Written Evidence submitted by Dr Kreseda Smith (MH0005)

Introduction

1. I am pleased to provide this response to the call for evidence exploring rural mental health. My name is Dr Kreseda Smith, and I am a Rural Criminologist and Lecturer at Harper Adams University. I have recently undertaken world first research examining the impact agricultural crime has on farmer mental health[1] [2]. I hope that I am able to provide some insights into the issues around this particular topic.

Question: What specific mental health challenges are faced by those living and working in rural communities?

2. It is often assumed that the mental health of those living and working in rural England is better than those living and working in towns and cities. Indeed, a review of the literature has concluded that incidences of psychosis and schizophrenia are lower in rural areas, and more ‘common mental disorders’ such as anxiety and depression have lower or similar levels to urban residents[3]. While mental health challenges in rural communities are likely to be similar in part to those in urban areas, they are exacerbated and enhanced by the additional contributing factors including social and geographic isolation, a lack of mental health services, poor access to primary care providers, and poor transport links. This is further added to by the very nature of rural communities, with people unwilling to seek help due to perceived stigma, lack of anonymity, and the persistence of the traditional rural masculinity (TRM) that heightens risk taking behaviour and reduces help seeking behaviour. Research in 2003 highlighted this issue, concluding that although rates of depression and depressive ideas were lower among farmers that the general population, their feelings of life not being worth living were much higher[4]. I would argue that this is still the case, and perhaps more of an issue with the added stressors that farmers, but also rural residents per se, have to contend with on a daily basis.

3. As noted in this call for evidence, research conducted by the Farm Safety Foundation found that 81% of farmers under 40 believe that mental health is the biggest hidden problem facing farmers today. While this is supported by a range of academic research looking at farmer stress conducted across the UK over the past four decades, the main issue remains the fact that rural residents and farmers in particular, are less likely to seek help for their mental health issues. This was noted in 2001 when the Scottish Executive concluded that stress, anxiety and depression were less likely to be considered as mental health issues needing treatment among farmers and crofters[5].

4. This ongoing reluctance, particularly within the farming community, to seek help for their mental health could be the main factor that leads to ongoing psychological problems, as well as physical health issues as a result of prolonged, unresolved, mental health issues. This is partly due to the persistence of the TRM as mentioned above, which dictates that farmers should be the strong, stoic, silent type that just ‘gets on with it’. And while is anecdotal evidence and press stories where farmers have broken their silence about their mental health, we are still very much reliant on the research that the Farm Safety Foundation and other organisations have conducted to understand how life is affecting our farming community. Although I have published on a narrow area of research recently, there is a distinct need for more academic research to underpin a strategic approach to addressing the issue of non-help seeking until crisis is reached.

Question: What is the current state of mental health and suicide prevention service provision for those working in agriculture and those living in rural areas more generally? Do they meet the specific needs of that community?

5. Rural Mental Health Matters[6] rightly note that services need to be close to the place of need, including mobile and outreach services. While true, I would argue that the approach to bring such services to rural areas would need to be carefully considered. As a result of TRM, low help-seeking behaviour, fear of stigma, and low levels of anonymity in close-knit communities, I wonder whether mobile services would be effective? They further argue that there is a need for parity in mental and physical health care services between urban and rural areas. Again, this is in my mind essential. However, according to the GMC[7], between 2009-2018 GPs in England dropped from 62 to 59.5 per 100,000 population. With about 90% of GPs being located in urban areas, there is an ongoing issue in recruiting and retaining rural GPs partly due to the change in lifestyle from urban living to rural living, but partly to the perception that a post as a rural GP does not offer much in the way of career progression, and indeed is often seen as an end of career role, despite attempts to make rural practice more attractive for younger GPs.

6. A range of American academic research addresses the issues of providing adequate and appropriate rural mental health services, but very little in England. However, some recent research seems to suggest the need for innovative ideas in order to overcome barriers to rural mental health care[8]. However, it is also noted that it is hard to generalise international research to the UK due to differences in psychiatric morbidity seen between urban and rural centres across countries[9]. Some research in England has suggested that factors affecting rural mental health provision will include cost, staff recruitment and retention, lack of specialisation opportunities, professional boundary issues, patient choice, and professional isolation[10]. In my opinion, these are substantial barriers to overcome to ensure parity in health care provision, whether physical or mental health. However, overcome them we must. My own research indicated that a satisfactory experience with a GP after being a victim of crime significantly reduced the likelihood of suicidal thoughts[11]

7. Despite the recognition of rural/farmer mental health being an issue in the National Suicide Prevention Strategy[12], funding for mental health services remains allocated in a similar fashion as policing resources – focused where hot spots exist. This generally means that most resources end up in urban locations. This leads to a situation where there is a perception that if services cannot be seen, they do not exist, and so people in rural areas tend to continue on stoically until they are in crisis. As a result, much of the great work being done currently around rural mental health is being undertaken by charities such as Farm Safety Foundation, YANA, RABI, Farming Community Network, and other rural stakeholders such as the NFU, Rural Services Network, and the CLA.

