Written evidence submitted by The Royal College of Psychiatrists (CBP0070)

Summary

Like many other parts of the NHS, mental health services have seen a backlog caused by patients unwilling or unable to access care during the pandemic, however the challenges faced by mental health services are more complex and more serious.

The pandemic has had a serious impact on the nation’s mental health, both indirectly in terms of isolation, social distancing, lockdown and economic impact, and directly in terms of hospital admissions, deaths, long COVID and other neurological and psychiatric complications. The impact on services will be felt for years to come.

Mental health services were stretched before the pandemic. Too many adults and children with mental illness experienced long waiting times. Too many were treated far away from their home.

The emergency one-year investment of £500 million was very welcome and had a significant short-term impact, meaning a lack of money was not a barrier to expanding services to meet the short-term needs. This has helped NHS England deliver 2.24m more mental health sessions during 2020/21 than the previous year (10.5% increase).

But despite welcome national investment, services are still facing immense pressures and increased demand as a result of the pandemic. The levels of unmet need have increased considerably. Longer waits for treatment are leading to more acute and complex need. Prevention and early intervention must be prioritised as they have an important role to play in reducing pressures.

Given the ongoing impacts of the pandemic, delivering against existing pre-pandemic targets is going to be extremely challenging. Especially as modelling suggests mental health demand will continue to rise significantly over the coming years. Official modelling of future demand must be made publicly available to inform investment and planning at both the national and local level.

There are major underlying issues limiting the ability of services to treat more patients and reduce waiting times, including ongoing workforce shortages, the current state of the mental health estate and the need for improved technology and digital infrastructure.

The Health and Care Bill and the upcoming Spending Review are critical opportunities for mental health. We urgently need long-term strategic plans for investing in the mental health estate and for expanding the mental health workforce. New local decision-making structures within the NHS must include mental health representation and must ensure that progress towards parity of esteem is being achieved.

The scale of increased demand for mental health services

The pandemic has already had a significant impact (directly and indirectly) on the prevalence and severity of mental illness within the population and on demand for mental health services. This has increased pressure on an already stretched and historically underfunded area of the NHS.

Post-pandemic demand can broadly be divided into three categories. Firstly, delayed or deferred first-time access, people with untreated mental illness who were it not for the pandemic would have accessed services earlier. Secondly, the deterioration of patients with existing mental illness due to the pandemic. Thirdly, previously healthy people who have developed mental illness due to the pandemic.

The impact of the pandemic on mental health has been driven by a range of factors, including social isolation, loss of informal support networks, acute stress, bereavement, financial pressures, long COVID, healthcare-related trauma (ICU admission and ventilation), widening inequalities and reduced access to routine care and treatment during the pandemic. Vulnerable groups include those clinically vulnerable to COVID, frontline health and care staff, people with existing mental illness, carers, people economically impacted by the pandemic and children and young people.

Demand pressures within mental health are much harder to identify and quantify than within physical health, as there is much less routinely published data to analyse. Mental health does not show up on the vast majority of waiting time reports. However, this is due to change significantly with the introduction of five new waiting time guarantees for community and liaison mental health services[1]. Investment will be needed to support the successful roll-out and implementation of these new waiting time guarantees.

We cannot achieve parity of esteem between mental and physical health without improving the quality and breadth of data on mental illness and the performance of mental health services. We recommend that the upcoming health and care data strategy includes a specific section on mental health, including plans to integrate mental health data and IT systems into the wider healthcare system. 

However, the measures that do currently exist present a clear picture of surging demand and NHS performance falling behind schedule on targets set out in the Five Year Forward View for Mental Health (FYFVMH) in 2015 and the Long Term Plan (LTP) in 2019.

Children and young people’s eating disorder services

The most recent data showed that 160% more children and young people completed urgent pathways in Q1 21/22 compared to the same period last year (852 compared to 328) and an almost fourfold increase in urgent cases waiting for treatment (207 compared to 56). For routine cases, the increases were 93% and 315% respectively.

