Fourth Report - Rural Mental Health

The current data and information relating to the shape and nature of mental health specifically in rural areas, communities and occupations is regrettably incomplete or unavailable and there have been many calls over time for this to be rectified. Given the strong indications of poorer mental health and well-being in rural areas, compared to urban ones, there has been a serious failure of logic and foresight in not ensuring that relevant data are collected and at a very granular level.

While experience of nature and the countryside is consistently identified as potentially beneficial for people’s mental health, our evidence is equally clear that the isolation inherent in rural living poses a significant challenge to the mental health of those who reside and work in these areas. In addition, other factors represent serious but currently unquantifiable pressures on the mental health of agricultural and veterinary workers.

We believe that, while the available evidence does not reveal a mental health crisis in rural England, there are more than enough glaring gaps, and obvious red flags, to warrant urgent and meaningful action, aiming to achieve a degree of preventative impact rather having to wait for an inevitable crisis to create a political imperative and free the necessary resource.

In particular, the long list of risks and stressors affecting the farming community and veterinary workers is perhaps the immediate priority, not least because there are real opportunities for substantial gains in this area with significant levers for change in the Government’s hands. (Paragraph 46) Suicide prevention and agricultural and veterinary workers

DEFRA should be an active stakeholder in any national suicide prevention strategy, as the Department is responsible for populations and occupational groups arguably at higher-than-average risk of poor mental health and death by suicide. However, DEFRA does not appear to have carved out a clear role in the last two initiatives— the national strategy and cross-government workplan—and its only reference in the latest consultation is to managing “green social prescribing”.

Adopting a more joined-up approach to public health focused on early intervention could make a positive contribution to preventing suicide amongst agricultural and veterinary workers. It would need to ‘wrap-around’ people at potential risk, incorporating the NHS, other key public services and the regular contacts that people have in their local community or economy, and be under-pinned by training in suicide prevention, and efforts promote working and workplace cultures that support good wellbeing.

We are very concerned by the evidence indicating that agricultural and veterinary workers have a higher-than-average suicide rate compared to the rest of the population. Although more accurate information is needed, a clear enough picture Rural Mental Health 77 was already established for the Government’s national suicide prevention strategy (published over ten years ago) to identify both as high-risk occupational groups and take clear steps to improve the situation. Given this, we were dismayed by the lack of focus on them evident in recent strategy progress reports and the cross-government suicide prevention workplan. Compared to other departments of state and their client groups, whether prisoners, military veterans or those in serious debt, DEFRA appears to have a very limited role in this area. The Government should address this shortcoming by creating clear objectives and actions when revising the national strategy.

Local government is carrying a substantial proportion of the responsibility for delivering the existing national strategy through local suicide prevention plans. However, it is unclear how much these have identified, or address, the specific needs of rural areas. Finally, we are very concerned that core local funding is not ringfenced.

We recommend that the Government: a) confirm the timeline and consultation process for revising the new National Suicide Prevention Strategy b) confirm and ringfence additional funding beyond 2023/24 for local suicide prevention to allow local authorities to contribute effectively to delivery of the national strategy, and c) commission the ONS to work with DEFRA and DHSC to address gaps in the suicide data and investigate establishing a ‘real-time surveillance system’ to identify trends in suicide by occupation to inform prevention policy action on suicide prevention in relation to agricultural and veterinary workers. During the development of the new suicide prevention strategy, DEFRA must do better to push rural and agricultural mental health priorities to the fore, seizing a substantial role and commensurate resources to deliver progress. The Department should also establish a National Working Group on agricultural and veterinary occupations to identify immediate priorities and actions to promote more effective suicide prevention for these groups, and to develop a more joined-up public health approach to suicide prevention across the NHS, public sector and local communities. (Paragraph 83) Rural mental health service provision, policy and strategy development

Although DEFRA is clearly responsible for working with the Department for Health and Social Care (DHSC) to ensure mental health policy and services are rural proofed, it is unclear what priority, resources and energy DEFRA has assigned to achieving impact in this area. The NHS Long Term Plan and Mental Health Implementation Plan, together, provide the national framework for ambitions on mental health but, again, it is unclear how far rural communities’ mental health needs are being taken into account not least when, as DEFRA confirmed, it does not have adequate data in this area.

