RCPsych Wales response to the HSCC inquiry into mental health inequalities
About RCPsych Wales
The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and setting and raising standards of psychiatry in the United Kingdom.
The College aims to improve the outcomes of people with mental illness and intellectual disabilities, and the mental health of individuals, their families and communities.
In order to achieve this, the College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. Nationally and internationally, the College has a vital role in representing the expertise of the psychiatric profession to governments and other agencies.
RCPsych in Wales represents more than 600 Consultant and Trainee Psychiatrists working in Wales.
For further information please contact: Ollie John, RCPsych in Wales Manager
Introduction
We welcome the opportunity to respond to the committee’s consultation on mental health inequalities.
Mental health inequalities are complex and are the result of a myriad of factors, and we join a number of organisations in Wales in their call for coherent cross-sector and cross-government action to tackle them. This includes addressing the social determinants of mental health as well as the inequalities faced by individuals with severe and enduring mental illness.
There are also a number of strategic opportunities to address mental health inequalities, including through 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.
It is well evidenced that existing inequalities have been exacerbated by the pandemic and that Covid has driven an increase in poor mental health.[1] However, we know that there are groups of people who are disproportionately affected by poor mental health in Wales. Below we will highlight the factors that contribute to worse mental health within these groups and will set out a number of recommendations.
Children and young people
At a global level, a recent report published by UNICEF estimates that more than 1 in 7 adolescents aged 10–19 live with a diagnosed mental disorder, with the report acknowledging significant gaps between mental health needs and mental health funding.[1] We know that the COVID-19 pandemic has caused tremendous challenges to the mental health of children and young people, causing disruption in their emotional, cognitive and social development.[2] In Wales, 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.[3]
Social isolation, socioeconomic challenges as well as bereavement played a major role, and children were isolated from their usual support systems, including friends, family members and school.
For children and young people, the barriers to accessing mental health services include patient factors, workforce, and service design factors. Patient factors include parental physical and mental illness and fear of contracting Covid. Workforce factors include pre-pandemic staff shortages which have been exacerbated due to staff burnout, sickness, absence and early retirement. Finally, service factors include access issues due to government pandemic restrictions, staff shortages resulting in scaling back services needed to meet the needs of children and young people and finally the sub-optimal collaboration between social services, CAMHS and Schools. Another barrier to access has mainly impacted children transitioning to adult mental health services. These patients have found themselves falling between the cracks between management at a primary care level and specialist adult mental health services.
There has been a significant effort around wellbeing and low-level mental health support, and Mind over Matter (2018) acknowledged that ‘education settings, including primary schools, secondary schools, colleges and universities, are key to promoting emotional well-being and good mental health’. The introduction of the Whole School Approach[4] was also central to the stepwise change needed to support the emotional and mental health of children and young people.
However, while we welcome investment in overall mental health support and early intervention for children and young people, it will not prevent those with severe and enduring mental ill health from needing support.
Existing services need to be horizontally equitable across Wales. CAMHS services in Wales desperately need increased funding and staff.[5] This requires equitable allocation of resources and staff across the whole of Wales to ensure we do not have regional discrepancy in access and mental health outcomes. This can include more investment in mental health support teams in schools to facilitate early detection, prevention and treatment, but also investment into sCAMHS.
Existing resources can be optimised through innovative ways of working that are cost effective. The use of health technologies such as telemedicine can help address patient access challenges through facilitating virtual appointments thereby overcoming regional coverage challenges with specialist mental health services. However, it’s crucial that digital platforms and new technology are robustly evaluated to ensure no groups are excluded and are receiving appropriate and timely care. It is critical that the views of children and young people as well as wider set of stakeholders are integrated in the planning and design of any future service.
Poverty
Poverty increases the risk of mental health problems and can be both a causal factor and a consequence of mental ill health.[6]It’s crucial to consider the social determinants of mental ill health, such as living in poverty, unemployment and unsafe or insecure housing.
The link between severe and enduring mental illness and socio-economic deprivation is also well evidenced. A study published in The British Journal of Psychiatry, indicated that although genetics are known to play a part in the development of mental illness, environment may also have a significant role to play. When researchers compared adults who had just been diagnosed with schizophrenia, they found that a significant number of them had been raised in poverty.[7] The findings show that "indicators of social inequality at birth are associated with increased risk of adult-onset schizophrenia’’.[8]
Learning disabilities and Autism Spectrum Disorder
Children and adults with learning disabilities as well as Autism Spectrum Disorders (ASD) were disproportionately affected by the pandemic, and the disruption to home life, schooling, as well as cuts to social care have had a negative impact on their routine and activities of daily living. A predictable routine can be central to the stability of this cohort of children and adults, and as such the pandemic, with all the associated disruptions, has been a source of increased anxiety. Members have told us that they have seen this present 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. Likewise, a member of our Intellectual Disabilities faculty told us that one of their patients has lost 5 days a week at their day centre and is now only getting 6 hours of 1:1 support. Having occupation and purpose in life is essential and day centres are part of this, as are increased opportunities for employment/training.
Severe mental illness (SMI): co-morbidities and life expectancy
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.[9] It is estimated that for people with SMI, 2 in 3 deaths are from physical illnesses that can be prevented.[10] Major causes of death in people with SMI include chronic physical medical conditions such as cardiovascular disease, respiratory disease, diabetes and hypertension.
