Context

Thrive LDN is a citywide movement to ensure all Londoners have an equal opportunity to good mental health and wellbeing. We are supported by the Mayor of London and London Health Board partners.

Since March 2020, we have also been coordinating the public mental health response to the coronavirus pandemic on behalf of Public Health England London, the Strategic Coordination Group and wider partners, with the aim of ensuring London’s diverse communities have the strength and resilience to cope with and overcome unprecedented events.

As part of our role, we produce regular working papers summarising the known impact of COVID-19 on Londoners’ mental health and wellbeing, implications for response and recovery planning, and suggested actions we take – locally, sub-regionally and regionally – to address immediate and anticipated future needs.

This work includes extensive community engagement and participatory action research with communities that are disproportionately at risk of poor outcomes in order to improve the representativeness and granularity of available information. To date, Thrive LDN has engaged with over 200 community groups and organisations and listened to over 10,000 Londoners with a view to understanding more about the experiences of 20 disproportionately at risk communities. Whist this work is ongoing, an initial summary of findings and suggested actions can be found here.

Comments and feedback are welcome and encouraged. If you would like to get in touch about this work please contact Helen Daly (helen.daly4@nhs.net), Thrive LDN Research and Evaluation Lead, and/ or Dan Barrett (d.barrett@nhs.net), Thrive LDN Director.

Overview

The COVID-19 pandemic has created economic, health and social uncertainty and insecurity across the world. The new variant of coronavirus that has become prevalent in London, the rise in COVID-19 cases and deaths, and the introduction of Tier 4 measures, followed by a national lockdown is a reminder of the unpredictability of this crisis.

It is currently not possible to determine the full impact on mental health and need for mental health services, but it is clear the effects are multifaceted. The uncertain nature of the virus and the restrictions in place impede on our natural and usual resources for wellbeing, as well as on our coping mechanisms and opportunities for social interaction. Data, research and insights collected have shown the detrimental direct effect COVID-19 is having on depression, anxiety, happiness, life satisfaction and loneliness levels across London, as well as the indirect effect on the factors which influence mental health and wellbeing, such as employment and income.

As the pandemic continues, it is necessary to recognise that the nuances of how uncertainty surrounding COVID-19 and the restrictions in place affect Londoners’ mental health and wellbeing in a way that is not necessarily straightforward or always obvious. In some cases, feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health and we need to be careful not to over-pathologise the natural process of how people are adapting to and coping with change.

However, existing inequalities have been exacerbated, leaving those who entered the pandemic vulnerable as a result of their socio-economic background and health status facing the most severe impacts. As the pandemic continues to evolve, its effects become more nuanced and the needs of Londoners become more pronounced and complex. This results in the requirement for a multi-agency approach that ensures that all Londoners who need help and support receive it.

There is clear evidence that the impact of COVID-19 has replicated and exacerbated inequality. Following a substantial period of rising case rates in London, leading to an increase in hospital admissions and deaths, it is important to reflect on what we have learned from the first months of the pandemic and about the effects of COVID-19 on health inequalities and what can be done to mitigate them.

Health inequalities are systematic, avoidable and unjust and there are varied differences in health and wellbeing between different groups of people. They arise because of the conditions in which we are born, grow, live, work and age, which influence our opportunities for good health and how we think, feel and act. These conditions shape our mental health, physical health and wellbeing. They also influence our exposure and vulnerability to SARS-CoV-2 infection, our ability to manage the consequences of the disease, and how the control measures affect us.

Substantial inequalities exist across protected characteristics and socioeconomic position in relation to the impacts of the coronavirus pandemic in London. This is both in terms of risk of COVID-19 infection, complications and mortality, and in terms of the negative economic, social and psychological consequences of Government policies to mitigate the health impacts of the pandemic. These COVID-19 related inequalities have been caused by processes of marginalisation and oppression, which before the pandemic had led to well-documented social and health inequalities, inequalities that have been exacerbated during the coronavirus pandemic. It is also important to acknowledge that years of structural racism and inequality has compounded mistrust, suspicion and fear between marginalised communities and power structures, creating a significant barrier for recovery. Unfair outcomes for population mental as a result of the COVID-19 crises include: a greater deterioration in their mental health for BAME men, reports of disabled people feeling failed and ignored by the government and single parents having higher levels of stress, depression, and anxiety.

