Will we fail once more on mental health?

Poor mental health is a bigger issue in Northern Ireland than it is elsewhere in the UK. A fifth of all adults show signs of mental health problems. An estimated one in every eight young people live with anxiety and depression.

There are several possible reasons for this. The link between deprivation and poor health is well established. Northern Ireland’s economy is weaker than other parts of the UK.

While poverty rates here are technically lower than in England, Scotland and Wales, this is down to low housing costs and other drivers of poverty, like a lack of good jobs and low household incomes, are broadly higher – and people in NI have generally felt greater anxiety about the cost-of-living crisis than those elsewhere in the UK.

Then there is the Troubles. The violence was devastating at the time, but its effects linger. Again, intergenerational trauma is an established issue that increases poor mental health in a population. Even people born after 1998 can feel the effects.

Despite that, we continue to spend less money per person on mental health programmes than other parts of the UK.

This week, the Northern Ireland Audit Office (NIAO) published a report examining local efforts to improve mental health. Mental Health Services in Northern Ireland found that, without “sustained additional investment”, ongoing efforts to tackle NI’s mental health crisis will fail.

Report

In 2022-23, £345 million has been allocated for mental health services, around 5.7% of the overall health and social care budget.

The NIAO’s report estimates that bringing spending in NI up to the same level as elsewhere in the UK could require an extra £190m per year.

An overarching, ten-year mental health strategy was launched by the Department of Health in Jun 2021. The Audit Office welcomed this strategy but said that its reforms require funding from outside existing departmental resources, and that the amount needed to properly finance its schemes come to around £1.2bn over ten years – cash that would need to be secured and allocated by an up-and-running Executive.

On top of the legacy challenges for mental health in Northern Ireland, Covid-19 proved another major setback – with the NIAO also warning that the full (negative) effects of Covid on mental health services may yet to be fully felt.

While services were maintained during the pandemic, availability of these services was reduced. People’s behaviour may also have changed, meaning a higher reluctance to seek medical help during lockdowns or when pressure on the health system was vastly increased.

In 2021-22, referrals were approximately 20% lower than pre-pandemic levels and, as of March 2022:

• Around 16,000 patients were on a waiting list (almost 20% higher than pre-pandemic)
• Performance against waiting list targets have deteriorated. Around half of those on mental health waiting lists wait longer than the nine- and 13-week target standards.

However, the pandemic did not create a trend, it simply exacerbated it. Waiting lists were already rising before March 2020.

“Waiting lists, which reached just over 14,000 by March 2020, saw a particular jump in 2018-19 which coincided with a peak in the number of referrals to services. In particular, there was an increase in numbers waiting to access psychological therapies, reflecting an acknowledged underinvestment and underdevelopment of services. Despite specific funding to address therapies waiting lists, numbers waiting increased by almost 40 per cent between March 2018 and March 2020…

“Workforce issues are also a key factor in the poor performance against waiting time standards. Health and Social Care Trusts identified mental health nurses as a particular area of concern, with data at the end of March 2022 indicating a vacancy rate of around 11 per cent. The 2021-2031 mental health strategy does, however, recognise the importance of workforce in achieving its vision for mental health, and includes an action for a review of the mental health workforce.”

The costs of improving NI’s mental health are significant. However, so are the costs of doing nothing.

Future – costs vs benefits

Per the NIAO report: “There are significant costs associated with mental ill-health, not only in terms of the impact it has on people’s lives and those of their families and carers, but also the wider costs to society in terms of the costs of care and treatment and lost production.

“A report, published by the London School of Economics and the Mental Health Foundation in February 2022, conservatively estimated the overall cost of mental ill-health in Northern Ireland in 2019 at £3.4 billion.

“There is potential, therefore, for significant benefits to be derived from improving mental health in Northern Ireland.”

How does change happen? One extra challenge is a lack of good data on mental health in NI – including about whether existing services actually work.

“In particular, there is a lack of outcome data in respect to mental health services, without which the Department of Health and Health and Social Care Trusts cannot determine whether the services provided improve patient mental health and reflect value for money.”

The department is trying to shift to an outcomes-based approach, however the “implementation timeframe is tied to the information technology systems through which it is to be facilitated, which are currently scheduled to be fully brought into use in March 2025.”

The NIAO paper made three recommendations:

1. The ten-year strategy requires proper funding – “While the draft Executive Budget provides a positive signal of intent, the Department of Health, in conjunction with the Executive, needs to secure adequate and sustained funding for the implementation of the strategy over its lifetime. Failure to do so would jeopardise the achievement of its long-term vision for mental health.”
2. Day-to-day service also need more money, and financial support should match that elsewhere in the UK – x “To do this will require a commitment towards sustained budget increases over the medium to long term. In this regard… the Department of Health should establish an explicit long-term funding ambition for mental health services, together with stepped interim targets aimed towards its achievement.”
3. Data must improve - “To support decision making and better monitoring of the effectiveness of services in improving people’s mental health, there is a particular need to develop an appropriate outcomes measurement framework.”

Commenting on the report’s findings, NIAO Comptroller and Auditor General Dorinnia Carville said: “The costs of mental ill-health are significant in Northern Ireland. As well as the human cost, the financial impact to society as a result of care, treatment and lost productivity is conservatively estimated at £3.4 billion annually in Northern Ireland. There are, therefore, significant benefits to be derived from improving mental health here.

“The Strategy for Mental Health 2021-31 provides a direction of travel for achieving the reform and improvement of services that is needed. However, adequate and sustained funding will be necessary to realise the Strategy’s vision.”