Written evidence submitted by the Money and Mental Health Policy Institute (MHB0021)
Introduction
The Money and Mental Health Policy Institute is a research charity established in 2016 by Martin Lewis to break the link between financial difficulty and mental health problems. The Institute’s research and policy work is informed by our Research Community, a group of nearly 5,000 people with lived experience of mental health problems or of caring for someone who does.
This written submission has been informed by this powerful, lived experience testimony and our wider body of research. In particular, it draws on two of our reports: Not a Secondary Issue, which examines the extent to which people in secondary mental health care face financial difficulty, and Recovery Space, which explores how services can minimise the financial harm caused by mental health crises. These reports relied on a mix of qualitative and quantitative research with over 200 members of the Money and Mental Health Research Community with experience of being under the care of secondary mental health services, at least 86 of whom had experience of admission to a psychiatric hospital. Unless otherwise specified, all quotes in this response are drawn directly from our Research Community.
Our response addresses one question from the Committee’s call for evidence and recommends how the issues we have identified can be resolved and the Bill improved.
Background
People from deprived areas are more likely to be detained under the MHA
● The risk of detention under the Mental Health Act (MHA) rises steadily with an area’s level of deprivation. NHS Digital’s 2020-21 statistics report, which is only the second annual report providing analyses of detentions under the MHA based on areas of deprivation, found that MHA detention rates are three and a half times higher in the most deprived parts of England compared to the least deprived parts.[1]
Recent economic adversity is a key risk factor for mental health patients who die by suicide
● Almost two in ten (19%) of all patient suicides (those under the care of mental health services) between 2009-2019 were by people who had experienced economic adversity - such as serious financial difficulties, loss of job, benefits or housing, workplace problems or homelessness - within the previous three months.[2]
People with mental health problems are more likely to experience financial difficulties
● The most recent detailed data shows that between 23% and 33% of people with a mental disorder are in problem debt. Our 2017 analysis found that in England alone, at least 23,000 people were in hospital for their mental health and were also experiencing serious financial difficulties.[3]
Opportunities to prevent and resolve financial difficulties for people detained under the MHA are being missed
● Despite this high prevalence of financial problems at the time of mental health crises, their role in contributing to mental health crises and the devastating financial and mental health consequences of crisis - financial problems are largely ignored in service users’ care and treatment plans. Our research found eight out of ten (81%) respondents reported that their crisis or relapse prevention plan did not mention finances.[4]
This submission will show how the Bill provides a prime opportunity to intervene preventatively to break the links between mental health crises and financial difficulties. This is more crucial now than ever, as the cost of living crisis hits and existing inequalities become further entrenched.
Q8. What more could the draft Bill do to reduce the impact of financial inequalities in people's experiences of the Mental Health Act?
Mental health and financial difficulty are intricately linked. There is a strong negative correlation between poor mental health and income. The average annual income for a person with severe mental illness (SMI) is just 75% of those without an SMI, an annual difference of £6,500.[5] Going without basic necessities like adequate food and heating has a severe detrimental impact on people’s mental health – particularly when this experience is prolonged.
Not having enough money means almost every part of life becomes a struggle... always being hungry or cold, not being able to socialise with others, stressing about every bill and every penny you spend, and the many, many other ways that struggling financially has an impact on your life, chips away at will to live." Expert by experience
The combination of lower average incomes and the cognitive and psychological effects of mental health crisis - which can impact people’s ability to earn and manage money - means that people can experience financial harm while detained under the Act.
What happens to people’s finances while detained under the Act[6] Mental health crises can impact financial capability - During a crisis, a person’s cognitive capacity may fluctuate, and financial management can fall entirely by the wayside. Financial behaviours can change, and people may disengage from managing their finances. Spending and borrowing may increase, or suicidal ideation can lead to people giving money away.
