executive, Centre for Mental Health; Peter Devlin, Director of Adult Social Care, Mental Health, Essex County Council, and Member of the Association of Directors of Adult Social Services; Chris Dzikiti, Director of Mental Health, Care Quality Commission; and Dr Victoria Tzortziou Brown, Vice Chair for External Affairs, Royal College of General Practitioners.
Report by the Comptroller and Auditor General
Progress in improving mental health services in England
(HC 1082)
Examination of witnesses
Witnesses: Andy Bell, Peter Devlin, Chris Dzikiti and Dr Victoria Tzortziou Brown.
Q1 Chair: Welcome to the Public Accounts Committee on Monday 17 April 2023. The Government have long had an ambition to achieve parity of esteem between mental and physical health services. Together with the NHS, they have a number of commitments to expand on and improve mental health service provision, which is widely acknowledged to be lagging behind physical health treatment. It is not easy and there is huge demand—growing demand—on mental health services. Of course, the pandemic has had an impact as well.
This is the first of two sessions that we are conducting on mental health services. Thanks massively to the National Audit Office for its Report, which is helping us in our inquiry. Today, we talk to stakeholders in the sector. On Thursday, we will be back to question the Department of Health and Social Care and NHS England.
I welcome four witnesses who deal with the issues on the frontline: Chris Dzikiti, Director of Mental Health at the Care Quality Commission; Andy Bell, Chief Executive at the Centre for Mental Health; Victoria Tzortziou Brown, Vice Chair for External Affairs at the Royal College of GPs; and Peter Devlin, who is Director of Adult Social Care, Mental Health, at Essex County Council, as well as being a member of the Association of Directors of Adult Social Services—he is here wearing two hats, and I guess you could not take either hat off even if you wanted to, Mr Devlin. Welcome to you all.
Before we go into full questioning, I will go through you one by one so that you can explain a bit about your organisation, where relevant—you in particular, Mr Bell, as we might not all be aware of the excellent work of the Centre for Mental Health. You can give us a couple of minutes about what you think are the big challenges ahead. Ms Blake will then kick off our questioning.
Forgive me, we just need to have a declaration of interest.
Olivia Blake: I declare an interest: just before being elected, I was a non-executive director of a mental health and learning difficulties trust.
Chair: Thank you, Ms Blake. Forgive me, Mr Bell—will you kick off?
Andy Bell: I work at the Centre for Mental Health. We are an independent charity. Our role is to tackle inequalities in mental health through the use of evidence, research and analysis. Our work spans mental health services and, more broadly, society, so we have a strong focus on the causes of inequalities in mental health and on what creates good mental health in society and what harms people’s mental health. We have an interest in the way people receive support for their mental health at different ages and life stages. We try to bring a real understanding of the structural, social and economic determinants of mental health to all the work that we do.
On the many issues that the Committee may want to ask about and that we have had an interest in, I think the first thing to say is that we know that the public’s mental health has been deteriorating in recent years. There is clear evidence, particularly in relation to children and young people. We know that mental health conditions are, of course, common and always have been, but that the cost of mental health conditions, when they are left untreated and not dealt with and when people do not get the right support, is incredibly high—it has often been underestimated—and so working for parity for mental health, not just within the NHS but across all public services and in the decisions made across Government, national and local, is incredibly important.
We also know, unfortunately, that not only are some groups of people more likely to experience poor mental health than others; very often, the same groups of people have poorer access to mental health support, and when they do get support for their mental health, it is less likely to be successful and create positive outcomes.
So there are many inequalities and inequities in the system. I think one thing that is really important is both to see the enormous amounts of progress that the NHS has made over the last four to five years in terms of closing the treatment gap—many of which are in the National Audit Office Report—and to see that, beyond that, there is a good deal more still to be done to bring about mental health equality. I’ve probably used up more than my two minutes, Chair.
Q2 Chair: Well, thank you very much indeed. Thank you also for the Centre for Mental Health’s evidence, which was quite shocking to read but very useful to us. Chris Dzikiti?
Chris Dzikiti: Thank you, Chair. My name is Chris Dzikiti, and I am director of mental health at the Care Quality Commission. At the Care Quality Commission, we published our report, “State of Care”, towards the end of last year. This looked at some of the challenges within mental health services. We spoke about the workforce issues, which continue to be a challenge. We highlighted some issues about the gaps in community mental health services; sometimes we see people coming into mental health services needing more support because they haven’t been able to access that support within community mental health services.
We also highlighted the issue about access to services and treatment, looking especially at children and young people. We find some children and young people being admitted to adult services because there is not enough provision within the children and young people’s mental health services. We also see children and young people on paediatric wards because of a lack of services. So we highlighted all those issues in our report.
The other thing I will say is that we focused on environment, which is a big issue. This has obviously been made worse by the pandemic. Some of the innovations or updates that need to happen to mental health environments have not taken place because of the pandemic, so we see an impact on the therapeutic care that is required to support people in mental health services.
Those are some of the challenges that we are seeing as we continue to regulate services. At the CQC, our main job is to regulate health and social care, to make sure those services are safe and to make sure patients are having a better experience of mental health services. We also have this opportunity: we recruit second-opinion doctors, who go in to support people who otherwise are forced to take medication, who don’t want to take medication; we need to check that the treatment plans that are being put in place are appropriate to meet people’s needs.
The last thing I will talk about is this. We also have our Mental Health Act reviewers, who go into mental health services to speak to people who are detained under the Mental Health Act, just to understand their individual experiences of being detained under that Act and their experience of the treatment they are getting in mental health services. I will leave it there as a start, Chair.
Q3 Chair: Thank you very much indeed. Victoria Tzortziou Brown.
Dr Tzortziou Brown: Thank you for the opportunity for the Royal College of GPs to contribute to this conversation. As GPs, we see people with mental health conditions; in fact, that is a large part of what we do on a day-to-day basis. It is made harder by the workforce and workload challenges that we face. We have many fewer GPs than we used to. We have problems retaining our existing workforce because of the significant workload. Because of the number of appointments and the limited time per appointment, we cannot provide the care to patients that they deserve and that we aspire to provide.
In terms of referrals to secondary care services and IAPT services, we have seen some improvement in access to IAPT services. However, we also have experienced that secondary care services have probably become more exclusive rather than inclusive. Therefore, there are times when we refer people to secondary care—they are not appropriate for IAPT, or they have had talking therapies before and they need secondary care interventions—but we experience that some of the referrals get rejected and people fall through the gaps, and therefore we have to take over and pick up the pieces.
We absolutely support the direction towards better integration in mental health services. We welcome the additional roles—the mental health practitioners who are joining our extended teams and the social prescribers—and we would like to work closer with our communities to provide better care to our patients in a holistic way. However, all those new roles are very new, and it will require a lot of effort to embed them in our services to become part of our teams. These are the challenges.
Q4 Chair: I know you are here to represent the Royal College of GPs more generally, Dr Tzortziou Brown, but how many of these other healthcare professionals do you currently have in your own practice, and how many could you absorb?
Dr Tzortziou Brown: In terms of mental health practitioners, each PCN in the coming year will have up to three full-time equivalent mental health practitioners. Each area varies significantly in terms of the number they have access to. Some areas have utilised all the numbers, and some areas do not have access. The RCGP did a survey of members, and only 44% of GPs said that they have access to mental health practitioners at their practice, and only 31% of those GPs who said that they had access said that this access was very or fairly good.
Q5 Chair: Do practices tend to pool that resource, or do you expect to have somebody in your own practice to do this?
Dr Tzortziou Brown: Usually these roles are available at primary care network—PCN—level. Each practice can access those roles through the primary care network.
Q6 Chair: We might probe that further, but thank you—that helps to clarify it. Mr Peter Devlin.
Peter Devlin: Good afternoon. Thank you for the opportunity to speak to the Committee this afternoon. My name is Peter Devlin. I am the director for adult social care, mental health at Essex County Council. I am responsible for Essex County Council’s adult social care mental health services—our operational community mental health social care services, our approved mental health professional service, and the mental health and wellbeing service. I am also the co-chair of the national ADASS mental health network, and I am here in that capacity this afternoon, although I remain a practising approved mental health professional, so I am still in contact and in touch with practice.
