Mental Health Inequalities

Published 19/12/2022 | Last Updated 19/12/2022 | Reading Time minutes

Connecting the dots: tackling mental health inequalities in Wales

This is the second chapter of the Health and Social Care Committee ‘Connecting the dots: tackling mental health inequalities in Wales’ report.

Mental Health Inequalities

Who is most at risk?

13. It is often stated that one in four people will experience a mental health problem. Recognising this can be helpful in reducing stigma, and encouraging people to talk about their own mental health or seek support. But, it can also disguise the fact that some individuals, groups or communities may be more at risk than others, and that this is often linked to broader inequalities in society. Box 1 identifies some of the groups and communities we were told may be at particular risk.

Box 1:

Groups identified as being particularly at risk of experiencing mental health inequalities

People from socioeconomically-disadvantaged backgrounds, or who are living in poverty.
Ethnic minority communities and racialised communities, including Gypsies and Travellers.
Older people.
Children and younger people, especially those with experience of care, school exclusion or adverse childhood experiences (“ACEs”).
Neurodivergent people, including autistic people and people with conditions such as ADHD.
People with a learning disability, or communication, speech or language difficulties.
People with sensory impairment or loss.
LGBTQ+ people.
Pregnant women and new mothers (the ‘perinatal’ period).
Disabled people, or people living with a chronic health condition or with serious mental illness.
Carers, including people who are caring for someone with a chronic or terminal illness, or who has mental health difficulties.
People with substance misuse issues.
Women, as a broad group.
Men, as a broad group, but in particular young men, middle-aged men and unemployed men.
Refugees and asylum seekers.
Homeless people.
People who have experienced trauma, including sexual violence or domestic abuse.
Offenders or others who have experienced the criminal justice system.
People living in rural areas, or in agricultural or fishing communities.
The health, care and education workforces.

14. Within these groups, individuals’ experiences can be very different, and the intersection of different inequalities and characteristics can exacerbate the impact of different inequalities and increase barriers (see Box 2 for examples). When considering mental health, support and services, the focus must be on the whole person rather than reducing them to aspects of their identity, condition or diagnosis.[17]

Box 2:

Examples of intersectionality in the older population in Wales

Ageism experienced by older people can be compounded by long-standing and pervasive inequalities such as racism or homophobia.[18] Older LGBTQ+ people are less likely to have access to support from family members as a result of discrimination, and may also be less likely to access health and social care services due to fear of discrimination.[19]

Overall, 23 per cent of respondents to Age Cymru’s survey of older people’s experiences of the pandemic reported taking on new or additional caring responsibilities during the pandemic. This rose to 43 per cent for older people from ethnic minority communities. Increased caring responsibilities can lead to people giving up employment, with corresponding implications for their income or financial security.[20]

15. Some of the ways in which different people experience mental health inequalities may be specific to the groups or communities to which they belong; other experiences are more universal. Box 3 summarises some of the experiences described to us.

Box 3:

How groups and communities experience mental health inequalities

Stigma, including the fear of being judged, of losing existing support, or being penalised, for example by children being taken into care.
Discrimination, including on the basis of age, ethnicity or sexuality.
Cultural barriers and language issues.
Lack of trust in services, including as a result of previous negative experiences or concerns about being dismissed or not feeling listened to.
Lack of knowledge about what help may be available or how to access it.
Lack of capacity within existing services, long waiting times, high thresholds for access, and gaps or variability in service provision, including a lack of specialist services.
Lack of clarity about referral processes, restrictive referral processes, and exclusion from services as a result of diagnostic overshadowing.
Geographic issues, including relating to rurality.
Digital exclusion.

16. In the course of a single inquiry we have not been able to examine the experiences of every group or community. Indeed, it would be reductive to define individuals’ experiences of mental health inequalities solely on the basis of their characteristics. However, focusing on the experiences of some specific groups (including those highlighted in Box 4) has helped us to examine broader systemic issues linked to mental health inequalities, including stigma and discrimination, inflexible services, and a lack of joined-up support.