Question: What are the causes of the higher than average rate of suicide amongst those working in agriculture? Are there other linked professions, such as vets, that have similar issues? How effective are suicide prevention services offered to these groups?

8. It was noted in 1997 that farmers have the highest rate of suicide of any occupation in the UK in terms of absolute numbers, this mainly being due to depression and an easy access to means[13]. Despite this acknowledgement, farmers and agricultural workers remain a group at most risk of suicide according to the National Suicide Prevention Strategy[14].

9. Farmer stress has been noted in British academic research over the last four decades[15] [16] [17]. Various factors have been identified as impacting farmer mental health, including finance, weather, government bureaucracy, and family relationships. Despite these multiple stressors, farmers are used to dealing with such issues, and are able to continue with work and homelife in the main. This is because these historically recognised stressors form a farmers’ ontological security, where the farmer retains a sense of order and continuity based on their own daily experiences[18]. However, recent additional stressors, I believe, are leading farmers to overtop their own ontological security, as they are providing additional stress that these farmers are simply incapable of managing in addition to the other stressors. These additional stressors include Brexit, COVID-19, and from my own research, agricultural crime.

10. My research has shown that the list of significant stressors should be extended to include agricultural crime as yet another factor that is negatively impacting on farmer mental health. This research suggests that, in particular relation to crime, pig farmers are more likely to experience suicidal behaviour after victimisation, crimes of violence (injury or infield slaughter of livestock, as well as threats of personal violence) are significantly associated with suicidal thoughts and behaviour, and the detrimental effect crime had on interpersonal relationships and isolation significantly increased likelihood of suicidal thoughts and behaviour. This clearly shows that farmers are already at or beyond their ability to cope with existing stressors, and are reaching crisis point.

11. One particular aspect of the current Government approach to improving mental health, is the prescription of exercise in green spaces[19]. During the initial phases of the COVID-19 pandemic, people were recommended to spend their available free time in green spaces, including the English countryside to aid in their mental health. However, I would argue that such approaches as this are not useful for rural/farming communities, as they may perceive that very same countryside as part of the problem.

12. The recent RABI survey conducted in conjunction with University of Exeter found that a third of those in farming could be suffering from depression, but this varies across sector, with pig farming reporting highest levels, and cereals/general cropping reporting less. This seems to support my own research that the impact is not the same across all farming sectors, and that livestock farmers – pig farmers in particular – seem to be under substantial pressure. However, this does not detract from the issues other sectors of farming are facing, such as reduced labour, uncertainty following Brexit, as well as the other, more well-researched, stressors.

13. Other rural professions may also be under pressure with mental health issues, and these should be acknowledged: rural policing[20], and rural teachers[21] have been discussed in the academic literature. However, vets are probably those most closely involved with farming. While the RCVS reported that 90% of vets found their work stressful[22], other research has suggested that rural vets were more concerned with worktime management, with no significant difference between rural and non-rural practitioners in terms of burnout[23]. However, it must be considered that, as stressful as it is when a farmer faces losing their herd to bTB, it must be equally so for the vet who then has to complete the act.

Question: Is sufficient mental health support made available to rural communities following “shocks” such as flooding or mass animal culls?

14. These rural ‘shocks’ seem to be occurring on an increasing frequent basis. Whether it is a natural environmental shock such as flooding, or whether it is some other shock such as Foot & Mouth, or TB testing, these provide additional stress to rural residents and farming communities.

15. Mental health services are likely to be available in the short term for unanticipated shocks, such as flooding. However, I would argue that this might not necessarily be the case for shocks that might be experienced by the farming community on a regular basis. Situations such as herd culls after a positive bTB test, or crop failure are unlikely to result in the offer of mental health support, despite the devastating impact these situations have on the farmer. I would imagine that help would be offered by charities such as those mentioned above, although these will not necessarily be specifically in response to such shocks, rather through general awareness of these organisations. If treatment or help is sought, it is likely to require travel, and therefore time away from the farm, thus providing yet another reason to not seek help.

16. In addition to this, as noted in a Hansard debate addressing suicide in the farming community[24], rural mental health services are often not adequate for the specific situations and issues faced by rural communities as they are designed by people in urban areas who have no concept of the help needed by rural/farming communities.

Question: Does the Government’s recent investment in mental health services adequately provide for agricultural mental health?

