Martin Shelley –
Mental Health Awareness Week, pushing for wider community support for people severely affected by mental illness, has just ended. Its message may have got lost amid all the talk of reduced infection rates and the economic impact of the lockdown, but the Department of Health and Social Care still decided to jump on board with a few headline-grabbing cash grants to mental health charities.
But those awards – worth just £4.2m – will have little impact on the wider provision of mental health services, already creaking under the strain of cuts to NHS and local authority budgets and now struggling to cope with the added burden of rising demand driven by the pandemic.
In fact charities are themselves stepping up to provide 24/7 mental health support to frontline care workers during the Covid crisis, as Mind, the Samaritans, Shout, Hospice UK and The Royal Foundation come together to launch a range of services under the Our Frontline banner.
So what would really make a difference to the state of mental health services in the UK, during the pandemic and beyond? Adequate funding is the only answer, rather than an increasing dependence on charitable activity.
There’s no getting away from the impact of ten years of budgetary constraints on health provision in the UK. Consider for example the fate of child and adolescent mental health services (CAMHS), the recipient of less than one per cent of the overall NHS budget.
In November 2019, Mind released figures showing that in the previous 12 months the NHS in England cancelled 175,000 CAMHS appointments – 25 per cent more than in the previous year. And last month the charity revealed that almost a quarter of people who tried to access mental health support over two weeks during the lockdown had failed to get any help at all.
This tightening of eligibility criteria was confirmed by a recent Pulse survey of GPs in which nearly 30 per cent said the rules governing CAMHS referrals had become stricter, with only one in five NHS mental health trusts now accepting appointments.
It’s surely no coincidence that the number of A&E attendances by young people with a recorded diagnosis of a psychiatric condition has almost tripled since 2010. Or that an increasing number of GPs are now advising parents to seek private mental health care for their children.
Current funding and staffing levels – and the number of beds available – across the mental health sector generally don’t help. Last month The Lowdown found that mental health services only received 13 per cent of the overall NHS budget despite accounting for 23 per cent of the disease burden, and that a fifth of mental health trusts saw a drop in income.
The staffing statistics were no better: in 2013 there was one mental health doctor for every 186 patients accessing services, and one mental health nurse for every 29 patients. By 2018 those figures had dropped to one for every 253, and one for every 39, respectively. No surprise really, given that – in 2017-18 alone – 23,686 mental health staff left the NHS.
Those stats showed that the number of mental health beds has also slumped, by nearly 3,000 since 2013, leading to local issues of availability. In November last year the Royal College of Psychiatry (RCP) published a report claiming that, to offer appropriate levels of care to patients in their local community, more than a thousand extra mental inpatient beds were needed.
Inpatient mental health care is also suffering from a poor ‘estate’. In its 2014-17 report on the sector, the Care Quality Commission found that many mental health wards were unsafe, but earlier this year NHS Providers noted that only three out of 20 mental health trusts were allocated funding in the first – and none in the second – wave of capital investment announced by the government last September.
So that’s the history. To assess how past decisions on funding might continue to play out in the current crisis, let’s focus on another area of mental health, of particular relevance during the lockdown. Substance abuse.
High street sales of alcohol leapt by 22 per cent in March as people prepared for the lockdown, prompting a joint statement from the Alcohol Health Alliance and the Commission on Alcohol Harms warning of “the toll of increased alcohol harm for a generation” to come. And the Guardian recently reported that vulnerable drug users were turning to dangerous alternatives such as heroin because of a pandemic-related shortage of synthetic cannabinoids like spice.
But this comes after local authorities – responsible for the delivery and funding of alcohol and drug addiction services since 2012 – had to reduce their spending on those services in 2018/19 on average by £155,000, despite soaring levels of hospital admissions due to alcohol abuse. Budget cuts collectively amounting to £2.4m for child addiction services were also imposed on councils in England last year.
More generally, after eight weeks into the lockdown the RCP warned that health services could be overwhelmed by “a tsunami of mental illness”, as people start to develop serious psychological problems for the first time.
And despite the restricted access to CAMHS appointments mentioned earlier, there has been a pandemic-related drop in referrals in recent weeks. The Birmingham Women’s and Children’s NHS Foundation Trust has seen a 50 per cent reduction in referrals since March.
Most people’s experience of accessing mental health care during the pandemic is now via computer or phone. Introduced to ease the pressure on hospitals and GP surgeries while reducing transmission of infections, this policy is proving to be no substitute for talk therapies, group workshops and other outpatient services now deemed inessential.
Guidance from the RCP suggests patients can find it uncomfortable to discuss personal matters at a distance, particularly with a doctor or therapist they’ve not met in person before, and the college advises that not everyone has access to digital technology.
The RCP’s stance is borne out by the experience of one community mental health nurse, who agreed to talk to The Lowdown last week, on condition of anonymity:
“All but urgent face-to-face patient visits have been replaced by phone contact,” she told us. “I haven’t seen a patient in person since March. This is a real change from pre-covid when around 80 per cent of the treatment I provided would have been face-to-face. Video consultations are possible for those with the tech skills, equipment, privacy and mental capacity needed, but most of my patients can’t manage this.”
Many of those patients are elderly and live alone. For some the only human contact they have is health appointments, so isolation is having a really detrimental effect on them. “I’m glad we can still call patients and make contact that way – sometimes they tell me they haven’t spoken to anyone all day,” she explained. “What we cannot see, though, is whether they are really coping. If someone has got washed and dressed, if there’s evidence of eating or having food in the cupboards – these are markers of mental health that cannot be assessed over the phone.
“Similarly, the nuances in conversation, eye contact and expression, which are all used to assess someone’s wellbeing, cannot be done over the phone either, so it feels that we cannot identify risks [such as self-harm] as accurately now.”
“As a practitioner I also feel more isolated from my team while working from home. We have daily Skype check-ins,” she added, “but they cannot replace the conversations that happen in a shared workspace that allow for a different perspective on a situation.
“And there’s now a possibility that community mental health teams may start to get referrals for traumatised hospital staff or people who’ve recovered from covid-19.
“I do feel under extra stress because of the pandemic. I have patients on my caseload with serious mental health problems, who I’m responsible for, who I’ve never met face-to-face. I cannot fully assess them or their living situation, or tell how well they are coping, yet the buck will stop with me if anything happens.”
Two points made by this nurse – about the enforced isolation from her colleagues, and the possibility she may soon get referrals from traumatised hospital staff – flag up the impact the pandemic is having on the mental health of NHS staff, and the inadequate support they may be getting.
Last month [April] the Institute for Public Policy Research (IPPR) launched its ‘Care fit for carers’ report, which claimed the covid outbreak was having a severe impact on the mental health of NHS staff, often through worrying about their ability to ensure patient or service-user safety because of a lack of testing and personal protective equipment. The IPPR noted that many patient-facing healthcare professionals are not eligible for bespoke therapy, and urged the government to address this situation – currently, it is only available to doctors and dentists.
That perhaps brings us finally on to health secretary Matt Hancock’s claim at the end of April that mental health support services were being “restored”. This was a surprise to many working within the sector, who were quite certain that mental health services had never actually shut down, but his statement also begs the question – given the ever-present threat of privatisation, and the prospect of virtual consultations becoming a more regular part of healthcare in the future – of what might be left of this vital part of the NHS to restore, once the pandemic is over…
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