Mental Health Bulletin 2020-21 Annual report

This annual Mental Health Bulletin uses data collected via monthly submissions during the financial year 2020-21 and provides the most detailed picture available of people who used NHS funded secondary mental health, learning disabilities and autism services in England.

From April 2020, NHS Digital implemented a multiple submission window model (MSWM) for MHSDS, which allows providers to retrospectively submit data for a specific reporting period once the initial provisional and performance submission windows have closed.

It was agreed that the MSWM described in Information Standard DCB0011 Amd 43/2019 was implemented in advance of the implementation date of MHSDS v4.1 i.e. within financial year 2019-20.

For the 2019-20 reporting period the MSWM acted as a “Refresh” of the data for the year. This allowed providers to submit any periods which they might have missed through the year or to resubmit any period of data within the 2019-20 period to address data quality issues. The same still applies to data for 2020-21.

As a result of the introduction of the MSWM, from  2019-20 the ‘Mental Health Services Dataset (MHSDS) relevant provider feedback’ table, usually included in the Metadata and Data Quality file, has been removed from this publication. Providers have been given the opportunity to address and correct any data quality issues through the MSWM and, as such, many of the comments will be no longer relevant or potentially misleading. The monthly provider feedback for 2019-20 onwards is available in the relevant Mental Health Services Monthly Statistics Publication series.

Some providers of services in scope for this collection did not provide one or more submissions during this financial year. Details of how the information presented in this report can be interpreted considering these issues can be found throughout this report, including the Data quality section, and in the Metadata and Data Quality Tables accompanying this publication.

Analysis of monthly submissions and associated data quality measures has already been released as a series of monthly publications (around ten weeks after the end of the month reported on). These monthly publications, alongside previous editions of the Mental Health Bulletin annual publication series.

Some providers did not make any submissions during the reporting period. Those not submitting are more likely to be smaller independent sector providers. However, NHS Digital hold limited information on the exact number and size of providers not making submissions during this reporting period.

NHS Digital are working to better understand and address this gap in coverage and have made increased progress over the past year. Information about those providers considered to undertake activity in scope of MHSDS is available. 

Given the information currently available it is likely that:

• The number of providers of adult mental health or learning disability and autism services submitting is not consistent with the volume previously making a submission of MHLDDS monthly data. The total number of providers submitting data has increased year on year. This means that any comparisons of 2019-20 mental health or learning disability and autism services statistics to prior year’s statistics should be made with caution. The increase in providers has remained more stable between 2019-20 and 2020-21 and as such some comparisons have been made between these years.
• The total number of providers submitting to MHSDS has increased from 302 providers submitting data in 2019-20 to 335 providers submitting data 2020-21.
• A number of non-NHS providers who had previously not provided submissions have started to submit information to the MHSDS during 2019-20 onwards. The number of non-NHS providers submitting has increased year on year since 2010-11, as such the numbers specifically for these providers are not comparable over time. In the majority of cases, nationally the number of people in contact with non-NHS providers is small in comparison with the number in contact with NHS providers. This means, the impact of this change in coverage will be limited overall when people in all type of service provider are considered.  

Time series have been maintained where possible within our reference tables, but the following changes must be noted when comparing uses of these services between different years:

• In many places analysis has been limited to 2011-12 as the earliest time period. This is because significant changes were made to the source of this information in this year (moving from version 3.5 of the Mental Health Minimum Dataset (MHMDS) to version 4.0) which means that information before 2011-12 is not directly comparable.
• The expansion in scope of the source of this information in September 2014 to include people in contact with learning disability services means that local knowledge may be required to interpret changes in the information presented between 2013-14 and 2014-15.
• The inclusion, in 2016-17, of information about people in contact with mental health services for children and young people means that the number of people in contact with all services from 2016-17 onwards is not directly comparable with the number of people in contact with all services in previous years.
• For key time series the number of people in contact with all services has been shown separately, from 2016-17, for:

1. people aged 18 and over
2. people aged under 18

• The number of people aged 18 and over in contact with services from 2016-17 is the most appropriate figure available which can be compared to the total number of people in contact with services in years prior to 2016-17.
• While this is the most comparable number available, there are two main differences between the number of people aged 18 and over in contact with services from 2016-17 and the total number of people in contact with services in previous years which must be understood;