Question: How joined up are key actors, such as Defra, DHSC, NHS England, Public Health England, and Local Government in their approach to improving quality of, and access to, mental health services in rural and agricultural communities?

17. The Government sporadically talk about rural proofing policy, despite the failure of the 2000 Rural White Paper specifically aimed at doing so. I would argue that the latest investment in mental health services fails to adequately provide for agricultural mental health, despite farmers and agricultural workers being identified as an at-risk group.

18. Despite calls in 2019 from the NFU for Government to provide more medical resources in rural communities to get the help they need[25], and further discussion in the aforementioned Hansard debate[26] where the then Minister for Agriculture, Fisheries and Food, Sir Robert Goodwill, stated that he would, in conjunction with other parts of Government, find and implement the best solutions to reverse rising farmer suicide, and provide help where and when it is most needed to save lives, rural mental health services seem no further forward.

19. The March 2021 announcement[27] of a £500million boost for a mental health recovery plan promised help for specifically targeted groups which have been most impacted, funding to level up mental health and wellbeing across the country, and additional funding to support suicide prevention. However, it is unclear from this statement, nor subsequent spending reviews how this funding will help rural/farming communities and the specific issues they face. Furthermore, it is not clear whether any of the additional funding for suicide prevention aimed at community and voluntary organisations would be channelled to those organisations supporting rural/farming communities.

20. Two Government documents released in 2021 are specific to this response; the COVID-19 Mental Health and Wellbeing Recovery Action Plan[28], and the National Suicide Prevention Strategy Progress Report[29]. Having reviewed these two documents, I wish to raise my specific issues relating to rural/farming communities and their equal and effective access to mental health services.

21. In the first document, there is a single paragraph of five lines within a 55-page document relating to rural communities; unfortunately, this paragraph provides only a vague statement to support the wellbeing of rural England in partnership with ACRE and its 38 Rural Community Councils to provide continuing support for a range of initiatives to address loneliness and isolation in rural areas. This does not seem to adequately appreciate the causes and contributing factors affecting rural mental health, or the huge impact it has on rural/farming communities. Neither does it consider the fact that those initiatives already in place do not seem to be effective in helping rural/farming communities. This whole paragraph could be seen as rural communities once again being treated like second-class citizens[30].

22. In relation to the second document, there is no mention of rural/farming/agriculture at all. Annex A discussed various aspects of the strategy. People who are disproportionately impacted by lockdown or restrictions are mentioned, but this seems to be very much from an urban point of view, discussing green social prescribing, and not considering the social/geographic isolation and other aspects impacting rural communities. The DCMS were listed as leading on this, but it is not clear what will be done, if anything, in rural locations. There is a focus on key workers, but no mention of farmers in the discussion. Most concerning, in my opinion, is the fact that despite this report having a section on actions aimed at Specific Occupational Groups, there is again no mention of farmers. This is despite the acknowledged issue with existing mental health issues and suicide in this sector, and the significant additional impact COVID-19 has had on the farming community.

23. It seems that, from these two strategic documents, that the key actors are, in the main, working in a joined-up way to address quality of, and access to, mental health services in general. This should be applauded as I am sure it is no mean feat. However, it is disappointing that neither of these documents make much, if any, mention of the quality of, and access to, mental health services for rural/farming communities despite being acknowledged as being particularly vulnerable to mental health issues and suicide. Moreover, it is not exactly clear how the announced funding will help improve quality and access to mental health services for rural communities, given that much of the detail seems to revolve around mental health services being embedded in primary care, which simply does not exist in many rural communities.

24. Despite the promise to ensure ‘everyone is able to access the support they need’, there is no consideration given, that I can establish, as to how this would work in rural/farming communities where primary care is scant, help-seeking behaviour is a major issue due to stigma, lack of anonymity, and the perpetual TRM. I maintain that, unless the issue of low help-seeking behaviour and the TRM can be addressed, the Gray Rhino of farmer mental health will remain, and will become ever larger over time. Furthermore, there does not seem to be any indication as to how, if rural residents were indeed to seek this help they are entitled to, they would actually attend any appointments, that are inevitably likely to be based in towns and cities where the facilities are? It is arguable that creating equal opportunity of access may not be as straight forward for rural communities due to the inherent issues of social and geographic isolation, even if the issues of fear of stigmatisation can be overcome.

25. To improve services for rural/farming communities, additional considerations need to be made, specifically a behavioural science approach to attitudes around talking about mental health, combine with ways of people being able to access services without it being obvious that this is what they are doing. Rural mental health service providers/Local Authorities also need to be aware that one size will not fit all, as is the case so often with rural community solutions.

January 2022