Child and adolescent mental health services (CAMHS)

Significantly more children are being referred to mental health services (0-18 year olds) than they were before the pandemic. The most recent data from May 2021 shows a 94% increase in the number of children being referred against May 2019.

Maternal mental health

16,000 women missed out on specialist perinatal mental health care during 2020/21 compared to the NHS England target for the year. Just to meet the previous commitment to treat 66,000 women a year by 23/24 we need to more than double capacity, which does not consider any possible increases in need.

Improving Access to Psychological Therapies (IAPT)

Only around one million people started IAPT treatment in 2020/21 compared to the target of 1.5million set by NHS England in the Five Year Forward View for Mental Health.

Adult secondary mental health services

We estimate that even without taking into account the likely increase in need because of the pandemic, around 215,000 adults missed out on referral to secondary mental health treatment in 2020/21, based on previous year-on-year trends. This highlights the need for more detailed modelling to get a better understanding of the unmet need.

Physical health checks for people with SMI

Almost 160,000 people with a Serious Mental Illness (SMI) were not given a complete physical health check by GP services in 2020/21 compared to the target set by the government. This programme was substantially behind schedule prior to the pandemic but has fallen even further off track.

Demand has increased significantly and the NHS is behind schedule on a range of targets, but it is anticipated that demand will increase even further over the coming years. A range of organisations have developed detailed modelling to estimate future demand, including the Strategy Unit, a specialist NHS team based in Midlands and Lancashire Commissioning Support Unit, and the Centre for Mental Health.

The Strategy Unit has estimated that there will be around 11% more new referrals to mental health services each year for the next three years and that the associated costs amount to an extra £1 billion a year, around 8% of annual NHS spending on mental health services.[2]

The Centre for Mental Health has estimated that 10 million people (8.5 million adults and 1.5 million children and young people) in England will need support for their mental health as a direct result of the pandemic over the next three to five years. The predicted levels of demand are two to three times that of current NHS mental health capacity within a three to five year window.[3]

The Department for Health and Social Care is conducting its own modelling of future demand for mental health services. We recommend that the Committee asks for this to be made publicly available once completed, given its implications for service planning and long-term investment.

Investment to support increased demand for mental health services

The NHS Long Term Plan included a commitment to significantly expand mental health services – with a ring-fenced increase in investment worth at least £2.3 billion a year by 2023/24.

In recognition of the short-term impact of the pandemic, the Government also put in an emergency one-year investment of £500 million for mental health services. This has had a significant impact, meaning that money was not a barrier to expanding services and helped NHS England to deliver 2.24m more mental health sessions during 2020/21 than the previous year (10.5% increase).
 

However, clearly the pandemic has had an enormous impact on demand for services which is likely to continue. Progress on delivering the Long Term Plan commitments has been set back. Without substantial additional investment to deal with pandemic-related demand surges, the ambitious commitments and targets in the Long Term Plan could fail.

We urgently need more data and better data to inform investment, looking at prevalence, risk, protective factors, access and waiting times. Services need to be able to proactively plan ahead for future demand, rather than play catch-up when they start struggling. As well as investment in services, we also need substantial investment in infrastructure, workforce, prevention and technology.
 

Investment in the mental health estate
We must invest capital funding into the mental health estate in order to improve the resilience of services, prevent transmission of the virus, improve the safety of patients and staff, support patient outcomes, contribute to staff morale and contribute to the NHS’ goal of providing sustainable healthcare.

The Care Quality Commission’s (CQC) has made an assessment that many mental health wards are unsafe and provide poor quality care in old and unsuitable buildings. Almost one million square metres (981,091 sqm, 21.6%) of the mental health trust estate is so dated that it was built before the NHS existed.

When the COVID-19 pandemic hit, the shortcomings in the mental health estate meant that patients and staff were put in increased danger because many wards were completely unsuitable for infection control. Unfortunately, a parallel between the situation in mental health wards and the situation in care homes can be drawn.