Financial difficulties can lead to or exacerbate mental health crises - Finances can be at the root of mental health crises and drive hospital admissions when people are unable to cope. Changes in benefits or debt collection activity can serve as a sudden trigger for crisis or suicidality.[7] Mental health crises can make it impossible to liaise with financial services and benefits agencies to manage reductions in income or increased outgoings caused by crisis and hospitalisation.
Admission to hospital for mental health problems can mean day-to-day financial management is missed and financial problems exacerbated - Mental health crises can lead to a change in circumstances, where incomes may drop and outgoings may increase. Such changes in circumstances can have immediate consequences, such as housing costs not being paid, debts mounting, and collections activity escalating. There is a risk that people are discharged from hospital without addressing financial matters, returning to the same financial environment that contributed to the crisis in the first instance. |
While people with mental health problems are three and a half times more likely to be in problem debt,[8] our research found that more than eight in ten (86%) respondents also experienced financial harm while under secondary mental health care. Seven in ten (72%) reported that they struggled to pay for essentials, such as food and heating, and over half (55%) reported having missed a payment for an essential bill, such as a mortgage, rent, energy or council tax.[9]
“I was never asked if there was anyone who was opening mail and keeping on top of my day-to-day living stuff. Thinking about that stuff terrifies me at the best of times, but it never occurs to me to think about it when I'm ill. It would have been helpful for someone to remind me that my day-to-day life was still going on and needed attention and servicing. It's always the same.” Expert by experience
To reduce the impact of financial inequalities in people's experiences of the MHA, the Bill should be amended to embed routine enquiry about money worries through statutory Care and Treatment Plans (CTPs) and Advance Choice Documents (ACDs). The Bill provides a prime opportunity to intervene preventatively to break the links between mental health crises and financial difficulties. To better cater to people’s holistic needs, including their financial circumstances, we propose a key, but small change, to improve the Bill to support those detained under the MHA.
Planning for financial matters should be included as a separate section with explicit prompts in the standard CTP and ACD formats
CTPs are documents written by healthcare professionals (HCPs) in conjunction with patients. CTPs set out how a patient's current and future needs related to or arising from their mental disorder will be met. ACDs are intended to enable people to express their views on the care and treatments that work best for them before the need arises to go into hospital. Both CTPs and ACDs are integral to shaping the care and treatment a person detained under the Act receives.
While both plans are holistic and are intended to cover a whole host of factors related to a person’s current and future care and treatment needs and preferences, the Bill does not make any stipulations around the document's required content - other than in relation to CTPs, the need to plan ‘for meeting the patients current and future needs arising from or related to mental disorder’. The Bill does not explicitly require HCPs to consider a patient’s financial circumstances. Without this stipulation, financial needs risk being overlooked in the face of immediate clinical needs. While this remains the case, opportunities are missed to intervene to provide targeted support to resolve or prevent financial difficulties, which can exacerbate people’s mental health problems and hinder recovery.
“I go in for treatment and come out to find my financial world is in a bigger mess than when I went in. The resultant terror, shame and guilt undoes all the work of the treatment, and I am back in crisis again.” Expert by experience
CTPs should include explicit prompts which encourage people to reflect on and stipulate their preferences around finances. The issues prompted should include employment, housing, and payment of ongoing liabilities and debts. These prompts would encourage HCPs to consider patients' financial needs in forming CTPs. Establishing a systematic approach to the identification of financial difficulties through specific prompts in CTPs would help to break the links between mental health problems and financial difficulties. Doing so would also bring England in line with other parts of the UK, including Wales, which already provides an explicit financial prompt in care plan templates.[10]
Research has shown that people who have experienced mental health crises want to be protected from the consequences of being financially disinhibited when unwell.[11][12] ACDs will already include prompts to ascertain people’s advanced preferences around arrangements for the care of any dependents or pets - should a person be admitted to hospital. However, despite the financial devastation that can follow detention under the MHA, there is no provision to include a prompt about arrangements for people’s financial needs should they be detained.