• Some children and young people are in contact with adult mental health and learning disabilities services. These people would have been included in the number of people in contact with services in previous years but will now not be included in the number of people aged 18 and over in contact with services in 2016-17. Some understanding of the size of the impact of this change can be found from information available in previous years’ editions of this publication series. For example, Table 1.2 of the Mental Health Bulletin: 2015-16 Annual Report edition shows that 35,673 people in contact with adult secondary mental health, learning disabilities and autism services were aged under 18, which accounts for 2.0% of people in contact with these services.
• The age at which people move from mental health services for children and young people to services for adults can be different in response to the particular needs of the person and to ensure continuity of care. As such there are people aged 18 or over in contact with mental health services for children and young people. These people would not have been included in the number of people in contact with services in previous years but will now be included in the number of people aged 18 and over in contact with services. More information on this is found here.

• These two differences will impact the comparability of the number of people aged 18 and over in contact with services from 2016-17 onwards and the total number of people in contact with services in previous years in opposite directions, which will reduce the differences to some extent. However, as an estimate of the impact of the second difference is not currently available the results of any comparisons made should be used with caution.
• The total number of providers submitting data has increased from 178 providers submitting data in 2018-19 to 302 providers submitting data in 2019-20 and 335 providers submitting data in 2020-21. Any comparisons of 2019-20 mental health or learning disability and autism services statistics to prior year’s statistics should be made with caution
• There have been changes to the children and young people receiving second contact with services measure methodology. From 2019-20 the methodology has been brought in line with the monthly methodology and this has become the official statistic for children’s access to mental health. As such when making comparisons with prior years’ statistics please do so with reference to the above change in methodology.

From information held centrally through submissions to the MHSDS, 2,803,244 people were known to be in contact with NHS funded secondary mental health, learning disabilities and autism services at some point during 2020-21. 768,083 of these were under 18 years of age and 2,029,568 were aged 18 or over.

A person is considered to be in contact with services in this publication if they have had an open referral with secondary mental health, learning disabilities and autism services during 2020-21. This may include referrals which did not result in an attendance with a service or treatment being received.

This includes people in contact with these services solely for treatment relating to a learning disability or autism. Experimental statistics are available in the Mental Health Services Monthly Statistics publication series which provide an indication of the number of people in contact with particular types of service at a point in time.

The following measures are an example of what is available in the MHSDS Monthly Data File:

• MHS01: People in contact with secondary mental, learning disabilities and autism services at the end of the reporting period
• AMH01: People in contact with secondary adult mental health services at the end of the reporting period
• CYP01: People in contact with secondary children and young people's mental health services at the end of the reporting period
• MH01: People in contact with secondary mental health services (including both adult and children and young people’s services) at the end of the reporting period
• MH01a: People in contact with secondary mental health services (including both adult and children and young people’s services) aged 0 to 18 at the end of the reporting period
• MH01b: People in contact with secondary mental health services (including both adult and children and young people’s services) aged 19 to 64 at the end of the reporting period
• MH01c: People in contact with secondary mental health services (including both adult and children and young people’s services) aged 65 and over at the end of the reporting period
• LDA01: People in contact with secondary learning disabilities and autism services at the end of the reporting period

The number of people in contact with NHS funded secondary mental health, learning disabilities and autism services in this report does not include people who are being treated for a mental health problem only within primary care settings. This will include people who are being prescribed medication or less specialised interventions for a mental health problem by their General Practitioner (GP).

It will also not include people referred for talking therapies with a service commissioned as part of the Improving Access to Psychological Therapies (IAPT) programme. Statistics showing the number of people referred for treatment with IAPT services during 202021 are available. 

These statistics may also not include people being treated for a mental health problem, a learning disability or autism where that treatment is not funded by the NHS.

The Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014 provides the most recent estimate available for the proportion of adults (aged 16 or over) in England who are being treated for a mental or emotional problem. These estimates are based on a survey of the residential population in England and provides a rich source of information on the prevalence of treated and untreated mental health disorders.

This survey estimated that in 2014:

• 13.1% of adults reported being in receipt of mental health treatment. This includes adults receiving any combination of medication, counselling or therapy.
• 0.2% of adults reported having spent time as an inpatient and 0.7% as using outpatient services as part of being treated for a mental or emotional problem during the three months prior to being interviewed.
• 2.3% of adults reported having spoken to their GP about a mental or emotional problem in the two weeks prior to being interviewed, and 12.5% reported having spoken to them about a mental or emotional problem in the past year.
• 7.8% of adults reported using community or day care services in the last year prior to being interviewed.

