Mental Health Policy Group submission to the Mental Health and Wellbeing Plan call for evidence

The Mental Health Policy Group (MHPG) would like this submission to be considered as part of the submissions to the call for evidence on the proposed 10-year cross-government Mental Health and Wellbeing Plan. We welcome this much-needed plan and look forward to continuing to work with the Department for Health and Social Care (DHSC) during its development and we are grateful for the department’s positive engagement with MHPG.

Our constituent organisations have submitted full responses to the DHSC’s survey on the plan and we have encouraged others, including our members, supporters and other organisations to take part.  Some of our organisations are also providing individual narrative submissions of evidence and have been involved in the ‘deep dive’ discussions that are also informing the development of the plan.

General comment

Although we acknowledge MHPG have been positively engaged by DHSC in the process for the plan we have been concerned about the timescales for engagement with smaller voluntary and community sector organisations and individuals with lived experience. We have worked hard to promote engagement, including publicising the call for evidence, and funding and resourcing workshops aimed at promoting engagement and responses to the call for evidence amongst people with lived experience and smaller charities and community groups. To be a meaningful plan it is essential that as many people with lived experience and civil society organisations, including smaller charities and community groups, inform and participate in its design and implementation. We would encourage their greater involvement in drawing up the implementation plan.

Our experience of engaging people in this process has shown there is a mismatch between the plan’s aims and the realities of people’s current experiences of their own mental health and the policy and services in place to support it. It is therefore important that the way the plan is communicated takes account of these experiences and how it will be received by people with lived experience of mental health difficulties.

The devolved nations have their own mental health plans. We would encourage learning to be shared across the nations, to co-ordinate best practice and ensure the participation of UK government departments whose remit covers the whole of the UK, such as the DWP and Home Office immigration and asylum policy.

We have consistently heard that even maintaining current mental health service funding is challenging but it is vital the plan is not seen as an alternative to properly funding and resourcing mental health services. It is very important that investment in prevention and early intervention work in communities is additional to secondary-care services and we strongly urge that vital additional budget is allocated, including in the next comprehensive spending review, for any new work that results from the plan. Without this, such work would need to be funded through existing departmental settlements which would come at a cost of something else, potentially having unintended consequences which might be harmful for mental health.

In summary, MHPG recommends:

• Frontloading prevention – immediate action is needed to address the social, economic, and environmental factors affecting mental health. This includes reducing poverty and discrimination whilst providing much greater access to genuinely affordable, decent housing, clean air, and high-quality, safe green and community space. 
• Investing in prevention and early intervention programmes – properly resourced, distributed according to need, voluntary and community sector, council and NHS support that is timely and effectively addresses social, financial, and clinical needs when problems occur. We also call for the scaling up of well-evidenced and cost-effective prevention programmes that address the root causes of poor mental health, such as anti-bullying programmes in schools, parenting programmes and workplace support and interventions. We support establishing a network of community-based early support hubs for children and young people.
• Resourcing clinical care to at least keep pace with inflation - with mental health referrals at record levels and well over a million people still waiting to start treatment, NHS mental health services need a cash boost of £300 million just to match inflation and deliver the investment package promised in the NHS Long-Term plan. There should also be a focus on ensuring equal access, experience and outcomes from services for all of the community. To make all of the above happen it is critical that the plan is accompanied by a robust and deliverable workforce plan that creates and sustains the workforce required to fulfil the government’s ambitions to level up mental health across the country.  

To be effectively implemented this new plan needs leadership from the very top of government, and a properly resourced action plan with strong governance to ensure milestones are met and corrective action taken when slips occur.  A cross-government approach to prevention and early intervention is important and should recognise that preventing and addressing mental health problems early can result in cost savings in many parts of government, such as the criminal justice system.

