Hospital admissions for mental health conditions before and during COVID-19

How did England compare with other countries?

In the UK, an estimated 1 in 6 people live with depression, and 1 in 4 with anxiety. The prevalence of mental health conditions increased during COVID-19, likely due to the pandemic itself, government measures including lockdowns and school closures, and disrupted access to mental health care. But how did England compare with other nations? Were our levels of mental health conditions higher than elsewhere? 

Such comparisons are helpful to gain insights into what targets might be achievable and where we might be falling behind. However, interpreting differences between countries can be complicated due to varying counting methods, needs and models of service provision. 

Launched in 2018, the International Collaborative on Costs, Outcomes and Needs in Care (ICCONIC) is a 14-country collaborative aiming to advance research on international comparisons of health care using patient-level data. It is led by researchers at Harvard and Brown universities and has been co-funded by the Commonwealth Fund and the Health Foundation. Eight partner countries were involved in research on hospital admissions for mental health conditions before and during the COVID-19 pandemic.

Here, we share what can be learned about England from this study.

Figure 1: How did hospital admissions for mental health conditions between 2017 and 2020 in England compare with other countries?  

The study found that England had the second lowest rate of hospital admissions for mental health conditions between 2017 and 2019 (142 hospitalisations per 100,000 people). Only Spain had a lower rate (97 per 100,000 people), while France’s rate was almost 8 times higher (1,064 per 100,000 people) than England’s. 

The study data also showed that England had the lowest percentage of admissions for serious mental health conditions (psychotic and mood conditions), which represented just 55% of all mental health admissions. This indicates that other mental health conditions (such as stress-related and behavioural conditions) accounted for a larger than expected proportion (45%) of hospital admissions in England. It may also suggest an unmet need for hospital care of serious mental health conditions.

The rates of hospital admissions changed significantly with the outbreak of COVID-19 in 2020 (see Figure 1). Like Spain and Canada, rates of hospital admissions for mental health conditions in England were stable between 2017 and 2019. But the picture shifted significantly when the pandemic hit, with a 15% drop in mental health admissions in England in 2020 compared with the 2017 to 2019 average. This decrease was also observed in other countries, with an even bigger drop in Spain (39%) and about the same fall in France (15%), but a smaller decline in Canada (8%) and Switzerland (3%). In England, this drop was particularly pronounced for serious mental health conditions (21% decrease). In contrast, hospitalisations for mental health conditions in the US and Finland increased year on year, and even more so between 2017–19 and 2020 (11% and 13%, respectively). 

What can we learn from this?

Overall, what we can see from this data is that fewer people were admitted to hospital for mental health conditions in England than in other countries between 2017 and 2020. But what might explain these differences, and what do they indicate about mental health in England?

There are several possible explanations for the lower rates of hospitalisation observed in England. First, differences in hospital admission rates between countries may primarily reflect differences in data definitions and collection – for example, how mental health diagnoses are coded in hospital data. This could mean hospital admission rates for mental health conditions in England are much more similar to other countries than suggested in this study.

Second, differences in hospital admission rates may reflect differences in how countries decide to provide services for people with mental health conditions. England has lower inpatient psychiatric care capacity than other countries, in line with a long-term policy of community-based care for mental health over the last few decades. Crisis Resolution Home Treatment Teams aim to prevent the need for hospitalisation. However, there are signs the reduction in mental health hospital beds in England has gone too far, leaving patients unable to access hospital care when they need it. The number of mental health hospital beds fell by 73% between the late 1980s and 2010s, much greater than the decline in beds in other areas, leading to higher thresholds for admission and more mental health patients being cared for in general and acute beds. Mental health beds have high occupancy levels (90% in April to June 2024), and people in need of mental health care are more than twice as likely to face 12-hour waits in A&E than other patients.

Third, it’s possible there may be less need for mental health hospital care in England. People in the UK report lower rates of emotional distress than those in Canada or those the US (although higher than in France, despite their much higher admission rates), and are less likely to want to see a professional when experiencing emotional distress. 56% of GP practices in England also report feeling well prepared to care for people with mental health conditions – lower than ideal, but higher than in France (31%) and the US (46%), both of which have higher rates of hospitalisations. However, deaths due to mental health conditions and suicides have increased steadily between 2014 and 2022. This suggests a large unmet need for mental health hospital care. 

We can also see evidence of this unmet need when looking at trends during COVID-19: reduced hospital admissions during the early stages of the pandemic are consistent with international evidence showing reduced rates of hospital care. Several studies have shown an increase in mental health conditions over the same period in England and other countries. This indicates the need for mental health hospital care increased in 2020, going against the trend of reduced hospital admissions.

Data issues

Lower levels of hospital admissions for mental health conditions in England could also reflect that the data do not completely cover hospitalisations at some specialised mental health trusts. This is unlikely to have a major impact on the findings for the 2017 and 2020 period discussed, however it does raise concerns for our future monitoring of trends in mental health care use. 

We used to know well how many patients were admitted to hospital for mental health conditions, but we are losing track of these really important data. Some mental health trusts no longer routinely submit data to the main data of hospital admissions in England (Hospital Episode Statistics), and diagnosis data is not well recorded in the Mental Health Minimum Dataset. This means we are less able to track the number of people detained under the Mental Health Act or hospital admissions for children, among whom mental health conditions have risen rapidly. 

Where do we go from here? 

Comparisons with other countries are helpful to contextualise the trends in mental health admissions in England. Overall, the rate of mental health hospital admissions in England appears to be lower than in most other comparable countries, and decreased more during COVID-19. A follow-on study further suggests that the effect of the pandemic on access to acute mental health services is still being felt. Hospital admissions for mental health conditions continued to decrease between 2020 and 2022, while deaths due to mental health conditions have continued to rise. These results together might indicate that we have reached the limit of long-term decreases in mental health beds, with a substantial burden of unmet need for hospital care among people with mental health conditions. While the government’s approach of prioritising community-based services and prevention through early treatment is sensible, there is nonetheless a need to improve access to hospital-based mental health care alongside. 

Acknowledgments

We are grateful to Steven Wyatt, Paul Seamer, Andrew Jones and Jonathan Spencer at the Strategy Unit who undertook the analysis of England data for this study and contributed to the interpretation of findings.