Welsh NHS Confederation response to consultation on mental health inequalities

Introduction 

1. The Welsh NHS Confederation welcomes the opportunity to respond to the Health and Social Care Committee’s consultation on mental health inequalities. 

2. The Welsh NHS Confederation represents the seven Local Health Boards, three NHS Trusts, Digital Health and Care Wales and Health Education and Improvement Wales (our Members). We also host NHS Wales Employers. 

Which groups of people are disproportionately affected by poor mental health in Wales? 

3. The Commission for Equality in Mental Health indicated in its report ‘Mental Health for All’ that chances of experiencing poor mental health are known to be closely linked and mirror a range of social, economic, ethnic and health inequalities. This has been reflected in the feedback we have received from our Members, who have identified a wide range of groups disproportionately affected by poor mental health in Wales. The adverse effect on individuals’ mental health is exacerbated wherever these groups’ attributes overlap. 

• Homeless people and those at risk of homelessness 

• Adults and children from the poorest 20% of households 

• Non-English/Welsh speakers 

• Asylum seekers and refugees  

• People in Gypsy, Roma and Traveller communities 

• People of African-Caribbean communities and minority ethnicities generally 

• People with autism and learning disabilities 

• Children and young people aged 11-25, particularly young women 

• People identifying as LBGT+ and under 35, particularly teenagers, or over 55 

• Those with hearing and sight impairments 

• Older people 

• Prison populations 

• People struggling with alcohol or drug issues, particularly men 

• People who have experienced extensive physical and sexual abuse 

• Sex workers 

• Health and care workers 

• Veterans 

• Women during pregnancy or the 1st year 

• Young, white, unemployed men 

• Isolated individuals with limited/no support network

4. Members also highlighted the significant impact of the COVID-19 pandemic on the mental health and wellbeing of the population. During the first wave, it was widely believed that any psychological distress experienced by the majority of the population as a result of COVID-19 would be short lived and a natural response to an unprecedented situation. However, there was also certainty that for some groups the effects would be more severe and long lasting. Evidence indicated that these groups could be those directly affected by COVID-19, those at heightened risk from being locked down at home, BAME individuals and those already identified as being at greater risk of poor mental health  

5.The Build Back Fairer: COVID-19 Marmot Review highlighted that existing mental health inequalities could be widened as a result of the pandemic. The Review also provided analysis of data from ONS Opinions and Lifestyle survey, which found having a disability was singingly associated with reports of high anxiety following the outbreak of the pandemic.  

6. The Influence of the COVID-19 Pandemic on Mental Well-Being and Psychological Distress: Impact Upon a Single Country examined psychological wellbeing and mental distress of the Welsh population during the first and second lockdown periods. It found that levels of psychological wellbeing were lower in second survey compared to first, with wellbeing continuing to be lower in women, young adults and those from deprived areas. It also found that the wellbeing gap between young and old also continued to broaden. 

What factors contribute to worse mental health within these groups? 

7. A number of potential factors were highlighted in the Marmot Review which could impact on already vulnerable groups. Issues such as financial/employment worries, loneliness, fear of infection and less access to goods and services were highlighted. Alongside these, our Members identified other factors including;  

• Access to travel 

• Access to mobile data/broadband 

• Chaotic lifestyles 

• Substance misuse 

• Homelessness or insecure housing 

• Family history of poor mental health 

• Low levels of educational attainment and unemployment 

• Socio-economic factors (relationships, employment, housing, finances) 

• Long waiting lists and the referral criteria which can delay access to services  

• Those unable to use problem solving abilities to manage crisis situations 

• Absence of insight into mental health conditions 

• Digital inequality 

8. Public Health Wales (PHW) has outlined the interconnected nature of some of the factors which can impact on mental health and wellbeing. In its report, ‘Unpaid Carers in Wales: The determinants of mental wellbeing’ it noted that “socio-economic position (i.e. economic status, level of education and income) can be both a cause and a consequence of poor mental wellbeing. A lower socio-economic position is associated with lower mental wellbeing. However, mental wellbeing can also impact socio-economic position”. It went onto explain that somebody’s status as a carer can further complicate this relationship. PHW has also explored the impact of wider determinants and population characteristics on wellbeing outcomes for young people during the COVID-19 pandemic in a report entitled ‘Children and young people’s mental well-being during the COVID-19 pandemic’. 

