We're grateful to read the British Medical Association (BMA)'s report on the mental health care system, and to learn about the experiences of doctors that are working within the system.
The report shares doctors' experiences working within the mental health system: from GPs, to emergency practitioners, to psychiatrists and others, and offers recommendations to the Government as to how they can work to improve not just mental health support, but the health care system as a whole through reducing the pressure put on the system by failings in mental health care provision.
It's somewhat disappointing, however, that the huge role that counselling/psychotherapy play in a private capacity, either through individuals or workplaces, has been overlooked. Where the system is failing those that can afford to pay for it, they are choosing to access therapy privately, thereby reducing the burden on the NHS out of their own pockets.
The NCPS argues that this further embeds inequality within our Society, and that if we wish to alleviate some of the causes of mental illness through - for example - poverty, then perhaps we should also be looking at how those that aren't experiencing poverty choose to use the resources they have to support their own mental health and wellbeing, and that fact that people who can't afford to do that are therefore not accessing those services, and subsequently ending up at crisis point and in A&E.
It's regrettable that the report doesn't examine patients' journeys from low-level issues with their mental health through to crisis point, as this is precisely where an understanding of the role of counselling/psychotherapy in mental health provision would have supported their work.
That being said, we're delighted to read the following section of the report:
However, there are limitations to NHS Talking Therapies. Firstly, the types of therapy available for people within the programme are limited. CBT is an effective therapy for some, but it is short-term and highly structured which may not suit everyone. For people whose illness is not complex or severe enough for specialist services, but for whom CBT is not useful, there are limited options within the NHS. With no other therapy treatment options available in primary care and higher thresholds for referrals to specialist mental health services, this is leaving a significant gap for access to other psychological therapies.
BMA Mental Health Report 2024 p. 33
The report touches on a number of areas, including a lack of funding, a lack of trained staff with the right mix of skills, poor interorganisational and interdepartmental working, as well as broader issues such as societal causes of mental ill-health, and the effects of all of these issues on particular, vulnerable patient groups.
We'll take a look at some quotes from the report, and share some of our thoughts around the issues presented by the BMA.
A lack of qualified staff is a particular problem for child and adolescent mental health services (CAMHS). 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 expanded at over 3 and a half times the pace of the psychiatry workforce.
BMA Mental Health Report 2024 p. 12
For children and young people the picture is also bleak. In February 2024 it was reported that the number of children referred to emergency mental healthcare in England had soared by more than 50% in three years.
BMA Mental Health Report 2024 p. 21
For children and young people, the latest evidence suggests that rates of mental illness may be growing at a faster rate than amongst adults. Between 2017 and 2022, rates of probable mental disorder increased from around 1 in 8 young people aged 7-16 to more than 1 in 6. For those aged 17-19, rates increased even faster, from 1 in 10 to 1 in 4. The importance of intervening early in someone’s life to prevent or manage mental illness cannot be overstated. Over half of all mental health disorders start before the age of 14, with 75 per cent by 24 years of age. Early intervention is therefore key. Despite this, many are not able to access the help they need when they need it. In 2022, a major study conducted by Young Minds of nearly 14,000 young people under 25 found that over 40% waited over a month for mental health support after seeking it.
BMA Mental Health Report 2024 p. 34
“The most heart breaking for us is seeing how many children we deal with, who, be they at school or university, are left waiting and waiting for years even to be seen once you know, and then they’re given a leaflet or, you know, an online programme, I mean it’s just horrendous.”
Interviewee 8, Consultant Psychiatrist
BMA Mental Health Report 2024 p. 34
This is something that members and regular readers will know we have been talking about for some time now. Cases are being referred to CAMHS where they could be seen by a counsellor/psychotherapist that specialises in Children and Young People's therapy. This would take the pressure of CAMHS, and mean that only cases that require more clinical intervention are referred, meaning they are seen quicker and by staff that are less pressured, burnt out, and demoralised, leading to a better patient experience.
Whilst GP training equips people to treat and support people with uncomplex common mental disorders, such as low-level anxiety and depression, it does not necessarily equip them for more complex cases. However, increasingly more complex cases are remaining in general practice due to the difficulties of referring them to secondary care.