I suppose that ADASS comes from the position that mental health is a societal issue before it is an NHS issue. Public population health management methodologies really bear that out—20% of good outcomes in terms of quality of life and length of life are attributable to NHS clinical interventions; the rest of it is associated with individual behaviour and choice and the societal infrastructure that people live and exist in.
Our view would be that recognising mental health in that societal context is where we need to move to next. The NHS plan over the last few years has driven some key standard approaches to the monitoring and measurement of waiting times and access, but we need to go much further in terms of extending the range of support beyond the NHS itself. We believe that the local authority has a pivotal role in relation to the alignment with its levelling-up agenda and the duty to address health inequalities and improve economic prosperity employment and so on for its population. That is on top of its wider civic responsibilities for the local environment, infrastructure and economy. We would like to see some of those agendas start to form around one another and coalesce.
As we have said, the local authority for adult and children’s social care has statutory obligations for individuals with mental health conditions and their carers. Also, much of the community infrastructure is still commissioned by adult and children’s mental health. Local authorities have a good relationship with their communities and the care sector and the expertise and infrastructure within those. We would encourage that to be built on, rather than be seen as discrete or separate to that wider effort.
Overall, we would want to see a stronger voice for mental health social care and a stronger collaboration. We are working closely with NHS England. We have developed quite a strong and progressive relationship that recognises the holistic needs of our populations, but we do need to go further with that. We need to go much further in the context of the mental health reforms and the change in the legislative landscape. We need to be seeing sufficiency in the range and type of community provision for the people and their families that we serve.
Chair: Thank you. We will probably get into the legislative issues later. I will now turn to Olivia Blake MP.
Q7 Olivia Blake: My colleague might want to come in on this, but the first area I would like to ask questions about is around the new systems we have in place in localities, including the changes we have seen to—I have forgotten the name now—
Chair: ICBs.
Olivia Blake: Yes—I was going to say STPs, but that is from a while ago. I would like to ask about the change to ICBs and the impact that is having on mental health as a priority, particularly in view of the fact that a lot of mental health funding still comes from national funds for specific services. Do you think that is the correct way to continue, or do you think more of a role should be played within ICBs on mental health?
Chair: Who are you directing that to?
Olivia Blake: I would like everyone’s input, if that is okay.
Chair: In the same order?
Olivia Blake: Yes.
Andy Bell: If we look at the legislation that set up integrated care boards and partnerships within integrated care systems—I keep being reminded to use the right last word in the acronym—there is a lot there that gives us hope. There is the focus on being responsible for the health and wellbeing of the population, and it is thinking about prevention. It has a very broad, holistic approach to prevention, including thinking about economic wellbeing. We know that the things that determine your chances of having good or poor mental health are very much about the environment you live in, the life you have, the experiences you have and the inequalities that exist. Integrated care boards and partnerships have a responsibility to see health through that lens, so that is very positive. We were really pleased that that Parliament included a stipulation that every integrated care board must have at least one member with expertise in mental health. That was a really positive development. It came very late on, but we were delighted with it.
There is no doubt that the structure of an integrated care system has a lot of potential if it brings in health and local government equally, if it really takes a preventative approach and if each system—since there are 42—treats mental health as as big a priority as physical health. We are relying on that.
Obviously, there are lots of ifs in what I just said. At the moment, as we know, the NHS and local government social care and health services are struggling. There can be a focus on other issues, such as elective backlogs and difficulties in emergency departments, and we know why.
Potentially, that means that mental health is put to the back of the queue. And we get to see whether there really will be a shift towards putting resources into prevention. Good words in integrated care strategies are nice—I have read a few now. I like all the words, but we need to see that translated into action.
In terms of the balance between centre and local, I think that is really difficult. We know from the past that when the Government has mandated improvements and expansion in mental health services, it has lasted while the Government has been putting in money. When the Government stops putting in money or stops requiring it, there has in the past been backsliding. On the other hand, unless integrated care boards and partnerships own the changes and really believe in them and want to do them for themselves, being mandated from NHS England will make it difficult to sustain those things. I think it is a really delicate balance. I wish I could give an easy answer to that.
Chris Dzikiti: I have worked in an integrated care system before and I have been in mental health services for the last 23 years, so I have seen some changes that come with positive outcomes for people. In terms of integrated care systems and partnerships or boards, it is a great opportunity to bring the whole system together in a system approach to healthcare for that population. What we have seen in the past is the challenge of trying to keep mental health as a focus when the system or the healthcare provision is challenged with other things like the performance of A&E targets and cancer targets. But this is a great opportunity as long as mental health is included in the planning from day one and is not an afterthought. Even when you talk about elective care in local systems, we see that elective care does not always refer to mental health services. So, for us, it is a great opportunity to give integrated care systems or boards the opportunity to really look at mental health. As long as mental health gets the same attention, that would be really helpful.
There is something about looking at things from a local point of view. I think, like Andy said, the integrated care partnerships, for example, is where people are. People have used the services before. That is where people with expertise of mental health services are. If they are given that opportunity to contribute to the planning from day one, I think we have an opportunity to improve mental health services, but, like Andy said, it is hard to tell at the present moment. I think we will see different systems at a different level of maturity, and we will see over time whether this is the best way forward. It is an opportunity to give those local systems local leadership and local ownership to address the local population needs around mental health services.
Dr Tzortziou Brown: I would agree with what has been mentioned. At a national level there have to be some key principles of the direction of travel. What are we aiming to achieve? For example, integration of services; attention on health inequalities; data that can guide improvement; innovation and research and evaluation of new services; and support to localise the base to innovate and work with their communities and work with their providers as a system across pathways—and co-produce with residents and patients and get the best care for their area. They should be given the opportunity and the resources to do this well—even fail in certain things, provided that there is evaluation and failure can be picked up early enough, so that we can find ways that work to deliver care for patients, and we can talk more confidently about the cost-effectiveness of the care that we deliver.
Chair: We like the words “cost-effectiveness” on this Committee. Mr Devlin?
Peter Devlin: ADASS is concerned that mental health gets overshadowed by the other priorities in the ICBs. The infrastructure in the ICBs is very much focused on supporting the acute hospitals—older people in frailty. We have much more mature infrastructure than we have in mental health. Mental health is still often regarded as a separate, slight adjunct to some of the bigger priorities, so we need to work hard to bring that much more into the mainstream.
The ICBs facing financial constraints was touched on by Mr Bell around where the focus and effort go. Is it around reducing elective treatment delays or is it on to prevention? I think the Hewitt report was very clear that we need to go further and be more courageous and make sure that we actually balance the focus of treatment and delivery together with prevention; otherwise, we will not shift the dial here, so we want to restate that.
I think we have an opportunity with the major conditions strategy to make that a whole-Government commitment and recognise that mental health, as I said previously, extends beyond the NHS, is a societal issue and we need our anchor institutions—our local authorities and what have you—to really grasp the nettle and support this agenda as well.
It should also help to galvanise the focus of the ICBs. We would be saying that we need to go further with population health outcomes at an individual level and aggregated to a population level, because there is a risk in mental health that we deliver against targets, but the targets are relatively narrow and that systems do not actually improve overall. To qualify that, I would say that we are not clear that there is a clear correlation between, for example, waiting time and access targets with out-of-area placements. What is that telling us about the overall economy of the health and social care system in local areas?
Chair: There is lots to probe there.
Q8 Mrs Drummond: I have a supplementary for Mr Devlin because you mentioned Essex. I spoke to my ICB this morning and talked about it. They said that it is far better developed in the cities, so, for instance, I am a Hampshire MP, but, in Portsmouth and Southampton, it is far better. Do you find that as well—that mental health is far better integrated in the cities where they have a much longer period when CCGs have been working with local authorities?
Peter Devlin: Essex is quite an unusual authority because, of course, it spans three ICB areas, so you are working with three different ICBs—three ICB strategies and what have you—so it is very difficult for the county council to be able to ensure that it has a fair and standardised offer across the piece when you have got three ICBs on the patch.
