Rural Mental Health: Government Response to the Committee’s Fourth Report

Seventh Special Report of Session 2022–23

Author: Environment, Food and Rural Affairs Committee

Related inquiry: Rural Mental Health

Date Published: 3 November 2023

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Contents

Seventh Special Report

The Environment, Food and Rural Affairs Committee published its Fourth Report of Session 2022–23, Rural Mental Health (HC 248), on 18 May 2023. The Government response was received on 20 October 2023 and is appended below.

Appendix: Government Response

Introduction

On behalf of the government, we would like to thank the Environment, Food and Rural Affairs Committee for its report on Rural Mental Health, published on 18 May 2023.

We would also like to thank everyone who contributed their time and expertise to engaging with the inquiry.

We remain committed to supporting thriving rural communities, as set out in our recent report Unleashing Rural Opportunity, published in June 2023. The mental health of our rural communities is an important matter and essential if those communities are to thrive. We recognise that those living and working in rural areas may face specific challenges in accessing the mental health services that they need.

Since the launch of the Committee’s inquiry in 2021, considerable progress has been made to help ensure access to mental health services in rural areas. We have reflected on the Committee’s recommendations to which we are formally responding to below.

Our Suicide Prevention Strategy for England: 2023 to 2028, was published on 11 September 2023. This strategy sets out our ambitions over the next five years to: reduce suicide rates, improve support for people who have self-harmed, and improve support for people bereaved by suicide, and it identifies actions to tackle known risk factors.

The strategy identifies and sets out plans to address several key risk factors for suicide which will be relevant for agricultural and veterinary workers, including financial insecurity and economic adversity, and loneliness and social isolation.

In August 2023, the Department for Health, and Social Care (DHSC) launched a £10million Suicide Prevention Grant Fund to support the suicide prevention voluntary, charity and social enterprise sector to deliver activity that helps meet the increased demand for support, and to embed preventative activity that can help to prevent suicides and stem the flow into crisis services.

The NHS’s Long-Term Plan, published 2019, made a renewed commitment to improve and widen access to care for children and adults needing mental health support. The plan committed to expand and transform mental health services, increasing investment in mental health care by at least £2.3 billion a year by2023/24, (total expenditure in 2022/23 was £13.64 billion, which includes spending for Learning Disability and Dementia).

In order to address health inequalities, NHS England (NHSE) allocates funding to each Integrated Care System using a weighted capitation formula based on the size of the local population and its needs. The formula takes account of the additional costs associated with rural areas in a few ways, including by factoring in population age, supply-induced demand, distance of services and the length of time it takes an ambulance to reach an incident.

We remain committed to delivering a Green Paper on transforming children and young people’s mental health provision. Work is well underway to roll out mental health support teams in schools and colleges. Around 400 teams are now operational, covering 3.4 million pupils and learners in England in 6,800 schools and colleges. A further 100 teams are in training, taking the total number of operational teams to approximately 500 by spring 2024. Teams will cover at least 50% of pupils in England by the end of the 2024 to 2025 financial year.

Through its Farming and Countryside Programme, Defra is working with a range offarming charities to ensure that planned changes in policy are delivered effectively, and any additional burden placed on farmers and landowners is minimised. This includes contributing to the Royal Agricultural Benevolent Institution’s Big Farming Survey, which has highlighted mental health challenges for farming communities,and the Yellow Wellies charity, which provides advice and information on how to identify potential mental health issues and provide tools for addressing them.

Defra’s Farming Resilience Fund provides free business support to farmers in England to help them adapt to the Agricultural Transition Plan. The expertbusiness support available is intended to have a positive indirect impact on farmer wellbeing, with delivery providers operating signposting services to professional mental health and wellbeing support where appropriate.

We continue to work closely with the veterinary profession, including the RoyalCollege of Veterinary Surgeons (RCVS) and the British Veterinary Association(BVA). Defra regularly engages with both these organisations and with the widerprofession such as Vet Life who have schemes in place such as the RCVS MindMatters Initiative and the BVA Good Veterinary Workplace Scheme to support themental health of veterinary workers. Given existing close working with the veterinary profession we do not believe that it is necessary to set-up a national working groupasrecommendedin theCommittee’sreport.

