Mental health in primary and community care: report - December 2024

Equality Impacts

In action 3.3.1 of the Mental Health Strategy Delivery Plan, the Scottish Government committed to equality impacting the options in this report. The findings of this analysis of the options, as well as the current pause on the implementation of the Mental Health and Wellbeing in Primary Care Services (MHWPCS), are summarised below.

This analysis is based on the evidence available through the Mental Health Equality Evidence Report 2023, the Equalities Impact Assessment (EQIA) framing workshop undertaken in 2022, the principles set out in the Mental Health in Primary Care Short-Life Working Group and the Mental Health and Wellbeing in Primary Care Services Planning Guidance, and engagement with the Mental Health Equalities and Human Rights Forum.

It should be noted that since, in some instances, these options build on existing programmes, they are subject to their own specific Equalities Impact Assessments. Where this is the case, it is noted at the relevant option.

Assessment of the options

Data

Positively promoting equality by: Providing some limited data to better understand demand, who is accessing general practice for mental health support, and their experience broken down by protected characteristic. In the longer-term work is underway to improve regional board access to existing local practice data.

Gaps: There is a need to improve the data recorded in general practice. Due to the limitations of the available this analysis relates to wider access barriers to wider services rather than specific to general practice.

The data also provides a national perspective and there remains a need for consistent, standardised data collection across all Health Boards.

Wider considerations: When collecting data about protected characteristics in general practice, it should be explained that any use of the data is anonymised as well as the purpose of collecting the data to avoid stigma.

Communities Fund

Positively promoting equality by: Strengthening links to community support and services, and increasing the support that, is targeted at, and can be accessed by those with protected characteristics. This may help to address some of the social stressors that can contribute to poor mental health. The Communities Mental Health and Wellbeing Fund for Adults focuses on addressing the mental health inequalities exacerbated by the pandemic and addressing the needs of at least one of the following ‘at risk’ groups women (particularly young women at risk of gender based violence); disabled people or those with a long term health condition; people from Black, Asian, and minority ethnics group; refugees and those with no recourse to public funds; those people facing socio-economic disadvantage; people experiencing severe and multiple disadvantage; people with experience of trauma; people who have experienced bereavement or loss; people disadvantaged by geographical location (particularly remote and rural areas); older people; and LGBTI communities).

Once pathways from general practice to the Communities Mental Health and Wellbeing Fund for Adults have been strengthened, this learning can be adapted to expand the scope of the work to create pathways to other third sector community supports.

Gaps: While strengthening this pathway is positive and may result in people accessing additional support, it does not in itself create additional capacity within general practice. It is unlikely that everyone who attended general practice for mental health support would be suitable for the funded projects as they are not exhaustive. It also does not address the issue of some people being less likely to seek support from their GP in the first instance, for example, disabled people.

Wider considerations: During the consultation session, wider issues were also raised around ethical procurement for funds like these, the reporting burden for successful organisations and sustainability concerns for third sector organisations as a result of short-term funding. Mental Health in Primary Care and Mental Health Unscheduled Care Resource Toolkits Positively promoting equality by: Providing a resource for general practice and unscheduled care staff containing information about how to access a vast range of additional support covering services tailored to gender, sexual orientation, ethnic minorities, disability, age (children and young people, students), neurodivergence, carers, parents and perinatal. It also includes essential training resources covering equality, diversity and human rights and cultural humility. Many of these resources have been developed by or in partnership with those with lived experience.

Gaps: The resource currently does not contain any resources tailored to meet the need of different religious beliefs and does not address issues around stigma for this group.

The resource does not fully meet the needs of ethnic minorities, especially asylum seekers, refugees, and those with no recourse to public funds. It is also unlikely to meet the needs of Gypsy/ Travellers who are unlikely to have access to the internet or seek support through general practice.

It may also not meet the needs of people who are homeless or experiencing addiction as they are also less likely to access support from their general practice as a first port of call.

While the resource is digital, it is targeted at the general practice workforce to direct people to additional forms of support. This will help overcome some barriers associated with digital inclusion, however; this will not overcome barriers for people who are not accessing support from general practice. It was therefore suggested that it should be adapted and promoted to relevant third sector groups.

Digital Therapies

Positively promoting equality by:

Increasing the use of digital therapies. The therapies (Silvercloud CBT, Sleepio and Daylight) are mostly aimed at adults with mild to moderate mental health needs, therefore these programmes can support those who would be seeking help in general practice.