Learning from 'No health without mental health'

Before sharing our views on this welcome new cross-government mental health and wellbeing plan it is worth reflecting on the outcomes of the No health without mental health cross-government mental health strategy published in 2011. This strategy had six main desired outcomes:

1. More people will have good mental health – this has not been achieved.  A record 4.3 million people were referred to clinical mental health services last year. Even before the Covid-19 pandemic, mental illness prevalence had increased substantially, and wellbeing scores were down (RCPsych, 2022)
2. More people with mental health problems will recover – this has been partially achieved.  Significant investment and targets for increasing access to psychological therapies have meant the 50% recovery target is being met or nearly met for common mental health disorders. Perinatal mental health services are also achieving better outcomes. There is a more mixed picture for serious mental illness – the lesson is that investment, minimum waiting times and standards are necessary to drive improvement (NHS England, 2022)
3. More people with mental health problems will have good physical health – this has not been achieved.  The premature mortality of people with serious mental illness has significantly worsened and had done so even before the Covid-19 pandemic (OHID, 2022)
4. More people will have a positive experience of care and support – this has not been achieved.  Care Quality Commission surveys show that, across many areas of care, the experience of using mental health services is at its lowest point throughout the period 2014 to 2021 (CQC, 2022)
5. Fewer people will suffer avoidable harm – partially achieved.  There has been a worrying increase in the use of the Mental Health Act since 2011 but the Use of Force Act is a positive innovation.
6. Fewer people will experience stigma and discrimination – this has been achieved. Time to Change (which is no longer being funded) appeared to galvanise a significant shift in public attitudes to mental health (Time to Change, 2021).

For the new cross-government plan to be effective, it is important that the lessons of No health without mental health and its implementation are learnt.  We consider the key learning to be that:

• There was no real implementation plan or delivery mechanism with buy-in from across government
• Although some clinical services benefitted from extra investment, targets and focus, many supporting services, like those commissioned and provided by public health and local government more widely, had their funding dramatically reduced, with the heaviest cuts falling in areas of greatest deprivation and therefore greatest mental health need
• Austerity also meant that deprivation and income inequality, that drives mental ill health prevalence, actually got worse.
• The two obvious successes: IAPT and Time to Change were properly resourced, had sensible targets and good governance.

Frontloading prevention – commit to reducing child poverty and discrimination

If the cross-government mental health plan is accompanied by investment and action to prevent mental ill health and improve wellbeing it is very likely to reduce prevalence and demand on expensive services during its lifetime.

Whilst clinical care accounts for about 20% of health outcomes, social determinants, like poverty and discrimination, are responsible for about 55% of health outcomes, with environmental and behavioural factors accounting for the rest (WHO, 2022). Behaviour, like smoking and substance use, and environmental threats, like air pollution and being surrounded by junk-food take-aways, are also strongly influenced by social determinants. For example, smoking rates are four times higher among people in the most deprived 20% of local authorities compared to the least deprived 20% (ONS, 2018). The stress of poverty reduces the ‘mental bandwidth’ people have to make healthy choices and drives ‘comfort-seeking’ behaviour which compounds poverty and worsens mental health (Mullainathan and Shafir, 2017).

• In addition to unhealthy behaviours driven by the stress of scarcity, which worsen the mental health of the most deprived, poverty also increases other risks, such as exposure to multiple adverse childhood experiences (ACEs). In a large, recent UK cohort study, children living in households in the lowest quintile (20%) of household income were found to be almost 12 times more likely to experience three or more ACEs by age eight years compared with those in the highest quintile (Marryat and Frank, 2019).  Another new study has found that a 1% increase in child poverty in the UK was associated with an additional five children entering care, mainly due to abuse and neglect, per 100,000 children. Researchers concluded that children's exposure to poverty creates and compounds adversity, driving poor health and social outcomes in later life, and they recommend national anti-poverty policies are key to reducing poor outcomes and improving wellbeing (Bennett et al, 2022). As a result of the causal links between poverty, ACEs and mental ill health, children and young people living in households with the lowest incomes (the poorest fifth) are 4.5 times more likely to experience severe mental health problems than those in the highest income (wealthiest fifth) households (Gutman et al, 2015).

ACEs lead to a substantially higher risk of poor wellbeing, mental ill health, and other negative outcomes during the whole lifetime of the person affected (Lippard and Nemeroff, 2019). For example, analysis shows that 46% of individuals with depression (Nelson et al, 2017) and 57% of people diagnosed with bipolar disorder report high levels of childhood maltreatment (Post et al, 2014). A landmark study found that experiencing a high number of ACEs (four to six compared to zero) increases the chance of depression by 460%, suicide attempts by 1,220% and intravenous drug misuse by 4,600% (Felitti, 2002).