We share the Committee’s concern that the Index of Multiple Deprivation (IMD) ascurrently formulated is less effective at reflecting deprivation in rural areas than it is in urban areas. To address this, Defra is collaborating with the Department of Levelling Up, Housing and Communities on a review and update of the EnglishIndices of Deprivation, including strengthening understanding of deprivation in ruralareasandhow itcanbe measured.

Improving mental health has been identified as one of the priority drivers for the well-being mission, which was initially set out in the Levelling Up White Paper and is subsequently being refined by government following further analytical work and engagement to define a clear, credible, and ambitious mission.

The government has committed to rural proofing policy making and its implementation to ensure that the unique challenges of rural communities are considered. The annual rural-proofing report is the key tool in highlighting this work. The second of those reports, Delivering for Rural England, was published September 2022. It sets out further details on the government’s approach to levelling up rural areas. The third report will be out later this year.

Online access to mental health services provides a solution for overcoming accessibility issues in rural areas, and realising these opportunities is dependent on digital connectivity. We are investing £5 billion in Project Gigabit is our flagship programme to enable hard-to-reach communities to access lightning-fast gigabit-capable broadband. As set out in Unleashing Rural Opportunity, BDUK (BuildingDigital UK), the executive agency of the Department for Science Innovation and Technology, is responsible for broadband rollout, and expects to have procured all regional contracts by the end of 2024.

The Department for Transport (DfT) will look for opportunities to work with Defra, DHSC, and NHSE to maximise health outcomes for rural communities through the transport system. DfT recently published its report “Future of Transport: supporting rural transport innovation” which considers how innovation and emerging transport technologies can improve rural communities’ access to services, which will include healthcare.

Whilst we note the Committee’s report recommendation for a joint Defra/DHSC ruralmental health team, we do not believe it is necessary to establish one. It is moreimportant that both departments, and others in Whitehall, work effectively togetherand ensure rurality is considered as an issue in delivery of policy. As set out in thisresponse, there are several areas where collaborative working across government is already taking place—for example on the suicide prevention strategy and the joint Defra/DHS Croundtable on farmers mental health we are planning for early next year—and this joined-up working will continue and develop further as opportunity arises.

We acknowledge the Committee’s recommendation to ringfence additional funding ,beyond 2023/24, for local suicide prevention. We are proud to be investing an additional £57 million in suicide prevention by 2023/24 through the NHS Long Term Plan. Through this, all areas of the country are seeing investment to support local suicide prevention plans and the development of suicide bereavement services.

Funding beyond 2024/25 is subject to future Spending Reviews, and we will consider further opportunities to build up on this investment for suicide prevention.

DHSC does not plan to develop a workplan with NHSE and local health and occupation charities, since setting and managing targets for local systems would notalign with NHSE’s new operating model, following the recommendations of theHewitt Review. However, DHSC is committed to improving the support available forpeople with mental ill-health, including those in the agricultural and veterinary sectors.

We do not agree with the Committee’s recommendations to issue a Call for Evidence on youth services. Given the Youth Review undertaken by the Department for Culture, Media, and Sport (DCMS) in 2021 was conducted so recently and with such a large number of young people engaged, and sector organisations and academics heard from, DCMS does not believe it is proportionate to run an additional external consultation at present.

We remain committed to improving the mental health support available to rural communities and access to it. We will continue to work together and across Government to ensure that this done.

Secretary of State Defra

Minister for Mental Health DHSC

Annex A: EFRA Committee Report on Rural Mental Health: Government response to recommendations

1. We recommend that the:

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]

The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for people who have self-harmed, and improve support for people bereaved by suicide.

