Royal College Mental Health Expert Advisory Group response to the HSCC inquiry into mental health inequalities
Background
The Royal College Mental Health Expert Advisory Group (RCMHEAG) brings together partners from across health and social care services and acts as a source of independent and impartial, evidenced-based expert advice for policy and decision makers.
The group also aims to ensure a sharper focus and understanding on the current and necessary support for the people we collectively represent in social care and in primary, community, and secondary care mental health services.
The advisory group has established common work areas of Covid Recovery (including workforce wellbeing), the Mental Health Workforce Plan, and Community Mental Health Services as initial priorities. These priority areas intend to offer scrutiny and guidance to compliment areas of national focus.
However, this is not exhaustive, and the advisory group will be keen to develop and receive further areas of interest.
The current, full membership is made up of:
· Royal College of Psychiatrists Wales
· Royal College of Nursing Wales
· Royal College of Speech and Language Therapists
· Royal College of Occupational Therapists
· Royal College of General Practitioners Wales
· Royal College of Paediatrics and Child Health
· Royal College of Physicians Wales
· Royal College of Surgeons England
· Royal College of Surgeons Edinburgh
· The Royal Pharmaceutical Society
· Chartered Society of Physiotherapy
· British Psychological Society
Additionally, the Group works closely with other forums such as the Academy of Medical Royal Colleges on areas that can sometimes sit outside of typical mental health service discussion, but span across health and social care.
Each of the group's membership will have individual priorities and we would wish to draw the Committee’s attention to these responses.
For further information please contact: Ollie John, RCPsych in Wales Manager:
Introduction
The Royal College Mental Health Expert Advisory Group welcomes this inquiry into mental health inequalities and is encouraged by this focus from the Health and Social Care Committee.
Mental health inequalities are the result of a myriad of factors and meaningful progress will require coherent efforts across all sectors. There are a number of opportunities to address mental health inequalities, including through embedding measures around this into the next iteration of the long-term strategy for mental health and through Health Education and Improvement Wales (HEIW) and Social Care Wales’ Mental Health Workforce Strategy.
We also call on the Welsh government to take cross-government action to tackle mental health inequalities by pulling together a delivery plan that outlines the action being taken across all government departments, how success will be measured and evaluated, and how individual organisations should collaborate across Wales to reduce health inequalities and tackle the cost-of-living crisis. Our response also highlights a number of specific recommendations at the end of the document.
Which groups of people are disproportionately affected by poor mental health in Wales? What factors contribute to worse mental health within these groups?
Covid has driven an increase in poor mental health.[1] This includes exacerbations of existing inequalities and health conditions and many new cases due to restrictions to lifestyle, loss of work and role, typical working environment and colleague support, loss of usual social support, and social isolation.
However, we know that there are groups of people who are disproportionately affected by poor mental health in Wales. Below we will give further detail on this and will highlight the factors that contribute to worse mental health within these groups.
Children and young people
Child health outcomes are the product of complex, inter-connected social, economic, personal and political factors. An individual child’s health is inevitably influenced by the world and environment around them, not only by the quality of care they receive from the health system, but also by the services they are able to access and by their family’s lifestyle.
Children are experiencing a high level of mental ill health. Research from Cardiff University found that 1 in 5 children were experiencing poor mental health prior to the COVID-19 pandemic.[2] The research further identified poor mental health was higher if:
· The child was a girl, with a significant gender difference by year 10,
· If the child was from a less affluent family,
· If the child did not identify as either a boy or a girl.[3]
A survey by Mind Cymru found that 75% of
young people said their mental health had worsened in the early
months of the pandemic. The survey also showed that a third of
young people who tried to access mental health support were unable
to do so.[4]
Certain groups of young people may be particularly vulnerable to poorer outcomes and require targeted support to ensure they have a healthy and happy childhood. Looked after children, children on the child protection register/ those who are known to social services and children with long term health conditions such as diabetes and neurodevelopmental conditions, experience higher levels of mental health issues but often have no additional resource to support them.[5]
Children and young people with long term conditions are more likely to develop mental health problems and may have poorer education outcomes. Young people with long term conditions should be empowered with self-management tools to control their health condition as they become adults. This is particularly important for young people as they navigate the transition from child to adult health services.