But I think your point around collaboration, and strategic collaboration at system level, both the relational element of things and the ability of organisations to come together at place level or small or unitary authorities, I absolutely agree with. I think they are more agile, nimble and more able to get the traction they need more quickly than bigger county council organisations, particularly county councils that are having to work across the footprint of three ICB areas.
Q9 Mrs Drummond: Hampshire is including unitary authorities, with Portsmouth, Southampton and the Isle of Wight. They are working all together as one ICB, which it seems will go okay. But are you saying that other counties are still quite divided and that, if they are not working with just one local authority, that is not going to work particularly well?
Peter Devlin: I think it is harder to work at scale and at pace as well because you have more relationships, more governance, more procedures and different decision-making forums that make it a more challenging environment to work in and to drive the changes that you want to see at pace. That is my point.
Q10 Mrs Drummond: And that means that mental health, which has always been the poor relation, is going to suffer more if there are more ICBs.
Peter Devlin: Essentially.
Chair: It is interesting to hear that there is such difference between just two counties.
Mrs Drummond: Yes, absolutely.
Q11 Olivia Blake: Are there any particular barriers that you feel stop that kind of integrated working happening at the moment? I ask that to Mr Devlin.
Peter Devlin: I do not think that we have a strong evaluative framework when we think about the health, social care and housing systems. What level of activity is happening? Where is it happening, and across which organisations? What is the impact of that?
The focus of the National Audit Office Report was correctly on the extent to which the mental health programme run and led by NHS England with the support of the Department of Health and Social Care is delivering against the objectives and priorities of that, and the activity that is associated with it. The spirit and ambition that sit behind the strategy are that we have inclusive societies and, actually, everybody contributes to mental health, and we have a wide range of collaboration across systems. The data reporting requirements stymied that, so the NHS data and digital reporting requirements still largely focus on NHS organisations.
There are technical issues with getting information in from other parts of the system that supports us in having a proper appreciation of the level of activity that is happening in mental health. That is because of the structural issues with NHS Digital and the way that the information is captured, and I suspect it is also indicative of some of the local organisations that are delivering, and delivering well, but do not necessarily have large IT infrastructure and capability. There is a risk that if the focus is just on activity and performance, it will suppress innovation and more lateral thinking around how we support our populations across health and care.
Q12 Chair: Can you give an example?
Peter Devlin: There is the Somerset example. The intention is absolutely right—to rethink our hosting the Mental Health Collaborative and our work there—but this is a national organisation with big infrastructure, and they are reporting that the organisations working around that mental health agenda are struggling to feed the data into the NHS Digital systems. There is still an issue with interoperability as well in relation to care records.
You have two major structural obstacles there. One is obviously that we need to share records across organisations to deliver holistic health and care services to our populations, and the second is that we are still not able to report in that area, which is one of the advanced areas in the country.
Q13 Olivia Blake: That is interesting. Coming back to the Report and the three areas it covers, do you feel that they are still relevant areas of concern, or would you be picking different ones from this point to interrogate with more data and targets?
Peter Devlin: Sorry, could you qualify those areas?
Olivia Blake: Yes: early intervention in psychosis, the access times and the new waiting list times.
Peter Devlin: Thank you. Those targets are valid, and they are driven with health signs behind them in terms of the nature of those conditions and the extent to which they will progress without early intervention.
I suppose one of the things that the targets fail to do is recognise the number of individuals who are waiting for core and community mental health services that sit outside those diagnostic categories. For us, measures that are standardised across the different diagnoses are equally as important and would give a more balanced representation of the overall service for individuals.
Q14 Olivia Blake: Focusing on early intervention in psychosis clearly indicates to me a want to prevent acuity later down the line for individual patients. Do you feel—and it is hinted at in the Report—that we have an increasing issue? This question is for Dr Tzortziou Brown, if that is okay. Do you feel that acuity is getting worse in other areas than just psychosis? Would that be fair to say, and is that a concern for you in what you are seeing coming through your door?
Dr Tzortziou Brown: It is difficult to say confidently without access to data on this. I would imagine that if we are not particularly good at prevention and looking after people more proactively, we are probably going to see more acuity going forward—more acute presentations. Also, if we exclude people from accessing core mental health services—because of dual diagnosis, for example, because they may have other issues such as misuse—
Olivia Blake: Substance misuse?
Dr Tzortziou Brown: Substance misuse, or because they have a forensic history—and we block access for those people because we develop super-specialised services, it is likely that we will see more acuity going forward.
Q15 Olivia Blake: Mr Bell, what is your view of the integration of priorities across those different areas, in particular substance misuse and that sometimes being a barrier, as we have heard? Do you think that there is enough focus on the system as a whole, or should it have more ministerial thought and action to join things up a bit more in that space?
Andy Bell: It is really important to say that the early intervention in psychosis—or the first-episode psychosis access standard—is clinically justified, because it needs to be two weeks. That and the waiting-time target for adult talking therapies and for children and young people with eating disorders were developed with the intention of being the first of many access and waiting-time standards for different areas of mental health care, based on clinical priority.
It has taken us an awful long time to get beyond those first three. The clinically-led review of standards—a couple of years ago now—published its proposals for some much more comprehensive standards, which in our view certainly need to be part of our system before we can even begin to talk about parity for mental health with physical health.
As you say, the challenge is that systems will always find ways of excluding people, of finding someone’s needs too complex or not quite right for us. As Victoria has already said, many people are told that their need is too complex for NHS talking therapies, but they will not be accepted on to the caseload of a community mental health service.
Q16 Olivia Blake: How are those people counted at the moment? Does that data exist? Is it collected or focused anywhere, because that seems like a black hole to me?
Andy Bell: Yes, that is the problem: we have enormous areas of invisibility. The data that is collected and the Report show that where those standards have been put in place, with the one exception of eating disorder services for children, over the past three years, those targets are by and large met, but the data we have provides a very partial picture in specific areas of the service. Yes, if we do not collect the data and do not know what is happening to people, first, there is no incentive for the system to meet their needs in a timely fashion and, secondly, we never know about it. That is deeply concerning.
Olivia Blake: We certainly get that experience in our inboxes.
Q17 Mrs Drummond: What are the barriers to collecting data, and why is the data not collected? How should it be collected, if it were to be collected?
Chair: Perhaps we will come on to Mr Dzikiti, because the Care Quality Commission will be rich on data—we hope. Mr Bell first.
Andy Bell: Ultimately, we need to do something equivalent to what happens in other areas of healthcare, where we know how long it takes between having a referral from a GP and getting access to treatment. In this case, as with the first-episode psychosis target, that is access to evidence-based treatment, as recommended by NICE—not just a first appointment with someone, then waiting goodness knows how many weeks for a second.
It is very easy for me to say that it is about measuring what matters and collecting the data robustly, but people working in mental health services will tell you that they have to collect lots of data about lots of things that they never hear back about. Again, the Hewitt review was quite clear about this: we need better data about mental health in particular, and we need that parity, but we need to collect data that is actually meaningful to people and that holds systems to account. The only way to hold them to account is to do that really transparently. It is no good having lots of complex data squirrelled away somewhere where the rest of us cannot follow it.
Chair: That is often a refrain of this Committee. Mr Dzikiti.
Chris Dzikiti: To add to what Andy said on the issue of data, we have collected a lot of data in the CQC. We use that data as a form of intelligence to understand how safe services are, and we use some of that data to inform where we go to inspect, so it is really helpful intelligence.
Where we have been trying to get to—where we need to improve when it comes to it—is data-sharing between organisations, especially the big stakeholders, such as ourselves, NHS England and the integrated care boards. We need to find a way, and we are starting to have those conversations about how to share data.
For example, for someone like me, I worked in a trust and, when I moved from a trust into an ICS, I was thinking, “Oh, there is so much data that we use in the trust that the ICS does not have access to”; when I moved from an ICS to NHS England, I was thinking, “Oh, I wish I had that data I was using in ICS”; and now I have moved to the CQC, I am thinking, “Oh, there is data I need from NHS England.” So, a lot of data is being collected, but it is about how we come together to start sharing some of those datasets to have one version of truth around mental health services.