Informed by the Mental Health Call for Evidence launched in 2022, the strategy identifies priority groups, suicide risk factors and the steps we need to take in consultation with individuals, organisations across national and local government, the NHS, the private sector, the voluntary, community and social enterprise sector (VCSE), and academia. This includes steps and actions to tackle known risk factors, many of which the EFRA Committee’s report rightly identifies as affecting those living in rural areas, including agricultural workers and veterinary workers.

In addition to the strategy, DHSC recently launched a £10 million Suicide Prevention Grant Fund to support the suicide prevention VCSE sector to deliver activity that can help sustain their services to help meet increased demand for support, or to embed preventative activity that can help to prevent suicides and stem the flow into crisis services. The strategic objectives of the Fund are:

  • to support non-profit organisations to configure their suicide prevention services and activities to better meet the increased demand seen in recent years,
  • to support a range of diverse and innovative activity that can prevent suicides, both at a national and community level.

The Fund is particularly targeted towards supporting suicide prevention activity in geographic areas where demand for services is greatest and where there are disparities in provision and access to services, compared to other regions in England.

We are proud to be investing an additional £57 million in suicide prevention by 2023/24 through the NHS Long Term Plan. Through this, all areas of the country are seeing investment to support local suicide prevention plans and the development of suicide bereavement services. Funding beyond 2024/25 is subject to future Spending Reviews, and we will consider further opportunities to build upon this investment for suicide prevention.

The government recognises that suicide risk by occupational groups may vary nationally, and even locally, and it is vital that the statutory sector and local agencies are alert to this and adapt their suicide prevention interventions accordingly. We know that there are a range of issues that veterinary sector workers and agricultural workers are faced with that are beyond their control, and which can impact on their mental health. We also know that the farming industry is a male-dominated industry and that men are at higher risk of suicide, and less likely to seek help or talk about mental health.

To further improve our understanding of risk, the Office for National Statistics (ONS) is using data from Census 2021 linked with other administrative datasets, including NHS Talking Therapies, Hospital Episode Statistics, and death registration data, which will help to improve understanding of the suicide rates in different occupations, including farmers. The aim is to use this data to identify where actions should be prioritised to support different occupations.

2. 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. [Paragraph 96]

We recognise the importance of “rural proofing” health policy and applying a cross-governmental approach to ensuring that the mental health needs of rural and other communities’ are reflected in mental health government policy.

Whilst we note the Committee’s recommendation for a joint Defra/DHSC rural mental health policy and delivery team, and agree that it is important for both departments, along with others in Whitehall, to work together to ensure rurality is considered as an issue in delivery of policy, we believe existing channels would be a more effective way of achieving this.

As set out in this response, there are several areas where collaborative working across government is already taking place, and this will continue and develop further as opportunity arise.

The government is committed to its levelling up mission to narrow the gap in Healthy Life Expectancy by 2030 and increase Healthy Life Expectancy by 5 years by 2035. As part of this, we recognise that different parts of the country face different health challenges. This includes rural areas where, for example, there is a higher proportion of older people, which presents specific social and economic challenges locally and nationally due to their health needs. Our approach will continue to focus on supporting people to live healthier lives, helping the NHS and social care to provide the best treatment and care for patients, and tackling health disparities through national and system interventions, such as the NHS’s Core20PLUS5 programme.

DHSC frequently engages other government departments, local government and VCSE organisations to ensure that the promotion of people’s mental wellbeing is of the utmost importance. Recognising the cross-government nature of the determinants of mental health and wellbeing, DHSC works closely with colleagues across government departments to build and support policymaking.

The upcoming Major Conditions Strategy will tackle conditions that contribute most to morbidity and mortality across the population in England, including mental ill-health, cancers, cardiovascular disease (including stroke and diabetes), chronic respiratory diseases, dementia, and musculoskeletal conditions. Health disparities exist across a wide variety of conditions from cancer to mental health and contribute to this variation in life expectancy. Different parts of the country face differing health challenges. In taking forward the Major Conditions Strategy we will work to reduce inequalities in health outcomes, so the community you live in does not make it more likely you will experience ill health.

Our interim report—Major Conditions Strategy: case for change and our strategic framework—was published in the summer.

