Written Evidence submitted by Professor Mark Shucksmith OBE (Newcastle University)*, Polly Chapman (Impact Hub Inverness) and Dr Jayne Glass and Dr Jane Atterton (Scotland’s Rural College, SRUC) (MH0014)
We are very pleased to submit evidence to the Committee’s Inquiry into mental health service provision in rural areas. For the last two years we have been conducting research into social exclusion in rural Britain, the Rural Lives project, with funding from the Standard Life Foundation and Research Councils UK (RCUK). During this research, among many other things, we heard evidence relating to the experiences of those with mental health issues and we now summarise some of these insights for the EFRA Committee.
The Rural Lives research was focused on three rural case study locations: the Isle of Harris and East Perthshire in Scotland, and the North Tyne Valley, Northumberland in England. The evidence-gathering work included desk-based analysis of a variety of secondary data relating to the case studies, and in-depth interviews and focus groups with ‘gatekeeper’ individuals and organisations in the case study locations and with those experiencing financial hardship and exclusion.
Summary of key points
Mental ill health and access to welfare entitlements in rural areas
Across the three case studies, interviewees told us about the generic challenges faced by welfare claimants. Many of these are not unique to rural residents: the complexity of the online system and the flaws in its design; payment delays; unpleasant experiences at medical assessment centres, and so on.
“It’s blindingly obvious, don’t mind me saying so, that quite a lot of the people who come have got mental health issues who, chasing them to go for interviews or if you don’t go to it… you get sanctioned… I went to the DWP Job Centre Plus to speak to them about it and that experience has sort of taught me a lot. The most welcoming person, the most friendly person, was the sort of security guard that they had on the door, there to keep ne’er-do-wells out. I mean, I was absolutely appalled by the attitude that was there.” (Gatekeeper, Perthshire)
“My [latest] assessment was just after Christmas, January, yes. But during the run up to that, it wasn't stressful at first but then as it got closer and closer, it got really, really bad, having to fill out the form with all the stuff. I was panicking. It was just horrendous. A lot of places are too busy… so there is nobody that helps you which is ironic because if you're ill, I don't know how you're supposed to fill in all the forms. It's just crazy because you would think if you're ill, it should be easier for you to get, not more difficult.” (Interviewee, Perthshire)
“I just know that my PIP is due to be reviewed round about now, so I just keep expecting a letter, which is horrible.” (Interviewee, Perthshire)
Some issues are compounded for rural claimants, such as the inability of the welfare system to cope with irregular and volatile earnings, and the centralisation and digitalisation of welfare systems with concomitant difficulties of accessing face to face support and advice. Digitalisation by default is a particular challenge facing people with mental ill health in rural areas.
The Rural Lives study found that rural claimants are also more likely to be disadvantaged by the centralisation and digitalisation of the benefits system if they lack access or can’t afford access to broadband, broadband is of poor quality, they lack digital skills or because of literacy or mental health challenges. For such groups, the very obstacles or disabilities which prevent them working with the predominantly online and otherwise centralised system may also form barriers to their receiving state support, compounding their financial hardship and vulnerability.
“Oh, that’s just the filling out of the form that’s the hard part; and the questions sound like they are trying to trick you. Depending on what the question is. It’s like can you make a meal? It’s like well yes, but sometimes I fall asleep when I am in the middle of cooking, but it doesn’t kind of … it just asks the question can you cook a meal? It’s just a lot of the questions they just give simple answers to, but it’s not always a simple answer. Like the examples they give are quite simple… not when it comes to mental… How it comes across is that they are trying to trick you into answering yes to the questions really the answer is, if you think about it the answer is no you can’t, just from the examples that are given.” (Interviewee, Perthshire)
“At the moment I’m supporting two women who, in the last two weeks, one was made redundant and the other one has run out of money […]. So I’ve been supporting them getting onto Universal Credit, but in order to do that, neither of them have got internet at home […], I’ve had to meet one of them on a park bench, we had a really bad time of trying to get on to the gov.uk Universal Credit website where you can sign on. So, neither of those two women would have got signed on without that and they’re both absolutely bankrupt, they’re both penniless.” (Gatekeeper, North Tyne Valley)
The Citizens Advice Bureau (CAB) and other organisations offering advice are also generally working hard to link up to one another, referring people to the most suitable services as required. However, there are still concerns about vulnerable people with literacy problems and/or poor mental health who are no longer able to access face-to-face support via designated outreach visits or drop-in services that have declined in all the study areas, and closed completely during the Covid-19 pandemic and lockdowns. These individuals require considerable face to face support to complete the forms and to maintain their online journal or they may lose benefits and face sanctions (with knock on physical and mental health impacts). This support is even more necessary when appealing against adverse decisions, with advocacy and help from voluntary and community sector organisations often particularly important. In all the study areas, for example, the CAB had successfully supported the appeal process for Universal Credit claimants, and CAB energy advisors had also supported people to challenge incorrect/inappropriate household energy bills and charges.
A final issue mentioned several times in all the case studies is the benefit system’s treatment of claimants with a long-term physical or mental illness or disability, several of whom we spoke to. Frustrations were expressed about the generic issue of needlessly frequent reassessments and disregard of evidence supplied by GPs and consultants. A specific rural dimension to these issues is the distance that claimants are required to travel to attend assessment appointments. In all three case studies we heard about the challenges this brings for rural residents. In the Western Isles, there is no assessment facility for those required to undergo a Work Capability Assessment, with those in Harris experiencing a long delay (often up to a year) before an Atos officer visits the islands, unless they can attend an assessment in Inverness or the Isle of Skye. Even in rural Northumberland, claimants in the North Tyne Valley must travel between 30 and 55 miles each way to Newcastle for assessments, often with public transport unavailable from much of the study area. In some instances, these challenges were cited by participants as reasons for delay in benefit receipt, leading to debt, or for lower uptake of benefits in rural areas. A close association between poor mental health and debt was also very apparent. Debts were referred to frequently in our interviews, either as a consequence of shortcomings of the welfare benefits system and/or as following from job loss or marital break-up.