Q18 Chair: Is there a barrier to sharing that? Is it GDPR or systems?
Chris Dzikiti: A lot of data is submitted to different organisations, but we have never cracked how we share that data. That is where we are trying to get to. We have started having conversations with other key stakeholders about how we share data that others have access to.
Q19 Mrs Drummond: The ICBs should help with this, surely.
Chris Dzikiti: Yes, between the ICBs, NHS England and ourselves, I think we should have enough data if we come together collectively.
Q20 Sir Geoffrey Clifton-Brown: I wonder if there is a problem here. Good afternoon, Mr Devlin. I think I heard you say that it was difficult in some instances to get medical records. Does it depend on the type of practitioner—whether it is a therapist or a qualified practitioner? Is there a problem getting hold of medical records?
Peter Devlin: It was not the medical records as such; it was the data that comes from other organisations that might be delivering against activity that is associated with the mental health programme and plan. NHS data seems to flow into NHS Digital reasonably well, notwithstanding some variability around definitions and parameters, but for external organisations that might be contributing to the overall activity around mental health, it is much harder to plumb that data into the NHS Digital mechanics so that we have a more consolidated understanding of what is happening from a data point of view—a performance point of view—in local systems.
Q21 Sir Geoffrey Clifton-Brown: In your organisation, for example, are you able to input that information on to somebody’s medical records?
Peter Devlin: Currently we cannot. From a mental health social care point of view, we have basic access to the health information exchange, which is a limited amount of information, but we would not be able to record on health records, and vice versa.
Q22 Chair: We understand there may be privacy issues both ways, but is it that that is the barrier, or is it the technical issues? You say it is easy for NHS organisations to input into NHS Digital, but harder for a series of local authorities around the country.
Peter Devlin: My sense is that it is more the technical issues that are the barrier.
Q23 Chair: Would you need patient consent to share anything either way? I am looking at Dr Tzortziou Brown as well.
Peter Devlin: You would need patient consent to share personal identifiable information. I suppose where you had multiple partner organisations delivering care and support to meet somebody’s needs, you would need patient consent for that information to flow between the partner organisations. But you can have synonymous data, which is free from individual information and has limited patient identifiable information, which should be able to be shared for the purpose of wider oversight.
Q24 Chair: Dr Tzortziou Brown, as a practising GP, do you feel that you lack access to that important social services data? Or do you have patients who want to separate what they are talking to you about from what they are talking to Mr Devlin and his colleagues about?
Dr Tzortziou Brown: I do have data from the acute trust—the secondary care trust. I do not have data from the mental health trust. That is for the local trust, by the way. If my patient attends the local trust—not a trust somewhere else in London—I can see what happened at that presentation, and potentially I can see the consultant’s letter. However, I cannot access the mental health trust’s data through that route. I can access some community services data. Certainly, I cannot access social care data through that route either.
Q25 Chair: Would you like to be able to access that data? Are there any barriers ethically to doing that?
Dr Tzortziou Brown: With patient consent and if it is relevant, absolutely, it would be helpful in some cases. Probably what would be even more helpful is having an agreed template for care plans for people with complex needs—it could be mental health needs and social care needs—that we all work to as an integrated care system. I know there have been attempts at London level and in other areas to develop this kind of shared template for assessing people’s needs.
Q26 Chair: That is interesting. In another life, I looked at criminal justice data, and everybody asks for different things. They think they are asking for the same information, but they ask for it in a way that means you cannot even read across. You are saying that there are examples of this single template that a GP or whoever would be—
Dr Tzortziou Brown: There are attempts to develop that. When we talk to patients, one thing that comes out quite often is that they are tired of having to repeat the same information to many different members of the team.
Chair: That speaks to many bits of NHS out-patient services.
Q27 Sir Geoffrey Clifton-Brown: Dr Tzortziou Brown, if Mr Devlin’s organisation prescribed a certain medicine and that patient presented to you as a GP and you did not know about it, that could be dangerous, couldn’t it?
Dr Tzortziou Brown: We do get some communication, in the form of letters, but we do not get communication in terms of seeing their records—the mental health records, for example.
Q28 Sir Geoffrey Clifton-Brown: So you would know if a patient had been prescribed something.
Dr Tzortziou Brown: Yes, I would.
Q29 Olivia Blake: I wonder if we could pick up on the point that Mr Bell was just making about the five new waiting time standards not being implemented. What are your views on that in general? Is that the biggest priority that needs to be dealt with, or is the data issue bigger? Which of the two is the biggest priority for you or your organisation?
Andy Bell: This is a chicken and egg question, isn’t it? We know from history that when access and waiting time standards are introduced, even if you are a long way from achieving them, as we would be if we implemented those standards, you have to start somewhere. It is often having the transparency and the requirement to do it that creates the activity: you create the data because you know you have to.
Clearly, there is no point coming up with standards that it is implausible ever to collect data on, but these have been thought through. Leading figures from NHS England have worked on the proposed new standards. In our view, it is a fundamental foundation stone of equal treatment for mental health in the NHS that those new access and waiting time standards are included in the system, and that proper data is developed around them. We have to accept that it will take a while to get to those from where we are now, given what we know from the National Audit Office Report about where we are now, but we could be waiting forever to get to the perfect point to introduce them; it will never come about.
Q30 Olivia Blake: Just a quick follow-up before I move on to other people. On children’s access to treatment for eating disorders, do you think that there has been an issue with there not being a target for adults at the same time? Obviously, a lot of people have grown up in that time. What impact might that have had on patients’ experience?
Andy Bell: There has rightly been a lot of focus on children with eating disorders, because we have seen the number of referrals rise very significantly, and stay high, since 2020. You would expect to see a similar thing among adults, particularly as the division at age 18 is purely artificial. There will be plenty of young adults in particular who may be experiencing similar things, and they are not so much on the radar. Again, if it is not measured, it does not seem to matter as much. That is where a comprehensive set of access and waiting standards for mental health support are fundamentally important so that nobody is left off the radar.
Q31 Olivia Blake: That is useful. Let me move on to the CQC’s ability to see good quality through these targets. Do you feel that you have the data to be able to pick up on issues as they develop, especially around patient safety and other issues, with specific reference to the targets?
Chris Dzikiti: Like Andy was saying about the targets, for us the target is a target. The most important thing we are really concerned about at CQC is patient safety. People can meet the targets, but it is more about people’s experiences of using mental health services and using those targets to drive how people are treated in mental health services.
We are talking about data just now, and there is a lot of quantitative data, which is helpful, but we also need more qualitative data to really understand whether those targets are making a big difference, because with qualitative data—people telling you their stories of accessing services—you have a real understanding of people’s experiences. The best way to measure how safe a service really is when you talk to people with lived experiences.
We do have tools and data to help us to see some of the challenges, or those areas that are most challenged where we need to support systems, and to lead us to really drive improvement when it comes to patient safety. We did a lot of work around cultures, for example, and we are looking at closed cultures, because that is where the biggest risk is—services where people tend to spend a long time and they become closed cultures. People spend a long time in forensic services, for example. Where closed cultures develop, people might not get the care that they need at any given time.
We have that intelligence that we use, but to go back to your question about the targets, they help us as a starting point. For example, we know that on early intervention in psychosis and on IAPT—improving access to psychological therapies—those targets have been met, but if we leave it at saying, “Targets have been met,” and we do not listen to people’s experiences of those services, we are missing the point. Some of the work we are doing within CQC is focused on spending more time with people with lived experience, to really understand their experience of using those services.
Q32 Olivia Blake: Do you feel that the CQC has the tools and resources to do that work effectively?
Chris Dzikiti: Currently, yes we do have the tools and resources to provide oversight of services but, like I said earlier, there are other systematic issues around, for example, workforce and environment that impact on some of the work that we do. I have talked about the work we are doing around closed cultures.
We spend a lot of time thinking about how we observe more, so we want to spend more time within services, observing the practice in those services. In the past two months we have been doing some work on spending more time in services. Our inspectors go in, spend time observing the care that is happening, how staff talk to patients and how patients talk to each other. We also have experts by experience who come with us and spend time talking to people in services to really understand what is happening in those services. We also try by all means to go into services out of hours, in the middle of the night, and during handover times, because that is where things are sometimes really challenging. We are doing all those things to try to make sure that we understand more what is happening.