Future collaboration will be supported by the roll-out of the Mental Health Impact Assessment Tool, which will assist policymakers, across government, to consider the mental health and wellbeing impacts of all policies without undue burden.

Integrated Care Boards (ICBs) are responsible for tailoring and delivering services in accordance with local population needs and priorities. While NHS England (NHSE) remains committed to addressing inequalities in mental health services, the EFRA Committee’s report recommendation to set targets to measure and improve outcomes for rural mental health services and support rural health providers, is contrary to NHSE’s new operating model. Setting and managing national targets for local systems as recommended by the Committee would not align with NHSE’s overall strategic direction towards fewer national targets and more local accountability, as laid out in the Hewitt Review.

However, NHSE has an ongoing programme of work to embed equalities thinking in planning and delivering commitments in local health systems. The NHS Long Term Plan set out this requirement through a commitment to advancing mental health equalities. The Long-Term Plan also committed to further drive progress towards digitally enabled mental health care. The pandemic has already significantly sped up the transformation towards virtual means of accessing mental health services when systems rapidly shifted to remote service delivery to be able to stay open. We recognise the benefits of expanding this provision as an opportunity to overcome transport and connectivity barriers in rural areas.

In response to the Committee’s recommendation that Defra should consult on how the Rural Wellbeing Framework will be used to measure rural communities’ mental health, the Rural Wellbeing Framework is intended as a tool to inform the development and evaluation of policies in rural areas and to incorporate wellbeing of communities and individuals. As such it can inform work on rural mental health, but it is not intended as a framework for measuring rural mental health and Defra does not intend to consult on its use.

3. 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. [Paragraph 115]

Unleashing Rural Opportunities, published by the Government in June 2023, sets out a range of actions being taken across government in support of rural areas including work to improve access to transport, digital connectivity, and support for farmers’ mental health wellbeing through Defra’s Future Farming Resilience Fund.

It is vital that everyone can access support for their mental health when needed, no matter where they live. Government recognises that those living in rural communities may experience different or additional challenges to accessing mental health support than those in urban areas. Work is already underway across government to address these challenges.

As part of the third phase of the NHS response to Covid-19, NHSE, DHSC has asked ‘Integrated Care Systems’ (ICSs) to develop digitally enabled care pathways in ways which increase inclusion, including reviewing who is using new primary, outpatient, and mental health digitally enabled care pathways. Digital solutions in mental health enable remote multidisciplinary team functioning and information sharing to reduce administrative burden and to improve patient experience, including patients with specific needs. A prime example of these are virtual appointments, that are today used across a range of services and are proving particularly beneficial for users in areas where services are often far away from people’s homes and communities.

In the Spring 2023 Budget, we announced over £400 million to support the long-term sick and disabled to remain in or enter employment, including around £200 million for digital mental health. This funding will modernise and digitise mental health services in England, providing wellness and clinical grade apps free at the point of use, pilot innovative digital therapies, and digitise the NHS Talking Therapies programme.

For rural communities, where access to talking therapy services may have been compromised in the past because it required long journeys to community hubs, patients now have a greater choice in how they receive therapy, and hence easier access. While DHSC recognises the importance of access to face-to-face care, NHS mental health services now also offer digital and remote access where appropriate to maintain care and accept new referrals. Therapy can be delivered via the telephone, text messaging, email or via digital packages that do not require the patient and therapist to be online simultaneously. This allows citizens to work around lifestyle and geographical factors, leveraging the power of digital accessibility.

For those with severe needs or in crisis, all NHS mental health providers have established 24/7 all-age urgent mental health helplines, which currently receive around 200,000 calls each month. It is intended that, by 2024 to 2025, all parts of the country will have introduced crisis text lines to enable easier access to crisis care for those with specific needs, such as people who are neurodiverse and other marginalised groups.

