Written submission from the British Medical Association (BMA) (MHM0051)

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

Key points:

• Demand for mental health care is increasing, with suicide now the largest cause of death for men aged 20-49 in England and Wales, and for all young people under 35 in the UK.
• Men and boys are less likely to seek out support for mental ill health, raising concerns of an underreporting in men and boy’s mental ill health rates[1].
• Men and boys are more likely than women to have lifestyle factors or behaviours which are generally linked to higher instances of mental ill health, such as substance misuse, smoking, homelessness and alcohol related diseases.

Recommendations:

• Where CCGs are not meeting the Mental Health Investment Standard they should be required to produce robust spending plans outlining how they will achieve it in the future.
• A BMA survey of CAMHS (Child and Adolescent Mental Health Service) professionals showed 91% of respondents felt that CAMHS is poorly funded, and 58% felt that changes to CAMHS funding levels had made them less able to do their job. The BMA has consistently called for greater investment in CAMHS to be able to meet rising demand.
• Support for Public mental health should aim to address the physical health needs of people living with mental health problems, this will be helpful in supporting men and boy’s mental health given that they are more likely to exhibit these lifestyle risk factors and less likely to seek support through traditional routes.
• Much greater investment is required in local public health services aimed at promoting mental health. Funding constraints are currently undermining the ability of local areas to invest in services designed to prevent people becoming mentally unwell.
• Local authorities should have clarity over their responsibilities for supporting public mental health, to ensure they are meeting the health needs of their local population. Currently there seems to be little guidance as to what services and interventions should be provided, or how spending in this area should be categorised.

Background

Mental health problems represent the single largest burden of disease in the UK (28%)[2] and are estimated to cost between £70 and £100 billion a year; a fifth of which is attributed to health and social care costs.[3] There is also an indication that demand for mental health care is increasing, with suicide now the largest cause of death for men aged 20-49 in England and Wales, and for all young people under 35 in the UK.

While men and boys may be less likely to present with mental ill health in medical settings, there is concern that this is due to an underreporting of symptoms. Boys and young men are however more likely than women to have other lifestyle factors or behaviours which are generally linked to higher instances of mental ill health, such as substance misuse, homelessness and alcohol related diseases[4].

While commitments made in the Mental Health Five Year Forward View (MHFYFV) and plans laid out in the NHS Long Term Plan (LTP) are a step in the right direction there is still more that must be done to meet the needs of all those experiencing mental ill health. This is particularly true in the case of groups who may be harder to reach and traditionally less likely to seek support.

Funding for mental health services

NHS England has committed to ensuring each CCG (clinical commissioning groups) meets the Mental Health Investment Standard, and that this will be validated by auditing.[5] We are clear that where CCGs are not meeting this spending target they should be required to produce robust spending plans detailing how they will meet the target and that they should have specific support to help them to do so. Data on whether individual CCGs are meeting the standard should be published in an accessible and transparent format and a concerted effort should be made to promote best practice approaches across the country.

Prevention, where possible, or early intervention is by far the most effective and beneficial means of treating children and young people’s mental health. However, despite this, data from FOI requests conducted by the BMA revealed that many CCGs are not increasing their spending on CAMHS[6]. In a 2017 BMA survey of CAMHS professionals, 91% of respondents felt that CAMHS is poorly funded, and 58% felt that changes to CAMHS funding levels had made them less able to do their job[7]. These findings are extremely concerning yet not at all surprising given that the BMA has for a long time warned of the need for greater investment in CAMHS to be able to meet the rising demand. This is particularly worrying given that there has been an overall increase in the rates of mental disorders among children and young people of all genders, with one in five waiting over six months to see a specialist.

Data from FOI requests indicate that just over a quarter of CCGs and only half of mental health trusts are increasing their real-terms spending on psychological therapies[8]. When comparing spending between IAPT (Increasing Access to Psychological Therapies) services and psychological therapies in secondary care, the majority (83% of CCGs and 64% of trusts) spent more on the IAPT than on psychological therapies. This is particularly concerning given that men are less likely to access IAPT therapies than women, with only 36% of referrals to IAPT being men[9], making them even more disadvantaged by this inequal division of resource.

FoI requests made by the BMA to CCGs and NHS mental health trusts, in 2018, revealed nine in 10 (166) of the 183 CCGs who responded have no records of waiting times for talking therapies for treating severe mental illness in the previous year and of the 47 mental health trusts that responded, 22 had no records of waiting times for talking therapies. Using responses from the trusts and CCGs who did keep records, the BMA found 3,700 patients waited more than six months for talking therapies. Around 1,500 patients waited longer than a year before therapy started. This situation must be urgently addressed to ensure everyone who needs them is able to access these therapies.