The other thing I spoke about earlier was the Mental Health Act reviewers, who go in to speak to individual patients, because we want to understand individual experiences. Sometimes we can understand the whole service but we might miss things. The whole service might be doing well, but if you do not speak to individual people about their experience of being detained under the Mental Health Act, you might sometimes miss what is going on in services.
Chair: That is very heartening, because a lot of constituents raise with us their feelings about being detained, and there are not many people they can talk to. It is heartening to hear that you have that proactive approach.
Q33 Olivia Blake: Dr Tzortziou Brown, on the same topic, do these targets help you as a GP to get action when someone comes in who is not very well?
Dr Tzortziou Brown: Obviously, there are mental health targets on access and they are helpful up to a point, but as with all targets, including those we have in general practice, the problem is that if they are just used to assess performance and not as a means of quality improvement, they can just act as a way of demoralising the profession even more.
The context needs to be taken into account when we interpret these targets as a performance tool. If we think about how we use data for quality improvement—what the requirements are—we see that it is about time and space. Clinicians need not just the data, which is a tool, but the time and space to work with other providers and professionals, and also patients and service users, to improve services. If that is missing, we will just have targets to beat people up with.
Q34 Olivia Blake: Would you like to see more focus on the targets than on outcomes?
Dr Tzortziou Brown: Experience and outcomes are important. I think the relatively more straightforward thing to achieve, provided that you have the workforce improving experience and clinical and patient reported outcomes, is the most challenging thing. That is where we need to be putting a lot of our energy. The problem is that if we just focus on access targets, they can become a way of gaming the system as well. People find ways of addressing the targets in a much more transactional way for getting access needs. It is only meaningful when it is associated with good quality of care as well. We need to holistically assess what care we give to patients, taking into account their experiences and the outcomes.
Q35 Olivia Blake: Mr Devlin, given everything we have just heard, do the targets feel relevant to your part of the system, or do they very much feel like the NHS’s problem and not a collective problem?
Peter Devlin: They very much feel like they are the NHS’s targets rather than a systems target, so I suppose I would, again, echo what my colleagues have said around targets being meaningful to people. From a local authority point of view, we want things that are co-produced. If you think about “think local, act personal” in the I-statements, they are built on the body of evidence from people with lived experience in their families about what matters to them. We would want that kind of methodology applied here, and we would want population health outcomes targets that are also based on the population health methodology. Those targets facilitate and enhance the collaboration within systems to deliver it against, so it recognises that all parts of the system must contribute towards achieving good outcomes for our populations. The targets should act to galvanise the system in a wider sense rather than being allied to the NHS plan specifically.
There is an opportunity to do that with some of the major conditions strategy work that is on the horizon. There is an opportunity to look at cross-ministerial action and activity to focus on some of those areas. As I said earlier, we need to redouble the effort on prevention.
Chair: Absolutely.
Q36 Olivia Blake: I have a couple of questions on the workforce. I want to ask specifically about early intervention in SEND and whether you feel there is a grip on the workforce issues in that area around diagnosis of ADHD, autism and other issues?
Peter Devlin: If you look at the prevalence and the rates coming through now of younger people with complex needs, I think the answer would be that it’s worrying. Again, we need to look at that in the context—
Q37 Chair: Do you think it is rising because it is better diagnosed, or is it societal impact issues as well? Obviously, some things will not be societal in autism, but is there a societal impact?
Peter Devlin: I think it is better diagnosed. There is also an increase in prevalence. Certainly in autism, we have experienced that. I don’t think local authorities historically have had services that cater for people with autism. It has been emergent over the last 20 years, in my experience. Again, I think the response needs to be health and care. Clinical interventions alone will not necessarily deliver the care and support that people need. I also think there needs to be more focus on trusted relationships with young people as well, equipping social care education colleagues with the tools and capabilities to have some of those relationships.
Q38 Olivia Blake: What about specifically on diagnosis? How is that impacting on the work you are doing in this space?
Peter Devlin: Transitions is a real challenge for us. In some respects, it speaks to the point that my colleagues raised earlier about the more you become diagnostic led, the harder it is for individuals who have a range of complex needs that span a broad base, because the pathways do not speak to them, so it becomes an inversive care system whereby every part of the system sees itself out of or excludes that individual from access to services. I think there is something around how we create collaboration in that space so that we do not have that across health and care.
Q39 Olivia Blake: Does CQC have a view on that because those services seem to be under a lot of pressure at the minute?
Chris Dzikiti: I think children and young people’s services are challenged. I agree with Peter: actually, there is more diagnosis than ever before. I worked on the transforming care programme some years ago. We saw an increased number of children coming in with autism, for example, because there was more diagnosis going on. That has helped, but what it means at the moment is that local authorities are challenged because they have children and young people coming in with quite complex needs, and the demand currently outweighs the provision. That is the challenge we are seeing. We are most likely seeing children and young people placed in unsuitable placements, such as in children’s homes, because there is not the provision for the support that is required. That is a challenge that we possibly will continue to see.
Q40 Olivia Blake: You have all mentioned workforce as an issue. Does the lack of a workforce strategy have any meaningful impact on your individual organisations, because we have been waiting for it for a while and everyone seems to be raising it as a concern? Would you like to see that sooner rather than later?
Chair: Shall we start with Dr Tzortziou Brown as she is a frontline health worker?
Dr Tzortziou Brown: We would absolutely like to see this sooner rather than later. We have been asking for the workforce plan, as the college of GPs. We have a significant problem with our workforce retention. We have been asking for 6,000 more GPs for several years now. Not only has our workforce not increased, but our full-time equivalent number of GPs has gone down. It has gone down by 7% since 2015. At the same time, the number of consultations we undertake has gone up by 9% since 2019. We see fewer GPs seeing a lot more people and presentations. Therefore, this results in burnout, and people leave. A lot of them leave due to poor work-life balance. Actually, it is interesting that we see similar findings in the report for mental health colleagues because I think the proportion reported here of those leaving due to burnout was about 20%. It is a huge issue.
Also, interestingly, talking about mental health for our patients, when healthcare professionals themselves feel burned out, it is much more challenging delivering compassionate care to patients, and this needs to be taken into account. When our own workforce feel that their mental health is being affected because of their workload, we need to take this seriously because it has implications for the care we provide to our patients. We do look forward to seeing the workforce plan. We hope that we will see numbers and resources put into it, and a clear implementation plan on how we will ensure that our workforce increases.
Q41 Olivia Blake: Just to follow up, and I probably can guess the answer, are you confident there is enough capacity in place for the plans to improve timely mental health care in all our communities?
Dr Tzortziou Brown: I’m not confident; I am hopeful. I think our profession, the medical profession, certainly would like to see some light at the end of the tunnel at this point—some hope that things will improve.
Q42 Olivia Blake: And would you like to see more prioritisation of alternative professionals in services?
Chair: Quicker to train them than GPs.
Dr Tzortziou Brown: We would welcome other professionals in our extended teams. We already have, as I said before, social prescribing and medical health practitioners joining us. It will take time for all of them to be embedded so that we can develop the understanding of our strengths and how we can use these extra roles in the best way possible. However, the extra roles do not replace the clinicians, who take years for us to train, so we need to keep that in mind. When people say, “Your workload will reduce because of these extra roles,” I am a little bit apprehensive. I do not think that that will be the case. Probably care will be provided in a more holistic way to patients, and that will be good, but I do not think that workload will reduce because of the extra roles, because the roles are different.
Olivia Blake: That’s very useful.
Q43 Chair: Can I come to Mr Devlin on the same issue? Children’s social services has long had a problem, but what is the vacancy rate and challenge for you across social services departments in England?
Peter Devlin: I think the vacancy rate, from the last Skills for Care benchmarking, was between around 15% and 20%, so vacancy rates in social care are high as well. They are attributed to a range of things, including pay and competition with other employment markets. The challenge for social care in relation to workforce is big—probably our biggest challenge, actually.