Given the opportunities to access mental health services online, we also recognise the importance of ensuring that everyone has access to good quality broadband. This why the government is delivering the biggest broadband upgrade in UK history. Project Gigabit is the government’s flagship £5 billion programme to enable hard-to-reach communities to access lightning-fast gigabit-capable broadband. It targets homes and businesses that are not included in broadband suppliers’ commercial plans, reaching parts of the UK that might otherwise not get the digital connectivity they need.

DfT will look for opportunities to work with Defra, DHSC, and NHSE to maximise health outcomes for rural communities through the transport system.

4. 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. [Paragraph 124]

DHSC fully recognises the importance of ensuring that NHS mental health services are accessible for rural communities. Work is already underway to support integrated care systems (ICSs) in providing rural communities with access to mental health services.

Firstly, the NHS Long Term Plan set out an expectation for all systems to grow and transform mental health services through increasing investment by £2.3 billion over five years and, in doing so, to reduce health inequalities and inequalities in access to mental health services. This funding is in addition to baseline funding for mental health services (Integrated care systems total expenditure in 22022/23 was£13.64 billion, which includes spending for Learning Disability and Dementia).

To allow for this, NHSE allocates funding to each (Integrated Care Strategy (ICS) using a weighted capitation formula based on the size of the local population and its needs. The formula takes account of the additional costs associated with rural areas in several ways, including by factoring in population age, supply-induced demand, distance of services and the length of time it takes an ambulance to reach an incident.

For aspects related to prevention and promotion of good mental health, local public health teams in receipt of the public health grant in rural areas are best placed to develop services and solutions that reflect their geography. Not only can they co-produce localised solutions with their communities, but the majority of mental health services (especially those that are the first point of contact) are commissioned locally. The Office for Health Improvement and Disparities (OHID)’s regional teams already work closely with local areas to ensure local accountability through a range of reporting mechanisms and relationships.

We therefore do not intend to launch a consultation as recommended by the Committee, but we will continue to ensure accountability through existing mechanisms.

5. 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. [Paragraph 133]

The government recognises the importance of early preventative support in schools and local communities for supporting children and young people to have good mental health and wellbeing and prevent poor mental wellbeing from developing into mental illness.

Work is already underway in rolling out mental health support teams (MHSTs) in schools and colleges. We remain committed to delivering the Green Paper on Transforming Children and Young People’s Mental Health Provision, and we have made progress. Around 400 mental health support teams are now operational, covering 3.4 million pupils and learners in England in 6,800 schools and colleges. 100 more teams are in training, taking the total number of operational teams to about 500 by spring 2024. Teams will cover at least 50% of pupils in England by the end of the 2024 to 2025 financial year.

A planning process has been put in place to ensure the selection of MHST sites (covering 2021/22 to 2023/24) adequately focuses on areas with higher levels of need, inequality, and disadvantage. This process requires all ICSs to work in collaboration with health and wider local system partners to determine where new teams should be located, and to prioritise reducing health inequalities and promoting equality of access to services. This should therefore ensure that MHSTs reach those children and young people with high levels of need who are most at risk of poor outcomes, including children and young people in rural locations.

DHSC has been working with other government departments, stakeholders and the VCSE sector to better understand the role that early support hubs might play in supporting children and young people’s mental wellbeing. DHSC has also recently commissioned, through the National Institute for Health and Care Research, a longitudinal study

to establish the effectiveness of the open access ‘hub’ model of early intervention and prevention support for children and young people’s mental health and wellbeing.

6. 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]

The government recognises the critical importance of good mental health and wellbeing to the agricultural and veterinary communities and notes with concern the evidence contained in the report.

Defra’s Farming and Countryside Programme works with several farming charities to ensure planned changes in policy are delivered effectively and seeks to minimise any additional burden placed on farmers and landowners. Defra has contributed to the Royal Agricultural Benevolent Institution (RABI) Big Farming Survey, which highlighted mental health challenges for farming communities. A combination of factors contributes to poor levels of mental health and wellbeing. The RABI survey found an average of 6 varied factors contributing to stress. These were a mixture of natural factors (for example weather), health factors including COVID-19, regulatory and financial factors (for example loss of subsidies), and social factors (for example rural crime and public access).

