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Case for action

CASE FOR ACTION

"Student mental health is a priority – not only because we want to help students to thrive and realise their potential both academically and personally, but also because of our responsibilities to our university community. We should support students in the same way that we would also seek to support staff experiencing mental health problems."

PROFESSOR SIR David Eastwood, University of Birmingham

Everyone has mental health: it affects individual productivity and contribution to community and economy. It shapes relationships, learning and purpose. It predicts wellbeing and satisfaction with life.

Approximately 1 in 4 people report a mental health problem each year.1 This may equate to 500,000 students per year. 50% of chronic adult mental illness starts in teen-age, and 75% before the age of 24.2 As participation in higher education in the United Kingdom has expanded, national trends in mental ill-health among young people have materialised in our student populations.

Mental ill health may have many negative consequences. It has strong associations with low levels of wellbeing, distress, self-harm and suicide. Chronic mental illness can change lives, and disrupt education and employability. It has consequences for the individuals experiencing the difficulties, for their families and friends, and their communities and workplaces. It confers additional risks and responsibilities on educational institutions.

Risks

Higher education institutions need appropriate action and contingency planning to manage crises and risks associated with mental distress and illness.

Suicide

In recent years, there has been a steady increase in the number of student suicides.3 Additionally, several universities in the UK and the United States have experienced a number of student suicides within a short period of time.

There is a strong relationship between mental ill health and suicide or self-harm, linked to depression, alcohol or drug use, or personality and other mood disorders.4 The ability to identify students who are at risk of suicide or self-harm or display suicidal behaviours is both important and challenging. Of those who take their own life in the UK, only 28% have been in contact with mental health services during the year before their death.5 Among students, only 12% who died by suicide were reported to be seeing student counselling services.6 Many students who need help do not necessarily seek it themselves.

Yet effective suicide prevention based on whole-community and whole-population approaches can lead to positive and timely interventions and the saving of lives. Approaches such as that adopted by the University of Wolverhampton and the University of Cumbria employ Connecting with People and the Columbia Suicide Severity Rating Scale (C-SSRS) respectively. Both of these interventions are preventative, providing training for students and staff and the relevant tools on how to appropriately support those in distress or at risk of self-harm.

Suicide is tragic, for the individual who takes their life, and for family and friends. It also presents difficulties for the wider student body, for staff and for university leaders. Good practice in suicide postvention includes immediate management of the crisis, sensitive handling of family and friends, effective communications work and appropriate liaison with authorities as well as longer-term work with students and staff. The burden on university leadership teams is not to be underestimated.

Pressure on support services

Since 2008 there has been a significant and steady increase in the number of students declaring mental health.7 Some universities have experienced a threefold increase in demand for support.

Increases in the demand for support services may be met with additional investment, though the correlation with improved outcomes is not clear. Ultimately, reliance on a deficit model of support needs to be replaced with a more strategic approach: an assessment of need and existing provision, action planning to address current and future requirements, and investment in services to meet this requirement.

Whole-population approaches deploying individual or community prevention, or early interventions are unlikely to justify disinvestment in support services. Campaigns against stigma or to encourage disclosure may, have the opposite effect in the short term.

Reputation

There is a public narrative of a crisis in student mental health. Headlines such as the ‘Epidemic of mental illness on campus’, ‘Student mental health is at crisis point’, ‘Do British universities have a suicide problem?’ characterise higher education as a toxic environment. In an alternative account, students are portrayed as vulnerable – a ‘snowflake generation’. Neither of these politicised narratives help students facing mental health difficulties; nor do they address the organisational and systemic challenge of student mental health which demands a rigorous and open assessment of need, appropriate planning and investment and a robust evaluation of progress.

Negative outcomes can be enormously damaging for universities: for example, the University of York’s portrayal by the media following the cluster of student suicides in 2015.

Positive narratives are harder to find, though increased investments are well received: for example, ‘University of York invests up to £500,000 in mental health support services’.