The Mental Health of Children and Young People in England, 2017 provides England’s best and most recent source of data on trends in child mental health.

Parents of 5 to 16 year olds were asked about contact with professional services and/or informal support because of worries about their child’s emotions, behaviour, concentration, or how their child was getting on with other people. 17 to 19 year olds were asked directly about such contact. Contact with services and support is described in relation to children in the results of this survey, although that contact may sometimes have been only with the parent (in relation to concern about the child).

In the results of this survey some children are described as having a mental disorder. This relates to identification on the survey using the Development and Well-Being Assessment (DAWBA), and not to an assessment done in any other setting or in relation to eligibility for services. While we are sensitive to the negative connotations that the term ‘mental disorder’ can have, it is used because the DAWBA does not just screen for general mental health problems, but applies operationalised diagnostic criteria for specific disorders.

This survey estimated that in 2017:

• Overall, 28.5% of children aged 5 to 19-years-old had contact with professional services (20.9%) or informal support (18.2%) due to mental health worries in the past year. 4.5% of children had contact with mental health specialists in the past year. Contact with services and support was more likely in children identified by the survey as having a mental disorder.
• Two-thirds (66.4%) of children aged 5 to 19-years-old with a mental disorder had contact with professional services. Contact with teachers was the most likely (48.5%), followed by primary care professionals (33.4%), mental health specialists (25.2%), and educational support services (22.6%).
• About half (48.6%) of children aged 5 to 19-years-old with a mental disorder had contact with informal sources of support due to mental health worries. Family and friends were the most common source of informal support (44.6%). 19.6% sought help from the internet.
• About one in four (24.1%) children aged 5 to 19-years-old with a mental disorder had no contact with either professional services or informal support in relation to worries about mental health.

A Wave 1 follow up survey took place online with the same cohort in July 2020 with results published on 22 October 2020. A further Wave 2 follow up survey took place online with the same cohort in February/March 2021 with results published on 30 September 2021. 

This series explores the mental health of children and young people before and during the coronavirus (COVID-19) pandemic. Experiences of family life, education, services and worries and anxieties during the COVID-19 pandemic are also examined.

Link to this series of publications is available. 

Many people who have a learning disability or autism use mental health services and people in learning disabilities and autism services may also have a mental health problem. This means that activity included in this publication is not distinctly divided into mental health or learning disabilities and autism referrals – a single referral may include contact with either type of service.

An understanding of the number of people in contact with mental health services and learning disabilities and autism services separately can be found in the Mental Health Services Monthly Statistics publication series.

Learning disabilities and autism service specific statistics moved to their own monthly publication, Learning Disability Services Monthly Statistics, from Final February, Provisional March 2018 data.

More detailed information about people with learning disabilities and/or autism who are in receipt of inpatient care is available from the Assuring Transformation (AT) collection. AT is a commissioner-based collection; data is collected on an ongoing basis and is published monthly and quarterly.

The MHSDS is derived from administrative systems rather than being a specific purposeful collection. The quality and completeness of particular data items from particular data providers is dependent on the use to which the data has so far been put. Due to this, data items which are used regularly for analysis or have been the focus of particular attention will be of better quality than less frequently used items, or those for which in depth analysis has not yet taken place. This is the fourth publication of annual figures on the use of restrictive intervention in inpatient mental health, learning disabilities and autism services. The data used to derive these figures may contain duplicates. Multiple interventions with identical dates and details (intervention type and duration) for the same individual have been identified. Currently it is unknown if these values are duplicates, record errors or genuine separate incidences therefore no data has been excluded. These potential issues may lead to the number of restrictive interventions shown in this publication being unreliable. As such these figures should be used with caution.

Statistics showing the number of people subject to restrictive interventions will not be affected by duplication and so are more reliable than statistics on the number of restrictive interventions. However, statistics on the number of people subject to restrictive interventions are still subject to other potential quality and completeness limitations. These statistics should be used in light of these limitations.

We would welcome any feedback or information you have to guide the assessment and development of these statistics via [email protected] (please quote ‘Mental Health Bulletin’ in the subject line).

Many people who are in contact with mental health and learning disability and autism services are only in contact with one provider; however, some people may be referred to more than one provider in the year (if they move house, become unwell on holiday, or need to be referred on for more specialised treatment for example).

