Mind Cymru’s response to the Health and Social Care Committee’s Inquiry into Mental Health Inequalities
About Mind Cymru
We welcome the Health and Social Care Committee’s inquiry into mental health inequalities as one of the most immediate and pressing issues within mental health currently.
In our strategy[1], launched in 2020, becoming a truly anti-racist organisation, supporting young people and fighting for people in poverty are three key priorities for us as an organisation. These are all groups who are subject inequalities in their experiences of poor mental health.
We have been developing our evidence base in these areas and our submission focuses on what we know or have specific expertise in. It is not an exhaustive exploration of all inequalities so it does not mean that we do not believe or feel inequalities experienced by other communities not mentioned in this response are not relevant, important or should not be addressed with urgency.
We believe it is also important to recognise in the context of this inquiry, experiencing poor mental health or receiving support for our mental health has an unequal impact on our lives. Those of us with a mental health problem are more likely to experience long term physical health conditions, have lower life expectancy, live in poverty, be excluded from education and/or employment and experience stigma. Whilst we will not be specifically addressing this point in our response it is important for the Committee to recognise that our starting point is already one of inequality,
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“I begged a GP for help I told him I’ve been back and forth for 11 years I think it’s more than depression. I begged him to send me to a psychiatrist he said no point he will tell you you’re depressed like I did. I said please do it anyway he said he would. 2 months down the line I’m in dire need of some help so calls the Dr back to find out he did not refer me and I now have to wait again for the process of referral absolutely appalling.” |
Overview
Mental health inequalities, both in terms of access to support and experience, is one of the most urgent mental health issues in Wales. Our evidence clearly identifies that there are communities within Wales who have an unequal experience of poor mental health and have more barriers to accessing timely, effective support. Despite Welsh Government strategy clearly stating that tackling inequalities is central to its delivery, we have not seen this translate into widespread improvements.
If you are young, from a Black or ethnic minority background or live in poverty, you are more likely to experience challenges accessing support for your mental health. This is not acceptable, as access to support for your mental health is a universal human right, including for children and young people under the United Nations Convention on the Rights of the Child. There is a need for collective leadership at all levels to ensure those of us with a mental health problem are supported in all aspects of our lives that may impact on our condition with the joint goal of eliminating mental health inequality.
We would expect any future Welsh Government strategy to strongly focus on and ensure investment is available for tackling these deep seated inequalities in the coming years.
1. Which groups of people are disproportionately affected by poor mental health in Wales? What factors contribute to worse mental health within these groups?
As with our physical health, there are many determinants in our lives which influence our mental health, such as having a safe and secure place to live or growing up in poverty. Inequalities in experiences of poor mental health must be considered within the context of the impact of these wider determinants.
The impact of Covid-19 pandemic
The coronavirus (Covid-19) pandemic has had a significant impact on the nation’s mental health, whilst exacerbating and compounding pre-existing inequalities. It is important to note that in many cases the pandemic of the last two years did not cause these inequalities, they have been present in systems and our communities for some time.
Our evidence to the previous Health & Social Care Committee’s inquiry into the impact of Covid-19, and its management on health and social care provides evidence on the overall impact of the pandemic, including its impact on existing inequalities. Additionally, Mind Cymru has published two research reports on the impact and consequences of the pandemic on mental health in Wales, which may provide further contextual evidence relevant to this inquiry.[2]
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“I suffered with anxiety and mild depression in 2017, but had received therapy and was coping well before March 2020. Since the pandemic began these symptoms have returned. I was put on furlough and the time spent alone with my thoughts with no distraction has been very damaging.” |
Evidencing mental health inequality
Understanding inequality of access within mental health services in Wales is severely impaired by limited availability of demographic data. This has long been a significant challenge and was raised in multiple inquiries by both the Health & Social Care Committee and Children and Young People Committee during the previous Senedd term.