Findings from communities indicate that for many communities across London, the coronavirus pandemic is seen as the latest crisis event in a crisis trend – a steadily worsening series of situations faced by disadvantaged communities across London. This is both a cause and consequence of poor mental health, felt both directly and indirectly.

Scope, methodology and limitations

Scope

The scope for this work is common mental health problems and the wider public mental health and wellbeing of Londoners. The work has a focus on advancing equality and reducing inequalities in the overall health and wellbeing of Londoners.

Methodology

The methodology is based on the pragmatic review of research and triangulation of multiple sources of relevant evidence relating to the COVID-19 pandemic, including population mental health data, analysis of the UK society and economy, and insights collected as part of Thrive LDN’s ongoing community engagement activities.

This rich and diverse range of information is methodologically varied and spans across different contexts and sample sizes, which in turn makes drawing comparisons and overall synthesis challenging. To ensure a level of rigour and reliable interpretation of the evidence, regular challenge sessions are held within the core team working on this, as well as with wider team members and partners, in order to test interpretation of data and assumptions made.

Limitations

Fundamentally, insights are limited by the availability of data and information. There will undoubtedly be data and information sources the team are unaware of and would appreciate being made aware of. There are also some data and information sources that we know will become available in the coming weeks. However, overall, representativeness and inclusiveness has been identified as a limitation across all sources of data and information,  with a lack of sufficient, granular intelligence available on the experiences and needs of different disadvantaged and marginalised communities in London.

The data and intelligence has been collated to inform the initial public mental health response to COVID-19. For many factors, it is still too soon to draw any definitive conclusions about possible shifts in mental health and wellbeing since the beginnings of the pandemic.

Impact on disproportionately at-risk groups

Many Londoners entered the pandemic from positions of disadvantage and there is convincing evidence that the pandemic seems to have simultaneously created new inequalities whilst widening pre-existing inequalities, both in terms of COVID-19 complications and deaths and in terms of the impact of the restrictions on mental health and wellbeing. Londoners with lived experiences of marginalisation and social disadvantage, who were already experiencing poorer social, economic and health outcomes, have been disproportionally affected by the pandemic.

People with the poorest mental health prior to the pandemic experienced the largest deterioration in mental health during the initial lockdown and are likely to be isolated and lacking support as restrictions continue to be put in place and the full effects of the pandemic are felt.

  • Black, Asian and minority ethnic communities, who experienced the highest proportion of people in their communities dying as a result of COVID-19.
  • Deaf and disabled Londoners, who report feeling failed and ignored by the government after being re-classified as ‘vulnerable’, therefore lessening their legislative support.
  • Families with children and single parents, who have had to cope with huge additional demands on their time to care for and educate their children from home.
  • LGBTQ+ Londoners, who report experiencing high levels of stress and depressive symptoms, especially amongst those who have experienced homophobic or transphobic harassment.
  • Older Londoners, who are more likely to be clinically shielding and experiencing long periods of isolation.
  • People with mental health problems pre-crisis, who are experiencing the largest deterioration in mental health during the initial lockdown.
  • Asylum seekers, who are living in cramped emergency hotel accommodation with limited access to the internet or means of communicating with a support network.
  • Women, who experienced a rise in domestic abuse and gender-based violence as well as mothers who are more likely to have lost their job since March 2020.
  • Young Londoners, who have had to endure the substantial impact of the closure of schools, colleges and universities.
Population mental health

Research has shown that the pandemic has had a detrimental effect on life satisfaction and happiness, self-reported anxiety and depression and suicidal thoughts, however a fundamental part of the public mental health response to tiered restrictions needs to be continuing to normalise what Londoners are experiencing and supporting them to build on the strength and resilience they already have.

Mental Health Foundation’s Coronavirus: Mental Health in the Pandemic study has looked at resilience across the UK during the pandemic and how people are coping. The latest research, published in September 2020, found that:

  • Most people (64%) say they are coping well with the stress of the pandemic.
  • The most common causes for worry were becoming ill with the virus, being separated from friends and family, being unable to cope with uncertainty, being unable to provide for their families and making existing mental health problems worse.
  • Of those who have experienced stress due to the pandemic, almost nine out of ten (87%) are using at least one coping strategy.
  • People have used a wide range of strategies to cope; these most often included going for a walk, spending time in green spaces, and staying connected with others.
  • Some people are resorting to potentially harmful ways of coping, including increased alcohol consumption, substance misuse, and over-eating, putting their mental and physical health at greater risk.