“I think that it’s well recognised that debt and poor mental wellbeing go hand in hand. It doesn’t matter which one comes first, whether it’s the poor mental health which then causes the debt or the debt causes the poor mental health. As a national organisation, we would say that about a third of our clients attempt suicide or consider suicide before actually asking for help. I think locally we would say 90% of our clients are either clinically depressed or have some level of stress and anxiety caused by their debt.” (Focus Group, Perthshire)
Social Isolation facing Older People in Rural Areas was the subject of a report by the Commission for Rural Communities in 2012 and this may still be useful to the Committee. It identified the roles of social care, services, transport and housing in relation to social isolation in rural areas.
Our Rural Lives research identified mobile phone and broadband coverage as further critical issues for rural populations. Limited coverage of both broadband and mobile phone signal adds to social isolation and there is also an issue with access to devices. Although access to IT facilities has improved in recent years, connectivity continues to present very serious issues for those without broadband, or who lack the digital skills or the necessary income to afford a broadband or mobile data contract. How far those organisations offering benefits advice and support can ‘reach’ into rural areas, either digitally or face-to-face, remains a challenge (see below).
Many rural communities have experienced marked social and demographic changes as rural homes are purchased by commuters and/or retirement migrants while young people leave to find further education, secure employment and affordable housing elsewhere. These changes bring both benefits and costs to rural communities, but one consequence is the fracturing of informal social support networks, exacerbating social isolation while simultaneously concealing hardship. In this context, the ability of voluntary and community organisations and the state to reach into rural areas in sensitive and appropriate ways is invaluable.
Work by SRUC and Support in Mind Scotland in 2017 further explores the importance of community support and connections for those experiencing mental ill health in rural areas.
Support for mental health in rural areas
The Rural Lives project revealed the range of specialist voluntary and community organisations that supported specific groups in relation to poor mental or physical health, housing and homelessness, ageing and social isolation, social care, fuel poverty, debt, and domestic violence, among many other challenges. The research team was impressed by the proactive ways in which many such organisations worked together to complement one another, to signpost people to the most relevant services, and to provide integrated and responsive advice, albeit sometimes with time-limited project funding.
Despite their invaluable contributions, voluntary and community organisations face severe funding pressures, making it harder for them to provide services across huge rural areas, and many worried that they will not survive in the medium term. In many cases outreach services have been curtailed or withdrawn for lack of resources, with attempts to provide access online or by phone instead. For many rural residents, access online or by phone is acceptable or even preferable to travelling for face-to-face support but, as noted above, for many others it is unhelpful or unfeasible, notably for people who lack literacy or digital skills or experience mental ill health and require face to face assistance. A plurality of means of access to help and support is important, not only because some people do not have digital access or skills, but also because some vulnerable people may require face to face support for reasons of literacy or mental health.
In Rural Lives we heard evidence that people with mental health challenges in rural areas often had difficulty in finding appropriate help. Often, those who found appropriate help had only found it through circuitous routes and happenstance. Even when individuals found a source of support, they found it frustrating and difficult if they spoke to a different person each time, sometimes without knowledge of the area and of the rural context, and perhaps passing them on to other departments: it was much preferred if a personal connection could be established and trust built up. Indeed, for people suffering with mental health challenges, a personal connection is vital.
“I wouldn’t have talked or spoken to you six years ago… I’ve been under the mental health team for the last six years, but I think coming here [Wisecraft[i]] and going to the walled garden has probably, well, has made the biggest difference … I go to another group on a Tuesday as well, that has made a difference too, but it’s been … it’s not been the NHS that’s made much of a difference … I just think this fills a gap that is missing in the NHS because there’s only so much they can do.” (Interviewee, Perthshire)
“I'm just exhausted all the time. I just want to sleep all the time. [Wisecraft helps] big time. I have a lot of paranoia. Coming here and speaking with everybody, you learn how things actually are and what you think they are. That helps a lot. It helps take away the paranoia for a short time and keeps you grounded. It's quite good, yes. In that way it's really, really good.” (Interviewee, Perthshire)
“Yes, [she] is really good because I had the paperwork for the fitness to work, or whatever the form is that you fill in with all the questions, and I did the basics of it but she helped me write out all the like information and what to put in it, because you read it and you panic…, it just makes you panic when you get this big form to fill in.” (Interviewee, Perthshire)
We came across several examples of voluntary and community organisations providing innovative, creative and caring responses to these challenges, despite funding constraints.
Further information on the Rural Lives project and all of the issues raised in this submission can be found via the project website. There is an executive summary and full report available to download, and a report focusing specifically on the evidence we gathered relating to the impact of the covid-19 pandemic and lockdowns on rural financial hardship.
[i] Wisecraft is part of the Perth and Kinross Association of Voluntary Service Ltd (PKAVS) Mental Health and Wellbeing Hub, based in Blairgowrie. It provides a safe environment for adults recovering from mental illness to rebuild their lives. It offers meaningful work-related experience, stimulates creativity through arts and crafts and builds confidence and self-esteem, as well as offering help and support. See https://www.pkavs.org.uk/Wisecraft.