Delays to the development of a Mental Health Core Dataset (MHCDS) and an outcome framework means it is not possible to fully assess access to and experiences of mental health services by demographic groups. This issue has previously been highlighted by both the Equality & Human Rights Commission and the Socioeconomic Subgroup of the First Minister’s BAME Covid-19 Advisory Group:
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“There are clear gaps in the data in Wales that make it difficult to understand the experiences of people sharing all protected characteristics. There is a particular lack of data broken down by the protected characteristics of sexual orientation, gender reassignment, religion or belief, and race. There is also a lack of disaggregated data on health outcomes.[3] – EHRC , 2018
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Despite a lack of date what is available points to clear inequalities in experience of poor mental health in certain communities. For example, we know that:
- People from racialised communities are more likely than White people to be referred to mental health services via ‘involuntary’ routes including justice and social services, than they are through ‘voluntary’ routes such as their GP.[4]
- In June 2020, people from racialised communities in Wales reported on average more than 4.1 problems associated with mental distress on the GHQ-12 score[5], whilst White British individuals reported 2.7, a difference of 55% in relative terms.[6]
- Public Health Wales found racialised communities in Wales reported higher levels of anxiety, feeling isolated and worrying a lot about their mental health. They were also more likely to be worrying a lot about their job and finances[7]
- Analysis published by WalesOnline of the Mental Health Act s.135/136 dataset found that in 2020 Black people in Wales were almost three times more likely than White people to be detained by police under Section 135 and 136 of the Mental Health Act.[8]
- More than a quarter of young people in Wales do not feel like they have mental health support at school.[9]
- Young people experienced the largest deterioration in their mental health at the beginning of the pandemic. The average GHQ score among those aged 16-24 in November 2020 rose by 3 points, or 24%, relative to the pre=pandemic period.[10]
- Nearly one-third of 16–24-year-olds in the UK (31%) reported some evidence of depression or anxiety in 2017 to 2018; this is an increase from the previous year (26%) and the same period five years earlier (26%).[11]
- Waiting times within Local Primary Mental Health Support Services are significantly and consistently longer for children and young people than for adults.
- More than twice as many people in Wales (aged 16+) experience mental health problems in the most deprived quintile (16%) than the least deprived quintile (7%).[12]
- Young people in the lowest income bracket are 4.5 times more likely to experience severe mental health problems than those in the highest.[13]
- The mental health gap between the lowest and highest income quintiles has widened significantly during the pandemic. The average GHQ-12 score in November 2020 for the lowest income quintile increased by 39% compared top pre-COVID19 period. In contrast, the highest income earners only experienced a deterioration in their mental health of 0.6 point (or 6.5%) over the same period.[14]
- On average, women in Wales exhibited worse levels of mental health after the onset of the pandemic, with the gap between reported wellbeing between men and women increasing from 9.9% to 14.1%.[15]
Finally, it is important to note that there is no routine, reliable and comparable measure of the prevalence (both treated and untreated) of mental health problems within the Welsh population. As a result, the true scale of mental health problems, inequalities between groups and changes overtime remains unclear. The absence of such a measure may also be masking inequalities and at risk-groups.
Racialised communities
Experiences of racism and discrimination can have a lasting and damaging impact on our mental health. This is supported by considerable research evidencing the links between experiencing discrimination and poor mental health: including depression,[16] anxiety and psychological stress,[17]and post-traumatic stress disorder (PTSD).[18] These issues were reflected in responses to the Welsh Government’s Race Equality Action Plan[19].
Our research, carried out in 2020, showed that existing inequalities in housing, employment, finances and other issues have had a greater impact on the mental health of people from racialised communities than White people during the coronavirus pandemic.[20] The findings reflect data from participants in both Wales and England who were aged 25+ and identified as Black, Asian or minority ethnic (just under 5% of the 14,421 adults who completed our survey):
· Problems with housing (30% of racialised people said this made their mental health worse vs 23% of White people), their job (61% vs 51%) their financial situation (52% vs 45%), difficulty getting physical health support (39% vs 29%) and caring for someone else in the house (30% vs 23%) disproportionately affected mental health for racialised communities.
· Racialised people are much more likely to want advice about money and benefits (40% vs 24%) and housing (19% vs 10%) to help manage their mental health.
This insight demonstrates the importance of considering the way in which experiences of multiple inequalities weave together to impact on our mental health. It is important that social issues are addressed alongside the particular mental health issue a person may be presenting with.