9. Our Members also expressed concern around the potential increase in mental health issues among the population as a result of the economic crisis arising from the pandemic. The Marmot Review highlighted that an estimated additional 500,000 would be experiencing mental health problems as a result of the economic crisis triggered by the pandemic, based on the outcomes of the 2008 recession. It also mentioned that the “prevalence of such mental health problems will be unevenly distributed, given the different economic impacts that the crisis has had on particular parts of the country and on particular groups”. 

10. Regarding health and care workers, it could be argued that they are at greater risk of burnout and post-traumatic stress disorder due to the nature of their work and their experience of responding to the pandemic and caring for patients. Doctors, regardless of stage of training or specialisation, are a group at high risk of developing addiction disorders. As highlighted within our briefing, Supporting Welsh NHS staff wellbeing throughout COVID-19, NHS organisations across Wales have introduced a range of initiatives during the pandemic to support staff health and wellbeing. 

For the groups identified, what are the barriers to accessing mental health services?  

11. There are a number of barriers to accessing mental health services, including location, cultural barriers, transportation, flexibility of services, digital exclusion, stigma, lack of knowledge amongst the public on what services are available and a previous bad experience of accessing mental health services.  

12. On health and care workers, the traditional culture of ‘toughing it out’ and not admitting weakness may exacerbate the mental health impact of tackling COVID on the front line and makes it difficult to seek out and accept help and support. 

How effectively can existing services meet their needs, and how could their experience of using mental health services be improved? 

13. Our Members seek to provide access and develop a wide range of quality mental health services, including a digital offer. However, our Members acknowledge that there are issues which could impact on patient experience, including long waiting times, lack of resources, poor quality environments and communication. Our Members have put forward suggestions around how services can be improved, including:  

• Different models of delivering care, such as extended hours, walk-ins, more self-referral 

• Societal change around mental health, such as reducing the stigma around conditions and raising further awareness around the Time To Change campaign 

• Improving self-advocacy for patients 

• Services needing to monitor patient outcomes and capture patient experiences to help build confidence in the services.  

• A ‘No Wrong Door’ approach to accessing services 

• Full integration of Whole School Approach and Whole System Approach to mental health would support the younger cohort. 

14. Specific concerns were also raised around insufficient beds for substance misuse inpatient treatment, the urgent need to expand seclusion capacity and offer a service to women in Wales who have mental health and learning disability forensic needs and capital investment for respite care to improve patient experience. More investment is also needed to ensure that children’s hospital wards are not used for certain CAMHS patients as it is inappropriate accommodation. 

To what extent does Welsh Government policy recognise and address the mental health needs of these groups? Where are the policy gaps? 

15. Welsh Government’s A Healthier Wales highlights a vision of “an equitable system which achieves equal health outcomes for all. The holistic approach we need is also one that provides an equitable level of treatment, care or support to people throughout their lives and irrespective of whether it is a matter of physical or mental health”. It sees a key role for Regional Partnership Boards (RPBs) in driving the development at local level of models of health and social care, including primary and secondary care, with early models of care focusing on priority groups, including people with mental ill health. RPB’s Wellbeing and Mental Health Boards bring together primary care clusters and partner organisations to help achieve this. 

16. It is also understood that the review of ‘Together for Mental Health: A Strategy for Mental Health and Wellbeing in Wales’ would inform the development of a future strategy. In relation to the development of the new strategy, Members recommended that it should consider required actions to address inequalities. These would need to take a universalism approach, with actions to be universal, but with scale and intensity proportionate to the level of need.  

17. Current policy aims to address inequalities, for example, by producing guidance for health professionals to be able to address the needs of these groups. However, gaps still exist and there are barriers to accessing care for many. This could be improved by increasing funding and awareness of services. The nature and configuration of community health services need updating due to the needs in society changing and with technological advancements.   

18. It is important that local government/social services and the NHS work as one system in relation to mental health. There is a need to drive further delegation of funding to Local Health Board level for capital and revenue to enable Boards to meet local circumstances and prioritise investments against a national commissioning framework. The gaps in women's forensic psychiatry services need addressing through targeted capital and revenue investment, and greater integration between medium and low secure provision. 

19. Our Members also recognised the need to improve elderly mentally infirm assessment facilities and long term residential/nursing home capacity to enable release of inpatient beds in the acute sector. 