DHSC does not plan to develop a workplan with NHSE and local health and occupation charities, since setting and managing targets for local systems would not align with NHSE’s new operating model, following the recommendations of the Hewitt Review. However, DHSC is progressing other ways of improving the support available for those within the agricultural and veterinary sectors.

Prevalence data (i.e., data on the prevalence of both treated and untreated psychiatric disorders in the English adult population (aged 16 and over)) is essential in establishing mental health need and unmet need in the population. The latest information on the number of adults with a diagnosable mental health condition (including a breakdown by occupation) was provided by the Adult Psychiatric Morbidity Survey (APMS) in 2014. The commissioning and delivery of the next survey was delayed by the Covid-19 pandemic. We know that services have been reporting increase in demand and changes in the complexity of cases, so it is likely that estimates from that 2014 survey are limited in what they can tell us about current prevalence. DHSC has commissioned the next iteration of the APMS to provide essential data on adult mental health prevalence to inform service planning, commissioning, and improvement.

Fieldwork on the APMS is taking place and reporting is planned for early 2025. DHSC will consider the findings of this survey, including in the context of improving the mental health and well-being of agricultural and veterinary communities.

There are currently no plans to commission Health Education England, now NHS England, to develop a specific training programme for rural NHS providers and staff.

However, NHS care providers must assess the learning needs of their workforce and ensure that their staff are equipped with the knowledge, skills, and expertise to deliver services to all the communities they serve. Employees have free access to a broad quantity of specialist materials via e- learning platforms and a mechanism is in place for NHS care providers to submit any identified gaps in training provision to ICBs to support the workforce planning processes.

Government works closely with the veterinary profession, including the Royal College of Veterinary Surgeons (RCVS) and the British Veterinary Association (BVA). Defra officials regularly engage with both these organisations as well as the wider profession. The profession has several initiatives in place, such as the RCVS Mind Matters Initiative and the BVA Good Veterinary Workplace Scheme and note too, the work that is being done by organisations such as VetLife to support the mental health of veterinary professionals.

7. 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. [Paragraph 144]

The government recognises that the current Index of Multiple Deprivation (IMD) does not make visible the level and distribution of rural deprivation that exists. To address this, Defra and DLUHC are already working collaboratively, as part of the work to review the IMD, to strengthen understanding of how deprivation in rural areas can be measured using small area administrative data.

Following a competitive tender process, Deprivation.org and Oxford Consultants for Social Inclusion have been commissioned by the Department for Levelling Up, Housing and Communities (DLUHC) to update the English Indices of Deprivation.

The project will seek to review, update, enhance and develop the Indices suite of National Statistics from the most recent IoD2019 release. The update will also take forward each action highlighted through DLUHC’s 2022 user consultation.

Provisionally, the release date for updated English Indices of Deprivation and the Index of Multiple Deprivation is anticipated in 2025.

8. 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 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]

Defra contributed to the UK Health Security Agency’s published guidance on providing advice about the impacts of being flooded on people’s mental health:

The Environment Agency (an executive non-departmental public body, sponsored by Defra) works with independent charitable organisations such as National Flood Forum – A charity to help, support and represent people at risk of flooding.

Local mental health care providers and the Voluntary and Community Sector will work with Local Resilience Forums as part of a multi-agency partnership to co-ordinate a response to a major incident and will provide the necessary mental health support to communities impacted by an emergency.

Although there are no plans to establish a dedicated funding stream for rural communities’ mental health need during and after crisis events, Defra and DHSC recognise the need to work closely together and with others to ensure that this support is carefully planned for and provided.

9. 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. [Paragraph 167]

The government recognises that uncertainty around future policy can be a source of stress for farmers and landowners and is committed to reducing this. In leading work with the farming sector, Defra understands the importance of working collaboratively to co-design farming reforms. Co-design is the right approach to making sure that farming reforms work for the sector through a process of testing, trialling, and improving policies and we are committed to providing as much certainty as practicable throughout this process.