Box 4:

Examples of groups whose experiences of mental health inequalities we have explored

People living with severe and enduring mental illness

While anyone may have periods of poor mental health, some people will experience more severe and enduring mental illness. This can be exacerbated by some of the wider, external factors discussed throughout this report. People in this group can therefore be particularly vulnerable to mental health inequalities. They often have poorer physical health, and may die on average 15 to 20 years earlier than the general population.[21] Children and young people in this group may be less likely to receive the support they need through either the whole-school approach or investment in early intervention.[22]

Suggestions made to improve support for people living with severe and enduring mental illness included more strategic national focus on workforce planning and development, greater investment in secondary and specialist mental health services, access to routine physical health assessments to identify and treat physical co-morbidities, expansion of programmes to support them into employment, and greater clarity about which health professional has overall responsibility for individuals’ holistic care when they are being treated for both physical and mental health conditions.[23]

The Deputy Minister for MHW said the Welsh Government had reviewed mental health secure provision, made progress in early intervention in psychosis services, and was investing in improving Child and Adolescent Mental Health Services (“CAMHS”) provision (including in-patient provision). She told us she was working with stakeholders to ensure the Welsh Government’s new mental health strategy met the needs of people with severe and enduring mental illness.[24]

Neurodivergent people

Neurodivergent conditions include autism, ADHD, dyslexia, dyspraxia and other learning, motor language and tic conditions. Neurodivergent people may be at much higher risk of depression, anxiety, OCD, self-harm, suicide, and mental illnesses such as schizophrenia and bipolar. There are also links with poorer physical health, including obesity, cardiovascular disease, diabetes and asthma.[25] People with lived experience of neurodiversity—including some who are neurodivergent themselves or who are carers for neurodivergent people—told us that supporting a neurodivergent child or young person with poor mental health can affect the mental health of parents, carers and the wider family.[26]

The inequalities faced by neurodivergent people can prevent them from seeking support, with consequences for individuals, their families and public services. Unmanaged ADHD can give rise to “unseen costs” for other public services such as healthcare, education, social services and the criminal justice system.[27] Exclusion from school is more common among neurodivergent people; it is possible that this relates to behaviours arising from an undiagnosed or unsupported condition. People who have been excluded from school are then less likely to be diagnosed or supported, leading to what Professor Amanda Kirby described as a “school-to-prison pipeline”. She added that once in the criminal justice system, individuals’ mental health might be considered, but “the underlying reasons, like ADHD, might not”.[28]

People from ethnic minority communities

Barriers and inequalities experienced by people from ethnic minority communities may include stigma, discrimination, lack of cultural awareness and sensitivity, insufficient service capacity and flexibility, fears of medication, inadequate translation services, financial barriers, and a workforce that does not reflect the diversity of Wales’ communities.[29]

The Deputy Minister for MHW said the Welsh Government was investing £1.4m in Time to Change Wales over three years, including work to “better understand the attitudes, beliefs and experiences of black, Asian and minority ethnic people towards mental health and accessing health and support services”. She said that other steps to improve mental health services for ethnic minority communities included setting up a task and finish group with the Wales Alliance for Mental Health, and funding Diverse Cymru to deliver a cultural competency scheme across Wales. She added that promoting cultural competency will “remain a key priority” in the Welsh Government’s new mental health strategy.[30]

Children and young people

Children and young people may be at particular risk of mental ill health, both as a broad general group and in relation to factors such as ACEs, experience of care, school exclusion or protected characteristics. The pandemic has affected children and young people as a group more than other age groups, and has also reinforced existing social inequalities.[31] The then Children’s Commissioner for Wales told us in March 2022 that many families see CAMHS appointments as the “golden ticket” for resolving a child’s mental distress or ill health, but that in many cases there are underlying social factors that need to be addressed.[32]

Our focus group with Welsh Youth Parliament Members (“WYPMs”) highlighted concerns about school and exam pressures, peer pressure, bullying and body image, poverty and the rising costs of living, and uncertainty about the future. One of the most significant issues reported was inadequate support from CAMHS, with some participants saying that young people saw “no point” in going to CAMHS, that it “never helps”, and that it was seen “almost as a joke”.[33] Similar issues were raised by young people who worked with Mind Cymru on its Sort the switch report when we and the Children, Young People and Education Committee met them in November 2022 to discuss issues relating to the transition between children’s and adults’ mental health services.

