Written evidence submitted by Rethink Mental Illness (CBP0085)

 

About Rethink Mental Illness

Rethink Mental Illness is a leading charity provider of mental health services in England. We support tens of thousands of people through our groups, services and advice and information. And we train employees, employers and members of the public on how best to support someone affected by mental illness. All of this work guides our campaigning for the rights of people living with mental illness and their carers.

 

Introduction

We welcome the opportunity to provide evidence to the Committee, and are pleased that the Committee recognises the significance of mental health in conversations focusing on the backlog of care.

 

It is undeniable that the pandemic has had a significant and far-reaching impact on mental health and wellbeing, which will be felt for many years to come. We were pleased to see the commitments made in the NHS Long Term Plan[1] to transform and expand community mental health services supported by at least £2.3bn of additional funding each year, which is set to reach 370,000 adults and older adults by 2023/24. New person-centred models of community mental health care will play a crucial role in addressing both the medical and social impacts of the COVID-19 pandemic. The recent emergency investment of £500m[2] attached to the COVID-19 mental health and wellbeing recovery action plan has also made a considerable impact in certain key areas, including accelerating rollout of the Community Mental Health Framework[3], investing in social care to ensure mental health patients only stay in hospital as long as is necessary, and establishing outreach programmes to ensure those living with severe mental illness receive support for their physical health.

 

The upcoming Comprehensive Spending Review will be critical in tackling the mental health need that has emerged via the pandemic. Further investment is needed to build on the progress made through the measures introduced by the COVID-19 mental health and wellbeing recovery action plan into the next financial year and beyond and deliver the commitments made in the NHS Long Term Plan.

 

The government must also set out reforms that address the broader challenges facing social care, that goes further than a cap on care costs and changes to means testing. Within this, the government must detail how social care reforms will meet the needs of those severely affected by mental illness who require vital mental health social care support.

 

 

Increase in mental health need during the COVID-19 pandemic

It became clear soon after the first lockdown began in March 2020 that the pandemic and its consequences were going to take a considerable toll on the nation’s mental health.

 

Research by University College London[4] has shown that those with pre-existing mental health needs were among the most likely to be affected by worsening mental health during the pandemic. In May 2020, Rethink Mental Illness surveyed 1,434 people severely affected by mental illness, and found that 79% said that their mental health had got worse.[5] This figure was still close to to 50% nine months later.[6]

 

The Centre for Mental Health estimated in October 2020 that two thirds of people requiring new or additional support will be those with existing mental health needs.[7]

 

As well as people’s symptoms getting worse, the significant drop in referrals for support, particularly at the start of the pandemic, will not only have led to a backlog but also likely escalation of need. Referrals into mental health services were almost 20% lower from April to June 2020 than the equivalent time period in 2019 (774,409 referrals versus 943,137.)[8]

 

The potential impact on NHS services

We currently cannot look to official statistics on waiting times to estimate how many people with severe mental illness are waiting for care, as these do not exist beyond those introduced to monitor Early Intervention in Psychosis services. However, a picture is likely to emerge as much-needed new access standards for mental health are introduced by NHS England.[9]

 

Several studies recommended by NHS England to forecast demand paint a stark picture for the near future. Research by Tees Esk and Wear Valley NHS Foundation Trust, the Centre for Mental Health, Mersey Care NHS Foundation Trust and York University indicated that demand for adult mental health services could increase by as much as 40%.[10]

 

Another study, by the Strategy Unit[11] estimates around 11% more new referrals to mental health services each year for the next three years. This model estimates that demand for crisis support will increase by a third in the three years from 2020/21 to 2022/23, while referrals to secondary care will rise by two thirds in the same period. Nearly 170,000 more people will be referred to secondary community services.

