‘When we (society) make people mentally unwell, we do not have the staffing, funding or physical space to enable them to become well again.’
This assessment – from an English psychiatrist whose anonymity has been protected as part of an in-depth investigation into the state of mental health services across the country – lays bare the tragic truth: society is making people mentally unwell and our systems and structures are unable to respond adequately when this happens.
These are painful, and costly, truths. It has long been clear good mental health is essential to a functioning society. Mental illness carries a huge cost to individuals and society as well as the health and social care system – some £101bn in England alone at the last estimate, roughly 5 per cent of the UK's GDP. Without appropriate treatment or support, mental illness can lead to lost productivity and the need for informal care. And away from the balance sheets, poor mental health can cause huge anguish to individuals, families and communities.
A recent review of more than 150,000 people in 29 countries found that around one in two people will develop at least one mental health condition in their lifetimes. And rates appear to be increasing, with the COVID-19 pandemic, in particular, having a significant effect on people’s mental health.
LOST AND CONFUSED: Young people increasingly experience mental illness
Rates of mental health conditions among children and young people seem to be rocketing, too. Between 2017 and 2022, rates of probable mental disorder in England increased from around one in eight young people aged seven to 16 to more than one in six.
In England, following decades of neglect, there have been moments of hope surrounding mental healthcare – with many ambitions and plans outlined to tackle the paucity of esteem between mental and physical healthcare. Mental health has been seen as focal for the NHS and commitments to various areas have been made alongside the introduction of waiting times and access standards for services.
However, demand continues to outstrip investment and many targets are not met. Services are widely reported to be overwhelmed by the numbers of people requiring care or seeking help by demand and the system is under huge pressure. Government figures show that the number of people unable to access the treatment they need in a timely manner continues to increase.
It is in this desperate landscape the BMA has published a study investigating the state of things through the eyes of doctors, patients and other experts. The report includes in-depth interviews with 10 doctors from across the mental health system, including those working in psychiatry, general practice, emergency medicine and public health.
This group of doctors were asked about their experiences of providing care, what helps and hinders them in their workplaces, how things have changed during their time in the service, and how the challenges of today affect patient care. These interviews were supplemented by discussions with patient groups and charities.
The ability to deliver and establish a relationship with a patient has been impacted by lack of fundingConsultant psychiatrist
The BMA study finds doctors are struggling to ensure patients receive the care they need in the face of inadequate funding, insufficient workforce and unsuitable infrastructure. The report also reveals doctors’ ability to support patients or provide high-quality mental healthcare is compromised by a society not designed to support good mental health and wellbeing.
Funding was at the heart of the concerns raised by all of the doctors spoken to. They highlighted how resource constraints are resulting in a system working beyond its limit. They said operating in an environment of scarcity means staff do not have the resources they need, and a lack of funding has wide-ranging effects including insufficient workforce and inadequate estates. It also makes it harder for different parts of the system to work together when there is competition for limited resources.
One consultant psychiatrist said: ‘The quality of the staff hasn’t changed, but the ability to deliver and give time and properly establish a relationship with a patient has really been impacted by lack of funding … I’ve been in the same trust for all these years ... so I’ve seen it change completely.’
The NHS has clear targets for mental health investment and spending, set out most recently in the NHS Long Term Plan for Mental Health (2021). Most notably this included a commitment to increase mental health funding by £2.3bn a year in real terms by 2023/24 compared with 2018/19. The National Audit Office’s analysis of available mental health funding data shows that, based on national and local spend, NHS England was on track to meet this target but suggests recent rises in inflation may put the target in jeopardy.
The entirety of society seems designed to make people mentally unwellPsychiatrist
The NHS also has a target for local healthcare bodies to increase their annual spend on mental health services at a faster rate than their overall allocation. There is also a commitment that funding for children and young people’s mental health services would grow faster than overall NHS funding and mental health spend. But, in the face of such need, and decades of a lack of focus, these targets are unambitious – and there is a big difference between increased funding and sufficient funding.