Our membership survey found that 38% of members said that their organisations’ estate has been unsuitable or very unsuitable for the cohorting of patients with suspected or confirmed COVID-19. 33% of clinicians said that the quality of buildings and estates in their organisation has negatively or very negatively impacted upon the care provided to patients during the pandemic.

A study in The Lancet showed that more than two-thirds (67.5%) of COVID cases in mental health hospitals were caught in hospital, compared to 11.3% for all types of hospital.[4]

With only two of the 40 new hospital buildings announced last year having been for patients with a mental illness, we sincerely hope that the mental health estate will be a focus for upgrades in the upcoming Spending Review.

We recommend £3bn of ring-fenced capital investment for a three-year Spending Review, plus £1bn for day-to-day capital budgets (based on £335m invested by mental health trusts in 2019/20 on equipment, backlog maintenance and investment in existing buildings) and the remaining £465m from our proposed £1bn Mental Health Infrastructure Plan due in the second half of the decade. A provisional breakdown for the £3bn is as follows:                             

• £535m for the first six mental health hospital investment projects in the Mental Health Infrastructure Plan to modernise the estate and close inpatient care gaps (inclusive of seed funding)                           
• £750m investment to improve the therapeutic environment and address critical safety issues – beginning to eliminate of mixed sex accommodation and procuring en-suite facilities for all single rooms, safety improvements and making the estate more suitable for disabled people
• £700m for building and redevelopment schemes to support the rapid expansion of community mental health services in the Long Term Plan, including digital infrastructure, clinical and office space             
• £300m to reaffirm the commitment to eradicate dormitories during 2022/23 and 2023/24
• £270m for crisis alternatives, A&E mental health spaces and mental health ambulances/transport vehicles             
• £204m to address the high, significant and current moderate risk areas of backlog maintenance in mental health and learning disability sites (2019/20 ERIC)             
• £120m for research and development covering areas such as prevention, improving effectiveness and productivity and life sciences             
• £90m for capital investment in drug and alcohol services to support implementation of the Dame Carol Black review             
• £37m for a mental health innovation fund

Investment in prevention and public health
Investment in prevention and public mental health is critical as a means of reducing pressure on stretched services and a stretched workforce. This should include investment in drug and alcohol services, social care and public mental health. Public mental health is about drawing on community resources in the widest sense. The COVID-19 pandemic has demonstrated the importance of this and the need to promote healthy lifestyles and prevent poor mental health at the earliest opportunity. This needs to be underpinned by world-leading mental health research to identify preventative interventions.

We recommend investment in drug and alcohol services in line with the Dame Carol Black report recommendation, reaching £396m additional funding by the end of the Spending Review period (en route to £552m additional funding per annum over a five year period).

We recommend that at least 4% of public health funding is allocated to public mental health, compared to just 2% at present.

Investment in technology

Investment in technology can improve care, increase productivity and release staff time. The COVID-19 pandemic has dramatically increased the need to embed technology into healthcare provision, with remote working and consultations becoming increasingly widespread across mental health services. Mental health providers should use the COVID-19 pandemic as an opportunity to improve patient care (e.g. choice) and workforce (e.g. increased flexibility) through digital technology and remote working.

We recommend £187m of investment for improving digital technology in mental health services.

The capacity of the psychiatric workforce to deal with increased demand

In the mental health sector, recruiting enough skilled staff to meet the needs of patients was already an urgent and substantial challenge before the pandemic. There have been several plans to try to remedy the workforce challenges surrounding the Five Year Forward View for Mental Health and NHS Long Term Plan, but workforce remains widely recognised as one of the biggest threats to their delivery.

Workforce planning regularly comes too late in the planning cycle creating difficulties in translating it into action. Short term workforce planning often fails to understand the length of time it takes to train staff and fails to sufficiently compare supply against demand. 

The Five Year Forward View for Mental Health was followed by a workforce plan – Stepping Forward to 2020/21: The mental health workforce plan for England. To enable the workforce to deliver the Long Term Plan, the NHS published the Interim NHS People Plan covering 2019/20, followed by We are The NHS: People Plan covering 2020/21, both of which were only one-year documents. All three workforce plans lacked tangible action to achieve the necessary growth in psychiatrists and were unaccompanied by the long-term budgets needed. 