Factors affecting mental health

17. During our work we have heard about the mental health implications of many external factors, including income uncertainty, poor housing, discrimination and fear, shame and humiliation, trauma, loneliness and isolation, and lack of voice, choice and control. Mencap Cymru spoke for many of those who gave evidence when it said:

“The key to erasing mental health inequalities is to address the underlying causes of mental ill-health We feel that for most people with a learning disability, mental health problems are not the result of an internal problem, but a result of the external.”[34]

18. A strong theme in the evidence was that the traditional ‘medical model’ of mental health—in which the provision of support and treatment is led by diagnosis of a condition—fails to recognise and address people’s broader needs because the human needs underlying a person’s poor mental health may be ignored or underexplored. Results include focusing on treatment instead of addressing root causes; siloed ways of working; and overly rigid and inflexible patient pathways.

19. Medication has an important role in treating mental health problems, but we heard concerns that too often it is used as a ’sticking plaster’ for people who are struggling with their mental health while little is done to address their underlying issues. Adferiad said that antidepressants were widely-prescribed for problems that actually required practical support to resolve, for example issues with housing, unemployment or abusive relationships, adding:

“In some disadvantaged communities antidepressants are seen as the only ‘answer’ to a poor quality of life, especially for women”.[35]

20. Dr Jen Daffin of Psychologists for Social Change explained that where poor mental health results from external factors or circumstances, medication can do little to address the underlying causes or help people change their circumstances, and the long-term use of medications can in fact be harmful.[36] Similarly, Andy Bell of the Centre for Mental Health said that greater recognition of factors that can contribute to poor mental health would provide opportunities to tackle the underlying issues, and “support people to live well and to recover”.[37]

21. The first priority in the Welsh Government’s current Together for Mental Health Delivery Plan 2019-22 is:

“To improve mental health and well-being and reduce inequalities through a focus on strengthening protective factors”.[38]

22. In September 2022, the Deputy Minister for MHW said that protective factors that contribute to good mental health include strong relationships, feelings of safety and security, access to food and warmth, employment (for income, protective focus and connection), good housing, and access to supportive public services. She added that the Welsh Government’s holistic cross-government approach to tackling mental health inequalities was reflected in its additional investment in mental health: £50m in 2022-23 rising to £90m in 2024-25.[39]

Poverty and disadvantage

23. The structural link between poverty and poor mental health was highlighted by many. We also heard significant concerns about the potential impact of rising costs of living on existing inequalities. Dr Tracey Cooper of PHW told us in May 2022 that she anticipated that the situation for people at risk of mental health inequalities would “deteriorate” as a result of increasing living costs,[40] and in September 2022 the Chief Medical Officer for Wales told us he was concerned about the impact of rising costs of living on people’s ability to heat their homes and afford healthy food.[41]

24. Dr Jen Daffin said the relationship between poverty and mental health is two-way—poverty can be both a cause and a consequence of poor mental health and distress. She added that failing to recognise the impact of poverty could be a barrier to finding solutions:

“…why, when we know that these things are causing people distress, would we just look to medicate that and to hide that distress? What we're seeing is not a tsunami of mental illness, but a tsunami of distress. And so the long-term solution to this, to break intergenerational cycles of mental health problems, of trauma, of distress, of poverty, is to go upstream and figure out how do we break that cycle”.[42]

25. Illustrating this point, Andy Bell noted that people whose poor mental health results from living in poverty or income insecurity, or who are at risk of homelessness through losing tenancy or missing mortgage payments, may be prescribed traditional approaches such as medication or talking therapies. However, while this may treat their mental health symptoms, such methods will not resolve the underlying issues.[43]

26. The Centre for Mental Health has published proposals it argues could increase incomes or lower costs for the poorest, or improve services in areas of greatest need.[44] Some of these proposals have already been implemented at least in part by the Welsh Government (such as free school meals and the introduction of the Real Living Wage in social care), and others would be within devolved competence (such as improving the provision of financial advice, increasing the supply of energy efficient social rent homes, improving access to free or cheap bikes or reducing smoking). Other solutions suggested to us for tackling the mental health inequalities faced by people living in poverty or disadvantage included improving access to advice services for housing and debt, as well as services such as legal aid.[45] Care and Repair Cymru suggested a practical step could be for the Welsh Government to work with organisations such as Dŵr Cymru Welsh Water to include information on mental health support in customer literature.[46]

