The state of health care and adult social care in England 2024/25

In last year’s report, we shone a spotlight on the longstanding health inequalities that Black or Black British people face, and our specific concerns around Black men’s mental health.

To develop our understanding of how Black men experience mental health care, we commissioned Queen Mary University (QMU) and University College London (UCL) to carry out a rapid review of what ‘good’ looks like in relation to access, experience and outcomes for Black men. As part of the review, the team carried out a literature review, which showed that Black people (that is, people of Black Caribbean and Black African heritage) continue to face stark and persistent inequalities in mental health care.

The literature review found that not only are Black people 3 to 5 times more likely to be diagnosed and admitted to hospital with schizophrenia compared with all other ethnic groups, they are also less likely to access care early. Inequalities affect Black people along the entire care pathway from access to diagnosis, assessment, treatment and recovery.

Members of the review team spoke with 23 people, including those with lived experience, family, carers, charities and advocacy groups, and providers of services to hear their experiences.

People described stigma as one of the main barriers to accessing mental health services – both in terms of the way communities often viewed mental illness as a sign of weakness or shame, and past experiences that have led to distrust in services. This was also reflected in the findings of the Ipsos survey, where professionals reported that cultural stigma can lead to a reluctance to seek help, disclose symptoms and engage with medicine. Differing cultural beliefs and practices related to mental health and wellbeing can also lead to misunderstandings and misdiagnoses.

Other key barriers identified by the QMU and UCL research included the availability of services and the lack of culturally appropriate models. Culturally appropriate care is sensitive to people's cultural identity or heritage. It means being alert and responsive to beliefs or conventions that might be determined by cultural heritage.

Tackling Inequalities in Health and Care was the theme for our engagement event with representatives from NHS trusts, community organisations, carers, and people who use services. Here, we heard that when people use services, they should feel culturally safe and connected to their identity, including having access to prayer spaces, cultural practices, and community. In addition, we heard that staff should demonstrate understanding of racial trauma and its impact on people who use services. Participants in the research by QMU and UCL felt that more work was needed to make people aware of the services available, reduce stigma regarding mental health problems and create a model centred on prevention, rather than treatment. One participant mentioned the use of satellite clinics embedded in the community and accessible to patients:

Satellite clinics that support the surgery in the villages once a week... If you can't get to the surgery or you just need some advice, or you just want someone to talk to, or you know you're worried about something, 'just come and talk to us.

[Family member/carer]

People who use services and their families who participated in the research described ‘good’ care as care that was open and inclusive. They described the importance of involving Black men in both decisions about their care, as well as the design of services.

All interviewees agreed that care should be holistic and address all aspects, including mental, physical and emotional care. They described the importance of culturally appropriate care that is tailored to individual people’s needs. One person who uses services explained how this affected them:

Being aware, me feeling confident in the knowledge that the therapist I'm speaking to has been through cultural awareness training. Has good experiences of working with, you know, ethnic minority or marginalised clients. And you know, I think of all the things, I think it for me, it comes back to this one issue which is around feeling that these folks are culturally competent.

[Person who uses services]

The research participants described how care that was not holistic and was focused on medication could mean that the causes of the patient’s mental health condition were not addressed and would probably continue to be there after the treatment ended. As one provider reflected:

If I come to you asking for help and I'm saying I'm struggling with low mood, don't assume what could help. It might not be medication, it could be [help with] housing. I'm not saying 'give me a job' because I might be struggling with employment. However, it's not the medication [that would help]. It could be [referring me to] someone who can help me to get a job.

[Provider]

People felt that the ability of services to deliver holistic care was also affected by the current fragmentation of the healthcare system, where there were notable gaps in the communication between providers. One of the family members described the impact of this:

You may see a nurse, an [occupational therapist], a psychiatrist, a psychologist...the multidisciplinary team sometimes is more challenging in the way that they communicate to each other. It shouldn't be our responsibility to take bits and pieces [of information] and make sure these are communicated.

[Family member/carer]

People also described the need for additional funding to deliver high-quality services, address gaps in staffing and scale-up initiatives that were having a local impact. There would also need to be additional investment to train more Black therapists to deliver care and integrate cultural competency training in practice:

Funding is a key issue. The reason why more models are not being introduced is because the funding isn't there to sustain it, so things may happen at pilot level, but they're never scaled up and embedded permanently, so there's loads of [small scale] activity that happens and it's brilliant and then it's done [and] the funding's finished.

[Advocacy group]

Findings from the literature review show that staff must be properly trained to fight racism and support Black men with respect and understanding, and that services need to be held accountable when they fail to do the right thing.

In October 2023, NHS England launched the Patient and Carer Race Equality Framework (PCREF). This is the first anti-racism framework for mental health trusts and mental health service providers, which sets out to improve access, experience and outcomes for people from ethnic minority groups.

We support PCREF as a practical tool to tackle racism and dehumanisation. We continue to encourage services to embed the approach through our regulatory and monitoring activity, and will be checking how services use the framework as evidence to inform our assessments. This includes how mental health services embed equity into their shared vision and ensure equity in experience and outcomes for people from ethnic minority groups. In our MHA monitoring visits we have found poor awareness of and lack of training about PCREF in mental health inpatient settings. We will discuss these findings in our upcoming Monitoring the MHA report.

As a regulator and monitoring body, it is important that we do not hold others to account for actions we are not taking ourselves. We stand against racism, violence, aggression and abuse in all forms. We are currently adopting the principles for an anti-racist organisation set out by the NHS Race and Health Observatory. Our approach will focus on how we address the effects of structural, institutional, and interpersonal racism. This includes addressing racism in our external regulatory work for people using services and providers, as well as internally for our colleagues in CQC.