There is also the need to take into account specific stressors for some people within these communities, such as the experience of the immigration system. This includes having uncertainty over their status and experiences of seeking asylum or refugee status, including the journey to Wales from their home country. Those seeking asylum or refugee status often have a specific and complex experience of trauma that needs to be understood and tailored support needs to be provided in order to help begin to rebuild lives in Wales.
Children and young people
We know that adverse childhood experiences, particularly those in early childhood, significantly affect our mental health long into adulthood. However, unequal access to mental health services for children and young people has been an issue for many years. At all points in the system there are challenges for children and young people in accessing timely mental health support and broadly the picture in terms of access to support from mental health services has not improved quickly enough during the lifetime of the current Together for Mental Health strategy.
Many of the issues have been well established by the previous Senedd’s Children, Young People and Education Committee’s ‘Mind Over Matter’ report[21]. This was further built upon by the Wales Youth Parliament’s own report entitled ‘Let’s Talk About Mental Health’[22]. Taken together these reports provide a clear story of inequality and a call to urgently improve the support provided to children and young people.
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“I have suffered with my mental health since I was 15, I wasn't taken seriously until I was 32, I was only offered tablets absolutely nothing else. I didn't even realise there was so many treatments available” |
Experiences of poverty
The Money and Mental Health Policy Institute has published a range of reports highlighting how both experiencing financial hardship can lead to poor mental health but also that having poor mental health can make it harder to manage financial issues. This creates a vicious circle for many of us with a mental health problem.
Their report ‘The State We’re In’ published in November 2021 highlighted how those of us with a mental health problem were at a higher risk of experiencing financial hardship during the pandemic when compared to the wider population. It found that people with a mental health problem were:
- Three times more likely to have fallen into problem debt than the wider population (15% compared to 4%).
- More than twice as likely to have relied on credit or borrowing to cover every day spending — for example, on food or heating (26% compared to 11%).
- More likely to have had zero savings to help them cope with emergencies. 1 in 4 people with mental health problems say they have no savings that they could use in emergencies (compared to 18% of the wider population), and nearly half (46%) say they can’t afford to save money regularly.
The pressure, worry and stress of living on a low income, managing benefits, living in poor quality housing, being homeless or experiencing periods of unemployment can have a profound impact on our feelings of self-worth and wider mental health. The well-publicised concerns around the increasing cost of energy and other basic items will only further exacerbate this issue. Most mental health organisations have experienced an increase in people seeking support for managing their finances during the pandemic, some of whom are seeking help for the first time.
Women and girls
Women and girls face inequality and discrimination both in their daily interactions and through systems and institutions, which have often been designed around a male service-user by default, and can sometimes be male dominated.
Experiences of sexism and misogyny are often compounded by a woman or girls’ intersecting experiences of discrimination on the grounds of their ability, age, class, ethnicity, gender identity, race, religion and sexual orientation - including racism, homophobia and transphobia.
The links between violence and abuse and poor mental health are unambiguous. UK wide research by Agenda shows that over half (54%) of women with extensive experience of physical and sexual violence meet the diagnostic criteria for at least one mental health condition and are also more likely to have multiple with about one in seven (15%) having three or more. Over a third (36%) of women in the extensive physical and sexual violence group have made a suicide attempt, and a fifth (22%) have self-harmed. One in ten (9%) have spent time on a mental health ward.[23]
Trauma can sometimes directly cause mental health problems or make someone more vulnerable to developing one. Some conditions are also known to develop as a direct result of trauma, including post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (complex PTSD).
Whilst there have been developments in perinatal mental health support for prospective and new mothers, there remains some issues in providing support, namely the lack of progress on development a Mother and Baby Unit in north Wales despite ongoing discussions.
2. For the groups identified, what are the barriers to accessing mental health services? How effectively can existing services meet their needs, and how could their experience of using mental health services be improved?
Whilst progress has been made in tackling stigma, many of us who experience mental health inequalities also experience higher levels of stigma from others as well as displaying self-stigmatising behaviours when considering our own mental health.
Time to Change Wales, the national anti-stigma campaign delivered by Mind Cymru and Adferiad Recovery and funded by the Welsh Government, has been at the forefront of tackling stigma for a number of years. In its most recent phase, the campaign sought to engage with Black and minority ethnic organisations, recruiting champions from these communities, in recognition that there was a need for more targeted, culturally informed support for communities in order to start a conversation about mental health that was both safe and informed. This has built upon work that Time to Change Wales has undertaken in more deprived communities, with many of the issues being similar.