Q44 Chair: That is social care. What about the very specialist mental health social workers? That takes some time. You can be trained, but it is experience that really counts. What is the attrition rate and turnover in that group?
Peter Devlin: I would need to get back to you to confirm, but—
Chair: I am just asking for your general impression.
Peter Devlin: My general impression is that, from a local authority point of view, social workers, including mental health social workers, are together with OTs the hardest group to recruit—a bit like your nurses and your psychiatrists in the mental health trusts. From my point of view, we go back to the models of care—recognising that holistic, person-centred care is beyond clinical intervention. You need to complement that with good care, support for carers, a wider infrastructure, and complement of services, including ensuring that you have good providers and adequate housing in your local communities to support individuals. That wider societal infrastructure has to be there, in terms of both the sufficiency and type.
I think Chris spoke about specialist services for people with complex needs. Often those are the individuals who are in hospital for much longer than they need to be, and hospital effectively becomes their residence. If we want to deliver and land the mental health reforms when they are further down the line, we need to go back, reset and re-evaluate what capacity we need in the community, in terms of both the scale and the specialist areas, and how we design and deliver that jointly. We welcome the NHS plan, but we need a social care plan to complement it, so that we bring both those aspects together as one. We would call for the workforce plan to be a combined health and care plan.
Q45 Chair: Mr Bell, is there anything you want to add about workforce? Then I will come to Mr Dzikiti.
Andy Bell: Thank you. The first thing I want to do is give a bit of credit. We do not have a long-term workforce plan, and yet the NHS has managed to increase its mental health workforce by 22% in five years, which is not at all bad. I think we can see where we have invested in particular areas in a focused way—I am thinking about perinatal mental health services, the development of new community teams and mental health support teams in schools, which are earlier on, but showing real promise through the evaluations that we have.
We are now building up a workforce of employment specialists to provide support with people who want to work in mental health services as part of community teams—building a whole new group of people to work in the mental health system. We can do things, and we have shown that where you do invest in the workforce, you get a lot out. The problem, of course, is that we don’t have a long-term plan. We make strategies up for five years, and then about a year later we see the workforce plan. Really, you need a workforce plan for what you are having in five years’ time, not a year ago. There is something about how we have vision for the kinds of things that Peter has talked about.
We know that the things that send people into mental health crisis are to do with difficulties with money, housing and relationships, so we should not see the additional support around more traditional clinical roles as being somehow not as good, a bit cheaper. In many cases, it may be what helps people to lead good lives. We need a more diverse workforce, too. The workforce is not representative of the communities it serves, and that is a major barrier for a number of communities to feel that mental health support is safe and trustworthy. We really do need a plan with a vision and a proper strategy, not just a retrofit to what the latest mental health plan says we need in a short time horizon.
Q46 Chair: Thank you. Mr Dzikiti?
Chris Dzikiti: Just a reflection on the workforce. Like everyone has said, we have seen providers and healthcare leaders trying to be creative and use other clinical roles, such as psychologists or OTs, to support mental health services. I think we need to also recognise the challenge we have around mental health nurses and psychiatrists, especially mental health nurses. Over a period of time we have seen a reduction of mental health nurses. For example, in June 2022 in London we had 16% of vacancies for mental health services compared with 11.9% for acute, so there is a big challenge when it comes to mental health nurses.
When we did some work last year on our community mental health survey, 40% of the people who were surveyed spoke about being able to see people who could support them for their mental health services. That was 40%, meaning 60% were not able. We know that the workforce has a big impact on those people accessing the services they need. There has been more work done by healthcare leaders to try to mitigate that challenge, but like Andy said, you still need specialists—for example, mental health nurses—to support you.
Q47 Chair: I will look to ask whichever one of you feels you can answer this. One of the things is the difference between the expectation of a patient and what the system rations out. Realistically, there is always going to be a limited pot of money and, as we know, growing demand. Some things will have a linear plan because it is a condition with a particular pathway. With things such as talking therapies, which are designed to catch people early, we have all heard constituents come and say they want to have weekly talking therapies for two years. That is what they want, but what they are actually going to get, after a very long wait—if they are lucky—is six months of something every fortnight, and that would be very high end.
The mismatch between what people think they want, and maybe do need—it is difficult for me to make that judgment as a non-clinician—and what is available is quite stark. Mr Devlin, is that always going to be the case a bit? People will always get close to someone, for instance, with talking therapies, and that can be a very good coping mechanism, but how do you work to ration that? I will perhaps come to Dr Tzortziou Brown as well on that.
Peter Devlin: There will always be a difference between public expectation and what is actually considered to be clinically suitable for somebody at any given time. Therapy in itself, or any kind of therapy, is very much a collaborative thing. It is quite different from prescribing, where you are intervening and somebody is taking some medication that is having a biological impact. With any psychological work, you have to be ready to engage in that therapy as well, and be motivated to change and to work with someone.
I suppose that for common mental health conditions, cognitive behavioural therapy is normally the standard. It is generally delivered on a fixed, short-term basis, and it is goal orientated. Those are some of the parameters that people engage with. Then there are the principles of cognitive behavioural therapy: it supports people to understand that the way they think about things affects their feelings and their associated behaviour, and that if they start to frame things differently, it changes the way they think and feel about things. There is probably an opportunity to do more formulation to give professionals who are working with individuals the principles of CBT to apply, and then of course there is an opportunity to do far more to support people from a digital point of view. We know that it doesn’t have the same clinical efficacy, but it can be rolled out. There is CBT online and other stuff that we can go further with as part of the offer to people.
Q48 Chair: Do you think something was learned during the pandemic? There is an awful lot of promotion of online apps and other facilities that people can use.
Dr Tzortziou Brown indicated assent.
Chair: I see Dr Tzortziou Brown nodding.
Dr Tzortziou Brown: As a GP, I see patients who need talking therapies and are not very keen on taking them up, and people who may benefit from talking therapies but would like a lot more sessions than are available. Interestingly, the inverse care law comes into it as well, because usually the people who have the most clinical need are the least likely to take up an offer. We need to identify that at a system level and in our individual interactions with patients. Saying that, tailoring care provision to the individual patient needs is very important. A very strict adherence to, for example, six sessions may not be appropriate for all patients, so there has to be flexibility if we can see a benefit to the patient having more sessions.
We have experienced some positive developments with IAPT services. A lot of the services in my area are now accessible through self-referral. People don’t even have to come to see me; they can access them themselves. There are also online services that people can access. If people are motivated enough and would like to take on these sorts of treatments, there are different ways they can access them online. For those who are not as motivated—who have the need but need extra help to engage—we need to put a lot more effort into that service.
Chair: Thank you for that.
Q49 Sir Geoffrey Clifton-Brown: I will start with you, Dr Tzortziou Brown. The Report tells us at paragraph 13, “Retaining staff is also becoming an increasing challenge: during 2021-22, 17,000 staff (12%) left the NHS mental health workforce, up from 13,000 (9%) a year earlier.” Should the NHS be training more people to go into mental health?
Dr Tzortziou Brown: We need to train more people in mental health and psychiatry-type specialities, and also in general practice, because as I said before, a lot of mental health care is being delivered within general practice. It is not just about training people; it is about retaining those we have trained. We need to do both, because at the moment we see a lot of people leaving the NHS or reducing their sessions because they cannot cope with the workload. It is both; otherwise, we will be spending a lot of money training people who will at some point—very quickly after they qualify—leave.
Q50 Sir Geoffrey Clifton-Brown: It is chicken and egg, isn’t it? If you haven’t got enough staff, they have got to do more patients. How do we break that logjam?
Dr Tzortziou Brown: Retention is something that we can address quicker if we value people more, improve the conditions they work in and, as I said before, give them hope that their concerns are taken seriously and that there is some light at the end of the tunnel. Training people will require more time, but with a good workforce plan, we could make a start.
Q51 Sir Geoffrey Clifton-Brown: Mr Devlin, with the introduction of ICB partnerships—this relates to Mr Bell’s comment—has the situation improved in social care?