Across the insights captured as part of Thrive LDN’s community engagement activities, struggling with uncertainty for the future was an extremely common theme. However, there has also been a definite theme of hope. Communities disproportionately affected by the coronavirus pandemic identified the significance of family and support structures as well as the support offered by the wider community and faith groups.

Findings from the London Community Response Survey show a clear relationship between community resilience and coping with uncertainty, and the power of regular contact, collectivising, and social networks.

There is a clear need to examine these assets further and explore how they can be reinforced to protect Londoners’ mental health and build strength and resilience in the long-term.

Direct impacts of COVID-19

Current evidence suggests there is a direct mental health impact of COVID-19. A proportion of people (5%) will experience persistent symptoms of the virus for weeks and months, and this has serious implications for people’s physical and mental health.

The pandemic has placed greater importance on digital connections due to the rapid transition to online services, however connecting and accessing services online is not an option for all Londoners due to an absence of devices, connectivity limitations and other factors. People who are digitally isolated miss out on a wide range of advantages including access to services, knowledge and goods, and this risks exacerbating existing health and other inequalities.

COVID-19 has and will continue to have a major impact on the individual and societal experience of death, dying, and bereavement. Social isolating measures, the lack of usual support structures and the changes implemented to services including end of life and palliative care have influenced experiences of grief and mourning for deaths of all causes during this period.

Loss of life by COVID-19 is a challenging kind of bereavement, with family, friends and communities requiring care and support, especially in the first days and weeks following their bereavement. A review of complicated grief confirms the pandemic has an increased prevalence of risk factors associated with complicated grief, for example, sudden/unexpected death and low levels of social support.

Due to the unprecedented scale and speed of the roll out of the COVID-19

vaccination it is likely there will be an impact on population mental health and wellbeing, such as health anxiety or stress.

Insights gathered from community research activities with Toynbee Hall have identified how experiences of structural racism and inequality have compounded mistrust, suspicion and fear within marginalised communities, which may lead to confusion, the circulation of conspiracy theories and reduced uptake of the vaccine by ethnic minority groups.

Findings from the UK Household Longitudinal Study published in January 2020 has shown overall intention to be vaccinated was high (82% likely/very likely) but reported that Black, Pakistani and Bangladeshi ethnic groups had greater vaccine hesitancy.

Financial impact

It is not possible to forecast the precise economic impact of a specific change to a given restriction with confidence, however it is clear that measures to contain COVID-19 have had a major impact on the economy and public finances.

Income and employment are intrinsically linked to health and wellbeing. There is a strong socioeconomic gradient in mental health, with people of lower socioeconomic positions having a higher likelihood of developing and experiencing mental health problems.

Official income statistics are not yet available to compare to those released before the pandemic, however The Health Foundation review of trends in income and poverty in recent years has shown the UK entered the pandemic from a position of stagnant income growth and low levels of financial resilience.

Today, as a result of multiple lockdowns, there are signs of increasing economic inequality, with more people on lower personal incomes reporting reduced income in the household. Furthermore, they are working fewer hours and are less able to save for the future, while fewer people with higher incomes have been impacted financially.

When stratifying employment loss and furlough by income level, the future economic consequences of COVID-19 are likely to be worse for those on lower incomes, creating an additional burden in the long-run on the mental health and wellbeing for Londoners in this group.

Despite unprecedented government support, financial wellbeing has deteriorated drastically. The latest IHS Markit Households Finance Index shows the largest fall in overall perceptions of financial wellbeing since the survey began in 2009, with a continued deterioration for UK households recorded in November.

The latest available data has shown households are using up more savings as cash availability falls again, with savings declining at the quickest rate for seven years. Household income from employment remains low, however the year ahead outlook for the financial situation is the least pessimistic since March. Overall, this is consistent with UK consumer confidence dropping sharply to levels not seen since the 2008 financial crisis.