The threat of poverty to mental health intersects with other inequalities such as those experienced by racialised communities. Poverty and rates of serious mental illness are very much higher among certain racialised communities in the UK (Synergi, 2017). There is no evidence of any heightened genetic risk among these groups but there is evidence that experiences of racism compound economic disadvantages to worsen mental health.

It is therefore vital that the cross-government mental health plan mandates a national mission to reduce child poverty and inequality by increasing the incomes of the most deprived families and reducing their costs. The plan should also recognise the effect of institutional racism and other forms of discrimination on mental health and support an anti-racist approach across government.

The Plan’s objectives for prevention must also include a commitment to scaling up cost-effective, well-evidenced programmes that can prevent poor mental health, such as anti-bullying programmes in schools, parenting programmes, and workplace support and interventions.  Their efficacy, and the return they offer on investment are described in detail in the Mental Health Foundation’s report on the economic case for investing in the prevention of mental health problems (McDaid et al 2022).

The plan must meaningfully tackle areas of government policy that are in direct conflict with good mental health. This should include, for example, the current lack of safeguarding in Department for Work and Pensions policy on welfare sanctions and the harmful impact on mental health of Home Office policy on indefinite immigration detention and deportation to third countries.

Mental Health Policy Tool

For some time, colleagues from across government and have been working with stakeholders to develop a new tool to assist government departments with considering mental health in their policy development. To ensure departments have a focus on the mental health impacts of policy moving forward, it is essential that the plan includes a commitment for the mental health policy tool be fully implemented by all departments, and utilised and completed in a transparent way for all policy development.

Environmental threats

Poor housing, unemployment, or poor work, financial precarity, air pollution, cheap alcohol, fresh-food deserts, lack of high-quality, safe green space and walking, cycling and public transport should also be a focus for preventing mental ill health and supporting wellbeing. If every citizen had secure, decent, genuinely affordable housing, with safe walking and cycling routes in clean, safe, green spaces to nearby community, workplaces and affordable, healthy shopping outlets, mental and physical health and wellbeing would improve. Environmental threats intersect with poverty, unemployment, poor work/financial precarity and discrimination, described earlier, as poorer and racialised communities are much more likely to live in worse housing and be exposed to air pollution and other threats to their health.

Investing in early intervention

In addition to frontloading prevention by committing to reducing the poverty and discrimination that drives mental ill health and other poor outcomes it is also vital that effective support is available as soon as problems occur.

Since 2010 cuts have seen local government spending power reduce by 16% (Institute for Government, 2022), with public health suffering even sharper reductions, down 24% in real terms (King’s Fund, 2021) with deprived communities suffering the most severe cuts.

There have also been cuts to early support services for children and families, vital for providing help at an early stage when families are encountering adverse circumstances, or when potential risks to children are identified early enough to reduce them.  In recent years local authorities’ funding has shifted markedly to statutory child protection and children in care services (Action for Children et al, 2020), and the Early Intervention Grant fell from £2.8 billion in 2010/11 to £1.1 billion in 2018/19 (LGA, 2020). 

A new study published in The Lancet has found that disproportionately large cuts to council and public health budgets led to worsening population health (Stokes, 2022). Researchers concluded: ‘Fiscal austerity is associated with worse multimorbidity and health-related quality of life. Policymakers should consider the potential health consequences of local government expenditure cuts and knock-on effects for health systems.’

It is important these cuts to public health and local government services that prevent poor outcomes are reversed, with a focus on fairly supporting areas with the greatest deprivation and prevalence of the adversities described above, and thus elevated much risk of experiencing poor mental health. We support the call for the grant to be restored, at a minimum, to 2015/16 levels by investing an extra £1 billion a year, and for it then to keep pace with growth in NHS England’s spend We suggest 4% should be ring-fenced annually for public mental health

This is particularly important for children, young people and their families. Public health and wider local government services need to be funded properly to ensure excellent and comprehensive early years health visiting, children’s centres, the new family hubs, early years support, free nursery education, youth centres and early support from child and family social care.  Community resources such as libraries and leisure centres are also important, as are whole-school approaches to mental health that include school nursing and counselling services.