27. The Deputy Minister for MHW agreed that poverty was a key factor in mental distress. She described the rising costs of living as the Welsh Government’s “primary concern”, and outlined actions including fuel support for people on low incomes, steps to ensure that carers can access financial support, and a single advice fund. She said that in 2022-23, the Welsh Government was spending up to £1.6 billion on targeted and universal support, and advice and information relating to the cost of living.[47]

Welfare benefits

28. Professor Rob Poole of the Centre for Mental Health and Society at Bangor University suggested that devolving responsibility for either the benefits assessment system or the wider benefits system to Wales could enable the Welsh Government to alleviate poverty by addressing barriers that may otherwise prevent people from accessing benefits to which they are entitled.[48] Similar calls were made by the Fair Treatment for the Women of Wales, which suggested that the devolution of social security and benefits could help support and empower disabled people, reduce their needs for mental health services, and reduce the likelihood of them living in poverty.[49]

Box 5:

Devolution of welfare: recent parliamentary and government activity

April and May 2018: the Fifth Senedd Equality, Local Government and Communities (“ELGC”) Committee twice recommended exploring the devolution of benefits.[50] The then Welsh Government rejected both recommendations.[51]

January 2019: the then new First Minister told Plenary he believed the devolution of the administration of universal credit should be explored, but that it should be done carefully to avoid disputes arising in respect of funding as had occurred in respect of the devolution of council tax benefit.[52]

April 2019: the Wales Governance Centre published research which found that, depending on the mechanism used, the Welsh Treasury could “stand to benefit considerably from the devolution of welfare powers”.[53]

October 2019: the ELGC Committee published a report on options for improving the delivery of benefits in Wales and recommended “further detailed exploratory work to better understand the costs, risks, practical implementation and benefits of the housing element of Universal Credit”.[54] Responding to the report, the Welsh Government indicated that further consideration was needed on its position on the devolution of any parts of the social security system.[55]

December 2021: the Programme for Government committed the Welsh Government to “explore the necessary infrastructure required to prepare for the devolution of the administration of welfare”.[56] This reflected the Cooperation Agreement between the Welsh Government and Plaid Cymru, which also notes that any transfer of power “would need to be accompanied by the transfer of appropriate financial support”.[57]

March 2022: the House of Commons Welsh Affairs Select Committee recommended the establishment of a UK-Welsh Government Inter-ministerial Advisory Board on Social Security, which should (among other things) assess the potential merits of devolving the administration of the same benefits to Wales as have been devolved to Scotland.[58] The UK Government rejected both recommendations, stating it “had no intention to devolve social security to the Welsh Government”.[59]

Diagnostic overshadowing

29. Failure to take a person-centred view and consider the wider determinants of mental health can result in diagnostic overshadowing, in which too much focus is placed on a person’s primary diagnosis. People may be bounced between different services or excluded from services entirely. Specific issues raised with us include:

People who have been diagnosed with personality disorders may be particularly at risk of stigma or a lack of support. This often includes women who have experienced abuse or violence, who we have heard may sometimes be inappropriately diagnosed with personality disorders when their symptoms may in fact be normal responses to trauma.[60] According to Andy Bell, people with such diagnoses may receive negative treatment from health professionals, be ‘blamed’ or stigmatised for their experiences, struggle to access support, or experience a lack of compassion.[61]
Mental health problems can be seen as an “inevitable consequence” of neurodivergence, leaving neurodivergent people unable to access mental health support.[62]
People who have a learning disability may find that their behaviours are seen as part of, or attributed to, their learning disability or condition when they may in fact be experiencing poor mental health or even a mental health crisis.[63]
Substance misuse can be a symptom and a consequence of poor mental health, but siloed ways of working can mean that support for mental health needs is denied until substance misuse issues have been addressed. Treatment pathways for ‘dual diagnosis’ (i.e. for mental health and substance misuse issues) do exist, but may not be working effectively across Wales.[64]