The Farming Resilience Fund provides free business support to farmers in England to help them adapt to the Agricultural Transition Plan. The current round runs until March 2025. The type of expert business support available is expected to have a positive indirect impact on farmer wellbeing, and providers are also asked to operate signposting services to professional mental health and wellbeing support where appropriate. Some delivery providers are offering this support from in-house experts and others are signposting support available from external services.

Defra has also worked with the Yellow Wellies charity, to provide advice and information on how to identify potential mental health issues and provide tools for addressing them.

The government recognises that training employees in mental health first aid can have a role to play as part of a holistic approach to raising awareness of, preventing, and tackling potential mental health issues in the workplace. It can also support employees in ‘frontline’ roles to provide support and signposting to members of the public, where appropriate. The Rural Payments Agency (RPA) is currently rolling out a refreshed customer excellence training programme which has a module on identifying and dealing with anxiety. All RPA field officers are provided with information so that they can refer farmers to appropriate professional support, such as Farming Helpline run by the Farming Community Network. Additionally, The Animal and Plant Health Agency provides Health and Safety Guidance to managers and employees. This includes detailed guidance for managers and employees who might be subject to or involved with a person making a threat of (or actual) self-harm or suicide.

However, regulatory change to mandate mental health first aid training would be a prescriptive measure that would not allow employers to tailor their approach to workplace mental ill health and would introduce a substantial financial burden on business, particularly to small and medium size enterprises. Given the potential complexity of supporting those with mental ill health, businesses may also need to consider whether they have staff employed with suitable skills to deliver such a requirement and this may potentially impact recruitment.

The Health and Safety (First Aid) regulations are designed to help individuals who require immediate intervention or support where necessary until professional emergency care arrives, which can include support for mental ill health where this need is identified in the employer’s assessment. HSE legal series guidance First aid at work: The Health and Safety (First Aid) Regulations 1981. Guidance on Regulations L74 (hse.gov.uk) provides interpretive guidance on the law and factors to consider. The First Aid Regulations do not prescribe the use of first aid training courses covering mental ill health at work. Instead, they enable an employer to consider, as part of their first aid needs assessment, their business size, nature of the work and employee needs. This ensures that the support an employer puts in place is tailored to their specific requirements. This risk-based approach is a vital part of health and safety legislation and allows businesses flexibility to respond to changing needs.

10. 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]

Government works closely with the veterinary profession, including the Royal College of Veterinary Surgeons (RCVS) and the British Veterinary Association (BVA). Defra officials regularly engage with both these organisations as well as the wider profession. The profession has several initiatives in place, such as the RCVS Mind Matters Initiative and the BVA Good Veterinary Workplace Scheme and note too, the work that is being done by organisations such as VetLife to support the mental health of veterinary professionals.

11. 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. [Paragraph 186]

The government already has extensive rural-proofing mechanisms which ensure that the unique challenges of rural communities are considered in all our policymaking. The government undertakes robust impact assessment processes when introducing any new policy. The annual rural proofing report is the key tool in highlighting this work. The second of those reports, Delivering for Rural England, was published in September 2022. It sets out further details on the government’s approach to levelling up rural areas.

The third report will be out later this year.

The Levelling Up and Regeneration Bill will benefit rural areas by giving communities more of a say on local plans, by a new infrastructure levy able to deliver as much, if not more, affordable housing than at present, and by a new requirement for infrastructure providers and other bodies to help local authorities in drafting their local plans.

As part of the third phase of the NHS response to Covid-19, NHSE asked ‘Integrated Care Systems’ (ICSs) to develop digitally enabled care pathways in ways which increase inclusion, including reviewing who is using new primary, outpatient, and mental health digitally enabled care pathways.

Digital solutions in mental health enable remote multidisciplinary team functioning and information sharing to reduce administrative burden and to improve patient experience, including patients with specific needs. A prime example of these are virtual appointments, that are today used across a range of services and are proving particularly beneficial for users in areas where services are often far away from people’s homes and communities. For instance, NHS Talking Therapies (Formerly Improving Access to Psychological Therapies (IAPT)) services provide evidence- based psychological therapies to people with anxiety disorders and depression.