Tackling stigma is important as it prevents people from seeking help at an early opportunity and can then lead to a deterioration where more intensive support is needed. Through tackling stigma we can help create a culture whereby all communities feel it is ok to talk about mental health and which actively encourages people to seek help and support.
Equally, during the pandemic Time to Change Wales reported an increase in people experiencing self-stigma[24]. This is where we seek to minimise our mental health as we believe there are bigger issues we or others are facing. This leads to neglecting the signs that we need support, even if it is just to talk to someone about our feelings and emotions.
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“Before March 2020, I had anxiety and depression. The past year has intensified those feelings. Perhaps I should contact my GP surgery, but I don't want to add to their already overburdened workload” |
This reflects the experiences of several local Minds in Wales who work in and with communities that experience high levels of deprivation. Their reflections include the need to encourage a conversation about mental health and have safe spaces for people to speak about their experiences. This would help to tackle the level of exclusion that communities feel and experience, whether this is financial, social or digital.
Ystradgynlais Mind have been delivering Mental Health First Aid to rugby clubs in their area under the #ItTakesBallsToTalk campaign (which is delivered by a number of other local Minds as well). This utilises the environment of the rugby clubs, where there is a feeling of familiarity and safety, to start a conversation about mental health and how those participating can support each other. This has led to a range of conversations, which have gone beyond the formal training and have begun to create a culture where it is normal to talking about your mental health and peers are comfortable in listening and supporting.
Trust in services
We have heard from both racialised communities and those living in poverty that they do not feel mental health services are for them. This is a complex barrier that involves support being consistent, accessible and responding to the needs of people. For racialised communities it also means having a workforce that reflects them and their experiences. It has been highlighted that having to explain time and again experiences of discrimination, trauma, racism and specific cultural/community dynamics can be retraumatising and lead to feelings that the support available is unable to meet their needs.
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“I have to explain to the therapist, my culture, and the nuance of my culture before I start speaking about what bothers me” Time to Change Wales participant[25] |
Utilising the knowledge and trust that community organisations have built is an important way in which some of these issues can be addressed. They can act as a bridge to support people to identify support that may be appropriate as well as providing direct support themselves.
As an example, Neath Port Talbot Mind have been working with Neath Port Talbot BME Community Association to build connections and provide pathways to support for ethnic minority communities within the area. At the heart of this partnership has been the desire from both organisations to learn from each other, build trust, listen and be responsive to the needs of communities. Both organisations have recognised the strengths and knowledge they bring to the partnership, enabling workshops to take place to better understand experiences and what needs to be done to improve support.
More can be done to work with community organisations, the mental health voluntary sector and statutory partners to support community led initiatives to raise the profile of mental health and provide trusted pathways to support. This could be ensuring community organisations are supported to engage with training and opportunities to become involved in programmes such as social prescribing, to providing more sustained investment in outreach teams from Local Health Boards, which have been focussed on Covid response, to build and maintain partnerships.
Access to early support
This is an issue for all groups with support offers being seen as not suitable (racialised communities), inaccessible (people living in poverty) or simply not able to meet demand (children and young people).
It is particularly stark for children and young people. For example, waiting to receive an assessment for primary mental health support can be considerably longer than the 28-day target, while the same target is regularly met for adults. There is a need to provide a greater range of non-medicalising support for young people in the early stages of developing worries about their mental health. This has to be based around their needs and supports them to understand what they are experiencing alongside different ways to manage their mental health.
There are a number of programmes delivered by local Minds which have provided these groups with support from Mums Matter (a perinatal support programme that includes establishment of peer support networks), social prescribing (a link worker with specific mental health knowledge supports people to find advice and activities that can improve their mental health) and Active Monitoring (a Welsh Government funded, nationwide service providing people with structured 121 sessions to help begin to manage their mental health). The strength of these programmes is that they have been operating as GP referral or as a self referral service, enabling people to find help themselves. Programmes such as these, commissioned by statutory services and delivered by the local voluntary sector, build on trusting bonds already formed with communities and it has been positive to see local commissioners looking to invest in these programmes.