Experience of trauma

30. Trauma results from an event, series of events, or set of circumstances that an individual experiences as physically or emotionally harmful or life-threatening, and that has lasting, adverse effects on their functioning or mental or physical wellbeing.[65] Throughout our inquiry we have heard that trauma is a significant cause of poor mental health, but that traditional mental health service models fail to adequately take it into account. Psychologists for Social Change said this risks perpetuating mental health inequity as it “obscures the necessary solutions from view”.[66] Expanding on this point in oral evidence, Dr Jen Daffin said that 81 per cent of people diagnosed with personality disorders had a history of trauma, but that diagnostic overshadowing, combined with a failure to explore individuals’ trauma, prevented them from receiving support for their trauma or distress-related issues.[67]

Our view

31. We believe that as a society, and as policymakers, we need to develop a shared and coherent narrative about mental health which is clear that mental health is more than the presence or absence of mental illness. While we need to ensure that there is effective support for people experiencing a range of mental health problems, we also need to build and maintain a greater focus on, and understanding of, the causes of mental ill health and what is needed to create good mental wellbeing. This would help to reduce stigma, and improve understanding that many people’s distress does not stem from something being wrong with them, rather it is an understandable response to their environment, circumstances and/or adverse events. This means recognising that mental health is complex, with many interplaying factors including mental, physical, spiritual and external circumstances. In addition, for good mental health, people’s ‘relational’ needs (i.e. having safe and supportive relationships with families, friends, and communities) must also be met.

32. Mental health is, to a great extent, shaped by the social, economic and physical environments in which people live. Mental health problems can affect anyone, but some groups of people are disproportionately at risk. We would encourage the Welsh Government, as it develops its new strategy for mental health, to review the evidence we have gathered, and to reflect on whether its strategy will adequately meet the diverse needs of the many groups who may be at risk.

33. We agree with the Centre for Mental Health and Society at Bangor University that mental health inequalities, like other types of inequality, do not just affect discrete, disadvantaged groups. Rather, “all sectors of society would experience tangible benefits from reductions in inequality”.[68] Unfortunately, we do not live in a society that is fully inclusive, accepting of difference, and where all people feel they belong. For too many people, there are significant barriers to accessing services, opportunities, and taking part in everyday activities. Those who experience disadvantage and discrimination in society are at much higher risk of poor mental health, and are also less able to access appropriate support. People’s vulnerability to mental health problems is often linked to inequalities in society. This includes inequalities related to protected characteristics and other factors such as poverty, inadequate housing, and lack of access to education or employment.

Recommendation 1

The mental health and wellbeing of the population will not improve, and in fact may continue to deteriorate, unless effective action is taken to recognise and address the impact of trauma, and tackle inequalities in society and the wider causes of poor mental health. This message, combined with a clear ambition to reduce mental health inequalities, must be at the centre of Welsh Government’s new mental health strategy.

34. The Welsh Government’s existing mental health strategy aims to address the range of factors that affect mental health by working across Ministerial portfolios. However, while we welcome this cross-cutting approach, we must acknowledge that not all of the policy, legislative and financial levers needed to tackle poverty or other social determinants of mental health are within the Welsh Government’s control. Others are controlled by the UK Government, and the Welsh Government can only seek to influence their use.

Recommendation 2

Ideally in its response to our report, but at latest by July 2023, the Welsh Government should provide a frank appraisal of which policy, legislative and financial levers for tackling poverty and other social determinants of mental health are held by the Welsh Government, and which are within the control of the UK Government. This appraisal should be accompanied by a realistic assessment of how far the Welsh Government can go in improving the mental health and wellbeing of the population using the levers within the Welsh Government’s control, and information about how the Welsh and UK Governments are working together to ensure the levers at the UK Government’s disposal are used to best effect to improve mental health and wellbeing in Wales.

35. The impact of the rising costs of living and the increased pressures on household finances on mental health and wellbeing is an acute concern. We welcome the provision of energy bill support for people on low incomes, and the steps being taken by the Welsh Government to ensure carers and vulnerable families can access support. However, many individuals and families may still struggle, with consequences for their mental health and wellbeing, and every effort must be made to ensure that people are supported.

36. We note the suggestion that devolving benefits, or the administration of benefits, could be a mechanism for improving mental health and wellbeing. We also note the Programme for Government and Cooperation Agreement commitments in this respect. There are different views within the Committee about whether this would be effective or appropriate. However, we all agree that it would help to inform the debate if the Welsh Government’s exploratory work were to include the commissioning of an independent review, and further research if necessary, into the impact that any such devolution would have on tackling physical and mental health inequalities in Wales.