Since the onset of the pandemic, remote access to Talking Therapies has increased significantly, from approx. 33% of appointments being delivered via phone/webcam and other virtual means to a high of 97%. As services return to more in-person face to face delivery, the proportion of activity still being delivered via remote technologies remains high at around 90%. This means patients can access therapy from the comfort of their own homes where they choose to do so.

For rural communities where access to Talking Therapies may have been compromised in the past because it required long journeys to community hubs, patients now have a greater choice in how they receive therapy, and hence easier access. Even though many rural communities have poor internet coverage, therapy is being delivered via telephone, SMS messaging, email or via digital packages that do not require the patient and therapist to be online simultaneously. This allows citizens to work around lifestyle and geographical factors, leveraging the power of digital accessibility.

The Department for Transport (DfT) will look for opportunities to work with Defra, DHSC, and NHSE to maximise health outcomes for rural communities through the transport system. DfT will soon publish its Future of Transport Rural Strategy, which will consider how innovation and emerging transport technologies can better support better health outcomes.

12. 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 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. [Paragraph 190]

The Levelling Up White Paper included a mission to improve well-being and to reduce spatial disparities in well-being.

The mission was published as exploratory in the White Paper and since then, government has been carrying out analytical work and engagement to define a clear, credible, and ambitious mission. The drivers of well-being and metrics for the mission are being finalised but mental health has been identified as one of the priority drivers for the mission. The mission will seek to improve the well-being of children and young people as well as adults.

The government recognises the vital role that youth services play in a young person’s life. This is why we have committed to a National Youth Guarantee: that by 2025, every young person will have access to regular clubs and activities, adventures away from home and opportunities to volunteer, including young people living in rural areas.

This guarantee was based directly on feedback from young people as part of the extensive Youth Review the Department for Culture, Media, and Sport (DCMS) conducted in 2021. The Youth Review focused on the out of school youth agenda and policy programmes and funding currently within the scope of DCMS. The Youth Review set out to ensure that longer term spending and programmes achieve maximum benefit, meet the changing needs of young people, and level-up opportunities across the country, including the needs of rural populations. DCMS engaged with over 6,000 young people and heard from over 170 sector organisations and academics. The findings were published on Gov.UK on 1st February 2022 alongside the National Youth Guarantee announcement. The guarantee has been supported by a three-year investment of over £500 million in youth services.

Because the review was conducted so recently and with such a large number of young people, we do not believe it is proportionate to run an additional external consultation at present.

To support equitable access to youth services we are already investing over £300 million through the Youth Investment Fund (YIF), building, and refurbishing up to 300 youth centres across the country. The published methodology for choosing eligible areas was carefully designed to ensure a spread of urban and rural areas. To date YIF has delivered approximately £4.7m of investment to rural areas (includes “rural” and “urban with significant rural”) through 54 small capital projects and 3 major building projects. As further grants are awarded this will increase.

There is an independent evaluation of YIF, being led by Ipsos Mori, that is running throughout the programme. We will look at findings on rural youth services receiving funding as they develop right across the National Youth Guarantee, ensuring findings are shared with Defra.

It should also be noted that, as set out in section 507B of the Education Act 1996, Local Authorities have a statutory duty

to ‘secure, so far as is reasonably practicable, sufficient provision of educational and recreational leisure-time activities for young people’. This is funded from the Local Government settlement, the majority of which is un- ringfenced, allowing local authorities to spend on services according to local priorities, including on youth services. The settlement is c£60 billion this year (FY 23/24) for councils in England.


Footnotes

1 The NHS Core20PLUS5 programme is an NHS approach to target the health inequalities seen in the 20% most deprived communities along with other vulnerable groups, by targeting improvement in five areas: mental health, maternity, respiratory diseases, cancer and high blood pressure. Core20PLUS5