Impact on community

Less well evidenced but no less important is the impact on community – on academic and operational staff, and on the student body – of low levels of student wellbeing and high levels of mental distress and illness.

Higher education leaders report their personal engagement with the social and moral aspects of the challenge of mental health in higher education and in wider society, its impact on social mobility and the widening of participation in higher education, and its centrality to the social mission of universities.

"Our explicit way of supporting young people engaged in the most important work in which they can be engaged: learning to know themselves and identifying the conditions that will provide for an authentic, flourishing life."

John DeGioia, President, Georgetown University

Regulation

Universities have a duty of care to their populations. There are multiple legal implications associated with the support provided for people with mental ill health at universities. The following provides a summary account of the regulatory frame for mental health in higher education. More detail may be found in in the ‘Student mental wellbeing in higher education: good practice guide’ (2015) produced by the Universities UK standing group on Mental Wellbeing in Higher Education.

Equality Act (2010)

The Equality Act 2010 in England and Wales, frames the issue of student mental health. Under this act, mental health conditions, may be considered as disabilities and, therefore, protected characteristics. Legally universities are obliged to protect people with disability against ‘harassment, victimisation and discrimination – including discrimination arising from disability and a failure to comply with the duty to make reasonable adjustments’ (Equality Act 2010). Scotland is covered by Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012.

Data Protection

The new General Data Protection Regulation (2018), will make universities more accountable for the data they collect and hold on individuals. They will have to document why information is collected, how it will be used, and who will have access to it. As some mental health conditions are considered as sensitive personal data, the regulation will have an impact on the way universities handle data on people who have disclosed this information.

Safeguarding

Universities are legally obliged and committed to safeguarding and promoting welfare and pastoral care for members of their community who are under 18 years of age, and adults who are at risk, including staff, volunteers, students, and visitors. At risk adults are those needing extra support or care, such as a person with a disability.

There are several different statutory obligations that universities must meet to fulfil this duty of care in regard to mental health and safeguarding children and adults at risk, including the prevent duty.

Consumer rights

UK universities are subject to consumer rights regulations, regulated by the Competition and Markets Authority (CMA). To comply with the law, universities must provide clear and accurate information for prospective students concerning the mental health support available, and have fair contractual terms and conditions.

The relationship between universities and students, and perspectives on the ‘customer’ experience are explored in ‘Education, Consumer Rights and Maintaining Trust. What students want from their university?’.

Success

Everyone has mental health. Higher levels of wellbeing positively impact engagement, satisfaction, and performance. Population mental health – the enabling of positive mental health and the avoidance of mental health difficulties through psychosocial education – is a strategic opportunity for higher education in three areas: firstly in how it improves retention and engagement; secondly, in its impact on individual and organisational performance; and thirdly, in its positive longer term consequences for individual wellbeing and productivity.

Engagement and retention

It is known that in schools and in the workplace, mental health issues have a negative impact on engagement and retention.8 Stress, anxiety, depression, grief, sleeping difficulties and relationship problems contribute to having a lower sense of belonging and engagement. In the higher education sector, a report by the Higher Education Academy (HEA)9 found that both engagement and a sense of belonging are strongly linked with higher retention and lower dropout rates.

The link between mental ill health and retention is further explored by Unite research, in a report which found that students experiencing a mental health condition are more likely to be thinking about dropping out from higher education 10.

Thinking about dropping out

Simpson and Ferguson (2012) found that there was an increase in the likelihood of retention, with the number of counselling sessions attended (per cohort).11 Supporting and promoting good mental health can therefore lead to positive impacts on engagement and retention.

Performance

Good mental health has a positive impact on learning, the ability to concentrate, and overall performance levels .12

With the right support, students with a diagnosed mental health condition can still perform highly – particularly in the case of students on the autism spectrum.

The most common mental health difficulties that students experience are depression, anxiety, stress, lack of energy or motivation, eating disorders, or trouble sleeping.13 These emotions negatively impact a person’s ability to learn and concentrate, the time it takes to perform tasks, ability to cope with stress and to juggle multiple priorities.