20. Members indicated that health inequalities could be reduced by increasing access to green space, as outlined in The Lancet’s publication Effect of exposure to natural environment on health inequalities. The King’s Fund’s Tackling multiple unhealthy risk factors: emerging lessons from practice also identified several lessons for service providers that want to focus on tackling multiple unhealthy behaviours that may trigger mental health issues among groups. These include: 

• Targeting individuals who may have a particular risk of multiple risk factors using evidence that is available on who those people might be in a local area 

• Approaches to behaviour change should ensure that the social factors behind accruing multiple risk factors are taken into account 

• Unhealthy behaviours do not respect organisational boundaries, and some of the best partnerships on addressing multiple risk factors occur when local authorities and the NHS set up formal referral routes between them 

• The academic evidence on how best to tackle multiple unhealthy behaviours remains weak. More can be done at the national level to invest in research in this area but the quickest win is to support local areas providing these services to learn and self-evaluate in practice. 

What further action is needed, by whom/where, to improve mental health and outcomes for the groups  

21. Health inequalities are the result of many and varied factors and arise as a result of the social and economic inequalities that shape the conditions in which people are born, grow, live, learn, work and age. The NHS alone does not hold all the levers required to create the necessary conditions for good health and wellbeing. As highlighted within our Health and Wellbeing Alliance briefing, Making the difference: Tackling health inequalities in Wales, meaningful progress will require coherent, strategic efforts across all sectors and Welsh Government departments to close the gap. 

22. The Centre for Mental Health’s report ‘Now or Never’ sets out 10 key areas for investment in the mental health system. Members recommended that all these areas should be considered as part of this consultation, with a focus on how these investments could be enriched to reduce inequality. 

23. Members raised issues of funding and called for parity between mental and physical health. More capital investment is also required in estates to help provide dedicated treatment and intervention spaces in more private settings.  

24. Members suggested there should be a shift away from targets that focus on process to ones concerned with improvements patient outcomes and experience. As highlighted within our Senedd election briefing, Valuing, engaging and delivering: A health and care system for future generations, to improve population health and wellbeing further, it is vital that meaningful person-centred performance measures and frameworks are developed across the NHS and local government which focus on patient experience, clinical outcomes, prevention, whole-system collaboration and applying value-based healthcare. The current NHS performance targets focus too specifically on acute and secondary care and do not always support the system to grow and redesign. While targets have a role to play, we must also look at the bigger picture, instigating a whole system change in the way treatment is delivered, how services are provided, and population health measured. A key driver within this is the Well-being of Future Generations (Wales) Act 2015. Taking a preventative approach will be key to address the mental health issues and their underlying causes and funding should be focused on more tier 0 prevention support prior to people accessing statutory services.   

25. Action at community level was also recommended, with our Members suggesting the need for better access to community hubs. There is also a need to invest in communities to support both individuals and mental health services to achieve required outcomes, utilising local schemes that will enhance and improve the population’s wellbeing. 

26. Within primary care, Members recommended the acceleration of cluster development under the strategic programme for primary care in Wales as this represents a fantastic opportunity to reduce inequalities in all areas. It was also suggested that the primary care model should be delivered with scale and pace as it emphasises place-based care, so that communities and individuals are supported to build emotional and mental resilience. There is also a need to increase social prescribing to culturally acceptable and innovative services. 

27. A focus is needed on improving the physical health outcomes for those people living with mental health conditions and to improve general awareness of the difficulties that the groups identified in this response face.  

28. There were also actions around specific groups which our Members raised including, prioritisation of co-occurring substance misuse and mental health, support for care givers and further research into the psychological effects of long Covid. Members also called for clarification of the most clinically effective pathway for children and adolescents which is currently poorly understood. 

Conclusion  

29. While primarily seen as a physical health issue, COVID-19 has had a significant impact on people’s mental health, including the health and care workforce. It is anticipated that there will be an increase in demand for mental health and wellbeing services over the coming years, as both people with pre-existing mental health conditions and the general public have been impacted by self-isolation, financial insecurity, bereavement, and increases in substance abuse and domestic abuse. Existing societal inequalities are also likely to be exacerbated, with certain groups being disproportionally affected. It is vital that providing care to people is based on individuals’ need and as a society we must value physical and mental health equally. We look forward to continuing to engage with the Health and Social Care Committee on this important consultation.