The RCPsych Wales Children and Adolescents faculty found that children and young people with learning disabilities as well as Autism Spectrum Disorders (ASD) were disproportionately affected by the pandemic and the disruption to home life and schooling, which negatively impacted their routine and activities of daily living. A predictable routine is central to the stability of this cohort of children, and as such the pandemic, with all the associated disruptions has been a source of increased anxiety. There’s anecdotal evidence that this has presented in the clinic in the form of increased challenging behaviour (physical aggression towards their families, carers and environment and self-injurious behaviour) with a disruptive impact on the wider family environment.
Poverty
Mental health conditions interact with and include biological, psychological, environmental, economic and social elements. The clearest evidence of this is the well-established overlap between those who experience mental health conditions and indicators of poverty e.g. poor housing, low income and poor educational attainment.[6] In Wales’ most deprived neighbourhoods, suicide rates are between two and three times higher compared to the most affluent.[7]
Gradients of social disadvantage also correlate to much poorer mental health outcomes in children and young people. Data consistently shows that poverty and inequality impact a child’s whole life, affecting their education, housing and social environment and in turn impacting their health outcomes. RCPHC’s State of Child Health indicators reveal a widening gap between the health of children from wealthy and deprived backgrounds.[8]
In order to reduce the prevalence of mental health issues, we need to address the social determinants. There is a significant amount of anecdotal evidence regarding work done by Allied Health Professionals (AHPs) to reduce health inequalities and influence the social determinants of health.[9] When considering how to re-shape and refocus activity to bring about change, planners and decision-makers need to consider what data would best inform them of service effectiveness and their positive impact.
Black, ethnic minority groups
It is now clear that experience of discrimination and inequality can increase the risk of developing mental illness. People who are subject to inequality go through life with higher levels of stress and mental distress, which places them at higher risk of attempted suicide and self-harm.
We know that people from ethnic minority groups are at increased risk of involuntary psychiatric detention:
· People of Black Caribbean and Black African heritage are all significantly more likely to be compulsorily admitted than White ethnic groups.
· Those from Black Caribbean backgrounds were also significantly more likely to be readmitted.
· South Asian and East Asian people are also significantly more likely to be compulsorily admitted than people from White British backgrounds.
· Migrants from all backgrounds are also significantly more likely to be compulsorily admitted.
· There is a growing body of research to suggest that those exposed to racism may be more likely to experience mental health problems such as psychosis and depression.
· Young African-Caribbean men are more likely to access mental healthcare in crisis and to be admitted via criminal justice routes.
· Adults from South Asia are least likely to be referred to specialist services, despite being frequent consulters of primary care. Research suggests this may be related to a lack of culturally appropriate services.
· Recovery rates following psychological therapies are higher among White British people compared to people of all other ethnicities.[10]
Much more needs to be done to shape the mental health services to meet the needs of a diverse population.
LGBTQ+ individuals
LGBTQ+ individuals have a higher risk of suicidality yet experience discrimination when accessing healthcare.[11] Among LGBTQ+ young people, 7 out of 10 girls and 6 out of 10 boys described having suicidal thoughts. They were around three times more likely than others to have made a suicide attempt at some point in their life.[12]
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%).[13]
There have been a number of instances where older people’s mental health has been neglected. The Ockenden report (2015), investigated patient safety in the older people mental health ward, Tawel Fan following significant concerns from families and staff. The report identified, among other things, that the ward had struggled to maintain appropriate staffing levels and subsequent patient safety.[14]
Children and adults with communication and speech and language difficulties
Research also highlights Children with a mental health disorder are five times more likely to have problems with speech and language (NHS Digital, 2018)3 and 81% of children with social, emotional and mental health needs have significant unidentified language deficits (Hollo et al, 2014).4 Adolescents and young adults with developmental language disorder (DLD) are more likely to experience anxiety and depression than their peers (Conti-Ramsden at al, 2008; Botting et al, 2016).
80% of adults with mental health disorders have impairment in language (Walsh et al, 2007) and over 60% have impairment in communication and discourse (Walsh et al, 2007). Likewise, over 30% of adults with mental health disorders have some impairment in swallowing (Walsh et al, 2007). There is a greater prevalence of dysphagia (swallowing difficulties) in acute and community mental health settings compared to the general population - 35% in an inpatient unit and 27% in those attending day hospital, which compares to 6% in the general population (Regan et al, 2006).
