Written evidence submitted by Student Minds (CMH0065)

Call for Evidence: Community Mental Health Services

This response was authored by Jenny Smith, Policy Manager at Student Minds, with support from Nicola Frampton, Dr. Gareth Hughes, and Dom Smithies. Student Minds (Registered Charity Number 1142783) is the United Kingdom’s student mental health charity, representing the interests of 2.9 million students in UK higher education, university staff, and the higher education sector. Please contact policy@studentminds.org.uk for any queries related to this submission.

Executive Summary
 

●       Rigid, diagnosis-led service access criteria drive students’ condition to deteriorate before they are able to access care, leading to an unnecessary worsening of their condition and extended periods without help.

●       Care pathways are not watertight and there are many ways students can “fall through the cracks.” Those with comorbidities, for instance, eating disorders and substance use disorders, often find themselves dropped by both services due to their clinical needs outside their specialism, leaving them with complex needs and no support. We are increasingly hearing cases of neurodiverse students being unable to access care for similar reasons.

●       Current funding models, including block funding and target-led funding, incentivise care providers to make decisions about treatment based not on patient need but profitability. This can encourage waste (spending on sessions that are not required) and a refusal to support those in greatest need of care (due to an expectation of worse patient outcomes). Removing the profit incentive from funding models will go some way to address this.

●       The expanding gulf between primary and secondary care leaves universities picking up the cases of students who are not well enough for the former, but too well for the latter. Despite this universities are not resourced to provide this level of care, nor are they inherently best suited due to their primary role as education providers.

●       Students are often a transient population and may change addresses and Trusts multiple times in a year. This creates significant challenges with regard to commissioning, funding, and managing service capacity.

●       Collaboration between community mental health teams, wider NHS services, the third sector, and public institutions such as universities is already happening. There are pockets of good and experiential practice across the country. This arises organically by concentrated efforts at the local level rather than by being rolled out, strategically, from the top-level down. Universities are part of the community and thus can feasibly form part of a wider network of support for a student.

What does high-quality care look like for adults with severe mental illness and their families/carers?

How could the service user journey be improved both within community mental health services and in accessing support provided by other services/agencies?

In this evidence we identify three changes which we believe will improve the service user journey in community mental health services and access to support provided by other agencies:
 

●       Moving from diagnosis-led to needs-led service provision

●       Providing for comorbid conditions

●       Facilitating patient choice between interventions

We prefer a needs-led approach which identifies the specific experiences or complaints a person has, and supports them on that basis. Currently, care pathways are broadly diagnosis-led, rather than responding to individual needs as they present. This problem starts at the lower level. IAPT practitioners are instructed to label patients as having depression or anxiety, but not both, even considering their significant comorbidity. Service boundaries determined by diagnoses are often rigid and do not account for the broad variety of experience within and between conditions.

This creates a number of gaps in the pathway, including a widening gulf between primary and secondary care (as discussed below), and inadvertently driving students to become more ill in order to qualify to receive care from some secondary services. We have seen this particularly in the case of eating disorder services. Where people with eating disorders fail to appear sufficiently unwell, for instance by having too high a Body Mass Index (BMI) they are turned away despite being in significant difficulty.

The lack of clarity around service remits creates a system where, under significant demand, teams are compelled to refer students outward and strip themselves of responsibility where students may be referred out to a different team. For instance, students with comorbid diagnoses (such as eating disorders and substance use disorders) may find that neither relevant service is willing to take them on due to patient needs beyond their specialism.

This is especially troubling as those with comorbid diagnoses are more likely to have complex, severe mental health needs. The service user journey can be improved massively thus by ensuring those with comorbid conditions are not “dropped” by services and that comorbidity is not a barrier to accessing support. We want to see a “watertight” care pathway where any student who is unwell enough to require support whatsoever will be able to access some form of care.

Patient choice is absolutely critical in order to deliver high-quality, person-centred care. There is no one treatment plan which works in every circumstance. We understand that staffing, funding, and capacity pressures drive primary and secondary care providers to rely on certain interventions (such as prescription medication and Cognitive Behavioural Therapy) in the first instance. While these interventions certainly work for some, they are no panacea.

How can community mental health services work with social care, the third sector and local government to better address service users’ health and wider social needs that are wider determinants of mental health outcomes?

Effective partnership working between community mental health services and other providers, as well as community institutions such as universities, is absolutely critical if truly community-based care is to be achieved. Universities already provide a variety of mental health support for their students, often plugging the gaps in public care pathways by picking up student cases that are deemed ineligible for support by community mental health teams. This is how we know partnership working across sectors is possible.

Joined-up working with appropriate information-sharing, clarity of roles and responsibilities, and integrated care pathways which embed all services providing this support, can ensure better continuity of care for students and facilitate smoother transitions between services.

