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Mental health inequalities

About Leonard Cheshire 

Leonard Cheshire is one of the UK’s leading charities supporting disabled people. Led by people with experience of disability, we are at the heart of local life — opening doors to opportunity, choice and support in communities around the globe. At Leonard Cheshire, in Wales and throughout the UK, we support individuals to live, learn and work as independently as they choose, in order to play our part in creating a fair and inclusive society.

We are one of the UK’s largest voluntary sector providers of services for disabled people. We have accommodation services, including supported living and registered care homes as well as social, education and leisure programmes, including day support, community outreach and respite support. 

Which groups of people are disproportionately affected by poor mental health in Wales?

The Welsh Government’s Action on Disability: The Right to Independent Living: Framework and Action Plan acknowledges that disabled people and people with learning disabilities are much more prone to mental health problems than the overall population,[1] and that the COVID-19 pandemic has had a disproportionate impact on the mental health of disabled people.[2]

Prior to the pandemic, the average rating of anxiety for disabled people was 4.27 out of 10,[3] which already compared poorly to an average anxiety rate for non-disabled people of 2.66 out of 10.[4] We also know that some groups of disabled people suffer from a higher prevalence on mental health complications. Between 25% and 40% of those with a learning disability have complications regarding their mental health, compared to an average of 25% for the overall population.[5] Deaf people are 50% more likely to have mental health problems.[6]

However, during the pandemic the anxiety levels for disabled people increased to a high of 6 out of 10 during the initial pandemic in May 2020,[7] reflecting the wide range of impacts that the pandemic had for disabled people. Many disabled people were required to shield or isolate. Some living in care homes or supported living accommodation were forced to self-isolate for up to 28 days if they tested positive for COVID-19 (i.e. longer than the requirement in the public as a whole). In some instances, “Do Not Resuscitate” Orders were given during the initial wave of COVID-19, instructing medical teams that disabled people who had tested positive for coronavirus must not be resuscitated in the event that they suffered cardiac arrest.

As lockdown restrictions have eased, there has been an associated reduction in the proportion of disabled people who felt their well-being was being impacted by COVID-19,[8] and those who described feelings of loneliness.[9] Nevertheless, disabled people remain at least twice as likely to report feeling lonely as non-disabled people.[10]

What factors contribute to poor mental health within these groups?

A wide range of factors clearly contribute to poor mental health, and we welcome the July 2021 call of the Steering Group of disabled people established by the Welsh Government, for “more research and better data… to understand the complex relationship between social factors, COVID-19 infections, mental well-being and disability in Wales.”[11]

One factor which we know about is access to digital technology and associated digital literacy, which became particularly important for the public as a whole during the pandemic as a means for reducing loneliness. However, access to digital technology is uneven, with the Welsh Government's Internet use and digital skills (National Survey for Wales) 2018-19 finding that only 79% of people with a long-standing limiting illness, disability or infirmity used the Internet, compared with 93% of those without such a condition. There is an urgent need for increased funding to enable the provision of training, ICT and Wi-Fi equipment to disabled people in Wales to improve digital inclusion and tackle loneliness and isolation.[12]

We also know that disabled people face a range of society-imposed barriers to employment, which itself serves as a means to combatting loneliness. Disabled people offer a wealth of talent, experience and perspective to the workforce, but 24% of employers admit that they would be less likely to employ someone with a disability and that 66% of employers admit that the costs of workplace adjustments were a barrier to employing a disabled person.[13]

We know that sports and social activities play a critical role in everyone’s mental health and wellbeing, improving fitness and providing a vital sense of community. But all too often, disabled people have been excluded from accessing facilities. Historically, this has sometimes been due to a lack of physical gym equipment, environmental factors (for example loud music can be challenging for some people with Autism Spectrum Disorder) or just a lack of understanding about the needs of disabled people, and the very fact that disabled people want to engage in sports and social activities. Going forward these issues need to be addressed.

Finally, the pandemic gave everyone an insight into a world where they could not get out and about. But inaccessible transport remains an ongoing reality for disabled people. For example, trains are often out of bounds for people with limited mobility and wheelchair users due to a lack of:

         accessible information when initially booking tickets or on-route;

         accessible routes to get to and from stations (with some dropped kerbs too steep or narrow to be safely negotiated in a wheelchair or mobility vehicle, some dropped kerbs compromised by parked vehicles in front of them and some not having a corresponding dropped kerb on the other side);

         step-free access to and from stations and trains;

         accessible toilets, which denies disabled people the basic dignity they are entitled to; and

         staff training (some disabled people have been repeatedly ignored by transport staff at rush hour, meaning that they get into work late, and then lose their job as a consequence).

Poor access to transport also has a negative impact on pursuing career and educational opportunities. Disabled people tell us this has resulted in them turning down job offers, missing interviews or not taking up an educational training course.[14]

For the groups identified, what are the barriers to accessing mental health services?