We also want to highlight the inequalities faced by people living with severe and enduring mental illnesses.
Severe mental illness (SMI): co-morbidities and life expectancy
Approximately 1 in 50 people in Wales has a severe mental illness such as schizophrenia or bipolar disorder.[15] The exact number of people experiencing severe and enduring mental illness is largely unknown as the Welsh Government do not gather this information centrally. What we do know is that there are 31,597 people registered as having a mental health illness on the GP Quality and Outcome Framework (QOF), although the breakdown is not provided.
Mental health problems can influence education, development, employment and physical health. 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.[16] It is estimated that for people with SMI, 2 in 3 deaths are from physical illnesses that can be prevented.[17] Major causes of death in people with SMI include chronic physical medical conditions such as cardiovascular disease, respiratory disease, diabetes and hypertension. 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 programmes. In addition, this patient group traditionally has poorly engaged with healthcare services, especially cancer screening programmes and health promotion such as smoking cessation advice. As a result, it’s crucial that routine physical health monitoring is available and accessible to people with SMI.
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?
The Covid pandemic has exacerbated challenges within mental health services, including staff shortages due to covid infection, isolation, staff illness and long covid. Staff stress, burnout, and early retirement have impacted workforce retention.
However, it was clear that even before the pandemic, barriers existed for a number of groups and individuals. As mentioned above, we know that reduced access exists for those in economically deprived communities, ethnic minority groups and LGBTQ+ groups. These groups of people still face discrimination and stigma, leading to a limited understanding of their needs.
Geography can also play a huge role in the inequity of access. 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. In many areas, services have been merged so that patients need to travel greater distances for appointments. For patients with mental health issues who are anxious or agoraphobic, needing to use unfamiliar services is an additional challenge. This could also act as a barrier to people who find it physically difficult to attend appointments and access local community resources.
The availability of support for lower-level mental health issues such as anxiety and depression via social prescribing can also vary, and in many areas this option has completely disappeared due to Covid. 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 seductive products) they are particularly well placed to identify early signs 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.
For those with severe and enduring mental illness, the greatest barrier to timely and appropriate mental health support is the lack of NHS inpatient beds and waiting times backlog for those in acute crisis; those who require longer term specialist adult mental health services, and for those needing specialist Child and Adolescent Mental Health Services (CAMHS). Mental health services, in particular specialist CAMHS, are experiencing significant difficulties regarding waiting times.[18]
Access needs to be open, appropriate, and fair to population groups who have been known to experience reduced access to, and satisfaction with, health and care services. The implementation of digital throughout the health service is a long-term objective of 'A Healthier Wales' and is an enabler to aspirations for us all to work more sustainably. Digital innovation can support in offering services in different ways that ensure increased service capacity and access, and better outcomes for patients in light of increased demand. However, it’s crucial that digital platforms and new technology are robustly evaluated to ensure no group is excluded and that everyone receives appropriate and timely care.
It’s crucial that people can directly access the right expertise when needed, but for this to be inclusive, services need to proactively identify local population groups that are not currently reflected on caseloads, then work with them to co-create access points and services that accommodate their requirements and preferences.
To what extent does Welsh Government policy recognise and address the mental health needs of these groups? Where are the policy gaps?
There will always be individuals who have complex mental health problems that require care and treatment from health professionals in inpatient facilities. Individuals with severe and enduring mental ill heath may be vulnerable due to nature of their illness, but their vulnerability will have increased due to the lack of strategic focus and investment in the workforce and mental health estate.
In recent years there have been efforts by the Welsh Government to address mental ill health. The budget for 2022/2023 provides an additional investment of £100 million for mental health services in Wales.[19] There has also been a significant effort around wellbeing and low-level mental health support, including the introduction of the Whole School Approach.[20] The Whole School Approach has highlighted the need to support the emotional and mental health of children and young people.
Investing in overall mental health support for the general population is welcomed as it will aid in preventing some mental health problems from deteriorating, but it will not prevent people with severe and enduring mental ill health from needing support.