Through previous research we have identified a number of enabling factors which will support better collaboration between services across the public, private and third sector. These include:

●        Timely access to GP appointments, including under temporary registration, preventing the unnecessary worsening of illness

●        For students to retain places on waiting lists regardless of whether they have temporarily changed addresses, such as for the summer or during work placement

• This can be enabled through the provision of a digital offering

●        The exploration of social prescribing as an additional form of support

●        Embedding mental health support within all education institutions and within the community, ensuring all young people have access to specialist support if they need it through their school, college, sixth form, or through local community support hubs. 

●        Commitment to working with education providers such as schools, colleges, sixth forms and universities to embed whole-institution approaches to mental health and wellbeing, through adequate funding and guidance. 

●        Investment in research to improve understanding of mental health and what works to improve mental health and prevent or protect against mental health issues. This includes specific funding for research into student mental health. 

●        Commitment to funding and implementing cross-sector suicide prevention strategies.

Addressing health inequalities is a central and necessary component of any effort to tackle the causes of poor mental health. Research demonstrates that racialised students, disabled students, LGBTQ+ students, international students, and other marginalised student groups, all experience increased rates of mental illness during and beyond their time at university.

We also understand that socioeconomic factors are significant contributors to mental distress. Within the student population these include (but are not limited to) financial hardship, housing insecurity, food insecurity, social isolation, immigration issues, and a sense of belonging (or lack thereof) within the community.

How could the funding system be reformed to more effectively drive transformation in the delivery of integrated and person-centred community mental health services?

At present, the funding system has a number of “perverse drivers” inbuilt which disincentivise person-centred decision-making. For instance, target-based funding models (as in the case of IAPT), discourage providers from taking on cases where the chance of recovery is lower. This is despite the likelihood that a person with a lower chance of recovery likely has more severe, complex needs, and thus arguably is in greater need of mental health support.

This results in a growing gap between primary and secondary care in terms of remit and service provision. Primary care services end up concerned with mild-to-moderate cases only, while secondary care services are limited to the most severely unwell. Consequently, a significant cohort of people with moderate-to-severe illness find themselves ineligible for any kind of support, despite their need and the impact of their condition on their quality of life.

Equally, block-funding systems where a service provider receives the same funding regardless of whether somebody finishes treatment early build inefficiency and waste into the system. At the same time, it seems inappropriate for providers to “drag out” service provision and extend the number of sessions a person receives when the need is not there, simply to access all available funding. As long as there remains a profit incentive for care providers, decisions will be made which either de-prioritise patient outcomes or waste resources to “justify” the spend. This is evidenced by the generally worse outcomes delivered by private care providers when compared against NHS and VCSE counterparts.

A more fundamental review of the funding model for mental health services is required if integrated, person-centred community care is to be achieved.  We also acknowledge that there is no one treatment plan which works for everyone and that patient choice must be enshrined within care pathways if our vision for person-centred community mental health care is to be realised.

What blockers or enablers should policy interventions prioritise addressing to improve the integration of person-centred community mental health care?

As the UK’s student mental health charity, we highlight a range of blockers and enablers which should be taken into account to improve the integration of person-centred community mental health care. In summary, these include:

Blockers

• Significant continuity-of-care issues which allow students to “fall through the cracks”.

▪        The transition from Child and Adolescent Mental Health Services (CAMHS) to adult mental health services can lead to a “drop” or change in the standard of care a student can expect. This can be disruptive to their treatment and recovery.

▪        The transience of the student population, often moving between addresses multiple times per year and consequently moving between Trusts, means students aren’t always able to access care when it is their turn.

▪        Service Level Agreements (SLAs) and care pathways which are not watertight, meaning some students will be (for example) too unwell for one service but not well enough for the next.

▪        Presumption responsibility is solely on universities to catch these conditions early - NHS needs to take more responsibility for students - it is ultimately responsible for other adults in the population

• Under-resourcing and under-funding. As established in the Lord Darzi review, the demand for NHS mental health services far exceeds availability.

• Waiting lists of MH support allow illnesses to develop unencumbered

Enablers

●        Continuity of care: students will benefit from an ongoing relationship with an individual or team, without unnecessary disruptions in care, including when they move address

●        Adequate funding and staffing of NHS services: with the outcome that individual staff members have manageable caseloads while not sacrificing on work-life balance or waiting times for those in need of support

●        Targeting mental health literacy, prevention and early intervention: as part of a wider public health approach for mental health, building mental health literacy into the curriculum and providing early, low-level interventions will give children and young people the skills to maintain good mental wellbeing and prevent some cases from developing into mental health conditions requiring medical support

●        Clarity on roles and responsibilities between teams, trusts, and higher education institutions: this should be supported by clear service level agreements between the NHS and other institutions

●        Effective multi-agency working and information-sharing: achieved through better use of technology, clear confidentiality procedures, and a patient-led approach

●        A public health strategy for student mental health: considering not just the role of the NHS but wider social determinants of health, necessitating collaboration between DHSC and other government departments

Appendix A: About this response

Our aim in submitting this evidence is to ensure the unique and specific needs of higher education students are considered in the design, delivery, and evaluation of community mental health services. Specific aspects of the student experience can lead to unique challenges in preventing, identifying and treating poor mental health. Students are a transient population who frequently move between addresses and NHS regions. By virtue of their higher education commitments which reduce their time available to work students also have a reduced ability to supplement their income through part time employment. This is particularly impactful for those whose degrees involve placements, such as students on healthcare courses. While at university, many students are going through significant transitions which expose them to greater stress and risk of poor mental health, such as the transition from Children and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS).

