Tackling inequalities

As we highlighted in our 2018/19 report, taking away a person’s liberty so that they can be treated in hospital has a major impact on that person’s life, work and family and as a result, it is essential that this is carried out in a manner that respects their human rights.

Tackling inequalities in health and care is a core ambition of CQC’s new strategy, and our equality objectives for 2021 to 2025 recognise the need to focus on the quality of care for people who are most likely to have poor experience or outcomes from care, including people detained under the MHA.

This applies to all people with serious mental illness, and especially people detained under the MHA and people who may not have mental capacity to make some important decisions, such as decisions about their care and treatment or where they live. In that context, CQC and the services we monitor must have an awareness of intersectionality, or how factors such as a person’s ethnicity, age, disability, education, sexual orientation, gender identity, immigration status, socio-economic circumstances, can lead to discrimination or disadvantage an individual.

We will be using our monitoring and regulatory activity to make sure that health and social care services understand and are taking steps to tackle inequalities in care. This includes having an awareness of how characteristics such as a person’s ethnicity, age and gender influence the quality of care they receive. In our equality objectives we highlight the following groups as an initial focus across the whole of CQC’s work:

• people from Black and minority ethnic groups
• people with a learning disability and autistic people
• people with dementia
• people who need accessible communication including Deaf people and people who do not speak English
• Lesbian, gay, bisexual and transgender people.

In its final report, the Commission for Equality in Mental Health highlighted that services should be accountable for reducing inequalities in access, experience and outcomes.

As highlighted in our January 2022 Insight briefing, reliable, quality evidence is a fundamental tool in identifying, tackling and improving service equality. However, we are concerned that poor recording of ethnicity is masking equality issues. Only through having access to reliable local and national data will services be able to identify gaps and measure progress towards closing them with benchmarking against other services. We encourage services to support system-wide efforts in tackling existing, and preventing future, health inequalities by improving how data to monitor equalities is captured and used. Solutions will require a system response, working with their communities.

Tackling racism

It has been a longstanding concern that not everyone detained under the MHA is treated equally. NHS digital statistics, published in October 2021 on the use of the MHA, while incomplete, suggest that in 2020/21:

• known rates of detention for people identified as ‘Black or Black British’ were over four times those of people identified as ‘White’
• Black or Black British people have longer periods of detention and more repeated admissions, and are more likely to be made subject to police holding powers under the MHA
• known rates of community treatment order (CTO) use for the ‘Black or Black British’ group were over 10 times the rate for the White group.

The process of reforming the MHA has highlighted the overrepresentation of certain minority ethnic groups of people who are subject to detention or CTO. Urgent action is required to address this longstanding inequality.

We recognise that some factors in inequality are broader than health care provision. Structural disadvantages, such as barriers to accessing earlier health interventions; poverty; education; insecurity of housing and lifetime experiences of trauma and exclusion due to racism, are the background against which admission and discharge from hospital under MHA powers take place. NHS digital statistics for 2020/21, published in October 2021 also suggest that the most economically deprived areas had rates of detention more than three and a half times higher than the rate of detention in the least deprived areas.

As the disadvantages and racism that people with protected characteristics face do not only occur when they undergo an MHA assessment, it is unlikely that rewriting the legal criteria for the use of the MHA powers will have an effect on this.

We welcome new guidance from NHS England and NHS Improvement that sets out the steps that mental health services need to take to fight stigma and inequalities across the sector. ‘Advancing Mental Health Equalities Strategy’, published in October 2020 included a commitment to develop a Patient and Carer Race Equality Framework (PCREF). This is an approach to help mental health trusts work with ethnic minority communities to achieve practical change. It stems from a recommendation from the 2018 Independent Review of the MHA, aimed at addressing racial disparity in access, experience and outcomes of Black or Black British people in mental health services.

We are keen to see the rollout of the PCREF, and have followed developments of the PCREF pilot sites, having benefited from presentations and training from people who use services, carers and staff at South London and Maudsley NHS Foundation Trust. Once developed, the PCREF will be rolled out by NHS England across all mental health trusts in 2022 and will be considered in our well-led assessments.

All health and social care services should have zero-tolerance towards racism and should be engaged with promoting equality, as part of their legal duties under the Equality Act 2010. It can be more challenging to manage the racist language or acts of people detained in hospital under the MHA, but where services are aware of racism or equality issues they must take action to address these.

During remote monitoring of a women’s ward in March 2021, we were told that the ward was trying to implement a zero-tolerance approach to racist language towards staff by patients “although it was often very hard to press charges”. We accept that patients and staff must be supported to report racist incidents to the police, although it is clear that this cannot always be expected to lead to prosecution, or that this would necessarily resolve the problem.

The Norfolk Safeguarding Adults Review, published in September 2021, suggests that there can be a ‘taboo’ of addressing racism expressed by patients with cognitive impairments. The review acknowledges that there are no quick fixes to addressing such racism, but suggests that the principles of restorative justice (that is constructive learning via mediation between a victim and the offender) have promise. In response the safeguarding board produced a seven minute briefing on managing racial abuse towards staff from people who lack capacity, which may be of use to services.

During our monitoring of Rampton Hospital in February and March 2021, we heard positive accounts of action taken to address racist incidents by some of the patients, directed towards both patients and staff

In response to our request for assurance over the hospital’s broader actions to address racism and other equality issues, we were pleased to hear the positive action they were taking to address this.

Lesbian, gay, bisexual and trans people

In recent years, health and social care services have generally improved their awareness of the discrimination and exclusion experienced by many lesbian, gay, bisexual and transgender (LGBT) people in their care. The government’s national LGBT survey of 2017, which had over 108,000 responses, showed that LGBT people feel their specific needs go unaddressed when accessing healthcare. The government’s subsequent LGBT action plan sets out the ambition that LGBT people should be able to easily access healthcare when they need it most, and feel comfortable disclosing their sexual orientation or gender identity so that they get the best possible care.

In our experience, some of the ways in which LGBT people’s needs are failed in inpatient mental health care can be through assumptions of heteronormative family structures (perhaps especially in older peoples’ services, for example by initially failing to recognise a patient’s same-sex partner); feelings of exclusion, or indeed typecasting, in wider cultural matters; fear of disclosing sexual identity as if this might be treated as part of a mental health problem; and the fear of bullying, violence or sexual assault from other patients.

Across the system, we have seen examples of excellent care that can be built on. For example, in the high secure sector, Ashworth hospital has shown exemplary practice in its sensitive, caring and intelligent approaches to trans patients’ care, which was reflected in other patients’ attitudes on the wards. The treating team at the hospital contributed heavily towards the interim NHS England guidance for secure hospitals about caring for transgender patients, including questions of balance between security and patients’ rights relating to gender identity.

Deaf patients

Over the last year, the increased use of personal protective equipment (PPE), in line with infection prevention control measures, has created communication barriers for some groups of people. During our monitoring visits, we saw some good examples of how services had adapted to manage these potential new barriers. For example, at one remote visit with a learning disability unit in November 2020, we heard that staff wore a large name badge with picture of themselves so patients could more easily recognise their faces when wearing PPE. For deaf patients, staff used a clear face visor to help with lip reading.

However, irrespective of the difficulties introduced by the pandemic, services can struggle to meet the basic communication needs of deaf patients. For example, at one service we heard that there were no staff available who had British Sign Language skills available on the ward for a deaf patient, which meant they were unable to communicate with staff. In response to our concerns, the service sought extra training for staff, including British Sign Language, and sought support from the local service for deaf people.

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The MHA and our concerns for key groups of people

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