Stepping Forward set out the intention to add 570 consultant psychiatrists and 8,100 nurses to the mental health workforce. Since March 2017 (the government’s baseline date), only 210 consultants and 3,010 mental health nurses have been added to the workforce, resulting in around 5,450 posts remaining unfilled with only a month of the original strategy period left to report.

When considering both sets of targets outlined in Stepping Forward and the NHS Long Term Plan, data from February 2021 shows that we are currently around 420 consultant psychiatrists behind the target for 2020/21, and, therefore, on course to miss the target by 2023/24. 

The number of vacant consultant posts across England more than tripled from 220 in 2013 to 708 in 2019. This picture looks significantly worse considering that as of 2019, 285 posts were filled by locum consultant psychiatrists. The highest consultant vacancy rates in England were found to be in eating disorders (15.0%), perinatal (13.7%), liaison (12.1%) and child and adolescent (11.9%)

We must train more doctors in the UK, which means we urgently need more medical school places and training placements. The government must increase the number of medical school places to 15,000 by 2029. The CPD budget within Health Education England must also be fully restored back to 2013/14 levels in real terms.

We were pleased the Government funded an additional 120 core psychiatry training programmes in 2021/22, however a further expansion of core training posts is required to meet increased demands. As statutory bodies, ICSs will be critical in overcoming both geographical and speciality shortages. Trainees are not simply ‘in training’. They are delivering services from day one, so an expansion of core posts has a direct impact on service delivery. We therefore recommend a continuation of the expansion of core psychiatry posts by making a further 120 additional posts available in 2022.

Given the mixture of responsibilities across government and arm’s length bodies when it comes to workforce, it is critical that there is joined-up working, accountability, and clarity on actions to be taken to deliver the workforce needed. The new Health and Social Care Bill presents an important opportunity to address historical issues relating to a lack a long-term workforce planning.

How might the organisation and work of the NHS and care services be reformed in order to meet the extra demand for mental health services

The new Health and Care Bill going through Parliament is going to significantly change the legal structure for how the NHS is organised and how local decisions are made.

The focus of the reforms on collaborative working, bringing together commissioning and provision, reducing barriers between primary, secondary and tertiary care and adopting a population health focused approach are all positive and should help mental health services work more seamlessly with each other and with other areas of the NHS and social care.

There is however, a danger that the new legislation will fail to prevent some local areas ignoring or undervaluing mental health care when they re-evaluate their services after the COVID crisis.

The RCPsych recently surveyed 120 members in England who were asked about the local involvement of mental health providers in Integrated Care System (ICS) decision-making. 42% of respondents sadly felt it was either ‘very poor’ or ‘poor’, with only 15% rating it good or very good.

The current wording of the Bill and the guidance published by the NHS means it will be possible for some areas to have no mental health representation on their ICS Board. We share the concerns of NHS Mental Health Trusts[5] that not having a mandated representative would be a backwards step for parity of esteem for mental health and may mean resources are diverted away from mental health services.

The Bill also sets out a new provision for the Secretary of State to report on who is responsible for workforce planning for health care but does not go any further to guarantee the NHS has a sustainable workforce to meet the country’s needs.

Recommendations for the Health and Care Bill

-         Representation from an NHS trust with responsibility for mental health should be legally required on ICS boards, alongside other types of NHS trusts.

-         ICSs should be legally required to achieve parity of esteem for mental and physical health in their decision-making and should report on this annually.

-         To ensure that we have the staff numbers required the Bill should be amended to require the Secretary of State publishes a report every two years, including an independently verified assessment of how many people currently work in health care and how many are likely to be needed in the next 5, 10 and 20 years.

Lessons learned and implications for future service delivery

The single biggest change to service delivery during the pandemic was the rapid adoption of remote working using digital technology. The COVID-19 pandemic has dramatically increased the need to embed technology into healthcare provision, with remote working and consultations becoming increasingly widespread across mental health services.