There are likely to be specific benefits for men who are less likely to engage in talking therapies, LGBTQI+ who can find the style and setting of face-to-face appointments can worsen their mental health, carers as they overcome barriers associated with long wating times and inflexible appointments. As well as children and young people, perinatal women, disabled people, and those with long term conditions, those in poverty and low income and those in rural areas.

Gaps: Digital therapies are not appropriate for all, and we need to consider barriers to access, particularly digital exclusion which can be a significant barrier for disabled people; ethnic minorities, especially asylum seekers; those in poverty and on low incomes, especially those with long term conditions; those in urban and rural areas and carers. While digital therapies would make a positive contribution to the support that can be accessed, it does not provide a holistic service in the same way face to face support in the community would and does not address the issue of long waiting times for those services, and the need for human contact for those in distress.

The digital programme is developing its own EQIA, which will consider mitigations for digital exclusion identified as a key barrier.

Psychiatric Emergency Plan Review

Positively promoting equality by:

Ensuring the review, and therefore the subsequent guidance and future development of the plans, take an equalities and human rights approach. The review is specifically focusing on where the roles, responsibilities, process and support may need to be adapted to meet the needs of:

• Homeless individuals
• Refugees & asylum seekers
• Individuals not registered at Scottish/rUK address
• Individuals with sensory impairment
• Individuals with dementia
• Older adults
• Neurodivergent individuals, including autism
• Learning disability
• Children and young people
• Children and young people in care
• Individuals in the perinatal and/or postnatal period
• Patients with caring responsibilities

Workshops with people with lived or living experience are also planned in early 2025 to ensure that the guidance is user informed.

Safe Spaces Report

Positively promoting equality by:

Ensuring the report was informed by lived experience to sets out what would need to be considered in the design and operation of safe spaces to ensure they are fully accessible to those with one or more protected characteristics. It also has a specific focus on those experiencing severe and multiple disadvantage.

Gaps: While the report outlines best practice and could be used by those developing services in future, there is no mandatory requirement to do so. However as part of the Public Sector Equality Duty, relevant services should undertake an Equality Impact Assessment where appropriate.

Time Space Compassion

Time Space Compassion has been considered under the Suicide Prevention Strategy equality impact assessment^[6]. Work is underway on a thematic review of lived experience to support the delivery of this approach.

Positively promoting equality by:

Improving the suicidal crisis response in primary care. Evidence, practitioners and lived and living experience input, show that primary care is a critical setting for identifying and reducing risk, preventing and providing postintervention support following a suicide attempt. The same evidence and intelligence highlight the need for improvement of response, support and patient safety, in this setting.

General Practice Nurse and Practice Management and Admin Staff

Positively promoting equality by:

Engaging with GPNs supporting mental health and wellbeing needs, particularly for those with long term conditions who may need support with both their physical and mental health, providing a more holistic service in general practice. By guiding staff to the ‘informed level’ on the ‘Mental health improvement, and prevention of self-harm and suicide’ knowledge and skills framework and the National Trauma Transformation Programme this will increase their confidence and has the potential to improve people’s experience of contacting their practice for mental health support.

This is an extension of the actions in the Mental Health Workforce Delivery Plan which were subject to a full Equality Impact Assessment^[7].

Target Operating Model/Service Specification

Equality impacts will be assessed as the work is developed.

The work may help Integration Authorities to redesign services and make better use of existing resource, however it is acknowledged that it does not create additional workforce capacity in general practice.

Impact of pausing the implementation of Mental Health and Wellbeing Primary Care Services

The mental health and wellbeing in primary care services would have significantly increased capacity for mental health support in general practice, and provided a holistic service providing advice, assessment and treatment for those with mild to moderate mental health and wellbeing needs, with a focus on early intervention and prevention. The services would have provided both clinical and social support to address the social stressors that contribute to poor mental health and wellbeing.

The services would have been available to all without the need for a referral, and there would have been a requirement on the services to positively seek to address health inequalities, proactively engaging those that are less likely to access support. Therefore, the services would have been beneficial to the population as a whole, but may have been particularly beneficial to those with protected characteristics experiencing poor mental health or wellbeing.

The options outlined in this report will go some way to increasing access to mental health support in general practice they will but they will not achieve the significant shift in care envisaged in the development of the Mental Health and Wellbeing in Primary Care Service model. The equality impacts, utilising the underpinning principles envisaged for the services, are summarised below.

Primary Care mental health services should have no age or condition/care group boundaries and meet the needs of all equalities groups.

