Mental health 360: inequalities

Overview

Some groups of people are more likely to have a mental health condition  

There is limited data on the proportion of individuals with a mental illness, but the data that does exist points towards higher prevalence among certain groups. The Adult Psychiatric Morbidity Survey found that in 2014, mental disorders were more prevalent among certain population groups. These included Black/Black British people, those not in employment, those in receipt of benefits or living alone, and those with poor physical health. Similarly, in 2022, a survey by the Office for National Statistics (ONS) found that younger people, women, those with a disability, and those living in more deprived areas were more likely to report symptoms of depression. Although the reasons for differences in prevalence rates between groups vary, a common factor is exposure to different forms of social disadvantage. For example, the high rates of psychosis among people from Black African and Caribbean groups are related to experiences of social disadvantage that include unemployment and social isolation, which represent forms of structural racism.  

There is a lack of equity in access to care 

There are marked differences between groups in access to services, highlighting under-representation or over-representation relative to the level of need. For example, a review of ethnic inequalities in the NHS Talking Therapies programme found that people of mixed heritage from ‘white and Black Caribbean’, ‘any other mixed background’ and ‘other ethnic groups’ were less likely to access services. Although the gap in access to Talking Therapies between people from ethnic minority groups and people of white British origin reduced slightly during Covid-19, this has not been sustained. Older people and disabled people are also under-represented in NHS Talking Therapies, relative to population need.  

As some groups are less likely to access services at an early stage, they are more likely to access treatment when very unwell or in crisis. For example, during 2021/22, the proportion of people admitted to acute mental health services who were not previously known to services was 17% for people from ethnic minority groups, compared with 12% for people of white British origin. NHS Benchmarking data also shows that people from some ethnic minority groups are over-represented in services for people with a high acuity of illness such as secure care, and under-represented in other areas of care, including services for people with eating disorders and for older people. Taking into account higher rates of prevalence, some groups are less likely to get access to treatment at an early stage and more likely to experience potentially more coercive pathways through care.  

There are large inequalities in use of the Mental Health Act 

Use of the Mental Health Act (MHA) also reflects pathways of access to care among some groups. In 2022/23, detention rates for people who identify as ‘Black or Black British’ were three and a half times the rate for people who identify as ‘white’. ‘Black or Black British’ people are also more likely than ‘white’ people to spend longer in hospital, have more subsequent readmissions, and to be detained through contact with emergency departments or the criminal justice system.  

Detention rates also vary across England, with risk of being detained under the MHA increasing incrementally with levels of deprivation. Rates of detention in the most deprived areas were nearly four times greater than rates in the least deprived areas.  

Some groups receive less effective and less satisfactory care 

Data here is limited, but the available evidence suggests inequalities in the effectiveness of treatment, as well as inequalities in access. For example, data on NHS Talking Therapies services found that recovery rates following treatment were lower among people who identify as disabled, people from some ethnic minority groups, people identifying as lesbian, gay, or bisexual, and people living in deprived areas. 

Patient satisfaction also varies by group. The 2022 Community Mental Health Survey found that younger people and those with more challenging and severe non-psychotic disorders were less likely to be satisfied with their care.  

People with mental health problems are at greater risk of wider inequalities 

As well as inequalities within mental health care, people with mental illness face inequalities in many areas of their life, including wider health and health care. The 2014 Adult Psychiatric Morbidity Survey found that the likelihood of five chronic health conditions increased with the severity of mental disorders, and with lower mental wellbeing. People with severe mental illness were five times more likely to die before age 75 than those who do not have severe mental illness, and the gap between these two groups increased between 2015 and 2020. A recent study found that two in every three deaths of people with severe mental illness before the age of 75 were potentially preventable, equating to 26,000 preventable deaths a year. This includes deaths from diseases such as cancer and heart disease that could have been prevented with screening or earlier treatment.  

Satisfaction with care provided outside mental health services is also lower for those with a mental illness. A survey by the Care Quality Commission (CQC) of people aged 65 and over who had used health or social care services in the previous six months found that those with long-term mental health conditions were less positive about their care. The GP patient survey also shows that people with a long-term mental health condition were less likely to report an overall good experience of care, or that they had received enough support.  

Actions to tackle inequalities  

The Advancing mental health equalities strategy, published in 2020, aims to reduce inequalities in access, experience and outcomes. In 2023, NHS England launched the Patient and carer race equality framework, which aims to help mental health trusts work with ethnic minority communities to bring greater transparency and accountability around race inequalities and support improvement. 

Some services are taking a positive approach to addressing inequalities. This includes services identifying members of the staff team to take a leading role for diversity, promoting an equalities approach across wards, and supporting staff and patients. In 2022/23 NHS England also provided funding of around £695 million to integrated care boards (ICBs) on the condition that they have a clear plan in place to address mental health inequalities in their area.   

In 2018, the government published the final report from the Independent Review of the Mental Health Act. Under the terms of reference, the review sought to understand and address the disproportionate number of people from ethnic minority communities detained under the Act. The government subsequently published a draft Mental Health Bill in 2022 for pre-legislative scrutiny. In the lead-up to the general election in 2024, 35 organisations called on the government to maintain its commitment to modernising the MHA. The Bill has subsequently been delayed until after the general election.  

To help tackle inequalities in wider health care, the NHS Long Term Plan committed to ensuring that 390,000 people with severe mental illness would receive an annual physical health check by 2023/24, with an interim target of 280,000 by 2020/21. This interim target was not met, though numbers are increasing.