Investment in technology can improve care, increase productivity and release staff time. Mental health providers should use the pandemic as an opportunity to improve patient care (e.g. choice) and workforce wellbeing (e.g. increased flexibility) through digital technology and remote working. The NHS has an opportunity to embed innovative practices that have been used during the pandemic and not to presume usual ways of working are most efficient.

However, it is important that any new technology is thoroughly evaluated before it is implemented wholesale and must be designed to ensure that as few patients as possible are ‘digitally excluded’. It is important that people with dementia, people who lack digital literacy or find technology challenging, people who have cognitive impairment, people with an intellectual disability and people who do not have access to digital platforms are not disadvantaged.

In order to maximise the benefits that using technology can bring, providers must also have adequate equipment. When we asked our members to assess the IT equipment available to them for remote working during the COVID-19 pandemic, we found only 19.7% of members in England (257 of 1,303) felt they were ‘fully equipped’ with a further 38.3% (499) responding that they were ‘well equipped’.

Fixing these problems is not merely one of going back to the pre-digital age to ensure nobody is excluded, but of finding the correct balance between face-to-face and digital treatments and ensuring clinicians are well equipped to provide both.

Other positive developments during the pandemic included

• Training: There has been increased mental health training for allied professionals and those working in universal and targeted services and increased physical health training for those in mental health settings.
• The use of infection control measures: Infection control could reduce the spread of other contagious diseases among patients and staff on wards (incl. influenza, colds, norovirus etc.)
• Workforce wellbeing and retention: The pandemic has put a greater focus on retaining specialist staff, incentivising return for retired staff and improving workforce wellbeing which could play an important role in addressing workforce challenges.
• Improved collaboration: During the pandemic, there were more frequent meetings and a closer working relationship between Royal Colleges, the Chief Medical Officer and the Secretary of State.
• Vaccine prioritisation for those with severe mental illness and/or intellectual disability: Vaccine prioritisation should be retained moving forward, considering the vulnerabilities of these patient groups for other illnesses, beyond COVID.

How effective has 111 been for mental health during the pandemic?

We do not know how many people are calling 111 with a mental health problem or how many calls are directed to a local crisis line (or how many transfers are successful and how many people access a mental health nurse). There used to be publicly available data on this, but there has been no new publicly available data since 2018.[6]

Many 111 call handlers do not have a good working knowledge of mental health services in local areas and local pathways for crisis, community and acute care. This results in callers being told to go to A&E as call handlers do not know where else to direct them. The NHS Long Term Plan contained plans to improve 111 for mental health, including a commitment that by 2023/24 anyone seeking urgent mental health support would be able to do this via 111.

When the pandemic struck, over half of mental health trusts did not have a public-facing 24/7 telephone number for access to urgent mental health crisis support. Many that did exist were difficult for to find and several websites directed people to A&E and 999 as the default option locally. During the pandemic NHS England and Improvement asked each local area to immediately establish 24/7 crisis lines for mental health.

High levels of demand on the 111 service meant that people were not getting the right support at the beginning of the pandemic. The local 24/7 mental health crisis helplines that were established helped overcome this to an extent. These are staffed by mental health professionals who can refer people to local mental health services.

By May 2020, NHSE/I reported that local crisis lines had been set up in every part of the country. Between April and July 2020, 770,000 calls were recorded. Early data covering April–July indicated high levels of variation by area in call outcomes. Some have been running for over a year now and there was a total of three million calls between May 2020 and May 2021.[7]

At present, local helplines are found via the NHS website, however by 2024 the ambition is to ensure these are connected to 111, which would significantly improve the service. If 111 works properly, there is no need for local areas to spend resources advertising their own local lines, as 111 can act as a first point of contact and transfer callers appropriately.

