Inequalities in mental health and why this data is a priority

Reducing inequalities is a defining feature of the NHS Long Term Plan, which acknowledges “…while we cannot treat our way out of inequalities, the NHS can ensure that action to drive down health inequalities is central to everything we do.”  The NHS Mental Health Implementation Plan 2019/20–2023/24 gives the detail underpinning the NHS Long Term Plan ambitions for mental health and sets the expectation that all systems need to reduce mental health inequalities by 2023/24.

The Advancing Mental Health Equalities strategy summarises the core enabling actions NHS England and NHS Improvement will take with the support of the Advancing Mental Health Equalities Taskforce – an alliance of sector experts, including patients and carers, who are committed to creating more equitable access, experience and outcomes in mental health, learning disability and autism services in England. This strategy is also an important element of the overall NHS plans to accelerate action to address health inequalities in the next stage of responding to COVID-19.

Submitting good quality data on protected characteristics and other vulnerable groups is therefore key to support the delivery of the strategy and achieve the NHS Long Term Plan ambitions.

Health inequalities are known to exist across protected characteristics and other vulnerable groups. However, there is still a lot we don’t know or can’t examine due to the limitations of the data available. We aim to establish a much better set of routine data to support health systems to advance equality.

Examples of the evidence on health inequalities

Sexual orientation and gender Identity - Individuals who identify as a sexual minority experience health inequality. Those who identify as bisexual have reported the poorest health and those who identify as gay and lesbian have reported poorer health in regard to mental functioning, distress and illness status when compared to their heterosexual counterparts¹. Research has also found there were disparities in the mental distress of bisexual and trans people compared to their gay and lesbian counterparts, resulting in the need for greater availability of specialist mental health services and counselling support for these groups^2,3.

Ethnicity - Ethnic minorities receive a lower quality of healthcare than non-minorities, even when controlling for access-related factors. The sources of these disparities are complex and are rooted in historic and contemporary inequities and involve many individuals at several levels, including health and social care systems (and their administrative processes), health and social care professionals and patients⁴.

Disability - Research has shown a relationship with disabled people and poor mental health across their life-course^5,6,7.

Accommodation type - Being homeless or sleeping rough have shown links with health inequality, with individuals being associated with shorter life expectancy, higher morbidity, and greater usage of acute hospital services^8,9.

The gaps in evidence

There is often a lack of diversity and representation within research which is leading to a smaller evidence base for mental health and a lesser understanding of its relationship to demographics data¹⁰. Research around gender identity and sexual orientation often combine health profiles of these individuals without considering the health inequalities of each individual group. Although combining these data can be useful for analysis, it may hide important issues specific to distinct groups and be difficult to identify key disparities¹¹.

The reasons for under-representation of ethnic minority groups in research are complex, and could be related to hesitancy from participants, lack of inclusion by researcher and/or health and social care staff, language barriers and other socioeconomic factors such as systemic inequalities¹². Disability academics have stressed that previously, research on disability issues has failed to focus on the issues of greatest relevant to disabled people and therefore fail to address the issues they face^13,14. There are difficulties in finding research about the rough sleeping population as they typically have experience high levels of traumatic life experience and negative experiences with health services that do not adapt to their needs, along with systems being inflexible in adapting their approaches to participating in research¹⁵.

We should be careful not to associate the lack of evidence and data with the clear risks certain population groups are exposed to. For example, a smaller number of reported mental health problems in certain demographic groups does not equate to these individuals having good mental health.

In addition, there are some important dimensions of health inequalities, such as deprivation, employment, income and educational attainment that are not protected characteristics under the Equality Act 2010. Therefore, the collection of equalities data and questions related to some of the main dimensions of health inequalities will support meeting the duties for these vulnerable groups.

Building evidence through our national routine data

By working with the system to implement this guidance, we aim to have robust and complete demographics data available for mental health, learning disability and autism services to better understand the inequalities experienced by patients. This guidance will also allow providers, advisers, lived experience practitioners, researchers, and other relevant stakeholders to input into and provide best practice to further increase the evidence base on health inequalities, improving as further iterations are published.

About outcome measures

Outcome measures are tools (usually in a questionnaire format) that help measure quality and effectiveness of the intervention or treatment offered to improve an individual's mental health and wellbeing alongside any other influences. They can also help the organisation monitor and improve effectiveness, efficiency and quality of the service offered to its patients, thereby its accountability.

Using outcome measurement tools allows us to measure change and when we talk about clinical outcomes, we are considering the difference that an intervention/ service is making. This change should be decided based on what is important to the patient and the service.

Why outcome measures are important

Outcomes should be used to improve person-centred care and ensure the care delivered is appropriate. Decisions should be made between clinicians and patients about the tool that is most appropriate, and this/these tools should be used routinely to guide care.

For service users:

• to help identify needs and areas for focus, and recognising any progress made 
• to aid care planning 
• promoting shared decision making 
• clear and systematic approach to identifying needs and monitoring change

For services:

• to understand the needs of the service users they’re serving, and ensure services are meeting them  
• to understand the difference they are making 
• to identify gaps in the service
• to demonstrate safety, quality, effectiveness and efficiency of the service
• to help guide service improvement and delivery

For commissioners:

• to identify gaps in commissioning in order to fill them 
• to understand how the services they commission are helping their service users 
• to have a better idea of need in the area

Outcomes measures are also important for understanding the benefit and impact people receive from mental health services and to measure progress of deliverables underpinning the NHS Long Term Plan for mental health.

How outcome measures can address inequalities

Understanding access alongside treatment patterns, demographics and outcomes measures is very powerful in policy development and implementation. Embedding outcomes measures across mental health services has to be co-produced and co-developed with Experts by Experience and/or people with lived experience and services.

It is vital that we drive routine use of outcomes measures and national reporting to monitor the impact/benefit people receive from services and link with demographic data, including protected characteristics, to develop metrics on equality and ensure good outcomes are achieved for all people in contact with mental health services.