Online PDF version © Copyright: National Collaborating Centre for Mental Health, 2019 Cite as: National Collaborating Centre for Mental Health. Advancing Mental Health Equality: Steps and Guidance on Commissioning and Delivering Equality in Mental Health Care. London: National Collaborating Centre for Mental Health; 2019. Vision for the Advancing Mental Health Equality resource Identifying and reducing health inequalities in access, experience and outcomes is essential to the delivery of high quality mental health care. The aim of the AMHE resource is to ensure that all mental health care, and mental health promotion, is responsive to the strengths and needs of each individual and community’s identity and culture. Not only are there moral, legal and economic imperatives for advancing equality, but learning and collaborating with all sections of society provides a valuable opportunity to innovate and enhance the way we provide care. Simply put, there is no quality without equality. Contents Introduction 3 Background 6 AMHE: Advancing Mental Health Equality: Guidance for commissioners and service providers 11 IDENTIFY: Understanding inequalities 12 STEP 1A: Use existing data and resources 12 STEP 1B: Work with communities 24 DESIGN: Generating ideas and problem solving 29 STEP 2A: Research 29 STEP 2B: Formulate plans 33 STEP 2C: Set out key priorities 36 DELIVER: Tackle and reduce inequalities; implementing change 38 STEP 3A: Create a strategy 38 STEP 3B: Implement the strategy 39 EVALUATE: Evaluating and improving services 45 STEP 4A: Collect data and measures 45 STEP 4B: Provide opportunities for feedback from people who use services, carers, the community and the workforce 46 STEP 4C: Review data and feedback 47 Advancing equality: the commissioning cycle 49 Definitions and abbreviations 51 References 53 Introduction Inequality exists across all aspects of society, particularly in health. The extent of health inequalities in England is well-reported, but was brought to light most notably in 2010 with the publication of The Marmot Review report: Fair Society, Healthy Lives1 which explicitly described the social gradient in health and the relationships between social status, economic position and health inequalities. The Marmot Review called for action from the central and local government, the NHS and the private sector to reduce health inequalities. Inequalities in mental health care are no exception. Mental health inequalities are varied and pervasive, affecting the access, treatment and outcomes that people can expect to receive. This Advancing Mental Health Equality (AMHE) resource was developed to support commissioners and service providers to tackle inequalities in mental health care and to ensure that support, care and treatment is: • high quality • appropriate to meet needs Box 1: Policy Objectives of The Marmot Review (2010) • accessible and serves people, regardless of any Reducing health inequalities structural, societal or cultural barriers, or protected (or will require action on six policy other) characteristics objectives: • supportive, compassionate and fair • Give every child the best start • effective, leading to the best possible outcomes. in life • Enable all children, young Despite previous efforts, evidence suggests that some people and adults to maximise groups of people continue to experience inequalities their capabilities and have when it comes to access, experience and outcomes. This control over their lives resource draws on numerous studies of the potential • Create fair employment and factors contributing to and perpetuating inequalities in good work for all mental health, as well as the large body of research, • Ensure a healthy standard of policy development and guidance aimed at reducing living for all inequalities in mental health care and tackling stigma • Create and develop healthy and social attitudes. While prevention forms a key part and sustainable places and of any discussion about inequalities, primary prevention communities at a public health level falls outside the scope of this • Strengthen the role and impact document. Nevertheless, this resource draws upon of ill health prevention. relevant discussions and ongoing work to ensure that Source: Fair Society, Healthy Lives there is a consistent message around prevention of poor (2010) mental health and its relevance to equality. Advancing Mental Health Equality 3 Access Experience Outcomes • Certain groups of people • People's experiences of • It is important to note that are less able to access care, including the types both access to care and the care they need, of care and treatment experiences of care which means they may they recieve, differ in influence a person's not receive appropriate quality according to outcomes and likelihood help, may receive help various factors. of recovery. too late, or via a less-therapeutic or • A person's experience of • People who have non-ideal route. care and treatment can difficulty accessing help, be affected by the timing and who experience • Although sometimes of services getting differential treatment, can referred to as 'hard to involved in their lives. have worse outcomes reach' groups, more than people who do not often than not, these • People with specific experience such people are simply not characteristics are difficulties. adequately enabled or predisposed by service supported to access and commissioning appropriate care. design or culture, as well as wider societal barriers, to have a poorer experience of care. This AMHE resource is designed to be used alongside Mental health problems disproportionately the Framework for Community Mental Health Care in affect people living in poverty, those who Adults and Older Adults (forthcoming) and Working Well are unemployed and who already face Together: Evidence and tools to enable co-production in discrimination. For too many, especially Black, mental health commissioning.2 Asian and minority ethnic people, their first experience of mental health care comes when The AMHE resource outlines comprehensive and they are detained under the Mental Health Act, practical steps for commissioners and service providers often with police involvement, followed by a to reduce inequalities in an achievable and measurable long stay in hospital. To truly address this, we way. It provides detailed guidance and methods on how have to tackle inequalities at local and national to identify and reduce inequalities related to mental level. health support, care and treatment. It will also support The 5YFVMH commissioners and service providers to evaluate and review their services, to measure the impact of changes and to identify areas for improvement. Advancing Mental Health Equality 4 an n e e Choice andAccess advocacyCompetentFamilies, workforceLeast carers restrictive Co-productionand support care*Knowing networksPerson-centred your populatioData collection carSupport and Representativeand us caree across workforc the lifesp AMHE KEY PRINCIPLES These key principles were co-developed with people with lived experience, mental health professionals, commissioners and service providers through focus groups, workshops and consultations. They are specific to advancing equality in mental health care and apply to all organisations, health and social care settings, services, and those commissioning them. Choice and advocacy: People who use services, their families, carers and support networks (as appropriate) are actively and continually involved in decisions about their care and treatment and are provided with adequate support to communicate and make decisions. Commissioners and service providers resource local voluntary, community and social enterprise (VCSE) organisations to carry out advocacy as an integral part of the service delivery package. Access: All individuals in a community, including those from diverse population groups, have equal access to mental health assessment, support, care and treatment that meets their needs. Commissioners and service providers ensure that potential barriers to access for people who may be at risk of experiencing mental health inequalities are understood and actively minimised through flexible and responsive services. Competent workforce: Staff working in mental health services are equipped with appropriate skills and training to minimise inequalities, and possess the competences to deliver fair, non-judgemental and least restrictive care. Families, carers and support networks: Services include families, carers and support networks (as appropriate) in a person’s care. Services recognise that some families and carers may experience difficulties accessing care and support for themselves and, as such, procedures are in place to identify and address their needs, regardless of whether their needs are related to their caring role. Least restrictive care:* Service providers work to ensure that restrictive practices are only used when absolutely essential for the safety and protection of the person or others. Services actively address any potential inequalities associated with the use of restriction. All people are able to access appropriate, timely support to reduce the potential need for restrictive care. Co-production: Co-production with people with lived experience is an essential and ongoing part of the commissioning, service development and service evaluation process; it is essential to advancing equality at every stage. Knowing your population: The development and delivery of mental health care actively reduces inequalities by