Written evidence submitted by Mind (DEL0165)

 

About Mind

  1. We're Mind, the mental health charity for England and Wales. We believe no one should have to face a mental health problem alone. We provide advice and support to empower anyone experiencing a mental health problem. We campaign to improve services, raise awareness and promote understanding.

Summary:

  1. Mind submitted initial evidence to the Committee’s inquiry based on early information and insight about the impact of Coronavirus on mental health services. This evidence builds on that submission and includes the latest findings from Mind’s research about the impact of Coronavirus on mental health. It also considers in more depth concerns around the provision of social care for people with mental health problems and the longer-term implications of the crisis.
  2. While we recognise the need to prioritise staff and resources to stop the spread of Coronavirus, it is vital that people with mental health problems can still access the support they need from health and care services. The Coronavirus pandemic is having a significant impact on our mental health and our research has also highlighted that people with existing mental health problems are struggling more than others. At a time when mental health is deteriorating, evidence also suggests that people with mental health problems are finding it difficult to access support from mental health services, which will potentially lead to them becoming more unwell and more likely to reach crisis point. To minimise the risk of this happening, we are calling on the UK Government to:
  1. The UK Government must also begin to plan for the longer term implications of Coronavirus and ensure that mental health services are equipped to deal with the additional demand that will be placed on them in the aftermath of the pandemic. Mental health services were already overstretched prior to this pandemic and as soon as we begin to pass the peak of this emergency, the UK Government must take urgent action to address workforce shortages, upgrade the mental health estate, develop a sustainable plan for social care and support people with the wider factors that impact on their mental health, such as financial security and quality of housing. Therefore we are calling on the UK Government to:

 

Detailed response:

How to achieve an appropriate balance between coronavirus and ‘ordinary’ health and care demand  

  1. The need to stop the spread of the coronavirus is clear – as is the scale of the challenge facing the NHS to treat the many thousands of people ill with Covid-19.  Many of these people needing care may also have mental health problems and we applaud the efforts of NHS England (NHSE) staff to treat and care for people fighting this disease.
  2. While we recognise the need to prioritise staff and resources to tackle Coronavirus, it is vital that people with mental health problems are still able to seek support for their mental health. In the immediate response to Covid-19 NHSE understandably entered crisis-response mode, and we have heard evidence that this resulted in vital mental health services being scaled back and people being unable to get support. For example, the Association of Mental Health Providers report examples of people not being able to access their care coordinators and people turned away from A&E when in crisis with nowhere else to go.[1] If people are unable to access the support they need, this is likely to lead to people becoming more unwell and more likely to reach crisis point. Further details are provided on this below.
  3. It is also important to ensure that some actions NHSE have taken as part of the immediate response to Covid-19 do not become the new normal, as they risk lowering the standard of care for those of us with mental health problems. For example, some reporting measures have been relaxed to accommodate the immediate pressures services are under, including the collection of certain data. While this temporary move may be justified, data is vital for effective decision-making and the overall accountability of mental health services and these processes should be resumed as soon as possible.
  4. There are likely to be other changes in service delivery too, including limits on the amount of engagement and consultation with people who use services. For example, where services have transitioned from face-to-face support to digital platforms, it is important that people receiving support are consulted as to whether receiving support in this way is appropriate or possible for them.
  5. We are urging the UK Government and NHSE to take steps to ensure that mental health services can continue to be delivered as far as possible and return to normal standards of service delivery as soon as practical. A key part of this relies on support for the mental health workforce to ensure the continued availability of mental health staff. Although some of the workforce, particularly junior doctors, have been moved to other parts of the NHS, for those who remain in mental health services it is vital that they have access to Personal Protective Equipment to enable them to continue to do their jobs. The UK Government should also ensure that sufficient testing is available to prevent mental health staff from isolating unnecessarily.
  6. People with mental health problems, may also have trouble accessing care and support from local authorities due to the changes to the Care Act in England, under the Coronavirus Act. Emergency powers, which were switched on immediately, mean that local authorities are only required to meet their duties to provide social care if there is a risk of breaching someone’s rights under the European Convention of Human Rights (known as social care easement). It is particularly worrying that the powers were introduced with minimal scrutiny, and the speed with which the powers were turned on is further evidence of the fragility of the social care system. We understand the intention is for local authorities to maintain a full service as far as possible, however, considering the pre-existing strain on social care teams, we are deeply concerned that many local authorities will resort to operating under social care easement. Social care can play a vital role in enabling people with mental health problems to stay well and live a full life, but people often find it difficult to get the care and support they need. We recognise that coronavirus presents real challenges to local authorities, however, we urge the UK Government to find ways to support local authorities to deliver on their duties - not effectively suspend duties indefinitely.
  7. We are also seeking greater assurance, transparency and accountability around social care easement. The UK Government has issued guidance to local authorities on social care easement, which includes some safeguards. However, while local authorities must have regard to the guidance, they are not legally obliged to follow it and we urge the UK Government to issue the necessary direction requiring local authorities to follow this guidance. We also recommend that the UK Government amends the process by which local authorities ‘switch on’ easement, so they request permission from DHSC to do so (rather than notify the DHSC, as is currently set out in guidance). Furthermore, we request clarification from the UK Government on how the implementation of these duties will be monitored to ensure that discrimination of people with mental health problems does not take place. Understanding the impact of such measures will be vital for when the emergency powers come under review.
  8. In practice, local authorities are expected to prioritise who they provide services to when operating under social care easement, including balancing needs arising from coronavirus and ‘ordinary’ demand. At present, this is down to local authorities' discretion, although guidance suggests they should prioritise those with the 'most pressing needs' or 'at highest risk'. When local authorities prioritise the provision of services, they must take into account those with ongoing care needs, including mental health needs.

