Mental health social care and winter pressures

This project will scope the issues involved in developing good winter planning for mental health social care (MHSC). This is a neglected area of research, meaning there is little robust research evidence to guide practice. In this section, we set out, first, the importance of social care in mental health care systems, then the wider context of winter planning in health and social care, and the impact of the pandemic. Finally, we define the focus of this project and the proposed methods.

Although the final project report will be relevant to stakeholders in MHSC, the longer-term research impact of this study will be seen in follow-on evaluative proposals, for example through the NIHR Health & Social Care Research Delivery programme and the NIHR Research for Social Care programme.

• Introduction

  Good social care is essential to a high-quality mental health care system, bringing distinctive roles, support, and values alongside NHS mental health care. In important respects, social care contributions are defined by legislation including the Care Act 2014, the Mental Health Act 1983 and the Mental Capacity Act 2005. These define social care roles and responsibilities in mental health including safeguarding, Section 117 aftercare, employing Approved Mental Health Professionals (AMHPs), providing advocacy, and considering mental capacity and Liberty Protection Safeguards (Deprivation of Liberty Safeguards). Social care also contributes to mental health care beyond these legislative requirements in terms of underpinning perspectives. A range of flexible social care supports is important to communities.

  It is clear, then, that social care needs to be coordinated with NHS care in local mental health systems. National policy recognises this interconnection of NHS mental health care and social care, and promotes integration to improve support, e.g. in emerging Integrated Care Systems (ICSs) and in the recent White Paper Joining up care for people, places and population reemphasise the importance of integration. Localities are planning the detail of this as they plan to implement The Community Mental Health Framework for Adults and Older Adults.

  However, as Lyn Romeo, then Chief Social Worker for Adults in England, commented regarding the relationship between social care and mental health care: “the vital role of social work, social care and local government can still sometimes be overlooked. Every day across England, thousands of social workers use their specific skills and knowledge to support people with mental health problems. Within local government, the NHS, charities, social enterprises, not-for-profit and private care organisations, social workers provide a distinctive contribution to mental health”.

  Developing good coordinated/integrated systems is challenging. Integration of mental health social workers into NHS teams, for example, is not a simple panacea. Benefits are not guaranteed, and integration risks leaving social workers feeling constrained within a health-dominated approach and NHS management.

  Adverse consequences may arise from failure of NHS and social care mental health support to work together, including risks to individuals and systems. A possible factor behind the rise in psychiatric admissions is a reduction in the quality and/or quantity of social care provision in community mental health. High bed occupancy, delays in transfers of care, and accessing alternatives to admission have all been highlighted in monitoring of the Mental Health Act. Failure to coordinate health and social care support may contribute to an increase in Out of Area Placements, where people are placed in care facilities away from their home locality, with negative impacts on their wellbeing and costs to families, friends and local care systems.

  Winter is noted as bringing additional pressures to the social care system and the NHS. Over the last decade, the Cold Weather Plan has been published and incrementally developed.8 The plan issues advice to local authorities, the NHS and other agencies on reducing harm to people from adverse cold weather. Winter planning has a higher profile in the NHS than in social care, but even there its impact has been uneven; it is largely focused on the urgent and emergency care pathway and flows through hospitals. Consequently, data to gain a holistic understanding of care systems in winter are lacking; mental health care is a recognised gap in analyses.

  Whilst the headlines for winter planning focus on extreme cold and snowy conditions, even relatively modest temperature drops down to 4-8 degrees Celsius can have significant impacts on services as people with some chronic conditions start to suffer more, and influenza and other communicable diseases can begin to put pressure on services and health and social care workforces. Guidance is, then, for localities to organise more generalized cold weather planning, and not only for extremes. A significant challenge in this is identifying vulnerable people; it often rests on opportunistic contact with staff as to how to identify vulnerability and the best interventions to address it are poorly evidenced. Despite mental health being a stated risk factor in the Cold Weather Plan, it may be overlooked in local planning. Lower mood during winter months, reduced capacity for self-care, or poorer physical health may increase vulnerability. Without good crisis services, some people may use A&E for mental health support and add to winter pressures in those departments

  The COVID-19 pandemic added extra complexity to considering and responding to demand on mental health services and on staff working in them.Overall, the pandemic has highlighted the need for mental health care systems to plan for more severe events, including weather-related, and consider adapting support to those conditions.