Non-health service support
As identified above many of the root causes of poor mental health lie beyond the remit of the health service. Experiencing poverty, lack of or insecure employment, racism and discrimination, poor quality housing or homelessness, all have a significant impact on our mental health. Creating a better and more consistent link between mental health services and wider community support is critical in addressing some of these issues. If we receive support for our mental health, but do not feel secure in our wider lives then it is highly unlikely that we will be able to focus on improving our mental health.
Programmes undertaken by Llanelli Mind with partner organisations have sought to support people who are at risk of becoming homeless, providing them with support to remain in accommodation as well as opportunities to train, develop new skills, volunteer in their local community and have someone to talk to if they need it. This type of support was described as life changing and demonstrates how focussing on the social factors in people’s lives can improve mental health outcomes.
Taking a trauma informed approach
In order to effectively meet the needs of these communities it is essential that a trauma-informed approach be delivered across services. Trauma-informed practices understand and respond to the high prevalence of trauma and its effects, as well as understanding that experiences of trauma can lead to development of coping strategies and behaviours that may appear to be harmful or dangerous. This has been identified as being particularly important when considering mental health support for women and girls, but equally can be effective for other groups.
Access to community mental health resilience
In October 2020 Mind, along with the Co-op, Scottish Association for Mental Health (SMAH) and Inspire (Northern Ireland), published a report entitled ‘Together Through Tough Times’[26]. The report explored what created mentally resilient communities in four different communities in each nation. We identified several factors that created resilience including having community hubs, an active local voluntary sector, an open culture around talking about mental health, safe public spaces, strong community connections and a strong community narrative of support. These factors being present within a community meant that there was a structure or framework that created a resilience that people were able to utilise to support their own mental health and that of others.
The report also identified those groups within communities that may struggle to access these pillars of community resilience and many of these groups were the same that experience mental health inequalities, including ethnic minority communities, young people, people experiencing poverty and people who are unable to leave their house due to caring responsibilities, a disability or an acute mental health condition. This creates a triple impact for some of being more at risk of experiencing poor mental health, being unable to access timely, appropriate mental health support and then also feeling excluded from some of the protection factors within communities that can help build mental health resilience.
The important role played by this community framework and infrastructure should not be downplayed. During the last two years we have seen how communities have come together to support those that need it and foster a narrative of community support. This narrative and the leadership needed on a community level to foster, grow and ensure it is inclusive needs to be recognised if we are to tackle mental health inequalities. The report makes a series of recommendations for building, safeguarding and improving community resilience as well as tackling the barriers so that everyone can benefit from what their community can provide.
3. To what extent does Welsh Government policy recognise and address the mental health needs of these groups? Where are the policy gaps?
The Welsh Government’s ‘Together for Mental Health’[27] Strategy has tackling inequalities as a prominent theme. The strategy makes clear the ambition that:
- People with protected characteristics and vulnerable groups, experience equitable access and services are more responsive to the needs of a diverse Welsh population
The strategy references taking a human rights approach as well as recognising the United Nations Convention on the Rights of the Child (UNCRC) as a framework for delivering the high-level outcomes for the strategy. Despite this, we do not believe that enough has been put in place to make the ambition of the strategy a reality for people.
Mind Cymru has previously called on the Welsh Government to re-join the Adult Psychiatric Morbidity Survey (APMS) which ‘provides data on the prevalence of both treated and untreated psychiatric disorder in the English adult population (aged 16 and over)’.[28] Wales last participated in the study in 2000. Alongside measuring prevalence, the survey also provides insights on access to mental health services and unmet need which would ensure services have adequate resources and capacity to meet local need.
There is also an urgent need for the Welsh Government to explore and put in place a system for monitoring the mental health of young people at a population level. The Children and Young People’s Well-Being Monitor, which was highlighted in Together for Mental Health as a way in which progress will be measured, has not reported since 2015.
In recent years Welsh Government has taken a number of steps to address some of the issues around mental health inequalities. We welcome the establishment by the Welsh Government of a Task and Finish Group to look specifically at the experiences of Black, Asian and minority ethnic communities, with a focus on actions that can be quickly taken to address the issues identified. The group, with a membership drawn from a range of mental health and Black and ethnic minority organisations, has identified a number of key areas in relation to access and experiences and will be looking to report in the coming months.