Peter Devlin: It is too early to say—that would be my position. As I said earlier on, we need to make sure that the ICPs and ICBs focus as much on prevention and population health management as they do on treatment. We just need to ensure that we recalibrate in that space. I think that ICPs are well placed, as well, to support a consolidated workforce plan. We do have a lot of people in social care who have a valued and important contribution to make to the mental health agenda, so we need to take every opportunity we can to unleash the capability in local systems to support mental health beyond NHS interventions.
Q52 Sir Geoffrey Clifton-Brown: I would like to come to you, Mr Bell, on this business of young people. Paragraph 19 says that “in 2022, the proportion of young people with probable mental disorders increased by 50% for 7- to 16-year-olds (from 12% in 2017 to 18% in 2022)”. Are you able to give us any sort of light on this problem? What is causing that huge increase?
Andy Bell: The answer is that we do not yet know for sure. It was very notable from the prevalence surveys—because we do now have a decent time series at last, having been in the dark about it for years—that over the last decade, the prevalence of mental health difficulties among children, young people and young adults, so let’s say from five to 25, has increased. There may be some degree to which survey methodologies are allowing a little bit more awareness and literacy about mental health to influence the figures, but none the less, the rate of increase that we have seen is such that it cannot be by chance.
In terms of the reasons, it is notable that there are some distinctions. For example, the increase has been more notable among young women than young men. There are inevitably concerns about the introduction of new technologies during that time, but I think to say, “Oh, well, this is a social media phenomenon,” is to simplify it beyond any kind of sensible way of looking at things.
When we ask young people—again, if you want to know what is affecting a group of people’s mental health, go talk to them—they say that the things that are bothering them are school pressures, fears about their lives when they leave school, dealing with poverty, dealing with racism, or girls experiencing bullying. Most cyber-bullying is an extension of real-life bullying. We need to see the rich picture of things that are putting young people’s wellbeing at risk. Girlguiding does some excellent surveys among its members, which provide really useful insights into some of the pressures that young people are facing.
Obviously, what we do not know is whether the very noticeable increase around 2020, which has been sustained over the past couple of years, will gradually drop as the short-term impacts of the pandemic stop—the long-term impacts won’t go away—or whether the cost of living crisis and growing levels of poverty will mean that we continue to see an increase. We really need to be very watchful.
Q53 Sir Geoffrey Clifton-Brown: We are here to learn. Do any of the rest of you want to comment on this concerning trend?
Chris Dzikiti: When we did our “State of Care” report last year, we saw a 30% increase in reports of children going to adult services when we compared 2021-22 with 2020-21. That is a massive increase, which means that there is a high demand for children and young people’s mental health services. Like Andy has just reflected, there are so many—
Q54 Chair: Can I just be clear? They transition at 16 from child services to adult services?
Chris Dzikiti: They transition from 18.
Chair: From 18, okay. Because in physical health it is 16.
Chris Dzikiti: Yes. They transition from 18. That is when adult services kick in. Obviously, the pandemic has had an impact—those lockdowns have had an impact—and I think pressures at school have had an impact. Where services have been able to have mental health support teams in schools, for example, you can see the benefits of those teams. It would be really beneficial in the future, actually, if we got more of those teams in all schools, because that would definitely support the aim of preventing young people from getting even worse in terms of their mental health when they are in school.
Q55 Chair: We have looked at this with school nurses. School nurses are funded by local authorities, which cut them back if there is a funding issue, even though they are health professionals, so there is a challenge. Who are the mental health teams funded by? In my experience locally, I think some are seconded in; they are referrals to the local health teams. Mr Bell, you look like you know where they are coming from.
Andy Bell: It is a really mixed economy. With mental health support in schools, you have traditional services, so schools may purchase their own—they may have a counsellor. In Wales, all secondary schools have to have access to counselling. That is not the case in England, but the majority have something. NHS England, over the last few years, has implemented a national programme of mental health support teams, which is a new development. Those are roughly on schedule to reach about a quarter to a third of schools by the time we get to 2024, so that is progress from a standing start.
Many schools will have a range of other forms of support for children—and indeed staff, who often also have significant challenges to their mental health. It is a real mixed bag. Where it is funded, very often there are bits and bobs of funding here, there and everywhere. Of course, not all kids are in school, so it is really important that we do not only think of schools as being—
Q56 Chair: I had a constituent at a surgery today whose son is autistic and was unable to stay in the special secondary school, even though he had managed through primary. He is therefore excluded. He is now taught outside by local authority tutors—very well, I have to say—but his mental health has deteriorated massively because he is no longer socialising with people his own age. He is finding access to inappropriate things online, breaking through the child locks and so on, and there is a danger that he spirals down.
I am interested in figure 12 in the Report, which highlights that therapists and clinically qualified staff have actually increased quite significantly compared with some of the other groups. Are some of these people in schools, do you think? I do not know who would know the data best. Mr Bell?
Andy Bell: Some of them may be. I think a lot of the stuff in schools is non-NHS, so it will be either provided by a voluntary sector organisation or directly paid for by the school themselves.
It is interesting that there is a shift towards psychological therapists, or therapists in a broader sense. In some ways, that is of course to be welcomed. NHS talking therapies, I suspect, are quite a large part of that shift. We know that there is still a long way to go in in-patient services; in mental health in-patient services, access to therapists is actually quite poor. The workforce in in-patient services tends to be predominantly medical and nursing still. In terms of the professional input, there is very little in the way of psychological therapy in those environments.
Chair: When I had a period of time a few years ago when I was a mystery shopper in the NHS with a sick family member, I think there were three people in the team, and if someone was off sick, they did not come and talk to you about the challenge of being isolated in a hospital ward for a long period of time. They were pretty stretched then, and that is the non-acute end, so goodness knows, if you had an acute mental health problem, it must have been pretty difficult. The Report is very clear, and it is pretty obvious how thinly stretched everybody is, so we have heard the workforce plan point loud and clear.
Q57 Olivia Blake: I want to ask about comparisons with other countries, on young people in particular. Is there any best practice that we should be looking to? That is probably for you, Mr Bell.
Chair: Anyone can chip in with any country that is doing a good job.
Andy Bell: By international comparisons, we do not provide children with a good, mentally healthy childhood. We have to put mental health services to one side for the moment.
Chair: So it is not mental health so much as—
Andy Bell: We know that this is not a mentally healthy place to be a child, particularly a child from more disadvantaged circumstances. There is something fundamental about how we learn from countries in other parts of Europe—and not just in the west, either—about how you create a mentally healthy childhood. There is a great deal we can learn there in terms of access to—[Interruption.] Sorry.
Q58 Chair: No—you were just moving on to the point about access to services. Who does that well?
Andy Bell: There is no way you would say, “Just do everything they do.” In any case, it is really hard to import models from other countries. One of the things that we believe very strongly from evidence is that we need to have something between what happens in schools and what happens in formal children and young people’s mental health services. Early support hubs is the name of a type of service that provides access to counselling, information and advice for young people on the high street in very easily accessible places without the need for a referral. There is a model that works very well in Australia. There is a model that is working in some areas here that we think has some applicability. Simply taking a model from Australia and dropping it here probably would not work. Learning from the fact that they do that at scale and thinking, “How can we do that at scale in a way that is appropriate in England?” would be really positive.
Dr Tzortziou Brown: It is still the very beginning. Integrated care systems are starting to develop, but there are some examples of starting to work closer with service users—our young people—and co-designing services, involving them in the design of the services a lot more than we used to. That is really promising because, first of all, we will create better services, tailored to their needs. Also, we will increase awareness of mental health issues and remove the stigma—something that we have already done for adults, I think. I see in my practice, for example, people coming to consult on their mental health problems probably more than before, especially people who were not forthcoming before—for example, male patients—but we need to do a little more work with young people. Involving them in the service redesign and transformation is a good way to do that.
Chris Dzikiti: On the support that I am seeing in other countries, Andy spoke very well about Australia. In Victoria, they have decided to look at children and young people’s mental health services by not just looking at CAMHS tier 4 or in-patient services but thinking about what is happening in schools and in public health, really looking at a much wider view of what mental health services are like and where they are being provided, and putting some resources in understanding what you need to do at every step of children’s lives, which they are finding really helpful.