Research conducted in 2015 on behalf of the Welsh Government noted that there were “significant geographical variations in access to healthcare services for disabled people across Wales, particularly regarding mental healthcare provision and access to rehabilitation services for people with chronic and long-term conditions.”[15] The report concluded that much of this inequality of access is attributable to a “lack of provision or funding for appropriate services . . .”[16]

Disabled people have previously complained about the Welsh Government’s suggestion that mental health support for disabled people be rationed primarily for crisis situations.[17] The Welsh Government has acknowledged in their Action Plan that there has to be greater emphasis on “preventative support” so that disabled people have the support which they need to obviate the requirement to access crisis mental health support in the first place.[18]

Going forward, we need clear evidence that preventative mental health services for disabled people are being prioritised and proactively used by disabled people. The Welsh Government should consider commissioning research into how disabled people engage with preventative mental health services in order to test the success of the relevant interventions.

How effectively can existing services meet their needs, and how could their experience of using mental health services be improved?

A key issue affecting disabled people and their ability to access mental health services is that they can only obtain appropriate treatment when they have reached a crisis.[19] We strongly recommend that the Welsh Government and NHS Boards implement measures to ensure that disabled people can obtain access to treatment and support when mental health problems start to develop rather than when they have reached a “crisis” situation. This in turn would relieve pressure on mental health staff whilst at the same time reducing many instances of severe mental illness amongst disabled people.

We strongly endorse the recommendation made in the Disability Steering Group’s ‘Locked Out’ report last year that the Welsh Government co-operate with Disabled People’s Organisations to improve the lives of disabled people who experience both isolation and loneliness.[20]

We have noted that technology has been advocated as a means to reducing mental health inequalities.[21] A report by Public Health Wales in 2020 acknowledged that disabled people receive unequal health outcomes and championed greater digital inclusivity as a means of reducing such inequality.[22] Such measures will clearly be of benefit to some disabled people. However, as previously noted access to digital technology and digital literacy is lower amongst disabled people than non-disabled people,[23] so caution must be taken that the introduction of virtual counselling sessions (for example) does not inadvertently exclude and isolate.

To what extent does Welsh Government policy recognise and address the mental health needs of these groups?

What disabled people require is access to suitable and inclusive mental health services. Existing Welsh Government policy falls short of fulfilling this aim in several respects. While The Together For Mental Health Delivery Plan 2019-2022 (TfMHDP) commits the Welsh Government to ensuring that “all people in Wales have access to appropriate mental health support” and that mental health inequalities are reduced, more needs to be done to meet these targets.[24] Specifically, the Welsh Government needs to tackle the digital exclusion of disabled people and to guarantee accessible public transport across Wales.

Leonard Cheshire has long campaigned for accessible public transport methods in Wales.[25] Where specialised health care services are few and disparate, some people will be required to travel long distances for care and the difficultly of this task is by no means equal across Welsh society. Disabled people with limited mobility or without access to a car may struggle to make such journeys without adequate provisions and could possibly incur higher transportation costs due to a lack of accessible public transport. The Royal College of Occupational Therapists has also noted that there is unequal access to occupational therapy, with people in more deprived areas often travelling further to receive services.[26] Without action on accessible means of public transport in Wales, these same issues are likely to impact on disabled people’s experiences of accessing non-local mental health services.

NHS Wales have made significant steps over the pandemic in offering telehealth and digital health care services to the general public. For example, over 250,000 video consultations were delivered across Wales between March 2020 and October 2021[27], and online mental health resources such as ACTivate Your Life[28] and SilverCloud[29] enable people to access support at their own pace. Such innovations have the potential to break down the aforementioned transport barriers. However, a credible plan to improve the digital literacy and digital access of disabled people must accompany this, alongside a review of how effective such technologies are at improving mental health outcomes compared with in person treatment.

It is significant to note that actions to support the mental health of the neurodiverse throughout the pandemic, who are deeply affected by mental health problems in the UK[30]are absent from the TfMHDP.[31] Autistic people have thus been especially impacted by lockdowns, as this group tends to have fewer and weaker networks of support.[32] It is clear that more needs to be done to acknowledge and tackle the inequality which this group faces.


What further action is needed, by whom/where, to improve mental health and outcomes for the groups of people identified and reduce mental health inequalities in Wales?

       More work needs to be done to reduce the digital divide between disabled and non-disabled people. If digital health care services are to become an important part of the mental health infrastructure in Wales, it is crucial to ensure that marginalised groups do not miss out on such innovations. We call upon the Welsh Government to increase funding for the provision of training, ICT and Wi-Fi equipment to disabled people in Wales to improve digital inclusion and tackle loneliness and isolation.

