What are health inequalities and how do they impact mental health care? 

Health inequalities are systematic, unfair differences in the status of people’s health and the care that they receive, between different groups of people in society. 

The evidence is growing too large to ignore. Health inequalities impact every stage of the mental health care pathway. From condition prevalence to access to treatment, and ultimately patient outcomes, the experience of mental health care varies hugely between population groups. This is directly impacted by social determinants, such as wealth, race, and sexual orientation. 

From the outset, certain population groups are disproportionally affected by mental health issues. For example, one study estimates that LGBTQ+ people are 1.5 times more likely to develop depression & anxiety disorders¹. The drivers of health disparities often involve complicated social determinants, as laid out in the recent ‘Build Back Fairer’ (2020) report, which reviewed inequalities during the Covid-19 pandemic². 

However, the inequalities do not stop at condition prevalence. There are worrying differences in the levels of access to mental health services for specific communities, with barriers such as cultural stigma or language preventing people from getting the treatment they need. 

And when patients do access care? We observe stark variations in the experiences receiving care and health outcomes from treatment, across different groups.

• 5x more Black / Black British patients were detained under the Mental Health Act than White counterparts³
• 1 in 7 LGBTQ+ people avoided treatment for fear of discrimination³
• £1 in every £8 spent on long term physical conditions is linked to poor mental health and wellbeing⁴
• 80% of homeless people in England reported mental health issues⁵

What does the law and national policy say about health inequalities? 

As outlined in the Equality Act 2010, it is illegal to discriminate against anyone based on nine ‘protected characteristics’: age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex, sexual orientation, and marriage or civil partnership. As part of the Public Sector Equality Duty, NHS England is required to ‘have due regard to the need to’ address 3 equality aims around eliminating discrimination, advancing equality of opportunity, and fostering good relations. 

There are also other vulnerable groups outside these protected characteristics which experience health inequalities, such as asylum seekers and rough sleepers. Many of these groups are recognised in other legal frameworks, such as the Care Act 2014 or the Children Act 2004. 

At the national level there has been some progress in acknowledging these inequalities as a key challenge for the NHS. In both the NHS Long Term Plan (2018) and the NHS 'Advancing mental health equalities strategy', national guidance has set a clear strategic direction for taking a more coordinated approach to reducing health inequalities and unwarranted variation in care. However, achieving real progress depends on local health systems developing bespoke solutions to tackle inequalities. This is crucial because, ultimately, mental health services are commissioned and delivered locally, and these services must be centred around local populations. 

How can we tackle health inequalities effectively? 

Local mental health services can better tackle inequalities through providing better access to services and more appropriate care to specific groups and communities, across various demographics.  

For example, this might include: 

• Adaptations for local ethnicities, cultures, and languages 
• Specialist provision for LGBTQ+ individuals (such as LGBTQ+ counselling services) 
• Integrated mental and physical care for individuals with physical disabilities 
• Specific provisions for patients who are homeless or rough sleeping 

…and other provisions for specific vulnerable groups.  

However, implementing the right targeted interventions requires the right data to understand the inequalities in the first place. This lack of data is currently holding services back from effective health inequalities interventions. 

Indeed, the PSC’s work in this area has allowed us to understand the barriers preventing healthcare systems from adequately investing in this problem and coordinating our resources effectively to do so.

• We need to design and deliver mental health services that target inequalities and reduce the substantial burden on local systems, staff and population health.
• We need to bring together resources, sponsorship and a co-ordinated effort to tackle these issues. To achieve this, we need to make a compelling case for improvement.
• We need to obtain accurate data to identify those inequalities and make the case for targeted people and financial resources, the case for targeted programmes of work, and investment. 
• We need to tackle a range of issues around data quality, due to data collection, integration, reporting, etc. We need to make the case that this will benefit staff and patients alike. 

What happens next? 

Considering this context, we have set out six key steps to overcome these barriers, based on The PSC’s experience supporting health systems to improve the quality of their data. 

1. Set the strategic agenda and make a compelling case for change: Do not underestimate the importance of ‘top-down’ sponsorship and visibility. This buy-in is critical to getting the investment, coordination, and decision-making autonomy required for meaningful change. To begin building momentum, highlight the current gaps in your data as a barrier to effectively tackling health inequalities. Showing the connection between this issue and wider systemic data quality challenges sends a powerful message to operational and clinical leadership. Codifying improved data quality within your organisation’s annual objectives signals that this is a priority area for everyone. 

2. Mobilise dedicated groups to review the opportunities and challenges: Improving data quality in mental health services is a complex problem to navigate and will require an appropriate forum for discussion and decision-making. If this does not already exist, we recommend setting up a committed forum (e.g. a ‘Task & Finish’ group) with a clear remit and authority to make changes to data collection and reporting. The first step is to conduct a diagnostic of the current methods of data collection, challenges being faced, and key opportunities for improvement. 

3. Meaningfully engage with the right stakeholders to deliver change: Changing how personal, often sensitive data is collected and reported will impact the experience of both patients and staff. Decision-making groups must engage with a wide range of stakeholders, including protected and vulnerable characteristic networks, staff teams (legal, digital, data, operational and clinical), people with lived experience, and providers working on similar issues. You can find guidance and best practice case studies from NHS England here. 

4. Set up the right digital tools and infrastructure: The digital systems used in mental health services play an important role in facilitating data collection and reporting. The digital templates used for registering patients and keeping records of patient interactions with care professionals offer a crucial opportunity for improving data quality. Agreeing the appropriate questions to ask and which categories or coding to use locally will need to involve the wide range of stakeholders mentioned above. However, simply collecting better data at one point in a patient’s journey will not solve the entire issue. Safely connecting systems across primary, secondary, and community care is crucial to harnessing the full value of data and reducing the burden on staff who may be manually filling in the gaps. 

5. Integrate new metrics into existing data reports: Know your starting point – measuring your baseline data quality will allow you to benchmark your performance in the future. By creating an indicator to assess the completeness and accuracy of your data, you can continually monitor progress and identify key issues as they arise. To maximise accountability, you can even report this progress to leadership on a regular basis. 

6. Support frontline mental health teams to transform: Care professionals and support staff play an integral role in delivering services and collecting data – by making changes, you may be asking for their time and effort. Dedicate resources for supporting, coaching, and training staff to co-design and sustainably implement new processes for recording data. Explaining how better data can improve direct care to patients and tackle health inequalities will be crucial to empowering your workforce. 

By following these key steps, mental health services can better understand the needs of their diverse patient populations and deliver more equitable care. 

If you would like more information regarding our experience in supporting organisations to tackle mental health inequalities, please contact Chris Bradley: chris.bradley@thepsc.co.uk. 

Author: Roshan Shah from The PSC Digital Team

Podcast Link: Can digital & data save the NHS? With Roshan Shah and Dr Gurprit Pannu. 

Article References:

1. Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and
Recommendations (2011). Haas et al. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662085/

2. Fair Society, Healthy Lives (The Marmot Review) – Economic Analysis (2010). Institute of Health Equity.
Available at: https://www.instituteofhealthequity.org/file-manager/FSHLrelateddocs/economic-analysis-fshl.pdf

3. Mental Health Act Statistics, Annual Figures 2021-22 (2022). NHS Digital. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-act-statistics-annual-figures/2021-22-annual-figures

4. Bringing together physical and mental health: A new frontier for integrated care (2016). Naylor et al. Available at: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Bringing-together-Kings-Fund-March-2016_1.pdf

5. Homelessness: statistics. (2022). Mental Health Foundation. Available at: https://www.mentalhealth.org.uk/explore-mental-health/mental-health-statistics/homelessness-statistics