Meeting the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak

  1. As highlighted above, it is likely that many people with mental health problems are not receiving the support that they would otherwise have received. In response to Mind’s survey, a third of adult respondents said that they had experienced difficulty accessing mental health support because their appointment was cancelled, or they had difficulty contacting their GP or Community Mental Health Team, or they felt uncomfortable or unable to do a phone or video call.[2] Difficulty in accessing this support, particularly support in the community, is likely to result in people becoming more unwell and more likely to reach crisis point and a third of adult respondents to our survey said difficulty getting mental health support has made their mental health worse recently.[3]

“I was attending an Eating Disorder Clinic as a day patient and now that has had to close due to the virus. Whilst I understand this was totally necessary it's been really difficult to transition from intensive support to essentially no support at all.” Mind survey respondent

 

“Not being able to access the relevant physical and mental health services has left me distraught and depressed as there is no way for me to treat my symptoms that are plaguing me daily.” Mind survey respondent

 

  1. Digital alternatives to face-to-face support are enabling some people to continue to access vital support at this time. However not everyone will have access to the technology or have the right skills to enable them to receive support via digital channels. We know that people with mental health problems, along with disabled people more widely, are disproportionately likely to be digitally excluded and according to data from the ONS, 22% of disabled people have never used the internet compared to 9% of the population as a whole.[4] Others may also not feel comfortable talking about their mental health online or may not be in an environment where they are safe to talk about their mental health.

Therapy has been moved to digital platforms which I am finding incredibly difficult to use and it heightens my anxiety as it is sensory overload. Mind survey respondent

 

Our daughter normally has private therapy every two weeks but doesn't feel comfortable talking to her therapist online so hasn't had it since lockdown” Mind survey respondent

 

  1. Worryingly, evidence suggests a number of mental health services have seen a significant drop in referrals at this time. The Health Service Journal reported a significant decrease in referrals to both Child and Adolescent Mental Health Services (CAMHS) and to Improving Access to Psychological Therapies (IAPT).[5] It is not yet known the full causes for this but it may be due to people being unaware that mental health services are available or feeling unwilling to approach the NHS at this time. Mind’s survey found that of the people who have not sought support for their mental health, 40% did not do so because they did not think their issues were important enough.[6]

I don’t feel like burdening services at the moment, I know not a lot can be done and I find telephone communication so hard. Mind survey respondent

 

I’m worried that I shouldn’t make a GP appointment when I normally would have done because my mental health is less important these days somehow. Mind survey respondent

 

  1. It is vital that the UK Government and NHSE continue to communicate the importance of people looking after their mental health at this time and encourage people to seek support if necessary. In particular, we are pleased to see Public Health England publishing guidance and raising awareness through the Every Mind Matters campaign and we urge the UK Government to continue to invest in this, now and in the aftermath of the crisis. It is also important that people with mental health problems continue to feel able and confident to seek support through their GPs, who are often the point of referral to other services.
  2. Even before the coronavirus pandemic, our social care system was already unsustainable and precariously fragile. It was faced with increasing demand and undermined by years of underfunding. Some local authorities and social care providers already faced a backlog of people needing community care and Coronavirus and the emergency social care easement measures risk exacerbating this situation. It is likely that people with the most severe mental health problems – who are least likely to have support from friends, family and their local community – could be particularly affected.[7] The UK Government must plan for how they will support local authorities to resume their full social care duties and deal with the back-log of cases arising due to the Coronavirus pandemic.