The Times has found that more students are requiring special consideration and are requesting extenuating circumstances in exams due to mental health difficulties. Depending on the nature of the extenuating circumstances request and its outcome, they have a negative impact on completion rates, exam results and future career prospects.

Satisfaction

Mental health is the biggest single predictor of life-satisfaction.14 Students aged 20–24, experience lower levels of wellbeing than the general population of the same age, with a decline year-on-year.15 They perform lower on measures such as life satisfaction, happiness, low anxiety and life worthwhile. This is important, not only because of the moral argument, but also because poor mental health can have a negative impact on the ability to learn16 and on engagement with education.17

Policy

Government approaches to mental health policy across the four nations of the UK varies. The below provides a summary of some of the key developments and policy documents in recent years.

Policy
Future in Mind 2015 The Five Year Forward View for Mental Health 2016 Implementing the Five Year Forward View for Mental Health 2016
The report set out a whole system approach for Children and Young People’s (CYP’s) Mental Health, focusing on prevention of mental ill health, early intervention and recovery. The independent report by the Mental Health Taskforce, commissioned by the NHS, sets out a case for transforming mental health care in England. The main aim of the report is to shift towards prevention and transform NHS care. The document lays out the process for delivering the vision and the objectives set out in ‘The Five Year Forward View for Mental Health’. It includes the timeframes, funding and partnerships needed for the delivery of the objectives.
Prevention Concordat for Better Mental Health Cuts to NHS trusts Disabled Students Allowance (DSA)
The document aims to increase prevention of mental illness and promotion of good mental health. Universities can play a key part in this working with local government, Clinical Commissioning Groups and wider stakeholders. Funding has been constrained for NHS trusts providing mental health services. This has had a negative impact on service provision and waiting times. In 2016, the government cut DSA funding, removing access to certain funding for students, who are considered disabled under the Equalities Act 2010.
Policy
Future in Mind 2015
The report set out a whole system approach for Children and Young People’s (CYP’s) Mental Health, focusing on prevention of mental ill health, early intervention and recovery.
The Five Year Forward View for Mental Health 2016
The independent report by the Mental Health Taskforce, commissioned by the NHS, sets out a case for transforming mental health care in England. The main aim of the report is to shift towards prevention and transform NHS care.
Implementing the Five Year Forward View for Mental Health 2016
The document lays out the process for delivering the vision and the objectives set out in ‘The Five Year Forward View for Mental Health’. It includes the timeframes, funding and partnerships needed for the delivery of the objectives.
Prevention Concordat for Better Mental Health
The document aims to increase prevention of mental illness and promotion of good mental health. Universities can play a key part in this working with local government, Clinical Commissioning Groups and wider stakeholders.
Cuts to NHS trusts
Funding has been constrained for NHS trusts providing mental health services. This has had a negative impact on service provision and waiting times.
Disabled Students Allowance (DSA)
In 2016, the government cut DSA funding, removing access to certain funding for students, who are considered disabled under the Equalities Act 2010.

Policy development

England

Since 2017, there has been an increased focus from government on children and young people’s (CYP) mental health.

  • In January 2017, The Prime Minister, Theresa May,committed herself to transforming mental health support in schools, workplaces and communities in the UK

“(Young people) want to grow up to be confident and resilient, supported to fulfil their goals and ambitions. So we are placing an emphasis on building resilience, promoting good mental health and wellbeing, prevention and early intervention looking at how we can do more upstream to prevent mental health problems before they arise”

  • A Green paper on CYP mental health is due to be published by the Department of Health and the Department for Education, with an expected emphasis on prevention and early intervention in educational settings, identifying a clear role for education in supporting positive mental health
  • The Health and Education Select Committee released a briefing on ‘Children and young people’s mental health – the role of education’
  • Mental health was mentioned as a key government priority in the Queen’s Speech in 2017
  • In the 2017 general election, mental health was mentioned in all party manifestos

Northern Ireland

The Northern Ireland Assembly has conducted research and produced an information paper, a review and a framework on mental health in the region. These documents aim to provide background information, highlight relevant initiatives, and indicate next steps.