Last month, NHS England National Directors for Mental Health for Learning Disability and for Health Inequality wrote to mental health trusts throughout England to ensure and prioritise the delivery of physical health checks for people with severe mental illness and people with a learning disability. Within this correspondence there was acknowledgement of the stark health inequalities faced by people with SMI and people with a learning disability, and how the pandemic has served to further exacerbate these inequalities.
There exist a number of barriers for people with severe and enduring mental illness, including workforce shortages, a lack of NHS inpatient beds and waiting times backlog for those in acute crisis or who require longer term specialist mental health services.
Likewise, whilst understanding that for the majority of people, mental ill-health as presented at primary care will not need specialist intervention, for many it will. We need to ensure that services are available for all.
We also can't forget the role of clinical prevention, we have lost the understanding that for many, it's clinical teams that prevent further deterioration and illness. The three kinds of interventions of promotion, prevention, and treatment are interrelated and complementary; however, they are somewhat different from one another. Psychiatrists are competent and specialist in prevention of mental illnesses and mental health promotion in various settings.
Health promotion mainly deals with the determinants of mental health and aims to keep people healthy or become even healthier. In other words, mental health promotion aims at enhancing individual's ability to achieve psychosocial wellbeing and at coping with adversity.
On the other hand, prevention of illnesses focuses on the causes of risk factors to avoid illness. There are three categories of prevention:
· Primary prevention focuses on various determinants in the whole population or in the high-risk group.
· Secondary prevention comprises early detection and intervention.
· Tertiary prevention targets for advanced recovery and reduction of relapse risk.
We must understand that for a significant number of vulnerable people a definition of prevention, best sits, as managing mental ill-health or mental illness.
We can support people living with mental health problems to stay well and prevent people from relapsing or reaching crisis point. Drawing focus and appreciation away from this understanding, serves to further disadvantage those who are vulnerable.
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.[11]
· Recovery rates following psychological therapies are higher among White British people compared to people of all other ethnicities
Much more needs to be done to shape the mental health service to meet the needs of a diverse population.
LGBTQ+ individuals
LGBTQ+ individuals have a higher risk of suicidality yet experience discrimination when accessing healthcare. Among LGBTQ+ young people, 7 out of 10 girls and 6 out of 10 boys described having suicidal thoughts.[12] They were around three times more likely than others to have made a suicide attempt at some point in their life.[13]
These groups of people still face discrimination and stigma, leading to a limited understanding of their needs.
We welcome the Welsh Governments Race Equality Action Plan and LGBTQ+ Action Plan, but they must ensure that they lead to services being targeted and co-designed with the people they are intended to support.
Older people
For older people, age discrimination is associated with worse psychological well-being and poorer physical health outcomes. Older people are less likely to be referred on to the most appropriate service, and there is a higher risk of their needs being overlooked. In some services, only 1 in 6 older people with depression receive any treatment, and whereas 50% of younger people with depression are referred to mental health services, only 6% of older people are.[14]
Likewise, older age mental health conditions are often associated with dementia due to preconceptions around someone’s age, and other issues, such as issues around substance misuse for example, don't get the attention they should. Research shows that diagnoses and treatments given to the younger patient were more appropriate than those for the older patient. This pattern has been confirmed in a recent study that suggests old people who self-harm are less likely to be referred to specialist mental health services than younger adults, despite a higher risk of suicide in this group.[15]
Utility of Video Consultation and digital
interventions
A mixed
methods survey for remote mental health services in NHS Wales,
published in the BMJ, presents real data gathered from operation of
a national video consultation service. This data is around the use,
value, benefits and challenges encountered by the patients and
clinicians in mental health services in
Wales.[16]
Consideration should be given to how video consultation impacts on socio-cultural factors, health inequalities, digital poverty and the need for reasonable adjustments. It will also be important to continue to measure key metrics such as equity of access, patient outcomes and experience measures for both patients and clinicians to compare their quality over time.
Recommendations
Children and young people
As mentioned above, to improve mental health and outcomes in children and adolescents and to reduce mental health inequalities in Wales, the government needs to:
· Increase investments in the Child and Adolescent Mental Health Services (CAMHS) across the full spectrum of services within the whole-system framework. These investments must be done in a way to ensure equity of access and outcomes across Wales and balance existing regional inequities.
· 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.
All adults with mental illness and learning disabilities
· 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
· 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.[17]
Workforce
· 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 highlight the importance of specialist roles are included in the design of the multidisciplinary team, and to ensure specialists can operate at the top of their licence
· Call for the committee to scrutinise the extent the mental health workforce plan engages and consults across service user and professional groups in its implementation
· Call to make working in the health service in Wales more attractive; This includes opportunities around remote working to make it easier for retired psychiatrists and those taking time off to care for children or relatives to return to work. Other opportunities include new credentials, bringing in support to enable psychiatrists to work to the top of their skill level.
Social determinants of mental health
· Advice services should be co-located in mental health settings, so that people with practical problems, such as financial and housing concerns, can receive the right support at the right time and the root cause of their problem can be dealt with appropriately
· There should be coherent cross-sector and cross-government action to tackle mental health inequalities, including addressing the social determinants of mental health.