Royal College of GPs Cymru Wales response to the HSCC inquiry into mental health inequalities
Introduction
The Royal College of GPs Cymru Wales is pleased to give evidence to this inquiry from the Health and Social Care committee. Our members note that due to a wide range of factors, from economic circumstance to geography to identity, mental health inequalities are prevalent in Wales. Following COVID-19 these inequalities have been exacerbated by already over-laden waiting lists and staff shortages. We urge the Welsh Government to take the below responses in conjunction with our calls for a detailed workforce plan and for further support following the increase in GP workload.
Which groups of people are disproportionately affected by poor mental health in Wales? What factors contribute to worse mental health within these groups?
The following seven groups have been identified as being disproportionately affected by poor mental health. However, it is important that any strategy aimed at inclusion does not inadvertently lead to exclusion, there will be people who do not fit into the following categories, of those who can be invisible to the system such as someone living in poverty but in what is perceived as generally an affluent area. The categories provide an important steer but there must be flexibility.
1. Children and young people:
One in five children were experiencing poor mental health prior to COVID-19. [1]Poor mental health is more prevalent in girls, children from less affluent families or if the child did not identify as a boy or a girl.[2]
Children and young people with learning disabilities and autistic children were disproportionality affected by the pandemic due to the disruption of home life and schooling: consistency and a stable routine is vital to these young people. Children with long term conditions are more likely to develop mental health problems.
2. Those living in poverty
Those experiencing indicators of poverty are more likely to have poor mental health.[3] In Wales’s most deprived areas, suicide rates are between two and three times higher compared to the most affluent areas.[4]
This also applies to children and young people. RCPHC’s State of Child Health indicators reveal a widening gap between the health of children from wealthy and deprived backgrounds.[5]
3. Ethnic minority groups:
Those from ethnic minority groups are less likely to seek help for mental health issues. Of this segment, young African-Caribbean men are more likely to access mental healthcare in a crisis. Adults from South Asia are least likely to be referred to specialist services. Recovery rates following psychological therapies are higher among white British people compared to people of all other ethnicities.[6]
4. LBGTQ+ groups:
LGBTQ+ individuals are more likely to commit suicide and are also at risk of discrimination when accessing healthcare including for mental health. [7]
5. Older people:
The World Health Organisation (WHO) reported that approximately 20% of people aged 60 or over have a mental health illness. The two most common illnesses are depression (7%) and dementia (5%).[8]
6. Those who experience speech, language, and communication difficulties:
Research also highlights those children with a mental health disorder are five times more likely to have problems with speech and language (NHS Digital, 2018)3
7. Those with severe mental illness:
Approximately 1 in 50 people in Wales has a severe mental illness such as schizophrenia or bipolar disorder.[9]
People with SMI are at a greater risk of poor physical health and die on average 15 to 20 years earlier than the general population.[10]
Patients with mental health problems are at greater risk of developing these issues due to a generally higher prevalence of smoking, side effects of antipsychotic drugs, and lack of engagement with screening problems.
In addition, this patient group traditionally has poorly engaged with healthcare services, especially cancer screening programmes and health promotion such as smoking cessation advice. Geography can also play a huge role in the inequity of access for these patients.
Provision of specialist services in mental health, such as psychotherapy and EMDR treatment, assessments for PTSD, eating disorders, autism diagnostic and management services, ADHD, and CAMHS provision is often inequitable and may not be available in a patient’s local area and patients may be unable to travel sue to their mental health or another factor.
COVID-19 has affected the treatment of lower-level mental health conditions such as anxiety and depression.
For the groups identified, what are the barriers to accessing mental health services? How effectively can existing services meet their needs, and how could their experience of using mental health services be improved?
COVID-19 has presented a significant challenge throughout primary care and no less so the provision of care at this level for mental ill health. Staff shortages due to infection or long covid the resultant stress and fatigue on GPs and practice staff continues.
However, even prior to the pandemic certain groups felt they could not seek help for mental ill health either because services do not exist in their area (as mentioned above) or due to fear of discrimination, as in the case of those in ethnic minority or LGBTQ+ groups.
In many areas there is limited support for low level mental health issues. Patients may not seek help from their GP as they doubt the likelihood of an onward referral. Initiatives, such as social prescribing, vary from area to area, while in some areas these provisions no longer exist due to COVID-19. There is a need for greater availability of social prescribing options and information as it can benefit patients and take some pressure away from mental health services and primary care.
Increasing access for support for lower-level mental health issues can also be improved through greater use of community pharmacists. By monitoring requests for over-the-counter medicines (e.g. anti-anxiety or sedative products) they are particularly well placed to identify early sign of mental health problems. However, at present, there is no formal mechanism in place for community pharmacists to act on their observations. Formal systems should therefore be introduced to enable pharmacists to directly refer patients to appropriate third sector services or health professional colleagues.
To what extent does Welsh Government policy recognise and address the mental health needs of these groups? Where are the policy gaps?
Recently we have seen an increase in investment for mental health. The budget for 2022/2023 provides an additional investment of £100 million for mental health services in Wales.[11] The College welcomes the introduction of the Whole School Approach.[12] The Whole School Approach has highlighted the need to support the emotional and mental health of children and young people.
The College supports the introduction of these such initiatives to improve mental health however we would urge the Welsh Government to review the remaining inequalities for those already suffering with severe mental health concerns, to ensure care is personalised and inclusionary of those with specific needs as well as general mental health.
What further action is needed, by whom/where, to improve mental health and outcomes for the groups of people identified and reduce mental health?
The College urges the Welsh Government to implement the designing of services which are both universal and targeted. Consideration should be given to general mental health and well as specific initiatives aimed at the groups above as well as those with existing severe mental health concerns. These services as well as any accompanying communications should be available in Welsh as well as English.
We accept that the many of the recommendations in theMind Over Matter report,[13] the intention of which was to improve awareness of mental health services for children and young people,[14]may have been delayed due to COVID-19 however the College urges the Welsh Government to resume this programme now that all restrictions have been lifted to improve awareness of mental health services.[15]
Following the implementation, we would also ask the Welsh Government to improve links between all services for children and young people, which would lead to better communication between colleagues and greater efficiency.
As mentioned above and in previous publications by the College, urgent investment in the primary care workforce, including but not limited to GPs and social prescribers. Together with this investment training must also be given to all professionals working in primary care to better support people with mental health issues, including pharmacists.
To support all the above, further investment in the use of technology throughout primary care is crucial to ensure the increased service capacity and access that the above would entail.