Key links:

Wales

The Welsh Government has stated their ambition and set out their strategy to improve mental health and mental health services. As part of it, they released a Wellbeing of Future Generations (Wales) Act in 2015. One of the outcomes from the Act was the establishment of a Future Generations Commissioner role, with mental health as part of the core remit.

Key links:

Scotland

The Scottish Government has released an action plan to make Scotland fairer. As part of the work on the delivery of the plan, a mental health strategy has been created. Additionally, Scotland appointed their first minister for mental health in 2016.

Key links:

International policy

Mental health is a key area for several international organisations, indicating the importance of the subject and giving the subject global prominence.

International policy
The United Nations (UN) World Bank (WB) The European Commission World Health Organization (WHO)
The United Nations Sustainable Development Goals aim to transform the world by 2030. Goal 3 is to ‘ensure healthy lives and promote well-being for all at all ages’, while many of the other goals address the wider underpinning determinants of health such as education, poverty, inequalities and justice.

The human rights of disabled people are set out in the UN Convention on the Rights of Persons with Disabilities.
The World Bank organised a series of eventson mental health, with the aim to make mental health a global development priority. The ‘European Framework for Action on Mental Health and Wellbeing’ positions mental health among the first public health priorities in the European Union. The Mental Health Action Plan for 2013-2020 was released by the World Health Organisation, concentrating on effective leadership, community based-care, prevention, and evidence enhancement.
International policy
The United Nations (UN)
The United Nations Sustainable Development Goals aim to transform the world by 2030. Goal 3 is to ‘ensure healthy lives and promote well-being for all at all ages’, while many of the other goals address the wider underpinning determinants of health such as education, poverty, inequalities and justice.

The human rights of disabled people are set out in the UN Convention on the Rights of Persons with Disabilities.
World Bank (WB)
The World Bank organised a series of eventson mental health, with the aim to make mental health a global development priority.
The European Commission
The ‘European Framework for Action on Mental Health and Wellbeing’ positions mental health among the first public health priorities in the European Union.
World Health Organization (WHO)
The Mental Health Action Plan for 2013-2020 was released by the World Health Organisation, concentrating on effective leadership, community based-care, prevention, and evidence enhancement.
1 McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins R (eds) (2009). Adult Psychiatric Morbidity in England 2007: results of a household survey. The NHS Information Centre: Leeds.
2 Jones, P. B. “Adult Mental Health Disorders and Their Age at Onset.” The British Journal of Psychiatry, The Royal College of Psychiatrists, 1 Jan. 2013
3 Office for National Statistics, 2016a
4 Healthy services and safer patients: links between patient suicide and features of mental health care providers. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
5 ibid
6 Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, 2017
7 Understanding provision for students with mental health problems and intensive support needs (Higher Education Funding Council for England) 2015
8 Guest, D. (2004) Employee well-being and the psychological contract. London: Chartered Institute of Personnel and Development.
9 What works? Student Retention & Success
10 McIntosh and Shaw. Student Resilience. Exploring the positive case for resilience. 2017
11 Simpson, A. & Ferguson, K. (2012) Mental health and higher education counselling services: Responding to shifting student needs. Journal of the Australia and New Zealand Student Services Association (JANZSSA). 39 (April), 1-8.
12 Public Health England (2014) The link between pupil health and wellbeing and attainment
13 NUS (2015) Mental Health Poll
14 Fleche and Layard (2015) Do More of Those in Misery Suffer From Poverty, Unemployment or Mental Illness?
15 ibid
16 Neves and Hillman (2017) 2017 Student Academic Experience Survey
17 Guardian (2017) Number of university dropouts due to mental health problems trebles