  In response to the pandemic, the government announced £87m to improve discharge processes from mental health settings, noting that this needed to be done with social care support. As local authorities planned for winter 2021-22 during that phase of the pandemic, many acknowledged that they faced difficult choices to prioritise needs, manage risks and plan actions.

  There are risks to individuals and systems, then, if winter planning for NHS and social care mental health support fails. A parallel might be drawn with physical health and social care and winter pressures. For example, there may be difficulties with community care, including social care, leading to increased admissions to hospital, and potential delays to transferring people out of hospital. Individuals may face a range of risks if services do not function well. In mental health, the added risk with these scenarios is more people being moved out of area. The detail of these risks in mental health is, though, poorly evidenced.

  Systems require a better evidence base upon which to plan for mental health winter pressures and to understand the role of social care in this. In Autumn 2021, DHSC requested that the National Mental Health and Wellbeing Policy & Oversight Group (POG) write guidance for local mental health and social care systems to assist with winter planning. This included a key focus on social care, such as its part in helping people to stay in their localities and connected.

  The POG is led by the third sector and the Association of Directors of Adult Social Services (ADASS) at the request of DHSC. Membership includes representatives from third sector organisations, including providers of MHSC, local authorities, DHSC (Chief Social Worker and policy colleagues), and people with lived experience.

  The POG experienced challenges in writing the winter planning guidance, including uncertainty about scope, articulating responsibilities, identifying good/promising practice, a poor evidence base, and limited data. This leaves important questions for improving winter planning. Lessons can be learnt about the process of developing the guidance and its impact on practice and planning. This project aims to scope these concerns, including establishing research priorities. The focus is on support for adults. This is timely as the stakeholders engaged in this work will have had time to digest the original guidance document, its implications, and lessons in one winter (2021-22), developing response in another (2022-3) and for planning for the next winter (2023-4).

   

• AIms

  1. To explore, at the national level, perspectives on and understanding of MHSC within winter planning in general and specifically for mental health support.
  2. Identify lessons and scope key issues arising from the process of developing the POG winter planning guidance, the place of MHSC within it, and scoping how we understand impact in this area.
  3. Identify promising services and localities that could be evaluated and prioritise research questions.
  4. Report project findings to inform future winter planning guidance and future research

   

• Design and methods

  Ethical review will be sought from the London School of Economics & Political Science.

  1. A sample of members of the POG will be interviewed to scope the issues involved in understanding winter planning and its relation to MHSC. This will include lead authors of the guidance, and representatives from the third sector, local authorities, ADASS, DHSC, and people with lived experience (who will be offered payment). We will interview relevant representatives beyond the POG in NHS England and the Care Quality Commission for wider system views. Interviewees will be asked to identify promising practices and localities/organisations thought to have been especially successful/stressed during winter. We will ask them for research priorities (N=15 interviews) (aims 1, 2 & 3).
  2. We will interview a sample of five additional people suggested by interviewees in stage 1 as having insightful views on the issues/good practice/priorities, e.g. from provider organisations and/or localities with relevant strengths (N=5) (aims 1, 2 & 3).
  3.  Analysis of data – All interviews will be conducted virtually by Michael Clark (MC). All interviews will be recorded (with permission) and transcribed. Thematic analysis will be used for the analysis as it offers a flexible yet structured approach suitable for this scoping.24 MC will undertake analyses; the whole team will discuss and reflexively review emerging findings.
  4. In an online workshop, we will present emerging main themes and findings with stakeholders from the POG and its networks (preparing for aim 4).
  5. Final report and other presentations to stakeholders, as identified throughout the knowledge exchange through POG stakeholder engagement (aim 4).

  Throughout all interviews, we will scope Equality, Diversity & Inclusion (EDI) issues in the context of winter planning and MHSC. We will ask interviewees about the extent to which winter planning for NHS and social care mental health support is being developed to be inclusive of different communities (covering protected characteristics and socioeconomic status). We will scope the challenges they face in this respect, e.g. access to data, engaging with individuals/communities, identifying vulnerable individuals, and drawing on evidence. We will ask for examples of promising practices to improve EDI in MHSC winter planning for future studies.