This has also unintentionally led to an inequality within mental health services and support for those with severe and enduring mental illness. There needs to be a greater understanding that care must be personalised, and that general mental health support will not meet the needs of people who will require specialist intervention. People who have been subjected to physical/sexual and emotional abuse often experience complex post-traumatic stress disorders which exacerbate existing mental health problems, resulting in the need for evidence based, trauma informed care and treatment. There will also always be a need for inpatient mental health services and a workforce available to provide complex clinical care, including CAMHS and services for children and young people.
What further action is needed, by whom/where, to improve mental health and outcomes for the groups of people identified and reduce mental health inequalities in Wales?
We call on the Welsh government to take cross-government action to tackle mental health inequalities by pulling together a delivery plan that outlines the action being taken across all government departments, how success will be measured and evaluated, and how individual organisations should collaborate across Wales to reduce health inequalities and tackle the cost-of-living crisis.
Service design
· To improve services in order to reduce these inequalities it is important that services are co-designed with the people the services are intended to support
· Services should be both universal across all aspects of life, and targeted, so that they are shaped and placed according to the needs of local population groups
· Where possible, people should be able to access mental health services in their preferred language, including the Welsh language.
Severe and enduring mental illness
· The Welsh Government must invest in all secondary and specialist mental health services to reduce the stigma and inequalities experienced by people with severe and enduring mental illness
- The Welsh Government must review the pressures facing mental health services in Wales: this includes the interface with the Criminal Justice System, the increased use of the Mental Health Act (MHA), as well as inpatient services, out of area placements and the response to individuals in crisis
· It’s crucial that individuals living with SMI and learning disabilities receive routine physical assessments to identify and treat physical co-morbidities and prevent early death
· As recommended in the National Clinical Audit of Psychosis, Welsh Government should expand the Individual Placement and Support (IPS) programme to a national offer, supporting people with severe and enduring mental illness into employment.[21]
Children and young people
· There is a need for increased awareness of mental health across all those working with children and young people, in line with recommendations made in the Mind Over Matter report[22] and accepted in principle by the Welsh Government to improve knowledge of signposting and services and to make sure there is quicker access to mental health services for those who need it.[23]
· We need to bolster CAMHS, as well as community delivered care for children and young people, by ensuring there is investment in both the specialist and wider mental health workforce (including paediatricians, children’s nurses, health visitors, primary care and allied health professionals) and mental health estate, to ensure that services are integrated, responsive to need and meet recognised and agreed standards of service and care to children, young people and families.
· Ensure that the enablers are in place to ensure adequate integration across all services operating within the child and adolescent continuum of care to help realise the ‘whole-system’ approach ambitions. Improved integrations amongst these entities and institutions will lead to improved efficiency, utilisation of finite resources and improved health outcomes. This includes facilitating the systems and processes needed to improve co-working and communications.
· Place children and young people at the heart of decision making and service design initiatives to ensure optimal outcomes.
Workforce
· Services and workforces need to reflect and be shaped by the culture of the communities that they serve, with a shared understanding of the desired outcomes for the community and the service.
· To achieve this there needs to be urgent investment in the mental health workforce, to ensure an appropriate number of staff with an appropriate skill mix in a safe environment.
This group has identified the mental health workforce strategy as a priority at the outset of its establishment, and we will remain engaged as an independent collective voice and will scrutinise this ongoing work. We have a number of longstanding recommendations in this area:
· Call for the committee to scrutinise the mental health workforce plan to ensure it considers the immediate challenges as well as the long-term vision for the workforce
· Call for the committee to scrutinise the extent the plan will drive change and include a wide range of professions given recruitment and retention challenges in the traditional workforce
· Call for the committee to ensure specialist skills and training are valued across the MDT, and that a full specialist MDT is in place to support patients, this includes specialist mental health speech and language therapists and occupational therapists to aid recovery. All specialist MDTs should also include a specialist mental health pharmacist with responsibility for medicines optimisation and to support appropriate prescribing and deprescribing.
This response is endorsed by:
The British Psychological Society
Royal College of General Practitioners Wales
Royal College of Nursing Wales
Royal College of Occupational Therapists
Royal College of Paediatrics and Child Health
Royal College of Physicians Wales/ Cymru
Royal College of Psychiatrists Wales
Royal College of Speech and Language Therapists
The Royal Pharmaceutical Society