According to Defra’s Statistical Digest of Rural England, if you live in the countryside your life expectancy increases and you are less likely to die prematurely from cancer, stroke or coronary heart disease. On average, people born in very rural areas will live up to two years longer than those in major urban area.
While that’s great news for your physical health; far from being idyllic many people living in rural areas have lower overall accessibility to key services (including GPS, hospitals) and experience poverty, isolation and mental illness. With NHS England setting up a new taskforce and Mental Health Awareness Week (MHAW) taking place 11-17 May 2015, what can we do to reduce both the stigma and inequalities facing people experiencing mental distress in the countryside? Jessica Sellick investigates.
While there is a wealth of data about the number of people coming into contact with mental health services (1,746,698 in 2013-2014 – higher than the 1,590,332 in 2012-2013) or the number of people spending time as an inpatient; there is less research into rural mental health. Evidence that does exist seems to suggest mental health is probably better in rural areas.
However, the literature also finds: (1) there are a number of factors specific to rural areas such as demography, access to services, social exclusion and deprivation that may contribute to stress, anxiety and depression; (2) some rural occupations – including farming – have high suicide rates; and (3) those that develop mental illness in rural areas seem less likely to seek treatment compared to their urban counterparts. How, then, can we put mental health issues at the forefront of rural communities? I offer three points.
Firstly, what is the provision of mental health services in rural England like – and is there a ‘treatment gap’ (perceived or actual) in accessing them? Mental health services in England deal with a wide range of issues – from depression and psychosis conditions to drug and alcohol services and dementia.
Often divided into separate areas (e.g. adult, child, older adults, substance misuse etc.), these services and the mental health pathways for accessing them are organised at a local level meaning they can differ depending on where you live. Back in 2010, ONS analysed area based mental health data which revealed specialist adult mental health service usage varies dramatically by age and local authority.
In addition to provision being a ‘post code lottery’, research in Scotland has found common mental health problems are not recognised by people in rural areas as something that requires treatment and practical support. There can be a culture of self-reliance and stoicism towards mental health problems which prevents rural dwellers seeking medical help.
In September 2014, the University of South Wales published a report for the Welsh Government exploring the options for high quality and sustainable healthcare in Mid Wales - taking account of rural needs and cross-boundary/area challenges. The study found a good range of primary mental health support services for those with less complex problems, crisis support services in the community (reducing the need for hospital admission), and support for people in the earlier and middle stages of dementia.
But significant problems remain, including access to inpatient facilities for acutely ill patients, nursing home and other provision for people with dementia, and access to crisis support in some parts of the region. What will be the impact of an ageing population on service design and delivery?
To ensure or reduce a ‘treatment gap’ in England health policies and practice should be ‘rural proofed’ to avoid any inequitable distribution of resources. Indeed this is important as mental health service policy and service provision has been characterised by a shift towards more community based care. So how can we balance the ‘quality of mental health service’ with ‘distance of travel to access these services’?
Addressing any gap comes at a time when the current health care delivery system is under pressure like never before.
In response to a parliamentary question, NHS England disclosed children’s mental health services in England has fallen by more than 6% since 2010 (some £50 million); and the Royal College of Nursing suggest mental health nursing has suffered heavy workforce cuts compared to other areas of medicine: compared to 2010, there are approximately 3,300 fewer posts in mental health nursing and 1,500 fewer beds.
Yet over the same period demand for services has risen by 30%. Alongside this, London School of Economics and Political Science has found 75% of people with depression and anxiety receive no treatment and the extra physical health care caused by mental illness costs the NHS at least £10 billion each year.
In March 2015, NHS England announced it was setting up a taskforce to identify the best ways to provide people and communities with the information and support they need to develop good mental health and resilience. The taskforce intends to break down the barriers between mental and physical health as well as identify the best commissioning and provision of support so that people can expect the same standard of care regardless of where they live.
Secondly, what models of care work well in rural areas? Given the wide variation in need and local level pattern of services it is not appropriate to specify a model of care that should be provided in a given rural area. While rural mental health needs may not differ from those in urban areas; the planning, management and delivery of services will vary.
It is important to recognise how delivering successful mental health support in the community in rural locations is often supported or operated by the charities and the community and voluntary sector. At a national level charities such as ‘MIND’ - which seeks to address the challenges and stigma faced by those living in rural communities as part of its core activities - through to Farming Help (which runs a helpline and provides other support services for the farming community) provide support.
At a more local level there are a plethora of examples of good practice. There are groups that provide mutual support and advocacy – HUG represents the interests of users of mental health services across the Highlands of Scotland and ‘You Are Not Alone’ (YANA) provides a confidential helpline for those feeling isolated, depressed or unable to cope. In some rural areas mental health services are provided using custom-built vehicles (e.g. the Mindfulness Bus in Norfolk and Suffolk and Doris, the Vale of Clwyd Mind’s mobile outreach vehicle); and/or or using existing community venues (e.g. nurse and farmer health checks at auction mart; and Reading Well).
The Suicide Awareness Partnership Training (SAPT) project at RCC (Leicestershire & Rutland) aims to increase the awareness of good emotional health and mental well-being, and to reduce the stigma of suicide. While these mental health projects can be the key to crisis prevention, they are often without stable resources to make it happen; impacted by Local Authority budget reductions around social care, housing and health and/or inflexible procurement and commissioning processes, finance, time pressures and service fragmentation.
Thirdly, how can we improve rural mental health services? The King’s Fund suggests encouraging new providers to enter the market and for the government to disseminate innovative service models and good practice. It is worth remembering – and demonstrated by the examples above – that in rural parts of the UK we already provide innovative solutions.
What is often lacking in current debates is a discussion around the ‘quality’ of mental health services being delivered in the countryside and ‘how to measure’ this – whilst being mindful of costs/budgets we need to look at the difference our interventions are making to an individual as well as the broader outcomes for communities rather than focusing simply on performance frameworks and value-for-money tests.
Above all, we need to change perceptions (e.g. anti-stigma activities) to break the silence. For many of us mental health is not about statistics, models or innovation but how we can ‘prevent things from getting to the desperate stage’.
Jessica is a researcher/project manager at Rose Regeneration; an economic development business working with communities, government and business to help them achieve their full potential. She is about to undertake a review of a Lottery funded project focusing on how to conserve and improve a town’s assets for future generations as well as completing a European project on ‘social value’.
Jessica’s public services work includes research for Defra on alternative service delivery and local level rural proofing. In her spare time Jessica volunteers for a farming charity that offers a 24/7 advice and support service for farmers, their families and the wider community with the purpose of 'preventing things from getting to the desperate stage'.
On Thursday 11 June 2015 the Rural Services Network is organising a Rural Health Conference. “Challenging Times – A New Dimension?” is being hosted at the Health and Wellbeing Centre in Truro. Speakers include Lezli Boswell (former Clinical Lead for Remote and Rural Services NHS England), Duncan Selbie (chief executive, Public Health England) and Lord Cameron of Dillington, (chairman of the Cameron Report 2015). Further details including how to book your place can be found here.
More information about the RSN’s work on health services and the Rural Health Network can be found here.