One of the psychiatrists interviewed says: ‘More funding applies if it’s £1 more than last year… [There needs to be] capital investment, workforce planning, training and then obviously spending on those staff to keep them employed and on their development.’
A consultant psychiatrist says: ‘I think lack of funding is a major issue. We haven’t had, well I can’t recall, any major investment for a while. Morale is low… I’m fed up. You know, I don’t enjoy my job as much as I used to.’
Perhaps the other most significant area highlighted by doctors in the report is the state of the workforce. Ultimately, it finds, there are just not enough trained staff to meet the needs of people with mental illness.
One psychiatrist says: ‘If someone is meant to be on the two-to-one [observation ratio] but you’ve not got enough staff, naturally that’s not going to happen … Or if you decide that that needs to happen, it means some of the other patients might not get the observation level they need. You have to make really difficult decisions. With the limited resources we have, who do we prioritise? Who do we look after?’
Soaring demand
The data tells a story of high vacancy rates, and low levels of recruitment and retention. Despite overall growth in the mental healthcare workforce, it is not keeping up with demand. Overall, the mental health workforce increased by 22 per cent between 2016-17 and 2021-22. Over the same period, the number of medical staff has increased by 13 per cent and nursing staff by 9 per cent.
Yet, while the workforce is increasing, the number of people in contact with services has increased at a much greater rate. The result is the growth in workforce is insufficient to meet demand.
It is a brutal situation which affects directly on doctors and patients. One consultant psychiatrist says: ‘We don’t have any crisis workers after nine o’clock at night. So, if there’s a problem after 9pm, they’re basically on their own. There’s a telephone line you can call, or it’s the police.’
Another says: ‘Historically what I’ve seen was … an issue around nursing recruitment and retention [and] medical recruitment and retention. But now I realise you’re having issues even with psychology and occupational therapy.’
A lack of qualified staff is a particular problem for child and adolescent mental health services. More children and young people are asking for help than ever before, and there are not enough staff to respond to that demand. Since 2016 the number of children and young people in contact with these services has grown at over three-and-a-half times the pace of the psychiatry workforce.
If we didn’t have a society that promoted body dysmorphia, we wouldn’t have as many eating disordersPsychiatrist
The BMA report attempts to be constructive in the face of crisis and also sets out examples of good care and collaboration, as well as tangible recommendations to address the challenges and issues identified.
On funding, it calls for the Government to determine levels of funding and funding targets for mental health services to be based on a full assessment of unmet need to ensure everyone who needs mental health support can access it. It also calls for ringfenced funding to be provided for mental health infrastructure.
On the workforce, the report urges a plan to expand the professionally trained mental healthcare workforce – supported by genuine incentive. It also suggests NHS England restores the number of training places for addiction psychiatry within the NHS to improve doctors’ ability to treat patients with substance-abuse issues. The report also calls for clarification on where funding withdrawn from NHS staff mental health and wellbeing hubs is being diverted to.
Away from funding and workforce, among a host of other areas of concern, a wide range of policy recommendations are suggested including government-regulating IT system supplies to make sure their products are interoperable by default and mental health social care being embedded in the NHS. It also calls for a major expansion of NHS-funded talking therapy training and the collection and publication of national data on ADHD referrals and waiting times.
ROCK BOTTOM: Society is making people unwell
The report lays bare a mental healthcare system in which doctors are struggling to provide the care they want for patients.
They are working in environments which are simply not conducive to supporting people and, while there have been recent focuses on mental health nationally and locally, there has been no overall improvement in services owing to insufficient funding and workforce among a host of other factors.
Perhaps most troublingly of all, the report paints a stark picture of a society which makes people unwell without the tools to help them when they are.
As one psychiatrist says: ‘The entirety of society seems designed to make people mentally unwell … if we had less poverty, if we had nicer workplaces, if we had, you know, housing that wasn’t rubbish. If our social services system worked and supported families where there was abuse or neglect or indeed removed children from those environments and looked after them well. If we didn’t have a society that very heavily promoted body dysmorphia, we wouldn’t have as many eating disorders.’