This would have positively promoted equality by ensuring mental health and wellbeing services would have been more readily available for those who need them by achieving significant additional capacity and diverse MDTs.

This would have promoted equality for all protected characteristics, as the services would have been providing support, advice and treatment for those with mild to moderate mental health and wellbeing needs, and the majority of those with protected characteristics report higher levels of anxiety and depression. We know from the Short Life Working Group report how important early intervention is in preventing escalation of mental health symptoms.

They would have promoted equality for Children and young people as they would have been able to access dedicated and tailored mental health and wellbeing support. We know that most GP Practices do not have tailored support, assessment and treatment for children and young people. It was anticipated that this cohort would have been prioritised. This would have potentially reduced referrals to CAMHS and contributed to bridging the gap in support for those who do not need to be seen by CAMHS and those waiting to be seen by CAMHS.

It would have also been particularly beneficial for perinatal women, who would have had the option to self-refer, in addition to the services linking in with relevant staff such as Midwives and Health Visitors. This would have allowed those who are in contact with and caring for perinatal women to link them into mental health support in general practice. The services would also have links with specialist and secondary care for those who need it, for example, those experiencing postnatal psychosis.

In addition, the further development of these services would have created more capacity within general practice for those with mild to moderate mental health needs, freeing up GP time which would free up time to dedicate to patients with more complex needs, which may have been beneficial for disabled people and those with long term conditions, including enduring mental health conditions.

Gaps: There would still be access challenges for those who are not registered with a GP, for example, asylum seekers/refugees and those who are homeless. The services would need to ensure that barriers to access for protected characteristics were adequately addressed and the services were not exacerbating existing inequalities.

Local systems will positively seek to address health inequalities, proactively engaging those that are less likely to access support.

This would have positively promoted equality by ensuring that those who do not currently access or enjoy full access to healthcare are proactively engaged. This would have been beneficial to all protected characteristics but especially disabled people who experience several barriers to accessing support from their GP, meaning they are less likely to do so.

Perinatal women may also have benefitted from this outreach as it could have gone some way to providing support for those who are reluctant to discuss their mental health for fear of the repercussions for themselves and their babies, however it is acknowledged that this group of people may be hard to identify.

Ethnic minority groups could have also benefitted as a lack of awareness of available services is one of the key barriers noted for this protected characteristic, and those in poverty and on low incomes also report a lack of signposting and access to information as a key barrier. Those in rural areas could have benefitted from outreach engagement to address issues around stigma and access, and it could have helped carers overcome issues with inflexible services.

Gaps: While this outreach engagement would have been positive, it is acknowledged that there would still be challenges engaging with all groups, for example Gypsy/ Travellers, refugees and homeless people who experience more barriers registering with a GP. There are known issues with the availability of interpreters which, even with more proactive outreach, may make it challenging to ensure that services are fully accessible to all.

Out of Hours period should have access to the full range of options available in hours, accepting some options may not be available immediately.

This would have positively promoted equality by ensuring that people have access to the same range of advice, support and treatment regardless of when they seek support, would have had a positive impact for all, including all equality groups as anyone can require crisis care. It would have strengthened pathways between unplanned and planned care making it especially beneficial for those who are least likely to be accessing planned care.

Evidence based psychological therapies need to be offered, with appropriate supervision and stepping up seamlessly to secondary care mental health services where appropriate.

This would have positively promoted equality by increasing the range of treatment on offer for all in general practice, including all equality groups, and ensuring people can access psychological therapies within a primary care setting with strong links to secondary care when appropriate.

This expansion in psychological therapy may have been particularly beneficial for older adults and may have addressed the current gap whereby older adults are less likely to receive PT treatment in Scotland, even though psychological interventions are effective amongst older people. It would also have benefitted men who are less likely to access PT.

It may have also benefitted perinatal women in need of psychological support, those in poverty or on low incomes who are more likely to have experienced psychological trauma and adverse childhood experiences and ethnic minorities reporting more moderate mental ill health/wellbeing symptoms. For those with more severe and enduring needs, the services would improve links to secondary/specialist care.

Seamless links to secondary care may have also been particularly beneficial for women who are more likely than men to record a GHQ-12 score of 4 or more (indicative of a possible psychiatric disorder) and may be more in need of secondary services.

Gaps:

People from Black, Asian and minority ethnic backgrounds have experienced poorer access to, and outcomes from, NHS talking therapies. While access would have been improved, care would still be required to ensure that therapies are better tailored to meet the needs of Black, Asian and minority ethnic groups, through provision of culturally sensitive therapy.