Lifestyle risk factors

Men exhibit higher rates of lifestyle risk-factors, such as smoking, drinking alcohol, taking illicit drugs and being overweight and obese.[10] There is a complex inter-relationship between mental health problems and various lifestyle risk factors, resulting in a significant comorbidity between them. For example, research shows that:

• In England, 41% of adults with a serious mental illness are smokers (more than twice the rate of the general population).[11] In the UK, smoking rates among adults with depression are about twice as high as among adults without.[12] In Wales in 2015, 33% of people with a mental illness were smokers, compared to 19% reported among the whole population.[13]
• In the UK, alcohol dependence among people with diagnosable mental health problems is almost twice as high as in the general population.[14] People with a severe mental illness such as schizophrenia are at least three times as likely to be alcohol-dependent as the general population.[15]
• In England, mental health problems are experienced by the majority of drug (70%) and alcohol (86%) users in community substance misuse treatment.[16]
• In the UK, obesity and overweight have been found to be more prevalent among populations with mental health problems, such as in those detained within mental health secure units.[17] People experiencing depression for example have been found to have a 58% increased risk of becoming obese.[18] This correlation might be as a result of taking some psychiatric medicines such as antipsychotics, which increase the risk of obesity (as well as diabetes).[19]

Lifestyle risk factors such as smoking and drinking alcohol, are sometimes a response to stress, but they themselves can exacerbate mental health problems and be damaging to physical health (which can further exacerbate mental health problems). Conversely, positive health behaviours such as physical exercise, getting enough sleep and eating a healthy diet can promote and improve mental health. Public mental health activity should therefore aim to address the physical health needs of people living with mental health problems, this approach may be particularly helpful in supporting men and boys mental health given that they are more likely to exhibit these lifestyle risk factors and less likely to seek support through traditional routes.

The BMA is a signatory to the Equally Well ‘Charter for Equal Health’, which highlights how services should have the right support to reach out to people with long-term mental health conditions: identifying those at risk, intervening early, preventing problems whenever possible and offering extra support when it is needed.

Evidence shows that lower educational attainment can increase the risk of mental health conditions, particularly anxiety and depression.[20] Girls perform better in education than boys.[21] Children and young people with mental health conditions may also have lower educational outcomes, due to missing school during periods of mental ill health (including while waiting to access mental health services) or being excluded if they have significant behavioural problems.[22]

Promoting public mental health

To improve public mental health, comprehensive action is required on the social determinants of mental health. The BMA supports a ‘health in all policies’ approach to policymaking and believes that the mental health support needs of men and boys may be better served by this approach which would allow those needing support to be identified and supported through a wider range of services.

To achieve this, much greater investment is required in local public health services aimed at promoting mental health. Funding constraints are currently undermining the ability of local areas to invest in services designed to prevent people becoming mentally unwell. A life-course approach to improving public mental health is also required, ensuring support for people’s mental health during childhood, education, employment and into later life. Again, such an approach would increase the routes to support allowing everyone, including men and boys, to be more easily identified and enabled to access mental health support and treatment.

Local authorities also commission mental health services, as part of their responsibility to promote public mental health and the prevention of mental health problems. Data on commissioned services should be published in a transparent and easily accessible form. According to local authority spending returns to the Department of Communities and Local Government, in England in 2018/19, local authorities allocated 1.6% of their total public health budget on promoting public mental health. In 2017/18, this rate was 1.2%[23] and in 2016/17, 1.4%.[24] In 2016/17 and 2017/18, one in every three local authorities (32%) that provide public health services say that they spent nothing at all on public mental health.[25] This data indicates a neglect of local spending on public mental health, including in some areas with a high prevalence of mental ill-health.[26]

The fact that many local authorities in England report no spending on public mental health activity at all suggests there may be some ambiguity about their role to invest in public mental health, or variation in the way in which this spending is categorised. This is supported by a 2014 FOI request by Mind, which highlighted variation in spending on public mental health, which Mind suggested indicated confusion about what local authorities in England should be doing to prevent people becoming mentally unwell.[27] It is important that local authorities have clarity over their responsibilities for supporting public mental health, to ensure they are meeting the health needs of their local population. Currently there seems to be little guidance as to what services and interventions should be provided, or how spending in this area should be categorised.

March 2019