These local services have been a lifeline, but they are not always well linked with 111. They are also not yet operating the full service as set out in the Long Term Plan. Many are staffed by temporary or redeployed staff. Some do not have an adequate technological system or comprehensively resourced crisis pathways sitting behind the service. There were also reports of 111 call handlers not knowing about these local crisis lines, however, this has now improved.

We recommend:

• Expediting work already underway to connect Integrated Urgent Care services to 24/7 mental health crisis services in each local area.
• Increasing the number of mental health specialists working in 111 and ensuring call handlers are able to triage and direct patients to the appropriate local mental health crisis lines.
• Routine collection of standardised data on 111 calls related to mental health, including age, gender and outcome.
• Urgent review of the implementation of NHS mental health telephone services and expediting improvements identified through this exercise.

Facilitating future innovation in mental health

Our approach to mental illness post-pandemic needs to be underpinned by world-leading mental health research to identify preventative interventions, as well as cutting-edge treatments and therapies.

Studies into the prevention, diagnosis, and treatment of mental health conditions are significantly underfunded. Only 3.9% of funding goes towards prevention of mental illness. The total expenditure on mental health research from 2014–2017 was £497 million, on average £124 million per year. These figures translate to just over £9 spent on research per year, for each person affected by mental illness. By comparison, £612 million is spent on cancer research each year, which translates to £228 per person affected – or 25 times more per person.[8]

We recommend £120m of investment in mental health research and development, covering areas such as prevention, improving effectiveness and productivity and life sciences research.

We recommend £37m of investment for a mental health innovation fund.

Long COVID and mental health

It is not fully known the extent to which long COVID is contributing to increased demand for mental health services because data on this isn’t routinely collected. However, we anticipate it being an important factor as research shows there can be neurological and mental health effects associated with both COVID infection and long COVID symptoms.

One in in ten people may still have symptoms of COVID after three weeks, and some may suffer for months. There is very strong evidence that those with a long-term condition are two or three times more likely to develop mental ill-health. People with two or more long-term conditions are seven times more likely to experience depression than those without a long-term condition.[9]

Data from the Office for National Statistics (ONS) estimates that 945,000 people living in private households in the UK (1.46% of the population) were experiencing self-reported "long COVID", and that the groups most affected are: those aged 35 to 69 years, females, those living in the most deprived areas, those working in health or social care, and those with another activity-limiting health condition or disability.[10]

There has also been research into neurological and psychiatric complications associated with COVID infection. A Lancet study found that among 236,379 patients diagnosed with COVID, the estimated incidence of a neurological or psychiatric diagnosis in the following 6 months was 34%, with 13% receiving their first such diagnosis. This was higher for those admitted to ICU, when the estimated incidence of a diagnosis was 47% and for a first diagnosis was 26%.[11]

Early data from the CoroNerve study (which the College are actively encouraging patients and clinicians to take part in) reviewed the clinical data of 125 people from across the UK who had new diagnoses of both COVID-19 and a neurological or psychiatric condition. It showed that although they were identified across all age groups, cerebrovascular events were overrepresented in older patients and acute alterations in mental status were overrepresented in younger patients.[12] Delirium is the most common acute neuropsychiatric syndrome associated with COVID and may be the only presenting feature of COVID in older adults and those with dementia. This is similar to what was observed in previous SARS and MERS outbreaks.[13]

A NIHR review of evidence around long COVID symptoms found that there are significant psychological and social impacts that will have long-term consequences for individuals and for society if not well managed. It found that health and social care services are not equipped to support people living with long COVID and staff need better information and education on the ongoing effects.[14]

In terms of providing better support for the mental health aspects of long COVID, it is vital that the rapid guidance developed jointly by the National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of General Practitioners (RCGP) on managing the long-term effects of COVID-19 is implemented locally.[15]

Liaison psychiatry services are a core mental health service for meeting the mental health needs of patients with long COVID.[16] When developing new service models for long COVID, it is essential that there is integrated commissioning addressing both the mental and physical health components.

NHS England must meet its Long Term Plan commitment of all general hospitals having mental health liaison services, with 70% meeting the ‘core 24’ standard for adults and older adults, by 2023/24.