- Nicola Byrom; @nicolabyrom
A report has been produced for the Higher Education Funding Council for England (HEFCE): Understanding provision for students with mental health problems and intensive support needs. It considers the recent dramatic increase in demand for mental health services among university students and how these services are currently funded and provided. The report comes at a time of imminent changes to government funding for disabled students. The government is instigating changes that will mean that Higher Education Institutions (HEIs) will be expected to provide a greater level of support to students, in line with reasonable adjustment expected under the Equality Act, while government funding (through the Disabled Students Allowance, DSA) will focus on support provision for those with greater needs. This may provide an opportunity to improve how support for students experiencing mental health difficulties is provided and funded. However, the report suggests that no one really seems to know what implications these changes will actually have, either in the short or longer term.
I have summarised this report, to provide a concise overview, available here (http://www.studentminds.org.uk/dsa-consultation). In this blog I would like to share some personal reflections and concerns about the future of funding for student support. Through the blog I consider the challenge that linking funding for student support to long-term conditions creates for provision of responsive mental health services and reflect on the implications of limited NHS mental health provision for students and HEIs.
Mental health exists on a continuum; we all have mental health and our mental health can fluctuate. However, the current structure of DSA funding cannot accommodate this fluctuation. While the report encourages HEIs to be proactive in their support for student mental health (through developing inclusive curricula and proactive measures, such as wellbeing and resilience initiatives), interviewees for the report reflect a combination of hope that the changes to DSA funding will help HEIs adopt a more social model of mental health and fears that it will push HEIs further towards a medical model of mental health. The social model of mental health proposes that individual mental health problems may have their root in social circumstances and experiences of trauma. The model recognises that anyone can suffer distress and repositions mental health as a social construct, not a purely individual concern. Currently however, even when informed by a social model, student services are “typically delivered on the basis of individual models… of mental health”.
As mental health fluctuates, I am concerned about the current situation of funding being linked to long-term problems. As one interviewee for the report highlights, mental health difficulties can be acute and require a rapid response “… it may be fine to wait 12/15 weeks under certain circumstances, but if you’re working with someone who is a young person who doesn’t have a lot of life skills, is away from home for the first time, that can be calamitous.” In the university environment, mental health can decline dramatically and have a substantive, negative impact on a student’s ability to study; “taking vulnerable people away from their personal support networks and then giving them a massive amount of academic pressure is ‘a potent cocktail’.’’
I arrived at university with a track record of mental health difficulties. I had experienced an eating disorder for years. I was however, very much in recovery. For me, I was doing very well. I did struggle. There were periods of time at university when I was self-harming to manage my anxiety levels. In my second year I started having panic attacks and developed an acute case of agoraphobia. I was fortunate to have a family who could support me and I left university early in the run up to a vacation to visit my family GP and take time at home to “unwind” and reset. Out of the university environment my anxiety subsided rapidly.
I did not hide my mental health difficulties. My friends and housemates knew that at times I was struggling and this in itself was helpful. I did not talk about my anxiety with tutors as it never seemed relevant, nonetheless, my tutors were incredibly supportive and intensive academic encouragement through my final year of studies had a very positive impact on my mental health. Could I have benefited from counselling or mentoring? Yes. I’m sure it would have helped. But for the university to have provided me with a mentor, I would have had to apply for the DSA. In my eyes, I was not disabled. Even in the depths of my eating disorder I would have found it difficult identifying as disabled. At university I would have said that I was simply adjusting and learning to manage my mental health.
Funding to support students with mental health difficulties is currently linked to the DSA and the Equality Act, which requires reasonable adjustments to be made to ensure that individuals with a disability have equal access to education. I understand that disability is defined as an enduring condition, spanning years. However, from my own experience, I am fundamentally uncomfortable with conceptualising mental health difficulties as disabilities. Tying mental health to the framework of disability seems to suggest that mental health difficulties are long-term, if not permanent. This is in direct contrast with recovery models that focus on change.
According to the report demand for mental health support has increased. However, by linking mental health difficulties and disability, capturing this demand is challenging. Across all institutions, the portion of students who have declared a mental health problem is 1.4%. This is a dramatic under-representation of the number of students experiencing mental health difficulties and there is an awareness that more needs to be done to encourage students to disclose. 1.4% needs to be viewed in context; within a year 25% of British adults will experience at least one diagnosable mental health difficulty and at some universities, counselling services are seeing nearly 10% of the student population.