 

Severity of need

People severely affected by mental illness must not be forgotten in discussions on the mental health impact of the pandemic. While there has been significant focus on the increase in adults developing symptoms of common mental health disorders such as depression and anxiety, trends show a worrying increase in the number of people showing symptoms of severe mental illness. In May 2021, referrals to Early Invention in Psychosis services with a first episode of psychosis stood at 13,261 - an alarming 73% higher than at the same point in 2019.[12]

 

We are additionally worried by increased reports of individuals presenting in hospital emergency departments with psychiatric needs. This was highlighted by NHS Providers towards the end of last year[13], and has been an emerging theme in CQC inspections of urgent and emergency care departments.[14]

 

Physical health of people with severe mental illness

We are additionally concerned that the physical health of those with severe mental illness has been neglected during the pandemic. People with severe mental illness (SMI) have a higher prevalence of obesity, asthma, diabetes, COPD, coronary heart disease, stroke and heart failure.[15] They are also at greater risk of premature mortality, with recent Public Health England data showing that those with severe mental illness are three and a half times as likely to die before the age of 75 than the general population.[16] Our research suggests that the COVID-19 pandemic and related restrictions may have exacerbated issues with physical health. Over half of respondents to a Rethink Mental Illness survey said that they were exercising less and eating less healthily under lockdown conditions.[17]

 

Physical Health Checks for people with SMI are designed to identify possible physical health issues early, and allow patients and their clinicians to take appropriate steps to minimise risk. The NHS Long Term Plan established a commitment for 390,000 people to receive a full annual Physical Health Check, with an expectation for 60% of people on GP Practice SMI registers to receive a check. However, in January to March 2020, the percentage of people who had received a check in the preceding year stood at 36%. This number has fallen further during the COVID-19 pandemic, reaching a low of 21.6% at the end of December 2020.[18]

 

Following investment via the government’s Mental Health winter plan[19] and COVID-19 recovery action plan[20], progress has been made towards establishing and beginning delivery of physical health outreach programmes across the country. The impact of this work is just beginning to be reflected in advancement towards the 60% target in several CCG areas. NHS England statistics show that the percentage of eligible people who had received a full Physical Health Check in the previous year increased by over 10% in 18 CCG areas in just one quarter (Q4 of 2020/21) despite the country being in lockdown conditions during this period.  

 

 

Addressing the backlog of mental health need

 

Ensuring rollout of the Community Mental Health Framework

The NHS Long Term Plan included a commitment to introduce new person-centred community mental health services. A new community-based offer will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use. This is supported by ring-fenced investment of at least £2.3 billion per year by 2023/24.

 

The Community Mental Health Framework sets out NHS England’s vision for the rollout of this commitment. Following initial rollout in a number of early implementer sites, full implementation of the Community Mental Health Framework began in April 2021.

 

The funding for this must be delivered through the upcoming Comprehensive Spending Review, as these new integrated models of care will have a vital role to play in addressing the mental health crisis that has emerged from the pandemic.

 

Partners in Community Mental Health Framework early implementer sites leapt into action at the start of the pandemic to address the urgent situation. In Somerset, the new Open Mental Health service[21] has been developed and is delivered in partnership by the NHS, local authority, VCSE sector and those with lived experience. It took the decision to bring forward certain elements of their planned new support offer when the pandemic hit. This resulted in the enhancement and expansion of a local 24/7 helpline, providing mental health support to all ages. The phone line provides 30 minutes of emotional support, leading to warm transfers to enhanced support where possible. Within this arrangement, organisations specialising in providing support around wider determinants of poor mental health, such as welfare and money advice, are able to provide immediate support to address practical stressors as individuals await clinical help. This can also help to prevent the escalation of need as people await treatment.

 

NHS 111 services could benefit from integration with dedicated mental health crisis lines, which in turn should be a key step within local crisis care pathways that have been co-produced with Experts by Experience. Evidence from the Cambridgeshire and Peterborough first response service found that this support led to a 25% reduction in A&E mental health attendances and a 19% reduction in emergency admissions.[22]

 

Considering parity of esteem within new investment to address the NHS backlog

The Mental Health Investment Standard (MHIS) is the requirement for CCGs to increase investment in Mental Health (MH) services in line with their overall increase in allocation each year. This is designed to promote parity of esteem between mental health and physical health, and addresses the long term underfunding of mental health services in the past.