Recommendation 3

By December 2023 the Welsh Government should have commissioned an independent review of the existing evidence, and such further research as may be necessary, to explore the impact of the UK welfare system on mental health and wellbeing in Wales, and what effect the devolution of welfare and/or the administration of welfare could have on tackling physical and mental health inequalities in Wales. The review and research should take into account issues of principle, as well as the practicalities and associated financial implications of retaining the current situation or any further devolution. The Welsh Government should commit to publishing the outcome of the review and research.

37. While severe and enduring mental illness may not be caused by the wider external determinants of mental health, factors such as poor physical health, insecure income and underemployment may exacerbate the underlying mental illness. We welcome the indication from the Deputy Minister for MHW that she is working with stakeholders to ensure the Welsh Government’s new mental health strategy meets the needs of people with severe and enduring mental illness. In addition to ensuring they receive the specialist treatment and support they need, steps must also be taken to mitigate the harm that can result from factors such as poorer physical health and insecure employment.

Recommendation 4

The Welsh Government should set out how the new mental health strategy will ensure that people with severe and enduring mental illness will have routine access to physical health checks, and what actions will be taken to minimise the impact of factors such as poverty, disadvantage and diagnostic overshadowing on this group.

38. It is a significant concern to us that participants in our Welsh Youth Parliament focus group told us that young people perceive CAMHS provision as a “joke” and that they see “no point” in referrals to CAMHS due to lengthy waiting times, being turned down for support, or being offered inadequate help. Our discussions with young people who have experienced the transition from CAMHS to adult mental health services also highlighted significant issues that need to be addressed, and we urge the Welsh Government to consider the recommendations made by Mind Cymru in its May 2022 report Sort the Switch.[69]

39. In its recent report, Young minds matter, the Welsh Youth Parliament Mental Health and Wellbeing Committee called for the review and reform of CAMHS. When making its recommendation, it said:

“The first WYP recommended that CAMHS be reviewed as a matter of urgency, to reduce waiting times and provide the funding and capacity to provide necessary support. Our consultation tells us that more work is desperately needed in this area as the issues our predecessor committee highlighted in 2020 are still as relevant today, and the impact its having on young people in the meantime can be devastating.

[…]

We want to see CAMHS reformed and overhauled. We know that the system is failing, and because of this we worry that that further financial investment will not have the desired effect”.[70]

40. We agree with the Welsh Youth Parliament that work is urgently needed to ensure that CAMHS is fit for purpose, and we urge the Welsh Government to consider and respond to the recommendations in Young minds matter.

— Chair's foreword

— Recommendations

— Summary

— Introduction

— Mental health inequalities

— Person-centred services

— Mental health is 'made' in communities

— Social prescribing

— Workforce

— Coordinated cross-government action

— Reform of the Mental Health Act 1983

— Annex: Mental health and emotional support

References

[17] We explore issues relating to person-centred services in chapter 3.

[18] RoP [para 262], 24 March 2022

[19] MHI85 Age Cymru

[20] MHI85 Age Cymru

[21] RoP [para 8], 6 July 2022

[22] MHI54 Royal College of Psychiatrists

[23] RoP [para 16], 6 July 2022; MHI65 Royal Pharmaceutical Society; MHI 73 Welsh NHS Confederation’s Health and Wellbeing Alliance Mental Health Sub-Group

[24] RoP [paras 125-126], 28 September 2022

[25] RoP [para 32], 8 June 2022

[26] Health and Social Care Committee, Mental health inequalities: stakeholder discussion, 8 June 2022

[27] MHI01 ADHD Foundation

[28] RoP [para 30], 8 June 2022

[29] RoP [paras 218, 233, 271, 311, 322 and 343], 19 May 2022

[30] RoP [paras 56-58], 28 September 2022

[31] RoP [para 276], 24 March 2022

[32] RoP [para 282], 24 March 2022

[33] Health and Social Care Committee, Mental health inequalities: Welsh Youth Parliament focus group, 10 October 2022

[34] MHI32 Mencap Cymru

[35] MHI62 Adferiad Recovery