DEFRA has produced a welcome framework and associated guidance for rural proofing policy but, for instance, claimed close working with DHSC and NHSE 78 Rural Mental Health over the new 10-year cross-government Mental health and wellbeing plan has not so far resulted in a single reference to rural priorities (rather the reverse). Furthermore, there is no indication yet that any consideration has been given to the effect of subsuming national mental health and well-being into the new holistic Major Conditions Strategy on the struggle of rural mental health for attention and appropriate prioritisation. The profile of rural mental health needs to rise much further for real progress to be made, with DEFRA taking a more active role alongside DHSC. We recommend: a) DEFRA and DHSC should establish a new joint rural mental health policy and delivery team to lead and improve on current “rural proofing” of health policy; and work with NHS England to set targets to measure and improve outcomes for rural mental health services and support rural health providers. b) The new joint DEFRA/DHSC rural mental health team should also set up a national working group, drawing together a range of experts, to identify practical changes to support more effective rural prioritisation within mental health services provision. c) The new joint DEFRA/DHSC rural mental health team should work with NHS Digital, to evaluate the availability of data and information on rural mental health services to start to address the gaps we have identified. d) DEFRA should consult on how the Rural Wellbeing Framework will be used to measure rural communities’ mental health.

The solution to providing accessible rural mental health services is unlikely to be “one thing” but more likely a package involving innovation and imagination from both patients and service providers. The new joint DEFRA/DHSC rural mental health team should consider how best to prepare and make an effective and integrated interventions with (i) the Department of Transport, and (ii) the new Department of Science, Innovation and Technology, in respect of achieving improved levels of accessibility to rural mental health services from new joined-up working, starting with the emerging rural transport strategy and Project Gigabit for rural broadband.

We conclude that NHS mental health services are often not fairly accessible for rural communities, with centralised services creating barriers to access, compounded by poor rural transport and weak digital connectivity.

Locally the NHS must focus on providing rural communities with good access to services in terms of location and/or via mobile or outreach services, through effective consultation and co-design, and bring the voluntary and community sector into the delivery landscape given its expertise in early intervention as trusted providers. It should put effort into reducing the stigma of mental health to support help-seeking behaviours.

The NHS also needs to open-up access to the rural veterinary community to reflect restrictions on their ability to attend appointments, and support people who need to Rural Mental Health 79 continue practising. Better digital provision could improve service access but must not be the default offer to rural communities, as it is not always appropriate or suitable.

We believe Integrated Care Systems (ICS) will be crucial to determining whether NHS mental health services are able to respond better in future to rural communities’ needs.

We recommend the joint rural mental health policy and delivery team issue a call for evidence on the effectiveness of the ICS-model for providing rural communities with access to mental health services and publish its findings with proposals to address any shortcomings, by the end of March 2024. The team should work with rural ICSs, health providers, and charities, to identify cost-effective care pathways to increase provision and remove barriers to NHS treatment for agricultural and veterinary workers, by increasing flexibility in appointments times, options for care, and location of services including outreach at auction marts.

Child and Adolescent Mental Health Services (CAMHS) have been under intense pressure for many years, but a lack of alternative rural social infrastructure and a fall in support for youth services means CAMHS is often the “only show in town”. However, focussing on providing ‘reactive’ mental health services will only go so far, especially given CAMHS waiting times, so the focus and resources need to shift to prevention. Early intervention via Mental Health Support Teams (MSHTs) is a positive development but needs to be rolled-out to all rural schools as soon as possible and adequately resourced with appropriately trained staff given the many responsibilities on schools. Youth service provision in rural areas also needs to be expanded but until that is delivered, whilst demand is high on CAMHS, and alongside MHSTs, much more investment is needed in other forms of prevention such as ‘Early Support Hubs’. Therefore, we recommend that DHSC, NHS England and DEFRA consult on proposals to reduce reliance on CAMHS by expanding preventative mental health support for children and young people by, (a) setting out a path to expand provision of MHSTs to 100% of schools and colleges in rural areas by 2026/27, and (b) committing to establish and fund ‘Early Support Hubs’ that can be accessed by children and young people in rural areas by 2024/25.