       Where mental health services are not offered digitally, it is imperative that disabled people have accessible transport links to services. This can only be guaranteed if the Welsh Government adopt a credible, pan-Wales accessible transport initiative, composed of the following actions:

o   The establishment of a legally binding duty upon the Welsh Government to take all reasonable steps to ensure that all train journeys in Wales are fully accessible by 2030.

o   Ensure all active travel routes include dropped kerbs at least every 100 metres to prevent wheelchair users having to take lengthy detours to cross the road.

o   Reassess transport systems (buses, taxis, measurements used for wheelchair parking spaces) with the intention of removing restrictions for disabled people in Wales.

[1] Welsh Government, Action on Disability: The Right to Independent Living: Framework and Action Plan, last updated 7th October 2019, p. 23. Accessed at: action-on-disability-the-right-to-independent-living-framework-and-action-plan.pdf (gov.wales) [Date accessed: 26/01/2022]; Foundation for People with Learning Disabilities, Learning disability statistics: mental health problems. Accessed at: Learning disability statistics: mental health problems | Foundation for People with Learning Disabilities [Date accessed: 26/01/2022]

[2] Welsh Government, Locked out: liberating disabled people’s lives and rights in Wales beyond COVID-19, 2nd July 2021. Accessed at: Locked out: liberating disabled people’s lives and rights in Wales beyond COVID-19 [HTML] | GOV.WALES [Date accessed: 25/01/2022]

[3] Office for National Statistics, Disability, well-being and loneliness: UK, 2019, 2nd December 2019. Accessed at: Disability, well-being and loneliness, UK - Office for National Statistics (ons.gov.uk) [Date accessed: 26/01/2022]

[4] Ibid.

[5] Foundation for People with Learning Disabilities, Pass it Own. Accessed at: Pass it On | Foundation for People with Learning Disabilities [Date accessed: 23/02/2022]

[6] All Wales Deaf Mental Health and Well-Being evidence to the Commission cited in Centre for Mental Health, Mental health inequalities: factsheet, 11th November 2020. Accessed at: Mental health inequalities: factsheet | Centre for Mental Health [Date accessed: 26/01/2022]

[7] Welsh Government, Locked out: liberating disabled people’s lives and rights in Wales beyond COVID-19.

[8] Ibid.

[9] Ibid.

[10] Ibid.

[11] Ibid.

[12] Leonard Cheshire Cymru, Manifesto Asks: Annex 8: Improve digital literacy amongst disabled people. 2020. Accessed at: Manifesto-Asks-Annex-8.pdf (leonardcheshire.org) [Date accessed: 23/02/2022]

[13] Leonard Cheshire, Manifesto Asks Annex 5 Remove Barriers To Disabled People Gaining And Retaining Employment, 2020. Accessed at: https://www.leonardcheshire.org/sites/default/files/2020-07/Manifesto-Asks-Annex-5.pdf [Date accessed: 23/02/2022]

[14] Findings from Leonard Cheshire’s research conducted with ComRes in 2018. For more information: https://www.comresglobal. com/polls/leonard-cheshire-disability-uk-disabled-adults-survey-hate-crime-section/

[15] Smith, Review of Evidence of Inequalities in Access to Healthcare Services for Disabled People in Wales, p. 91, Para 8.1.

[16] Ibid., p. 91, Para 8.2

[17] Welsh Government, Action on Disability: The Right to Independent Living: Framework and Action Plan, p. 23

[18] Ibid.

[19] Welsh Government, Action on Disability: The Right to Independent Living: Framework and Action Plan, p. 23

[20] Welsh Government, Locked out: liberating disabled people’s lives and rights in Wales beyond COVID-19

[21] Matthew Honeyman, David Maguire, Harry Evans and Alisha Davies, Digital technology and health inequalities: a scoping review, Public Health Wales NHS Trust, 2020. Accessed at: https://phw.nhs.wales/publications/publications1/digital-technology-and-health-inequalities-a-scoping-review/ [Date accessed: 26/01/2022]

[22] Ibid.

[23] Welsh Government, Internet use and digital skills (National Survey for Wales), 2018-19, 11th September 2019. Accessed at: https://gov.wales/sites/default/files/statistics-and-research/2019-09/internet-use-and-digital-skills-national-survey-wales-april-2018-march-2019-207.pdf [Date accessed: 26/01/2022]

[24] Welsh Government, Together for Mental Health: delivery plan 2019 to 2022, 24th January 2020. Accessed at: https://gov.wales/sites/default/files/publications/2020-10/review-of-the-together-for-mental-health-delivery-plan-20192022-in-response-to-covid-19_0.pdf [Date accessed: 26/01/2022].

[25] Leonard Cheshire, Leonard Cheshire Cymru 2021 Senedd Election Manifesto Calls, 24th July 2020. Accessed at: https://www.leonardcheshire.org/sites/default/files/2020-07/english-brochure.pdf [Date accessed: 26/01/2022].

[26] Royal College of Occupational Therapists, Health equity – what’s next?, 19th January 2022. