Feeling the strain – mental health services
Increased pressure on people’s mental health and wellbeing leads to increased pressure on mental health services at a time when they are already straining due to lack of resources and staff. The Scottish Government has recognised that “the current system is not delivering as we would wish despite the efforts of thousands of dedicated and skilled people across Scotland.”
Services in all sectors are now finding more and more people want to access their support and that many of these people require greater levels of support. The manager of one community-led health organisation described how they were receiving “definitely referrals now that are far more complex and challenging than when I started five years ago.”
In terms of reduced services, participants in our discussions highlighted issues around geographic variation (the idea of a ‘post-code lottery’), growing waiting lists, delayed diagnoses and more stringent assessment criteria. They listed a number of services that had been withdrawn recent years in their local areas, including CPN, translation services and advocacy.
“Support from the Start and all these sort of initiatives that are now practically dead and no funding, they were starting to to have an effect on, there there were all sorts of things that were there to support families and to to help them, but that's all fallen by the wayside. The budgets are so badly cut that you're lucky if you can offer basic programmes and community centres and things.” (Manager of community-led mental health project)
Existing services were described as losing, or reducing, their focus on recovery, early intervention and being people-centred. There was also an issue around lack of continuity, both in terms of continuity of service experience and staff. Services were not seen to be joined-up and people we spoke to noted that a lot of wider services essential to people’s mental health and wellbeing, such as money advice, were disappearing.
Investment
It was acknowledged that investment in mental health and wellbeing was a fraction of what goes into health services more generally. However, when the lens was focused in on where resources are directed within mental health and wellbeing services, the amount of investment in community-based services was recognised as significantly less than what goes into clinical services.
“Public health is the poor relation, or health improvement is the poor relation within the health service. If there are cuts to be had because the impact is not instantaneous, it doesn't cut down waiting -well, it will eventually cut down waiting lists - we suffer a lot from funding, not being given or being cut. And it would help turn off the tap further up. But if you're a chief exec and you see waiting lists, or you see a ‘in five years time, you'll see a much better’, you know, you're gonna go with the immediate.” (Public health consultant in mental health)
Scotland’s new Population Health Framework states that it is focused on ‘primary prevention’, which it defines as “action that is designed to stop problems from emerging in the first instance”. What is clear is that prevention is at the centre of policy when the reality on the ground is that preventative work and services are being eroded.
From what interviewees told us, a range of compounding factors have been hitting services at once. For instance, one person working in public health said that, during and after Covid-19, a lot of front-line NHS staff have experienced trauma and burn-out. This, in turn, has affected their ‘bandwidth’ in terms of empathising with, and supporting, others. Another issue raised by the same person is that mental health and wellbeing services are being further stretched by the rising demand for diagnoses for conditions like autism and ADHD.
The impact of reduced support - a feedback loop
With more people requiring support from already-strained services, it is inevitable that this can have a further negative impact on people’s mental health and wellbeing. Participants in the interviews told us of people struggling to receive the support they needed or being denied services they previously qualified for.
“But certainly now, you know, the anecdotal information we're getting even from clients was perhaps they had had care before and then there's been an assessment, a review done and they're not eligible for that anymore.” (Manager of community-led health organisation)
The impact of being denied formal NHS services was made clear by one person we spoke to.
“One of the quotes that kind of jumps out in my memory was somebody saying they were told if they hadn't made a plan to complete suicide then they couldn't access help. Which when someone is reaching out for help at that stage you don't want: ‘Oh, it's not bad enough yet.’ (Public health consultant in mental health)
Where people did manage to access services, these were described as being inadequate.
“One of the things that we see is that people are struggling to get appointments for anything. They can't get seen. And when they do, I think there's an absolutely skeleton staff available to support people” (Manager of community-led mental health project)
In addition, people who do qualify for services are having to wait longer for support receive less support-time. Waiting times were seen to be risking ‘tipping people over the edge’ and it was observed that receiving less than the full course of treatment could, in some situations, be worse than receiving none at all.
Another issue that was highlighted was that people were too-easily being ‘dropped-out’ of the support system due to a combination of nobody following up with them, overly punitive measures and a lack of joined-up services.
“Folk get in touch and request an assessment, and at that point they're triaged and then the assessment will take place. And they maybe at that moment in time they're assessed as being low level in terms of need. And we all know how quickly that can change. But folks think that once they're in the system, you know that that's them. Actually, as soon as people's situation changes, they need to get back in touch with care management because I think they're so busy, they won't necessarily review somebody for six months or whatever like that.
“So if people are missing appointments [...] they've got to go back, they've got to wait a while for another appointment. By that time they're getting to the point where they don't want to go to appointments. They're needing support to go to appointments and then they're struck off.” (Manager of community-led health project)