 

On 7 September 2021, the Prime Minister announced a new health and social care levy which will raise around £36bn over the next three years.[23] Around £25bn of this funding is expected to go to the NHS to tackle the backlog in elective care, but addressing the backlog of mental health need was notably absent from the Government’s announcement.

 

The government must clarify whether the Mental Health Investment Standard applies to new funding committed to addressing the NHS backlog. Given the substantial impact of the pandemic on mental health need, it is crucial that mental health services receive a fair proportion of this funding.

 

Extending funding to continue measures introduced by the COVID-19 mental health and wellbeing recovery action plan

Investment accompanying the Government’s Mental Health Winter Plan and COVID-19 mental health and wellbeing recovery action plan has been vital in the short term for addressing some key areas of need, including accelerating rollout of the Community Mental Health Framework, investing in social care to ensure mental health patients only stay in hospital as long as is necessary and establishing outreach programmes to ensure those living with severe mental illness receive support for their physical health.

 

As we emerge from restrictions, it is more crucial than ever that people with severe mental illness (SMI) are supported to deal with physical health issues that may have emerged in the backdrop of the pandemic. Outreach around physical health driven by the VCSE sector will play a crucial role in supporting GPs to deliver key commitments around physical health and SMI as primary care recovers from the pandemic. Further investment is vital to allow for the continuation of these outreach programmes, ensuring continued progress towards the NHS Long Term Plan target.

 

Investing in mental health social care services

While we welcomed the Government’s COVID-19 mental health and wellbeing recovery action plan, we remain concerned that too little of the overall funding package over the next three years has been targeted at social care. Addressing the backlog of need created by the pandemic must also look beyond the NHS, as a lack of social care is a major reason that patients cannot be discharged or experience repeated, avoidable mental health crises. 

 

When introducing the new Health and Care Bill,[24] which seeks to bring about better integration between the NHS and local authorities, the government rightly acknowledged the interdependence between health and social care services.

 

Mental health social care plays a vital role in supporting people living with severe mental illness to recover following hospital care, stay well and prevent further crises. Mental health social care services will be central to realising the ambitions of the Community Mental Health Framework, but welcome investment into the NHS has to be contrasted with local authority cutbacks to mental health social care services that the recent funding annocement has still not adequately addressed.

 

Social care funding for people with mental illness and their carers can mean the difference between living a fulfilling, independent life and a relapse leading to a hospital stay or worse. For example, the Crisp Commission found that almost 40% of delayed discharges from mental health inpatient units were caused by a lack of appropriate housing[25], and there was a total of 37,051 days of delayed discharge between May 2020 and April 2021 due to patients awaiting a place in supported accommodation services.[26] Keeping patients in hospital is more expensive than treating them in the local community. Analysis of four accommodation services provided by Rethink Mental Illness suggests that between April 2019 and Mar 2020 these services saved the NHS at least £750,000 in reduced inpatient costs.[27] An inability to discharge patients who are well enough to leave hospital can lead to others being sent far from home for treatment. Sending patients out of area to receive treatment is also more expensive for the NHS, and is also associated with longer hospital stays[28].

 

The £87m of discharge funding provided by the COVID-19 mental health and wellbeing recovery action plan has been critical in providing additional support for those leaving hospital, such as temporary accommodation or care at home. This funding must continue over the next three years to address increased need for community mental health services and enable Trusts to move service users out of hospital beds as quickly as possible.

 

With the announcement of the new Health and Social Care levy on 7th September, we are pleased that the Government has begun to rise to the significant challenges facing the social care sector. However, what has been announced so far does not represent the detailed vision for reforming social care that is so desperately needed.

 

A cap on total care costs will help people of all ages living with severe mental illness when these changes come into force in 2023, as will the increased threshold under which those requiring support will have their care costs covered by government.

 

However, focusing on protecting assets, as well as some funding to develop the social care workforce, still leaves many problems with the current social care system in place. Unless these problems are addressed social care providers will continue to struggle and many people who need social care will be unable to access the support they need. 