Improving care and support

‘Parity of esteem’, the principle by which mental health must be given equal priority with physical health, was enshrined in law by the Health and Social Care Act 2012 and the Health and Care Act 2022. The Government requires NHS England and all NHS bodies to work for parity of esteem to mental and physical health through the NHS Mandate. There are, however, many areas where parity of esteem has not yet been realised and this cross-government plan is an opportunity to rectify this. Mental health problems account for more than one quarter of the burden of ill health but less than one tenth of NHS spending (Centre for Mental Health, 2021). Apart from the obvious point that any illness should be alleviated where possible, mental illness reduces life expectancy – it has a similar effect on life expectancy to smoking, and a greater effect than obesity.

Mental ill health is also associated with increased chances of physical illness, increasing the risks of the person having conditions such as coronary heart disease, type two diabetes, or respiratory disease. Poor physical health also increases the risk of mental illness. The risk of depression is doubled for people with diabetes, hypertension, coronary artery disease and heart failure, and tripled in those with stroke, end-stage renal failure and chronic obstructive pulmonary disease. Children experiencing a serious or chronic physical illness are also twice as likely as their peers to develop emotional disorders.

Action is also needed on smoking, which is the leading cause of preventable ill health and premature death and is more common among people with mental health conditions, contributing to inequalities in health, income and employment.  Further, recently published analysis from ASH and Bristol University has also found that smoking increases the risk of developing schizophrenia by between 53% and 127% and of developing depression by 54% to 132% (Wootton et al, 2022).  Action to address smoking for individuals and the population will reduce the burden of mental ill health in society and improve the wellbeing of people living with mental health conditions. Targeted action within mental health services and wider action across the population can secure change. 

The Government ambition is for smoking to be at less than 5% by 2030. As current rates of smoking are much higher among people with mental health conditions there is a risk that those still smoking by 2030 will be concentrated in the mental health population, exacerbating the health inequalities and the stigma already experienced by this population.

Priorities for achieving parity:

• Appropriate waiting times are established for a wider range of mental health services so that people with mental health problems know the maximum time they can expect to wait for treatment. This should mean funding the roll-out of the Clinically-led Review of Standards as the next step towards closing the treatment gap with physical health services.

• National Institute for Health and Care Excellence (NICE)-approved and recommended mental health therapies should entitle people to access them in the same way they are entitled to NICE-approved drugs.

• Committing to continuing the Mental Health Investment Standard for the duration of the ten-year Mental Health and Wellbeing Plan
• A major, multi-year capital investment programme to modernise the mental health estate and ensure it is fit for purpose.
• A workforce plan for mental health backed by urgent financial investment to address dangerous shortages of staff and ensure the workforce better reflects the communities they serve.
• Mental health mainstreamed in other areas of the NHS, eg equal priority for investment in mental health workforce training and education, capital and digital
• A sustainable funding solution for social care, essential to help people stay well and avoid reliance on specialist mental health services.

• Funding the implementation of the draft Mental Health Bill, including expanding and upskilling the workforce and funding capital improvements, and implementing the Patient and Carer Race Equality Framework.
• A focus on improving people’s experiences of mental services and addressing disparities in access, experience and outcomes between individuals and communities, including working with the VCSE to offer a wider choice of services and support tailored to the needs of local populations.
• Expansion of supported housing provision within mental health pathways so people with a severe mental illness can live as independently as possible in the community.

• Reducing the premature mortality experienced by people with severe mental illness must be a priority and an ambitious target should be set with commensurate resources to reach it.  Action must include action to reduce smoking: the 10 Year Mental Health Strategy should heed the recommendation of the Independent Review of tobacco, the Khan Review (OHID 2022) to “Tackle the issue of smoking and mental health. Disseminate accurate information that smoking does not reduce stress and anxiety, through public health campaigns and staff training. And make stopping smoking a key part of mental health treatment in acute and community mental health services and in primary care.”

