By Andy Bell
Just over a week ago, NHS England published its Advancing Mental Health Equalities strategy. The strategy sets out the steps the national body responsible for the NHS in England intends to take to address the stark inequalities in the experiences of different communities and groups of people of mental health services.
Mental health inequalities, as the strategy recognises, exist on multiple dimensions. First, mental health inequalities affect many different groups of people: for example because of their age, ethnicity, gender or gender identity (among other things). And second, as the Commission for Equality in Mental Health has also pointed out, inequalities exist at different stages in the system: in the determinants of mental health, in access to mental health support, in people’s experiences of mental health care and in the outcomes people get from services. As it is an NHS strategy, Advancing Mental Health Equalities deals with access, experience and outcomes; stating that the determinants of mental health have to be addressed elsewhere.
The strategy identifies three key areas for action. The first is to support local systems to address mental health inequalities in their areas. This includes the Patient and Carer Race Equality Framework (PCREF), a key recommendation of the 2018 Independent Mental Health Act Review report to build the capacity of health and care organisations to improve the support they offer to Black communities.
inequalities exist at different stages in the system: in the determinants of mental health, in access to mental health support, and in people’s experiences and outcomes of mental health care
The second is to improve data and information to support improvement in the system. This is vital for two reasons. First, there is currently very little transparency about how well NHS organisations are addressing mental health inequalities, if at all. In our recent research for the Commission for Equality in Mental Health, data about inequalities in experiences and outcomes from services was hard to find, and piecemeal where it existed. And second, without transparency, we cannot create accountability. This will be essential if we are to build a system where services can account to their communities for how well and how far they meet their needs.
The third major ambition is to develop a “diverse and representative workforce at all levels of the system…which is equipped with the skills and capabilities it needs to advance mental health equalities.” This is perhaps the most far-reaching and challenging aim in the strategy. If it is to have a significant and lasting impact, it will need to bring about root-and-branch changes to the ways people are recruited into mental health service roles, how they are educated and trained, supported and supervised. It means tackling inequities in professional hierarchies, in organisational practices and in service cultures. It cannot be achieved through a few brief training courses without structural change.
Mental health equality has never been more important, and it can be ignored no longer.
Advancing Mental Health Equalities is an ambitious strategy with a clear vision and theory of change. The recent history of mental health policies and strategies is littered with such documents. So what will make this one work? It has the benefit of falling within the ambit of the NHS Long Term Plan, with pledges of additional funding for mental health services and plans for rapid growth in the workforce. These will be essential if it is to succeed. But it will also need time. Previous strategies seeking to address mental health inequalities – for example 2005’s Delivering Race Equality – were given too little time to make an impact, or in the case of the recent Women’s Mental Health Taskforce report, big ideas but no resources or commitment to act. We must ensure that Advancing Mental Health Equalities gets the resources and the time it needs, backed up by determined leadership and robust evaluation to enable learning and adaptation to take place along the way.
But we must also remain mindful of the determinants of mental health: the missing piece in the puzzle. The strategy notes that the NHS has little influence over these; though it does have some, and both nationally and locally it could do a great deal more to influence wider systems and policies to address the causes of the inequalities it faces. And just as importantly, health and care services must ensure they do not repeat and reinforce the discrimination, disregard and disempowerment too many people experience in their lives.
Failing to [tackle the determinants of mental health] means that the NHS will face an uphill struggle in the context of a toxic wider system that creates more mental health inequalities faster than health and care services can respond to them
To tackle mental health inequalities from their roots, however, we also have to address poverty and economic inequality, racism and discrimination, exclusion and injustice. And that will require action from national government as well as business and civil society, and public services including education, justice and housing. Failing to take these steps means that the NHS will face an uphill struggle in the context of a toxic wider system that keeps creating more mental health inequalities faster than health and care services can respond to them.
Next month, the Commission for Equality in Mental Health will publish its final report. It will explore what a system designed for equality in mental health could look like, and crucially what actions are required to get us there. We hope that it will spur action at every level to make equality the centrepiece of achieving better mental health for us all. Mental health equality has never been more important, and it can be ignored no longer.