 

The government must set out reforms that address the broader challenges facing social care, that goes further than a cap on care costs and changes to means testing. Within this, the government must detail how social care reforms will meet the needs of those severely affected by mental illness who require vital mental health social care support.

 

Addressing wider determinants of poor mental health

Financial insecurity and socioeconomic deprivation have been driving factors of poor mental health during the COVID-19 pandemic. Research by NatCen[29] showed that those who had became newly dependent on universal credit and self-employment grants experienced the most dramatic and ongoing decline in mental health and wellbeing, with 42% of this group reporting poor mental health earlier this year. Around 1 in 7 people who depended on different types of non-work-based financial support, such as additional benefits, borrowing and use of savings, to stay afloat during the pandemic reported receiving a new mental health diagnosis between May 2020 and January 2021. We are deeply concerned that the removal of the £20 uplift in Universal Credit and Working Tax Credits at the end of September 2021 – which represents the largest overnight cut to benefits since the second world war - will further amplify financial hardship and subsequent mental distress. We urge the government to reconsider its decision to remove this lifeline.

 

The pandemic has also had a significant impact on unpaid carers, with three quarters reporting feeling exhausted and an alarming 44% close to burnout.[30] Rethink Mental Illness surveyed 304 carers of people with a severe mental illness in May 2021[31], finding that almost two thirds said that specialist carers support for those supporting someone with a mental illness would be the most helpful support in terms of protecting their wellbeing and ensuring they can continue to provide care. When friends and family members feel unable to continue caring, it falls to the NHS and local authorities to fill this gap. ADASS’s Autumn survey for 2020[32] reported an 11% increase in the proportion of individuals presenting with need to local authorities as a result of carer breakdown, sickness and unavailability between June and October/November 2020. Following a uniquely debilitating year for carers of those affected by a mental illness, investment in specialist carers support and wellbeing services is vital to protect carers’ own health and stop the charge of carer burnout.

             

 

 

For more information about this response, please contact Harvey Crawford, Policy Manager (Health and Social Care)

 

 

Sept 2021


[1] NHS England (2019) NHS Long Term Plan https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/

[2] GOV.UK – Mental health recovery plan backed by £500 million https://www.gov.uk/government/news/mental-health-recovery-plan-backed-by-500-million

[3] NHS England (2019) The community mental health framework 

[4] University College London: Fancourt et al - Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30482-X/fulltext

[5] Rethink Mental Illness (2020) COVID-19 briefings: Access to NHS mental health services for people living with severe mental illness - https://www.rethink.org/media/3793/access-to-mh-services-final-040220.pdf

[6] YouGov Lived Experience and Discrimination survey (commissioned by Time to Change – a campaign ran in partnership my Rethink Mental Illness and Mind) – February 2021

[7] Centre for Mental Health (2020) COVID-19 and the nation’s mental health – forecasting needs and risks in the UK https://www.centreformentalhealth.org.uk/sites/default/files/publication/download/CentreforMentalHealth_COVID_MH_Forecasting3_Oct20_0.pdf

[8] NHS Digital (2021) Monthly Mental Health Services Statistics - https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-services-monthly-statistics

[9] NHS.uk – NHS England proposes new mental health access standards. https://www.england.nhs.uk/2021/07/nhs-england-proposes-new-mental-health-access-standards/

[10] Tees, Esk and Wear Valleys Foundation Trust, Centre for Mental Health, Mersey Care NHS Foundation Trust and York University https://www.hsj.co.uk/mental-health/mental-health-demand-could-rise-by-40pc-warns-nhse-research/7029085.article

[11] Strategy Unit (2020) Estimating the impacts of COVID-19 on mental health services in England. https://www.strategyunitwm.nhs.uk/sites/default/files/2020-11/Modelling%20covid-19%20%20MH%20services%20in%20England_20201109_v2.pdf

 

 

[12] NHS Digital (2021) Monthly Mental Health Services Statistics - https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-services-monthly-statistics