Where people know that deteriorations in their mental health can lead to financial problems, gathering their preferences around preventative action is crucial. ACDs provide an opportunity for people to protect themselves from financial harm by putting in place support, planning and preferences for when they are unwell. As detailed in Table 1, we propose a series of explicit prompts specific to ACDs to support people to consider their preferences for advanced care and treatment around their finances.
Table 1: Prompts for inclusion in the financial planning section of the ACD
Financial planning | Suggested prompts for inclusion |
Changes in financial behaviours which may be indicative of early signs of relapse, such as: | ● Disengagement with finances ● Impulsive spending ● Unusual or excessive generosity ● Unusual or increased borrowing |
Planning arrangements for financial support needs may include: | ● Preferences around arrangements for how priority bills, such as rent or mortgages, will be paid ● Preferences around access to credit, such as credit and debit cards, or access to the internet to apply for credit while hospitalised ● Potential identification of a preferred third party to deal with financial issues on their behalf, such as debt or benefits ● Advanced planning on giving a third party permission or the legal power to deal with financial matters, such as a Lasting Power of Attorney, or third-party mandate with their financial service provider |
By including finances in ACDs and offering explicit prompts, people can be supported to have greater control and choice, setting out advanced preferences and preventative measures to safeguard themselves from the financial harm caused by mental health crises.
Facilitating routine enquiry and linking patients to existing sources of support
Including financial circumstances in ACDs and CTPs would be a systematic way of facilitating and promoting routine enquiry about financial difficulties for people detained under the MHA. This would help to prevent financial difficulties from exacerbating mental health problems and hindering recovery. Systematically supporting HCPs to incorporate a person's financial circumstances into their CTP would allow people to make a plan for their finances in ACDs for potential future admissions. It would also serve to identify and link people up with existing sources of support.
In 2021, new legislation was introduced to give people in England and Wales receiving mental health crisis treatment respite from debt collection activity and escalating fees and charges.[13] The tool, the Breathing Space Mental Health Access Mechanism (MHAM), has the potential to mitigate many of the financial and, consequently, mental health harms identified above. Yet there is no systematic approach to the inquiry of financial difficulties for people detained under the MHA. Therefore, simple opportunities to intervene and use this readily-available resource are being missed. The inclusion of a financial difficulties enquiry in CTPs and ACDs would be a gateway to the routine offer of Mental Health Breathing Space to people detained under the MHA.
15 September 2022
[1] ONS. Mental Health Act Statistics, Annual Figures 2020-21. Published October 2021
[2] The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report: UK patient and general population data, 2009-2019, and real time surveillance data. 2022. University of Manchester.
[3] Bond N, Braverman R and Clarke T. Recovery Space - see full methodology, Annex A. Money and Mental Health Policy Institute. 2018
[4] Money and Mental Health Survey. Base for this question: 75 people with experience of mental health crisis who were aware of and had seen their crisis or relapse prevention plan. 2017
[5] Bond, N. and D’Arcy, C. Mind the Income Gap. Money and Mental Health Policy Institute. 2020
[6] Bond N, Braverman R and Clarke T. Recovery Space - see full methodology, Annex A. Money and Mental Health Policy Institute. 2018
[7] Bond N and Holkar M. A Silent Killer. Money and Mental Health Policy Institute. 2018
[8] Money and Mental Health Policy Intitute. The Facts. (Accessed: 15/09/22)
[9] Bond N and Preece G. Not a secondary issue. Money and Mental Health Policy Institute. 2022. Base for this questions: 163
[10] Gov.Wales. Guidance: Care and Treatment Template. 2019.
[11] Atkinson et al. The development of potential models of advance directives in mental health care. 2003.
[12] Bond N, Evans K and Holkar M. A little help from my friends. Money and Mental Health Policy Institute. 2019
[13] The Debt Respite Scheme (Breathing Space Moratorium and Mental Health Crisis Moratorium) (England and Wales) Regulations 2020