Within most of the analysis presented in this publication a person is counted against any category that applies to them. For example, if a person has been in contact with both NHS and non-NHS providers during 2020-21 they will be counted against both types of organisation. This will lead to the total for all underlying categories summed together being a higher number than the overall total.

This is a change to the methodology used prior to 2016-17 as the structure of the previous source of these statistics made counting people in all categories appropriate to them problematic. For example, in years prior to 2016-17 a person was only assigned to the provider type in which they had their highest level of care (such as being admitted as an inpatient prioritised over community-based activity). The change to the methodology has been enabled by the introduction of the MHSDS and provides a fuller understanding of people in contact with, for example, different types of service. The impact on comparison made with statistics for previous years will be small, however these comparisons should be made with this possible effect in mind.

In some places the methodology remains unchanged as counting people once is more appropriate:

• In analysis of people admitted to inpatient services as part of their contact in comparison to people who are not admitted, the two categories are mutually exclusive by definition.
• If a person is in contact with more than one provider each provider can record that person’s demographic information differently due to data quality limitations. In order to avoid counting people in more than one age group, ethnic group, or gender group one record is selected in order to provide consistent demographic information for each person. This selected record is used in all analysis except that shown at individual provider level, for which the record submitted by that provider is used. Further information about how these records are selected can be found in the Derivations table within the Metadata and Data Quality Tables which accompany this publication.

Some of the statistics in this publication are counts of activity, such as bed days or admissions, rather than counts of people. When we count activity, we count all activity across all of the person’s contact with these services. This is the same methodology used in previous editions of this publication series and as such there are no changes to methodology for these statistics which would limit comparability. Changes to the scope of these statistics would still need to be considered separately.

From 2016-17 the MHSDS - supplemented by the Annual uses of the Mental Health Act 1983 in English acute trusts (MHA Acute) collection - became the official source of statistics on the use of the Mental Health Act 1983 in healthcare settings.

Statistics on uses of the Mental Health Act 1983 in these settings for 2020-21 can be found separately in the Mental Health Act Statistics, Annual Figures: 2020-21 publication.

To prevent the release of disclosive information, for the 2020-21 statistics within this publication any sub-national figures numbers less than five (including zero) are replaced by a “*” symbol. All other sub-national numbers are rounded to the nearest five. National totals are not suppressed or rounded. Calculated values in the data files are based on unrounded numbers but rounded to the nearest whole per cent to prevent backward calculation. Where a value is suppressed, the corresponding percentage is also suppressed. This approach prevents identification of a person through cross referencing different publications.

Statistics for years prior to this have the suppression rules agreed for those years applied to them. This is to allow you to accurately compare what is presented here for those years with previous publications in this series. This means that for 2014-15, suppression rules are the same as for 2015-16 through to 2020-21 except for calculated values being rounded to one decimal place. For previous years’ numbers 1-5 have been replaced by a “*” symbol and secondary suppression has been applied as required to stop these figures being revealed by a combination of other figures in the publication.

For the second time, within this publication we present both statistics produced by NHS Digital and statistics produce by NHS England. Any statistics produced by NHS England are clearly marked and dual badged by both NHS Digital and NHS England. NHS Digital has worked with NHS England in assuring the statistics and methodologies before they are published here.

The measures published in this report which use NHS England methodology are:

• Number of people in contact with Specialist Perinatal Mental Health Community Services
• Number of discharges from adult acute beds eligible for 72 hour follow up
• Number of discharges from adult acute beds followed up within 72 hours
• Proportion of discharges from adult acute beds that were followed up within 72 hours

The methodologies for the construction of each measure is available in the Mental Health Bulletin: Metadata and Data Quality Tables.

The key difference to consider when using the statistics listed above is the methodology for assigning Clinical Commissioning Group (CCG) to activity; a brief explanation of the different methodologies is presented below and any CCG level statistics should be used with consideration of these differences.

• NHS Digital – the CCG is assigned to activity based on the most recent information about an individual and, as such, activity measured will be attributed to a single CCG. The activity is based on a person's CCG of GP Practice if available, otherwise the CCG of Residence (based on Postcode of usual address is used).
• NHS England – the CCG is assigned to activity based on the information available at the time of activity and, as such, activity measured may be attributed to multiple CCGs. The activity is based solely on a person's CCG of Residence (based on the postcode of usual address)