[13] NHS Providers (2020) Parliamentary briefing – Current NHS pressures. https://nhsproviders.org/resource-library/briefings/parliamentary-briefing-current-nhs-pressures

[14] Care Quality Commission – Report from inspection of St Thomas’s Hospital - https://www.cqc.org.uk/location/RJ122/reports

[15] Public Health England, Severe mental illness (SMI) and physical health inequalities briefing, https://www.gov.uk/government/publications/severe-mental-illness-smi-physical-health-inequalities/severe-mental-illness-and-physical-health-inequalities-briefing

[16] Public Health England, Severe Mental Illness – Excess under 75 mortality rate in adults with severe mental illness (SMI), https://fingertips.phe.org.uk/profile-group/mental-health/profile/severe-mental-illness/data#page/6/gid/8000039/pat/6/par/E12000007/ati/102/are/E09000002/iid/93582/age/181/sex/4/cid/4/page-options/ovw-do-0_car-do-0_ine-vo-0_ine-yo-3:2015:-1:-1_ine-ct-39_ine-pt-1_eng-vo-0_eng-do-0

[17] Rethink Mental Illness, COVID-19 briefings – the impact of COVID-19 lockdown measures on the physical health of people living with severe mental illness, https://www.rethink.org/media/3813/physical-health-during-covid-19-outbreak.pdf

[18] NHS England, Statistics – Physical Health Checks for people with severe mental illness, https://www.england.nhs.uk/statistics/statistical-work-areas/serious-mental-illness-smi/

[19] DHSC (2020) Staying mentally well: winter plan 2020 to 2021. https://www.gov.uk/government/publications/staying-mentally-well-winter-plan-2020-to-2021.

[20] DHSC and Cabinet Office (2021) COVID-19 mental health and wellbeing recovery action plan. https://www.gov.uk/government/publications/covid-19-mental-health-and-wellbeing-recovery-action-plan#:~:text=The%20COVID%2D19%20mental%20health,to%20recover%20and%20live%20well

[21] Rethink.org – Somerset Open Mental Health - https://www.rethink.org/aboutus/what-we-do/somerset-open-mental-health/

[22] Positive Practice - Cambridgeshire & Peterborough Mental Health Crisis First Response Service & Sanctuaries - http://positivepracticemhdirectory.org/adults/cambridgeshire-peterborough-mental-health-crisis-first-response-service-frs-sanctuaries/

[23] GOV.UK (2021) Record £36 billion investment to reform NHS and social care. https://www.gov.uk/government/news/record-36-billion-investment-to-reform-nhs-and-social-care

[24] DHSC (2021) Working together to improve health and social care for all – white paper setting out legislative proposals for a Health and Care Bill. https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all

[25] The Commission to review the provision of acute inpatient psychiatric care for adults, Old problems, new solutions: improving psychiatric care for adults in England, https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/policy/policy-old-problems-new-solutions-caapc-report-england.pdf?sfvrsn=7563102e_2

[26] NHS Digital, Mental Health Services monthly statistics, https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-services-monthly-statistics

[27] Based on national level costs of mental health inpatient treatment, the actual costs of providing our services, and the referral information for the people who use them.

[28] In Sight and In Mind, Rethink Mental Illness and RCPsych (2020) https://www.rethink.org/media/3571/insightandinmind_rehabreport_rethinkmentalillness_rcpsych_february-2020.pdf

[29] NatCen (2020) Finances and mental health during the COVID-19 pandemic. https://www.natcen.ac.uk/media/2050425/Finances-and-mental-health-during-the-COVID-19-pandemic.pdf

[30] Carers UK (2020) Caring behind closed doors: six months on the continued impact of the coronavirus pandemic on unpaid carers https://www.carersuk.org/images/News_and_campaigns/Caring_Behind_Closed_Doors_Oct20.pdf

[31] Rethink Mental Illness (2021) Carers Survey report

[32] ADASS (2020) Autumn survey 2020. https://www.adass.org.uk/media/8305/adass-autumn-survey-report-2020_final-website.pdf