I am originally from Zimbabwe. They are using community services differently. They have a model that they call the Friendship Bench, which was started by elderly women who just decided to sit on a bench and waited to talk to women with depression or with perinatal mental health issues. They realised that women would go and sit on that bench and start talking to those grandmothers. Then it became a model. Now it is a well-established model, because the focus is how to support people in the community. Some people find it difficult to come into in-patient mental health services, so how do you support people within the community and make sure that they are being supported by people they know and are familiar with? Those old grandmothers are being very helpful. As a model, it has been really impactful for women with depression.
Q59 Chair: So it is not expensive—it is not rocket science.
Chris Dzikiti: No, it is very cheap, because those grandmothers do not have much to do. They are volunteering to do that piece of work, so it is a really cheap model of care.
Chair: Does anyone else have international models?
Mrs Drummond: I have given you a list. The Netherlands is the best.
Q60 Chair: Mrs Drummond has been doing her homework on this issue. We have our witnesses in on Thursday. If you were sitting in our seats on Thursday and you had to say that there are three things that they need to do, either in the short term or the long term, to sort things out and make sure that we are delivering better mental health services, and indeed preventing some issues in the first place, what would you want from the Department of Health and Social Care and NHS England? I will start with Mr Devlin. We will take money out of the equation because we know that money is always going to be an issue. We are not saying more funding at this point. We are saying, “If you had the money, how would you spend it?”
Peter Devlin: For me, it is how we build more collective and active system collaboration across the piece, really making the best of that relationship between health and care, and in particular prevention and community services. I would extend that to our thinking differently about new models—moving away from traditional models—in the context of society as it is now.
Q61 Chair: Things like taking into account online access?
Peter Devlin: Online access, and also admission prevention services that are more able to work with people who might have clinical interventions as well as care and support as part of a blended model of health and care. So it is pushing the boundaries of what we can do to support people rather than them going into hospital, what we need in terms of clinical functions and what we need in terms of care and support, and how we are speaking to the populations that we are serving, picking up on Andy’s point about making sure that our workforce reflect the communities that we are serving from an ethnic and racial profile. So system collaboration, new models and partnership is one aspect.
I think there is something about how we are going to address the issues associated with data to give us a real, consolidated ability to—
Chair: That has come across loud and clear.
Peter Devlin: Yes. And there are the population outcomes: from a mental health point of view, what indicators, at individual level and at system level, aggregated up, would give us a really clear sense about our collective effort—as well as defining that—so that we can measure the impact that our activity, individually and collectively, is having on our populations overall?
They feel like the two main areas. We need to move from a focus on activity to something that is more nuanced towards outcome and experience, and that is co-created with the people who we serve.
Dr Tzortziou Brown: If I had to ask for three things, probably they would be data, time and space.
Chair: So again, it is not rocket science.
Dr Tzortziou Brown: No. And trust—trust people who care. Those in the medical profession joined the profession because we wanted to help people to get better, and the same goes for the other health and care teams who we work with. We need to be trusted. We need to be given the space to come together and work with our service users, to innovate and to be assisted to evaluate what we are doing, and use data as a tool rather than solely for performance management purposes.
Chris Dzikiti: In the last six months, I have visited services, so if I don’t reflect on this, I think the people who I have spoken to will be wondering why I haven’t reflected on it. Let me just bring this to life. I visited a service and one of the gentlemen there took me aside and said to me, “There are 19 of us here. We’ve got two showers and one bathroom, so I have to wait in a queue to get a shower.” That is not right. That is a human need. So I have to reflect on environment in mental health services—
Chair: It dehumanises people.
Chris Dzikiti: Yes. If I had a magic wand, I would start on environment, because where we have seen services that have developed their buildings or their environment, we have seen a positive impact on how people feel—how patients feel and how staff feel. We know that environment plays a big part in the therapeutic care that people can deliver and that people can receive in mental health services.
That would be the first thing. I can talk for a long time about that, because I have seen so much—
Q62 Chair: We had a recent Committee visit to Denmark, where they were designing maternity suites for better outcomes. There was some cynicism to overcome with midwifes, until they saw it in action, but it was very interesting. So that is not happening here—or not that you have seen so far.
Chris Dzikiti: I have seen some places where they have done it and the big positive impact it has had. Some trusts have done it, and they have done it very well, but on average the mental health estate needs to be improved.
Q63 Olivia Blake: Can I follow up on that? There is a lot of competition for money and capital expenditure. Do you feel that mental health has enough access to that?
Chris Dzikiti: My understanding, if I am not mistaken, is that in the new hospital programme mental health has 2% so far, so that tells you.
The second thing—I know everyone talks about workforce—is to focus on the workforce. If we don’t, I think it will continue to be one of the biggest challenges. Like I said, I have been in mental health services for 23 years. The mental health workforce will be a challenge. During the pandemic we saw the focus we gave to the people who work in the NHS. It was positive. I have colleagues who work in the NHS, and the attention we gave to the workforce and the support that was available to them during the pandemic was really great, but since then we have seen that support dropping down.
There is something we need to do around the workforce—around mental health nurses and learning disability nurses. We are seeing a challenge of learning disability nurses being trained less and less. There is something we can do on workforce. Thinking about bursaries again might be helpful, because then we can attract people and give them an incentive to train and become mental health nurses or learning disability nurses.
The third thing for me is continuously building support within community services. The challenge we sometimes end up with is that in-patient mental health services are challenged because there are not robust enough community mental health services. For example, we continuously see people with learning disabilities and autistic people remaining in hospital, not because they need to be in hospital, but because there is not the support within community mental health services. Those are the three things I would do with a magic wand, if I had one.
Andy Bell: I’ve got about 23.
Chair: Restrict it to the top three. The evidence from both you and the Care Quality Commission has been very helpful, and we already have that on the record.
Andy Bell: I am mindful of not spending money, so the first is free: have a proper, long-term Government mental health strategy across the whole of Government, with a view to ensuring that we plan for the future of promoting the mental health of the whole population. That would include a mental-health-in-all-policies approach. Imagine if policies around social security, justice, schooling and early years were made with mental health in mind. Think of the difference we could make. The first thing would be a proper, whole-of-Government approach, in a sense to try to reduce the ever-growing level of need, which is translating into demand.
Secondly, we really do have to try to shift the system from late intervention to earlier. That is incredibly easy to say and incredibly hard to achieve, particularly now, but we have seen some examples. There are new care models for children and young people in a number of areas of England that used relatively small amounts of funding from NHS England to dramatically reduce the number of children who were sent to hospital out of area or who spent long amounts of time in hospital for their mental health. They did that by investing in intensive community support within the local place that the children were in. It is really difficult to do that transformational change, but we know that it can happen. That is perhaps where integrated care boards and partnerships have the gift of being able to do that.
Thirdly, we must focus on equality as well as the treatment gap. We focus rightly on the treatment gap and the number of people getting care versus the number who are not, but we need to have a really strong focus on equality within that. We know that there are huge disparities between different groups of people, and they are deeply unjust. We really must shift towards that as being just as important. As a psychiatrist said, “There is no quality without equality.”
Chair: Thank you very much. This is such a broad area. We are talking about different age groups, different backgrounds, different mental health conditions, and the community right through to acute hospital care—everything that GPs and others on the frontline, such as social workers, are doing every day. It is quite a big topic for us to cover, but we hope that by shining a light on it we will be pushing the Department to achieve what the Government have set out that they want to do. I think all of us would agree that the stop-start nature of policymaking, which is something we all have to take responsibility for as active politicians, can be a big barrier.
We don’t deal with policy on this Committee; we deal with how well taxpayers’ money is being spent delivering things. We know from the work we have done before that money invested in this area now is going to save money in the long run. That is just sometimes a difficult thing to convince different Treasuries of at different times.
Thank you very much for your time. The transcript of this session will be published on our website in the next couple of days—thank you to our colleagues at Hansard. It will be uncorrected, so if there are any changes, you do need to let us know. We will be seeing our Government witnesses on Thursday. Thereafter, we will be producing a report, which you will get slightly early notice of. Thank you very much.