Meeting extra demand for mental health services as a result of the societal and economic impacts of lockdown

  1. As a result of the Coronavirus pandemic, we anticipate an increased number of people will experience poor mental health and will need access to mental health support. Just under two thirds of adults who responded to Mind’s survey say their mental health has got worse during lockdown and over one-third of respondents describe their mental health as currently poor or very poor.[8] We are particularly worried about the mental health impacts on those who suffer bereavements, those working on the frontline of health and care services, and those facing financial insecurity as a result of Covid-19.
  2. Mental health services were already struggling to meet existing demand and there are critical shortages within the mental health workforce. A survey of mental health staff by the BMA, published in January, highlighted that four in ten found their workload “unmanageable” or “mostly unmanageable” and over 50% said they were too busy to provide the care they would have liked to on their last shift.[9] These pressures will have been exacerbated during the Coronavirus pandemic and there may be long term implications for the mental health workforce, as junior doctors moved to other parts of the NHS may now be less likely to choose mental health as a career.
  3. To ensure mental health services can deal with the long-term implications of this pandemic, the UK Government must create a sustainable mental health workforce and we would urge the UK Government to publish the NHS People Plan as soon as possible. The UK Government should also be taking steps to support the mental health of the NHSE workforce as a whole, including the mental health workforce, to support them to deal with the additional stresses placed on them due to Covid-19. Polling by YouGov highlights that half of healthcare workers say their mental health had deteriorated since the Covid-19 crisis began and this may increase as the pandemic continues.[10]
  4. As part of workforce planning, NHSE should also be considering what additional skills and training may be needed to support mental health workforce to respond to additional demand. In particular, it is vital that the mental health workforce has the skills and training to be able to take a trauma informed approach to the delivery of services.
  5. Covid-19 has drawn further attention to the need for investment in the mental health estate, with reports of Trusts struggling to isolate patients with Covid-19 because of inappropriate facilities. The Mental Health Act Review identified the need for significant multi-year capital investment in what Prof Sir Simon Wessely described as some of the “worst estate the NHS has” to ensure that mental health buildings are safe, conducive to recovery and do not put people at risk of suicide.[11] There is also an urgent need to end the use of mixed sex and dormitory wards which the CQC has found puts people at risk of sexual assault. We were disappointed that the Government announcement in October of £2.7bn for six hospitals and seed funding for another 34 did not include any funding for mental health hospitals. Urgent investment is required as a matter of parity, particularly given the anticipated increased pressures on services.
  6. We also urge the UK Government to publish their long awaited plan for social care and set out long-term, sustainable solutions for the funding and provision of social care. This must address the needs of working age disabled people, as well as older adults, including those of us with mental health problems. A sustainable social care system is vital for managing the demand on health services and as part of their plan the UK Government must set out how they intend to work with local authorities to tackle high levels of vacancy rates in the adult social care workforce.
  7. Finally, to try to reduce the pressure on services, the UK Government should urgently look at how it can use policy levers across government to support people to have good mental health. Our mental health is affected by a huge range of things – the quality and security of our homes, employment status and money worries, and experiences at school. All these aspects of our lives have been adversely affected by the coronavirus outbreak and the UK Government needs ensure they are considering all these factors as part of the UK’s coronavirus recovery plan. This should include investment in public mental health interventions delivered in local communities, reforms to the benefit system to ensure it is fit for purpose, improving people’s rights in the workplace, ensuring people can access safe and secure housing and working with schools to provide support for young people.

 

Meeting the needs of rapidly discharged hospital patients with a higher level of complexity

  1. Mental health units were already under pressure before the pandemic. We recognise the potential health risks around Coronavirus for those left in hospital, however we are concerned that the drive to discharge all patients where safe and feasible could have left people at risk in the community.
  2. In a survey Mind carried out in 2017 about people’s experiences of leaving hospital, over one third of people said they were discharged sooner than they should have been, two out of five said that staff did not plan for their ongoing care and support, and one in four did not receive any support.[12] The risk of suicide is increased in the 2-3 days immediately following discharge when people are particularly vulnerable and the impact of isolation under lockdown, or reliance on family to stay safe, is likely to further complicate this.
  3. We are concerned that the pressures of the pandemic for both individuals and services will create greater need among people discharged and greater difficulty in meeting these needs, especially given reduced capacity in community teams. This may be exacerbated by temporary changes to social care, under the Coronavirus Act, which will make it more difficult to access social care support. For some people, difficulty accessing social care assessments could lead to them being discharged with inadequate support.  For others – particularly those with more complex mental health needs who require higher levels of support in the community - difficulty accessing social care assessments and support may lead to them being forced to stay in hospital when they are ready to be discharged.
  4. The UK Government must ensure people with mental health problems can be safely discharged from hospital and that anyone who is discharged has access to health and social care support in the community to enable them to manage their lives and mental health.

 

Providing healthcare to vulnerable groups who are shielding

  1. Some people with mental health problems, particularly those with severe mental illness, are part of the shielding group. However, the use of ‘vulnerable’ has also caused confusion as there are many people with mental health problems who are not clinically ‘vulnerable’ to coronavirus, but are vulnerable in other ways and will be facing specific challenges during lockdown. For example, their mental health may lead to them facing challenges accessing food and medicines at this time.