It is very important for the farming and veterinary communities to feel that their circumstances are understood by NHS staff when seeking to access, or receiving, support (otherwise this may work against help-seeking behaviours). Charities with specialist-knowledge can gain people’s trust from a position of credibility, so it makes sense to engage them to boost NHS staff understanding and/or to develop occupationally specific mental health initiatives, to provide a model for the NHS to improve support for farming and veterinary mental health. We recommend that DHSC and DEFRA identify farming and veterinary mental health as high priorities for action and by September 2023, develop a work programme with NHS England, public health and agricultural and veterinary charities to identify measures and targets to improve mental health outcomes for these occupational groups; and that DHSC mandate Health Education England to work with agricultural and veterinary charities to develop a training programme for rural NHS providers and staff to be launched by Autumn 2023, about these occupational groups’ mental health needs to improve their care. (Paragraph 136) 80 Rural Mental Health

We welcome the Government’s commitment to provide more funding for mental health and to ensure local mental health spending increases by the same proportion as overall increases in local health funding. Despite this, we are concerned by the possibility that the system used by NHS England to allocate funding fundamentally disadvantages rural areas. The Government’s settled view is that the system is fair and balances a range of complex criteria. We consider more work to be needed to ensure that appropriate resources fully respond to rural communities’ mental health needs and reflect the additional costs that rural areas must carry as, if this is not the case, rural communities will remain disadvantaged. We are pleased the Government is working to address shortcomings in how rural deprivation is measured. However, we ask the Department to provide us with a detailed statement of the process and the formula, in reply to this report, upon which to seek assurances from an independent source such as the National Audit Office.

We recommend that DEFRA and the Department for Levelling Up, Housing and Communities set out a timeline and process by which to review and revise the Index of Multiple Deprivation with the aim of more accurately capturing rural deprivation. The Government should commit to reaching a position by the end of this year, 2023, whereby it can commence a consultation on draft changes to the Index and guidance for decision-makers, and how the Index should be used to support funding decisions.

Crisis events can have short- and long-term effects on people’s mental health, but civil society groups told us NHS support is minimal or short-term, despite greater support being likely to help people deal more successfully with trauma. Rural health providers suggested only limited local planning takes place with no extra resources being available, while NHS England suggested more funding could be made available. An ICS told us much work is underway to plan for crisis events. NHS England was focused on the “clinical” response with ICSs leading “on the ground” and expected to make best use of “tools” provided by the Government.

However, as more extreme weather events are predicted to occur, the Government and NHS England need to adopt a more proactive approach to the mental health and well-being implications of crisis and shock events rather than just leaving it to local areas. We welcome the provision of Mental Health First Aid training for front-line public sector staff working with rural communities during crises. We also welcome the fact that advice and easements are available to help farmers cope with the financial challenges.

We recommend that by the end of this year, 2023: a) DEFRA and DHSC, working with all relevant public health, environmental and first responder stakeholders, assess the readiness of local plans for crisis events, and commence consultations on upgrading local preparedness for rural populations’ mental health, and b) HM Treasury, DHSC, DEFRA and NHS England review current emergency funding mechanisms and how these can be improved by establishing a dedicated Rural Mental Health 81 funding stream, to enable local areas to quickly access more resources to respond to rural communities’ mental health needs during and, crucially, after crisis events. (Paragraph 156) Addressing mental health in government policy and regulation

Government policies and regulatory activity are key sources of stress for the farming community so Ministers should think hard about the impact of their decisions. The Environmental Land Management (ELM) programme is a case in point given the prolonged uncertainty. DEFRA’s attempt to take account of mental health at least in terms of this policy, is to provide separate mitigating support under the Farm Resilience Fund (FRF), rather than embed it into ELM. It is unclear whether it is reaching people in most need; if mental health is integrated enough with business resilience; or if it makes best use of established and trusted support groups.