Student mental health and wellbeing has scarcely been considered in the public health approach of previous governments: the word “student” was not mentioned once in the 2014 NHS Five Year Forward View, and only eight times in 136 pages in the 2019 NHS Long Term Plan . Not long after, the previous government’s strategy work for mental health was folded into the Major Conditions Strategy alongside such diverse and fundamentally different conditions as cancer, cardiovascular disease and musculoskeletal disorders. While none of these conditions exist in isolation, in some ways meriting a holistic approach, mental health charities expressed concern that this amounted to a de-prioritisation of mental health by the government of the time. 

Universities themselves lack the infrastructure, funding and remit to deliver suitable mental health support on their own. Students are members of the community and have as much of a right to NHS mental health care as any member of the general public. While we developed our flagship programme, the University Mental Health Charter, to support the higher education sector to better support good student mental health and wellbeing, it is critical that the NHS plays its part. We hope this response provides some insight into the challenges facing student mental health as we understand them, as well as direction as to how we believe the NHS can better support this segment of the population.

Our research

At Student Minds we pride ourselves on being student-led and evidence-driven in all that we do. In April 2024 we released our Student Mental Health Manifesto, which laid out our vision for the next government’s approach to student mental health and wellbeing. The Manifesto was co-produced by a student steering group, supported by the testimony of over forty expert sector experts and 165 student research participants. Beyond this we draw on our wider body of work, detailed in our “further reading” annex. 

Appendix B: Further reading 

Documents that are not publicly available can be supplied upon request from policy@studentminds.org.uk .

Student Minds (2024). The Student Mental Health Manifesto. [online] Leeds: Student Minds. Available at: https://www.studentminds.org.uk/studentmentalhealthmanifesto.html.
 

Student Minds (2024a). The Labour Mental Health Review - Response by Student Minds.

Frampton, N. and Thompson, D. (2023). Understanding Student Mental Health Inequalities: Part-time, distance learner and commuter students. [online] Available at: https://www.studentminds.org.uk/uploads/3/7/8/4/3784584/2023_distance_learner_report_final.pdf.
 

Smith, J. L. (2023). Climate Change and Student Mental Health. [online] Available at: https://www.studentminds.org.uk/uploads/3/7/8/4/3784584/climate_change_and_student_mental_health.pdf.
 

Student Minds (2022). APPG Students Inquiry into the Cost of Living: Evidence. [online] Available at: https://drive.google.com/file/d/1u1FL-J-Ia2kcRaXwQM0BuHuUM_OnXcEG/view.
 

Student Minds (2022a). Mental Health and Wellbeing Strategy Consultation Response.

Frampton, N.; Smith, J. L.; and Smithies, D. (2022b). Understanding Student Mental Health Inequalities: International Students. [online] Available at: https://www.studentminds.org.uk/mh-inequalities-international-students.html 
 

Frampton, N.; and Smithies, D. (2021). Life in a Pandemic. [online] Available at: https://www.studentminds.org.uk/lifeinapandemic.html 

Smith, J. L. (2021). Supporting Students with Eating Disorders. [online] Available at: https://www.studentminds.org.uk/uploads/3/7/8/4/3784584/2021_ed_final_artwork.pdf 
 

Hughes, G.; and Spanner, L. (2019). The University Mental Health Charter. [online] Available at: https://hub.studentminds.org.uk/university-mental-health-charter/ 
 

Smithies, D; and Byrom, N. (2018) LGBTQ+ Student Mental Health: The challenges and needs of gender, sexual and romantic minorities in Higher Education. [online] Available at: https://www.studentminds.org.uk/uploads/3/7/8/4/3784584/180730_lgbtq_report_final.pdf
 

Student Minds (2014). Grand Challenges in Student Mental Health. [online] Available at: https://www.studentminds.org.uk/uploads/3/7/8/4/3784584/grand_challenges_report_for_public.pdf 

External

Universities UK. (2022). Suicide-safer universities: sharing information with trusted contacts. [online] Available at: https://www.universitiesuk.ac.uk/what-we-do/policy-and-research/publications/features/suicide-safer-universities/sharing-information 
 

de Pury, J. and Dicks, A. (2020). Stepchange: mentally healthy universities. [online] Available at: https://www.universitiesuk.ac.uk/what-we-do/policy-and-research/publications/stepchange-mentally-healthy-universities.

January 2025