Mental Health for All? The Final Report of the Commission for Equality in Mental Health

• Mental Health for All? The Final Report of the Commission for Equality in Mental Health
• Centre for Mental Health (November 2020)

Some groups of people have far poorer mental health than others, often reflecting social disadvantage. In many cases, those same groups of people have less access to effective and relevant support for their mental health. And when they do get support, their experiences and outcomes are often poorer, in some circumstances causing harm. This “triple barrier” of mental health inequality affects large numbers of people from different sections of the population.

Mental health inequalities cause harm to individuals, families, communities and society as a whole, and reducing them will have multiple benefits: better lives, a fairer society, and a stronger economy.

While mental health has become a higher profile policy imperative in the last two decades, the deep inequalities that cause mental health difficulties, and the stark inequalities in people’s access to and experiences of mental health services, have been hidden in plain sight. The Covid-19 pandemic has brought these injustices to the surface. But it also creates a unique window of opportunity for a new start.

Tackling inequality

Mental health inequalities are economic and social inequalities. Inequalities in wealth, power, voice and autonomy weigh down on groups and communities that end up with the poorest mental health. Racism, misogyny, homophobia and other forms of oppression, discrimination and injustice put pressure on communities and individuals, causing long-term harm. Yet they are not inevitable.

The commission has explored a wide range of ideas to boost mental health equality. There are no simple solutions. Communities, local organisations and national government need to work together to generate change at scale. It is a collective good and a collective responsibility. Businesses, charities, faith groups and others in civil society all have an impact on wellbeing. Community initiatives provide opportunities for mutual aid, collective action and a positive identity for groups that have been poorly supported, unheard and dismissed.

Local authorities, city regions and devolved administrations across the country can take action to pursue mental health equality in their communities. By viewing the public’s mental health as everyone’s business and taking a holistic view, they can be a catalyst for system change, the redistribution of public resources and wider investment for mental health equality.

The Advancing Mental Health Equalities programme, instigated by NHS England, sets out a clear and comprehensive agenda for practical change in mental health services. The commission hopes that this programme will receive the resources it requires to make a difference nationwide, and will continue to receive support from leaders nationally and locally for as long as it is needed. National leadership is vital to back action to achieve mental health equality.

In a system designed for equality, action would happen at each of these levels, for example to:

• Tackle poverty and financial inequality: for example through a Living Wage, workplace justice and a fairer benefits system
• Secure housing for all: including action to prevent homelessness, improve housing conditions and protect against climate emergencies
• Tackle racism and discrimination: for example addressing hate crime and ending “hostile environment” policies
• Invest in early years: including a national programme to support positive parenting
• Support inclusive education: creating places where everyone can flourish and prevent discrimination.

Recommendations for change

The report’s recommendations identify some of the large-scale changes necessary to make a system designed for mental health equality possible. Taken together, they could reset the mental health system towards greater equality and help to break the triple barrier of unequal determinants, access and outcomes. They are:

1. Communities can make a vital contribution by taking action to tackle inequalities and promote mental health and wellbeing inclusively. But they need investment from public bodies, charitable funders and civil society organisations to lead change. This should include sustainable funding for user and community-led organisations and robust partnerships, so that successful approaches can be scaled up and influence the whole system of services locally.
2. Local authorities need an urgent funding boost to co-ordinate action to pursue mental health equality. They have shown that they can build partnerships to help them to understand needs and assets in communities, identify gaps and inequalities in existing support available, and help develop practical solutions. But to fulfil their potential, local authorities urgently need funding to build their capacity to work in a collaborative way with communities.
3. Statutory bodies should maximise their role as anchor institutions in their local economies. Local and combined authorities and devolved administrations can use their powers and responsibilities to boost inclusive economies. Creating more inclusive economies will give local people more opportunities to participate in activities that improve their wellbeing, prosperity and life chances, and have greater influence over their environment.
4. Mental health services must implement the Advancing Mental Health Equalities strategy in full. The strategy must be given the necessary resources, senior leadership commitment and time to make a difference. Fully implemented, the strategy will facilitate urgently needed improvements in mental health support: improving access, experience and outcomes for groups that currently miss out. It will increase transparency about how well NHS organisations are addressing mental health inequalities.
5. New organisational networks – like Primary Care Networks and Integrated Care Systems – should collectively rethink the whole system of services and change the way they are designed so that they specifically redress inequalities and provide holistic support, including with work, housing and money advice. This would help build trust with different local communities and communities of interest. A whole-system approach to mental health services should mean no one is left out because of gaps between different services – so people are offered support quickly and not made to “battle” for help.
6. Mental health services should be accountable for reducing inequalities in access, experience and outcomes. This should include accounting to local communities for the steps they have taken and progress they have made towards closing gaps; and transparent publication of progress with benchmarking against other services.
7. The government must tackle poverty and commit to reduce income and wealth inequality. Reducing inequality of wealth and income would reduce the number of people who experience poor mental health and also offer people who experience mental health challenges greater security and better opportunities to lead fulfilling and valued lives.
8. The government must commit to tackling all forms of racism, discrimination and exclusion. This should include action to address injustices in public life and public services (in education, criminal justice, housing and employment, for example) and a commitment to end “hostile environment” policies.
9. The government should set a clear ambition and roadmap for achieving mental health equality. This should include both immediate and long-term actions to be taken in all departments to enable action towards mental health equality. It should also include an agreed set of measures to assess progress towards this ambition, including public health metrics for local authorities.
10. The government should refresh and update the Public Sector Equality Duty. It should strengthen the positive requirement for public sector organisations to take steps towards equality in all aspects of their work: including in the development, commissioning and design of services. This would create a bedrock for mental health equality by deepening the duties on public bodies to pursue equality and ensuring that wealth and income inequalities are given the same status in the implementation of the law as the other nine protected characteristics.

• Kadra Abdinasir is head of children and young people’s mental health, the Centre for Mental Health, and strategic lead for the Children and Young People’s Mental Health Coalition

• Read more in CYP Now's Children's Mental Health Special Report