We hope that DEFRA’s attempt to reduce regulatory stress is a positive change in cultural practice. However, encouraging and investing in Mental Health First Aid (MHFA) training for people dealing with farmers is a pre-requisite to ensure they are skilled and able to signpost to mental health support. We recommend that: a) the next round of the Farm Resilience Fund prioritises providing mental health support to the farming community as a key deliverable alongside business resilience, to ensure it is more firmly established so that farmers engage with mental health support, and b) the Government develop an implementation plan by December 2023, to fund and roll-out the MHFA- training to front-line staff—across the public sector, auction marts, farming organisations and charities—who deal with farmers.

The Government should look at how to respond to the occupational demands placed on farmers, agricultural and veterinary workers and any cultural barriers that: prevent these workers from taking time away from work, are detrimental for mental health without opportunity for respite, or are a block on taking time off when sick or injured to recover and to dealing with mental ill-health.

Although it will be challenging for the Government to address this given such occupations can involve lone workers in often isolated rural locations, we recommend that DEFRA sets up a working group to: a) explore options to establish or expand models such as a cooperative or insurance cover system for agricultural workers; and a locum/ GP-holiday-cover model for veterinary workers to provide greater access to leave away from work and to take time off sick to recover from mental ill-health, and b) review provisions with the veterinary profession to consider how veterinary workers can be supported to maintain their licence to practise during periods of ill-health or sickness absence. (Paragraph 172) 82 Rural Mental Health Improving rural communities as places to live

Some of the challenges of rural daily life can have a significant impact on people’s mental wellbeing. The UK Government needs to address these, including through its various funding routes for levelling-up; but without more detail we cannot evaluate the difference it will make. On upgrading transport infrastructure and digital connectivity the Government appears to be investing significant resources and making progress which may potentially improve rural communities’ wellbeing and access to mental health services. But it needs to move much faster to push forward the new rural transport strategy, to deliver real change, so that ‘demand response’ bus services are embedded and sustainably financed, and to join-up rural public transport with local health planning. We also hope it will tackle the shortfall in rural digital infrastructure; but until then, flexibility in NHS digital provision will remain limited for rural communities as will the gap in digital skills unless it is addressed.

We recommend that: a) the Government set out how rural proofing has been applied to the Levelling-up and Regeneration Bill; and work with the Office for National Statistics (ONS) to rural proof the Levelling-Up metrics to ensure progress in rural areas is measured effectively b) DEFRA and HM Treasury set out the geographical distribution of projected funding for rural levelling-up against need c) the Department for Transport, DEFRA, DHSC and NHSE set out how the new rural transport strategy will provide rural communities with access to health services that is comparable to that experienced by urban communities, and d) the Department for Digital Culture Media & Sport (DCMS), NHS Digital and NHSE issue a call for evidence to rural communities, Integrated Care Systems and health providers, and about current digital access to mental health services, and consult on proposals to address any shortfall by the end of this year, 2023.

Given the over-reliance on CAMHS in rural areas as a response to mental ill- health amongst children and young people there is an urgent need to address the shortfall in youth services. Including youth services under the levelling-up agenda would give children and young people’s wellbeing the strategic prominence and profile it needs. It is therefore a missed opportunity that it has not been included in the levelling-up missions, or at least, identified as key to levelling-up in the ‘rural overview’ of the missions (in DEFRA’s second rural proofing progress report). The Government is investing new funding to grow youth services, but we are not able to evaluate how much it addresses rural need or to what extent it is starting to bring them up to previous levels of service. (Paragraph 190) We recommend that: a) the Government amend the Levelling-up and Regeneration Bill to include an additional mission on young people’s mental health and wellbeing and the Rural Mental Health 83 provision of youth services; and develop a metric to measure progress with ONS, for youth services and outcomes for young people’s wellbeing in rural and urban areas b) DCMS and DEFRA issue a call for evidence, consulting with local government, charities and children and young people, to assess current and planned new provision for rural youth services against need, to establish if a projected shortfall remains, and c) by the end of this year, 2023, DCMS and DEFRA to publish findings from the call for evidence on rural youth services and develop proposals to fund and make up for any shortfall in provision over the next ten years. 84 Rural Mental Health