Locally and at ICS level the 10 Year Mental Health Strategy should secure implementation of the Public Mental Health Implementation Centre and Action on Smoking and Health public mental health and smoking framework (Public Mental Health Implementation Centre et al, 2022)

• It is vital that people using mental health services have 24/7 access to a crisis team and that these teams are not scaled back to cut costs.

Tackling disparities in outcomes of racialised and other communities

NHS England is piloting the Patient and Carer Race Equality Framework in four NHS mental health trusts. The cross-government plan should look at what can be applied from this framework, not least the need to ensure compliance with equalities duties nationally. Similarly, because of discrimination, LGBTQ+ people have higher rates of mental ill health including self-harm and suicidal thoughts (NHS England, 2016). When seeking to improve community health, the cross-government plan authors should have equalities issues at the forefront of their minds. It is vital to be informed by public health data about which groups of people, with characteristics protected under the Equalities Act 2010, are suffering disproportionately worse outcomes. For effective solutions to be developed, these groups must be well represented in decision making, be listened to, recognised, and included in creating solutions, commissioning, and providing support, which should include peer support programmes. 

Improving people’s experience of services

As well as expanding access to services, it is crucial that we look to improve people’s experiences of services in order to also improve outcomes. This means basing services on co-production, co-design, co-delivery and co-evaluation with people with lived experience of mental health problems, with a particular focus on people from marginalised communities. The NHS and partners should champion the role of community-led and peer support groups in supporting health and wellbeing needs so they can be well resourced, have the right visibility and are interwoven into the wider support offer.  We want to see services based on human rights principles, such as being person-centred, culturally appropriate, services taking into account the needs of marginalised groups, services being accountable when things go wrong and the experiences of people using services are captured and assessed. We also want to see much greater use of trauma-informed approaches to care. 

Workforce

In the mental health sector, recruiting enough skilled staff to meet the needs of patients is a historical and substantial challenge. While there have been several plans to try to remedy the workforce challenges surrounding the Five Year Forward View for Mental Health (for the period ending 2020/21) and NHS Long Term Plan, workforce remains widely recognised as one of the biggest challenges to their delivery. We must ensure that this cross-government plan does not suffer the same fate. It is critical that the plan is accompanied by a robust and deliverable workforce plan that creates and sustains the workforce required to fulfil the government’s ambitions to level up mental health across the country.  

With an already unacceptable treatment gap – two-thirds of people who would benefit from evidence-based treatment do not receive it – and challenges meeting existing demand, there is a pressing case for this new 10-year national mental health plan to address the demand and supply issues within the mental health workforce. This is crucial to ensure that services can meet future demand given increased prevalence of mental illness.

Over the next 10 years, we want to see progress on:

• Building a sustainable pipeline for the future. At present, recruiting from overseas is crucial for fulfilling workforce commitments, however, it is unsustainable and unethical to over-rely on international recruitment to get the workforce that we need. We must train more doctors here in the UK.
• Upskilling the workforce. Delivering the right care at the right time in the right place, with a more focused role on health promotion and prevention, will require consideration of integrated training opportunities and enhanced generalist skills. This should include mental health competencies for ‘non-mental health professionals’ including nurses, doctors, staff working in acute settings, GPs, advanced care practitioners, pharmacists, and VCSE staff. It also includes physical health competencies for mental health staff, including psychiatrists, psychologists, and social care staff. Integrated care presents opportunities to better care for people with mental and physical healthcare needs. Training should, therefore, look at management of common chronic physical and mental comorbidities such as alcohol and mood disorders and diabetes and depression. There is also particular demand for mental health skills in primary care, paediatric units, and emergency departments. Credentialling is a good way to offer training and/or upskilling where there is not currently a pathway in place. However, for more staff to undertake these certificated courses, central funding could be provided to Trusts to enable them to release staff.
• Continuing to embed new roles that benefit delivery of personalised and integrated care to people with mental and physical multimorbidity. This includes community connectors, non-medical prescribers, advanced care practitioners, primary mental health care workers, social workers, local authority representatives, mental health practitioners, nurses, healthcare assistants and peer support workers. These types of roles can support holistic patient care, early intervention and enable the right skill mix. There should also be roles with skills to detect issues and effectively treat patients across the primary/secondary care interface. For example, primary care roles within specialist mental health units, physical health nurses within early intervention in psychosis teams, and social prescribers within community and inpatient mental healthcare.
• Integrating services beyond health and social care, including housing, policing and beyond. However, to maximise the role of the workforce, action will be required to ensure the workforce is equipped with the right skills. For example, team working, leadership, digital clinical skills, consultation and liaison skills, cultural competence, and the ability to work closely with primary care and other interfaces will all be important.