I suffer from depression and anxiety anyway but going to get my prescription I find extremely stressful- trying to get GP on the phone, then queuing for the pharmacy and the last 2 times there have been issues with missing items or incorrect items. My anxiety is through the roof.Mind survey respondent

 

“I was unable to leave my home due to mental health problems before all this, as accepted by the governments home assessment, but now I am not recognised as "vulnerable" and expected to leave my home to get food for my children and I, leaving me distressed when I am unable to get deliveries!” Mind survey respondent

 

  1. We are concerned that so far people with mental health problems have often been overlooked in discussions about the national response. We were particularly disappointed that when the NHS Volunteer Responder scheme in England initially published the criteria for who could self-refer to the scheme, people with mental health problems were not included. We urge the UK Government to put in place a cross-government plan for supporting anyone who may be vulnerable at this time, including those in the shielding group, but also those who face additional barriers for other reasons, including due to their mental health.

Supporting mass testing and vaccination once they become available.

  1. Access to testing has been a critical factor in determining the continued availability of health and care services during the pandemic. It is vital that those working in mental health service are able to access testing as soon as possible if they, or those they come into contact with, with are experiencing symptoms of Coronavirus. This will minimise the impact on the pandemic on the already over-stretched mental health workforce and it is important that testing is available for people working in statutory services and voluntary and community services. It is particularly essential to ensure that staff in inpatient wards can access testing to ensure safe staffing levels.

How to ensure that positive changes that have taken place in health and social care as a result of the pandemic are not lost as services normalise

  1. The crisis has increased public awareness of the importance of looking after your mental health and of the connections between physical and mental health. The UK Government should continue to build on this and as highlighted above, we would encourage the Government to continue to invest in campaigns such as Every Mind Matters to highlight the importance of looking after your mental health.
  2. There have also been some innovations in the delivery of mental health services in response to the pandemic, including the move to making greater use of digital technology. Making greater use of technology has the potential to enhance the availability of mental health services, however as highlighted above it is vital that people are given a choice over whether this method is right for them. It has also been encouraging to see the rapid expansion of 24/7 urgent and emergency mental health support and mental health A&Es. This highlights what can be achieved when the UK Government and NHSE prioritise improving mental health support.
  3. The Coronavirus has also emphasised the vital role of voluntary and community organisations in supporting people to stay well in their communities. As highlighted by the Digital, Culture, Media and Sport Committee, the support of charities has been needed more than ever as the country responds to the challenge of Coronavirus and we have also seen people come together to support each other and their wider communities.[13] This support will continue to be crucial as the country looks to recover from this crisis and the UK Government must ensure that the voluntary and community sector is integrated into recovery plans and that the sector receives the support it needs to continue to deliver vital services.
  4. Finally, as highlighted above, this health pandemic has provided a critical reminder of how our mental health is affected by so many factors in our lives, including our physical health, our social connections, our financial security, our living situation, support through schools and in the workplace. As we move on from the crisis the UK Government must recognise the importance of these connections and prioritise developing a cross-government approach for mental health, to support the recovery from Coronavirus.

 

May 2020


[1] Association of Mental Health Providers, Covid-19 and the VCSE Mental Health Sector: Briefing. April 2020

[2] Mind survey of 13,595 adults in England and Wales, Results from 07.05.20

[3] Mind survey of 13,595 adults in England and Wales, Results from 07.05.20

[4]  https://www.goodthingsfoundation.org/sites/default/files/research-publications/ofcom_report_v4_links.pdf

[5] https://www.hsj.co.uk/coronavirus/major-drop-off-in-referrals-to-childrens-mental-health-services/7027373.article

[6] Mind survey of 13,595 adults in England and Wales, Results from 07.05.20

[7] Crowley J, Lubian K, Smith N, McManus S. (2019) Patterning of mental health needs and support in England: a latent class analysis of the Adult Psychiatric Morbidity Survey 2014. London: Mind TO BE PUBLISHED LATER IN 2020.

[8] Mind survey of 13,595 adults in England and Wales, Results from 07.05.20

[9] BMA Mental Health Workforce Report, January 2020

[10] IPPR Media Release, 23 April 2020

[11] https://www.gov.uk/government/publications/modernising-the-mental-health-act-final-report-from-the-independent-review

[12] https://www.mind.org.uk/media/18839049/leaving-hospital-minds-good-practice-briefing.pdf

[13] https://committees.parliament.uk/committee/378/digital-culture-media-and-sport-committee/news/146310/governments-emergency-funding-too-little-too-late-to-protect-charities-from-covid19-crisis/