BMA Mental Health Report 2024 p. 19
Of course, there is a third option, which is direct referral where appropriate to counsellors/psychotherapists on Accredited Registers using, for example, something akin to Social Prescribing or Personal Health Budgets. They do not have to stay within general practice, nor do they necessarily have to access psychiatrists or psychologists.
Volunteer services are also crucial for the promotion and protection of good mental health and can be vital to prevent the onset of acute illness. Where NHS services cannot necessarily provide specific support for groups that are unfortunately often still less well served by mainstream services, such as LGBTQ+ groups, the voluntary sector can provide tailored support for people who would benefit from a more inclusive approach to mental health promotion and prevention.
BMA Mental Health Report 2024 p. 24
It's great to see the BMA recognising the role of the third sector in supporting mental health within the UK. With many NHS-commissioned counselling services working with, for example, trauma, or rape/sexual abuse, being closed across the country in favour of services staffed by psychological wellbeing practitioners (as reported to us by our members), we hope that this report will help to address that.
There is a well-established body of evidence showing that prevention is better than cure and benefits us all. From a population health perspective, the chances of becoming ill are lower. For the doctor, there is less demand on over-stretched services. For the UK government, it is more cost-effective. The cost of mental illness is significant, and the aforementioned figure of nearly £101 billion in England alone is an underestimation as it does not include the costs associated with dementia, intellectual disabilities, alcohol or substance abuse, or deliberate self-harm or suicide. Despite this, there appears little sign the UK government has grasped the significance of the issue and how failing to tackle these wider social issues is increasing demand for NHS mental healthcare. Doctors feel they are picking up the pieces of a government that is failing to protect the mental health of the population and mitigate demand on overstretched NHS services.
BMA Mental Health Report 2024 p. 27
Counselling/psychotherapy are perfectly placed to act as preventative therapies. Not only is it preventative in terms of reducing the risk of worsening mental health, but there was a study conducted recently at Barts Health NHS Trust and the East London Foundation Trust that shows that it has a preventative effect when it comes to worsening physical health, too. You can see our blog post and a link to information about the study here.
The doctor-patient relationship is crucial in mental healthcare to promote recovery. For people who have suffered trauma, who are experiencing feelings of acute anxiety, or who are in emotional distress, it can be hard to trust someone enough to share details of difficult life experiences with them. To establish a trusting relationship takes time, and to maintain that trust requires continuity of care. Unfortunately, doctors are increasingly unable to see their patients as often or for as long as they might like, both in primary and secondary care.
BMA Mental Health Report 2024 p. 32
It's great to see the BMA report acknowledging this; it would be even better to understand that the relational aspect of counselling/psychotherapy is what makes it such a valuable resource in mental health provision.
This section felt important enough to pull out in its entirety, as it echoes much of what the Society has been saying for some time:
There are not enough opportunities for doctors to refer patients to psychological therapies beyond the NHS Talking Therapies Programme
In mental healthcare, there are two main types of clinical care, psychological and pharmaceutical. Both can be effective for patients, especially when used together. However, the provision of psychological therapies requires more staff and is therefore more impacted by the disparity between demand and supply in the NHS.
“Fundamentally, we don’t have the resources for patients that we did 10 or 15 years ago. So thresholds for seeing us are much higher than they were, thresholds for having talking therapy are completely in a different league to what they were 10 or 15 years ago, and waits for stuff like that are much longer.” Interviewee 1, Consultant Psychiatrist
Psychological therapies deployed by psychologists, psychotherapists, family therapists, and medical psychotherapists are crucial in the treatment of mental illness. The most common, publicly available talking therapy service available for people with a mental illness in England is the NHS Talking Therapies Programme, formerly known as Improving Access to Psychological Therapies (IAPT). This is a short-term primary care talking therapy service for people with a common mental disorder (such as anxiety, depression, or obsessive compulsive disorder), with most treatments based on cognitive behavioural therapy (CBT). This programme is a centrepiece of the NHS’ recent focus on mental health, with over 1 million people using the service annually. NHS England continues to expand it, with the aim of reaching a significant proportion of people with a common mental disorder. Recovery 33 rates for the service are getting better (though still only just above 50%), and targets for people to be seen within six weeks are consistently met. Latest data shows that in August 2023, 89.7% of referrals waited less than six weeks to access NHS Talking Therapies services, and 50.3% moved to recovery (slightly above the target of 50%).