The cross-government plan should be underpinned by the need to recruit and retain a psychiatric workforce that enables the delivery of high-quality care for patients sustainably in the long-term.

The recent Now or Never systematic investment review from Centre for Mental Health and the NHS Confederation’s Mental Health Network (O’Shea, 2021) documented that enhancing, protecting, and treating NHS staff health is crucial to providing good health care by preventing absenteeism, lower productivity, and staff shortages.

Centre for Mental Health modelling suggests nearly 700,000 health and care staff may require mental health support following the pressures of dealing with the pandemic (O’Shea, 2021).

In July 2020, a third of all NHS staff absences were due to stress, anxiety, or mental health problems. This consistently represents over 25% of total absences (NHS Digital, 2021c).

The cross-government plan should provide a funded strategy for the mental health of NHS, social care, and other staff that:

• Quantifies current health needs across all staff
• Estimates mental illness that will result from the pandemic
• Offers structured investment in prevention, treatment, and recovery for both
• Is culturally aware and, in some cases, culturally specific
• Offers help to all staff
• Builds on the NHS People Plan.

Its design should reflect the framework of enhancement, prevention, management, crisis and recovery, and should link to clear goals, with an accompanying evaluation to determine impact. Health and care staff need to be healthy to provide excellent health care. This requires an investment strategy for treatment which aims to protect, enhance, and improve the mental health and wellbeing of NHS staff. The absence of such a strategy risks high levels of staff shortages through absenteeism and resignations. A strategy should commit the cost of a 1% increase in staff absences to treating staff recovery (O’Shea, 2021).

Suicide prevention

We welcome the government’s commitment to update the suicide prevention strategy and suggest an effective strategy must include:

• A robust multi-year delivery plan sitting alongside the strategy to drive change and hold the government to account for reducing suicide rates
• Funding for local action after 2023/24 when the NHS Long Term Plan funding runs out
• Strengthened accountability and progress measures: during the current strategy period, too often it has felt like reporting has been done retrospectively rather than suicide prevention being proactively built into cross-government policymaking from the outset
• A new ambition for suicide reduction with the new plan enabling us all to see a clearer line between national and local activities and their impact on suicide rates.
• Include greater recognition of the links between suicide and inequalities
• The promised comprehensive real time surveillance system for suspected suicides needs to be fully operational as a matter of urgency

Research

The Covid-19 pandemic has exacerbated inequalities in mental health in the UK. Those with pre-existing mental illness, young people, women and some racialised communities are among the most likely to experience worse mental health impacts as a result. Despite this, longstanding limitations in mental health research mean that we do not have the necessary evidence to inform responses to the population’s increasing and starkly unequal mental health needs. If we do not address these weaknesses, we could see worsened inequality in mental health outcomes in the UK.

Fit for purpose? Addressing inequities in mental health research exacerbated by Covid-19 was produced on behalf of the Mental Health Research Group, an independent group of leaders in mental health in England. It highlights the inequities in mental health research funding and production, what gets investigated and who gets to contribute, as well as who and what is left out of the conversation. It shares examples of work taking place to address mental health inequalities and to challenge inequities of power and influence within mental health research.

The report calls for systemic change in the ways mental health research is planned, funded and delivered in the wake of the Covid-19 pandemic. It calls on all those who carry out, fund or manage research to:

1. Ensure wider representation of groups and communities that have been silenced or overlooked, especially racialised communities.
2. Invest in widening the range of people and organisations that can get research funding, including community and user-led organisations.
3. Ensure resources are targeted towards key areas that will help to build the evidence base for tackling mental health inequalities, including children and young people, prevention, and factors that influence mental health.
4. Find ways to bring together and value different types of knowledge in the production of evidence to inform policy and practice.