The development of statutory guidance for a whole school approach to mental health alongside the amendment made to the Curriculum and Assessment Act to place a greater prominence for mental health in the design of curricula could create a step change in the support provided to all pupils in Wales. It is very positive that Welsh Government took these steps to improve this provision and now this must be delivered to meet the needs of pupils. Young people have consistently fed back to us that they want more time during the school day to discuss issues relating to mental health, without being medicalised for the feelings that they are having.
Equally, the development of the NEST/NYTH framework for early and enhanced support[29] provides an excellent opportunity to transform the support provided for all children and young people in Wales. The framework will be used by Regional Partnership Boards to determine what support should be available to all children and young people who need it.
The recent announcement by Welsh Government of a further three years of funding for Time to Change Wales is particularly welcome as the focus for the coming years will be working with organisations and employers to tackle stigma in racialised communities and in more deprived areas.
Overall, the policy and strategic framework is in place to tackle mental health inequalities, but there needs to be a greater focus on ensuring that the strategic direction and actions result in tangible improvements for people seeking support or experiencing poor mental health. There is also a need to diversify the voices around the table at all levels, in policy development, local delivery and service design, to ensure that community needs are being met.
4. What further action is needed, by whom/where, to improve mental health and outcomes for the groups of people identified and reduce mental health inequalities in Wales?
Mental health inequalities cannot be seen or tackled as solely an issue for our health services, it needs to be recognised across Welsh Government and public sector delivery in a range of activities. To this end there are a range of actions we would want to see developed:
· The successor strategy of Together for Mental Health to again make tackling mental health inequalities a priority, with urgency and time limited actions. This should be a regular discussion in all the partnerships and governance arrangements around any new strategy and there should be greater diversity of organisations around the table to inform these discussions.
- Welsh Government need to ensure there are no further delays in delivery of the Mental Health Core Dataset and that there are a full range of protected characteristics data is collected and published
- Welsh Government and Local Health Boards to ensure current data collected prioritises questions relating to protected characteristics, including providing extra training or guidance on approaching these questions if needed
- Welsh Government to publish data, with caveats around sample sizes, on protected characteristics and mental health services
· Welsh Government should re-join the Adult Psychiatric Morbidity Survey and explore options for measuring population level mental health prevalence for children and young people
· Funding should be made available on a local level to support community organisations to meet the mental health needs of the communities they represent
· Engagement and outreach support within every Local Health Board in Wales should be developed with long term investment to build trust and relationships with communities
· Recommendations from the ‘Together Through Tough Times’ report should be taken into account as Welsh Government develop their new mental health strategy, alongside being considered in work being undertaken around community development, planning and reviving town centres
· The Health Inspectorate Wales and Social Care Wales Mental Health Workforce Strategy should look to specifically tackle diversifying the mental health workforce, through providing information, financial support and mentoring
· Community organisations should be proactively engaged and supported to develop delivery of primary care programmes such as social prescribing, peer support and other community led initiatives
· Staff education and training across health services should take a trauma-informed approach, and should cover a gendered approach to trauma including violence and abuse, and wider inequalities. Clear and safe information recording and sharing about experiences of violence and abuse and related issues should be consistently implemented across health services to avoid the re-traumatisation of women having to repeatedly re-tell their stories.
· The mental health impact of violence against women and girls should be explicitly addressed, through a cross-department approach. This should be incorporated into a future mental health strategy for Wales following on from Together for Mental Health.
· Community based programmes such as Mums Matter, social prescribing, Active Monitoring and peer support should be part of a standard primary care, early support offer. These should support both self referral and GP referral.
We hope that this Committee inquiry will capture a range of voices and experiences directly from the communities experiencing mental health inequalities. Too often their voices are not heard prominently enough in the discussions about their experiences. We believe the report of this committee should mark a watershed moment in moving the approach to mental health in Wales forward, becoming more inclusive of a wide range of experiences and meeting the needs of everyone in Wales.
We would be happy to discuss further any aspect of this response.
Simon Jones
Head of Policy & Campaigns
Mind Cymru