However, there are limitations to NHS Talking Therapies. Firstly, the types of therapy available for people within the programme are limited. CBT is an effective therapy for some, but it is short-term and highly structured which may not suit everyone. For people whose illness is not complex or severe enough for specialist services, but for whom CBT is not useful, there are limited options within the NHS. With no other therapy treatment options available in primary care and higher thresholds for referrals to specialist mental health services, this is leaving a significant gap for access to other psychological therapies.
“So if you’ve got quite a low level mental health problem like anxiety or depression, you can actually access [NHS Talking Therapies.] But then as soon as that person feels suicidal, that becomes like an exclusion for that. And then you wonder who’s gonna see them. And if you become repeatedly or have long-term suicidal ideas, you seem to be excluded from a lot of things. And then if you look at, say, the specialists in the complex needs services, they’ve got massive waits to go in there.” Interviewee 4, Consultant Psychiatrist working in A&E
Secondly, people with active suicidal ideation, or more complex mental illness (or severe mental illness known as SMIs), such as bipolar disorder, personality disorder, or a primary diagnosis of an eating disorder are excluded. For example, for someone with a personality disorder, a different type of therapy, Dialectic Behavioural Therapy (DBT), may be more useful, but it is much harder to access than CBT. People with an SMI are therefore more adversely affected by poor access to psychological therapies.
“So you get, you know, a little bit of CBT or whatever when really you need…psychodynamic therapy or interpersonal therapy or DBT…Access to non-drug therapy is shockingly poor.” Interviewee 7, Psychiatrist
Meanwhile, there are inequalities in outcomes for people from black and other ethnic minority communities within the NHS’s largest talking therapies programme. This should be of deep concern. In addition to this, the most recent Adult Psychiatric Morbidity Survey found that 14.5% of white British people aged 16 and over were receiving treatment for mental health compared with only 6.5% of people from black and minority ethnic backgrounds. Improving access to Talking Therapies must be a crucial part of addressing this disparity. The NHS Race and Health Observatory report noted poor outcomes can be tackled and even disappear when access is improved, and culturally sensitive therapy is provided.
BMA Mental Health Report 2024 p. 33
Although the expansion of NHS Talking Therapies has largely been a success, there needs to be a wider range of psychological therapies available, with more consideration of how to close the gap for people from black and minority ethnic groups. This will ensure people are not unnecessarily excluded from better mental health and a better quality of life.
BMA Mental Health Report 2024 p. 33
A recent major study by the NHS Race and Health Observatory into IAPT (or the NHS Talking Therapies Programme as it is now known), found that in comparison with White British people, with the exception of Chinese people, people from minority ethnic groups (including non-British White people) experience worse outcomes (although this has narrowed in recent years), wait longer for assessment, and are less likely to receive a course of treatment following assessment. One recent study also found that black people were less likely to refer themselves to NHS Talking Therapies (known as IAPT at the time of the study).
BMA Mental Health Report 2024 p. 37
Another practical step that can be taken to address poorer rates of access and outcomes is to address the overwhelmingly white Talking Therapies practitioner workforce. The ethnicity of the Talking Therapies programme workforce is broadly consistent with population demographics across England, with 80% of staff reporting their ethnicity as ‘White or White British’ compared with 83% of the wider England adult population. However, the fact that black people have higher rates of mental illness suggests a significant disparity. In a survey for the Race and Health Observatory report just over one-third of clinical leads (34%) and commissioners (36%) ‘disagreed’ or ‘strongly disagreed’ that in their Talking Therapies programme, the clinical workforce reflected the population served. A 2016 qualitative study found that black and minority ethnic service users felt that therapists may not understand their presenting problem within their psycho-social context. The importance of representation cannot be overstated when working with a population who have little faith that their culturally specific needs will be accounted for in treatment.
BMA Mental Health Report 2024 p. 37
This is something the counselling/psychotherapy profession is already tackling, and we have been working together to improve diversity within the profession and within our clients for some years now. We have co-produced a highly-regarded toolkit for training providers to utilise within their institutions in order to promote inclusivity and anti-oppressive practice, and are all actively working together in order to ensure that this is embedded within training across the profession.
You can find out more about the project, and download a copy of the toolkit, here.