The discrepancy in these numbers is important because the funding that a university receives to support students is linked directly to the number of students receiving the DSA. There is a huge gap between the number of students experiencing mental health difficulties and the number receiving support through the DSA. To receive the DSA, a student experiencing mental health difficulties has to recognise and accept this. They then have to identify themselves as disabled and choose to disclose their mental health difficulties as a disability. This is challenging enough. However to claim the DSA a student’s mental health difficulty has to have a long-term adverse effect on his or her ability to carry out normal day-to-day activities or study. Long-term here is defined as a problem that has persisted for over a year. As such, of the small proportion of students who have declared a mental health difficulty, only 33% receive the DSA.
So the question to ask is how are universities funding support services for student mental health? Student Services, including counselling services, are funded by core university funding, including student fees and funding from HEFCE in the form of the Student Opportunity disability allowance (a non-ring-fenced allocation of funding linked to the number of students claiming DSA). The report identifies that institutions are topping up funding from the SO disability allowance by £2 to £5 for every £1 received.
It could be argued that as HEIs are institutions for education and not health care, they should not be expected to provide any form of counselling or support beyond that provided for students in receipt of the DSA. After all, students should be able to access support for mental health difficulties through the National Health Service.
However, mental health has an effect on ability to study. A recent study found that, of the students attending one university counselling service, 92% identified themselves as having problems with their academic work. Of those students, interviewed on conclusion of counselling, 67% considered that it had been important in enabling them to address those issues. Further, acute mental health difficulties, if not addressed quickly, can have a substantive impact on a student’s ability to study, having a direct influence on the HEI’s ability to meet its responsibility regarding education. One GP points out that if a young adult loses three or four weeks of their academic year, they will struggle not to slip back a whole year if they have problems. Students usually have to wait 12 to 14 weeks for mental health support through the NHS.
The report identifies that HEIs see their responsibility around mental health as helping with academic management, offering short-term support around managing the impact that a student’s condition has on their studies (or longer-term support supported by DSA funding). HEIs rightly state that they are not a ‘therapeutic community’ or the ‘5th emergency service’. While they are not a medical service and cannot provide medical support to students, they are often left providing ‘holding support to students.’ Extensive waiting lists within the NHS are leading some GPs to “refer individuals back to their HEIs for support.”
This echoes concerns that Student Minds has been raising through the Transitions Campaign regarding health inequality experienced by students, due to a lack of recognition in the NHS about the needs and circumstances of students regarding mental health. The NHS mental health provision is predicated on people living with their family and having support at home. “There is somehow the belief that we’re a therapeutic community and one of the discussions I’ve had repeatedly over the years with psychiatric units, with psychiatric teams is, would you have discharged this individual to a bedsit in the centre of the city? And if their answer is no, then why have they discharged them in exactly the same way to the university?”
In 2014 the government published a policy paper, “Closing the Gap: Priorities for essential change in mental health” and the then Deputy Prime Minister hosted a conference. This gave me the opportunity to ask why students, as a population at high risk of developing mental health difficulties, did not feature once in the paper. In reply, the Deputy Prime Minister asked “surely the provision of support for students is the Universities’ responsibility?”
It seems, from the recent report for HEFCE, that universities are picking up this responsibility, holding and supporting students who should be seen by the NHS, despite the universities’ firm belief that they are not a medical service. Universities seem to be providing this relief to the NHS without any related government funding, and a recent study demonstrates that University support services really are masking a substantive gap in primary care provision. The study compared students attending counselling services at 11 universities with a similar non-student population receiving primary care services. The study found that university counselling services deliver a service to people who closely resemble NHS primary care service users in terms of severity and the risks that they pose to themselves. They concluded that, student counselling services are “providing considerable relief from a potential additional burden on primary health care.”
The report reflects considerable frustration on the part of GPs. The Student Health Association, the national body representing health professionals that work with students, are currently working with NHS England to try to find a better way to fund young people’s health through a national approach. In a climate when the NHS and universities are under more pressure than ever and the government is making decisions about the resourcing of mental health services, it’s crucially important that students are fully represented in the discussion. In recent restructuring of Student Services, some universities, including the Universities of Leeds and Southampton, have bought mental health services (IAPT) onto the university campus, creating explicit links between services provided by the University and by the NHS. This seems to be an interesting way forward.
I would like to side with the hopeful; staying optimistic that changes in funding will help HEIs adopt a more social model of mental health, creating more space to support the fluctuations of health. I hope that the fantastic work that Mental Health Advisers have done over the recent years will continue to be developed and built upon and that HEIs can support those with long-term conditions to thrive, whether they identify as disabled or not, while also increasing capacity to reach out to those experiencing acute difficulties.
Student Minds are interested in hearing your views on the findings of this report and want to better understand the direction that various stakeholders in the sector believe support for students should be heading. Today we’ve launched a consultation and invite any students, staff, health professionals or other concerned parties to share your views: www.studentminds.org.uk/dsa-consultation