Further to this, estimates looking across personal and economic wellbeing that cover the period from 27th March to 6th December 2020 as part of the Opinions and Lifestyle Survey have indicated a slight improvement in people’s perspectives of their personal household financial situation since the summer. Throughout the pandemic, the percentage of people reporting that they were unable to pay for an unexpected but necessary expense of £850 has remained stable but significant, with a weekly average of 31% from 9th April to 20th December 2020.

Suggested actions

Research and Community Insights

  • Undertake and support community participatory research and engagement to understand more about how COVID-19 has impacted the mental health and wellbeing of Londoners, how they have used their assets and systems to withstand, adapt to and recover from adversity, and what support they need going forward to strengthen their mental health and wellbeing.
  • Undertake scenario planning to understand more about how future trends may impact Londoners’ mental health and wellbeing.

Communications

  • Communicate clear and consistent public mental health messages that: (1) Speak to now; (2) Promote resilience; (3) Promote community / neighbourliness; (4) Promote universal mental health support offers, particularly support available to manage anxiety and (5) Promote that mental health services are still open.
  • Utilising the opportunities for mental health signposting within non-mental health services and settings, such as testing clinics and ward discharge.

Advancing equality

  • Develop targeted communications, campaigns and activities to address language, cultural and structural barriers that impede upon Londoners’ equitable access to information, advice and support.
  • In co-production with target communities, develop and implement more culturally competent public mental health education and prevention campaigns, and public mental health programmes.

Resilience

  • Develop and implement universal and selective resilience promotion programmes, including settings-based approaches, parenting programmes, digital technology programmes and physical activity promotion.
  • Provide further free training, development support and grants to voluntary and community sector organisations, particularly micro-organisations, to build the resilience of wider support systems.
  • Utilise neighbourhood and community assets to improve social cohesion and social support and develop more safe places for social connection and interaction via. community and peer support.

Enhanced support

  • Improve bereavement referral pathways, being mindful of the different ways individuals might seek support for a bereavement, and develop targeted bereavement support signposting toolkits and campaigns for different vulnerable groups at varied levels of intensity.
  • Undertake targeted outreach to people who are unemployed, struggling with debt and/ or at risk of eviction and ensure accessible mental health and suicide prevention support is available.
  • Develop targeted mental health and suicide prevention support offers for disproportionately at risk groups, for example those with pre-existing mental health issues, Black, Asian and minority ethnic communities, Deaf and disabled Londoners, Families with children and single parents, LGBTQ+ Londoners, Older Londoners, Women and Young Londoners.
Thrive LDN’s response

Coordination

Thrive LDN are supporting the Strategic Coordination Group and associated sub-groups to implement mechanisms for embedding mental health and wellbeing into pandemic response structures by conducting mental health and wellbeing impact assessments to identify risks and mitigating actions relevant to each group’s remit.

Research, community insights and development

Thrive LDN will continue to work with Public Health England London to undertake research and community engagement projects to understand more about the impact of COVID-19 on Londoners’ mental health and wellbeing and to develop mitigating actions.

Communications and campaigns

Thrive LDN will continue to work with partners to regularly develop and distribute a Public Mental Health Communications Toolkit and to develop targeted, culturally-competent communications projects to support disproportionately at risk groups.

Young Londoners and parents

We will continue to deliver and scale up our Young Londoners’ mental health projects, namely Youth MHFA training, and we have started a new Parental Mental Health programme.

Right to Thrive

We are currently expanding our Right to Thrive programme to offer additional support, training and development opportunities to grassroots groups and take further action to advance equality.

Resilience

Thrive LDN has mobilised a new Resilience programme across London. This includes a resilience and social connectedness promotion campaign, a new series of open-access, clinically-led Wellbeing Webinars, an emotional resilience programme and several targeted resilience promotion projects.

Enhanced support for disproportionately at risk groups

In response to the rising number of Londoners over-indebted, in October 2020 we started a new partnership programme to develop enhanced mental health and suicide prevention support for those struggling financially. We will take a similar developmental approach to develop enhanced support for other disproportionately at risk groups.

Suicide Prevention

We will continue our work to develop and promote additional support for those bereaved by suicide, expand the Suicide Prevention Information Sharing Hub and deliver Suicide Prevention Education Training for schools, colleges and universities online.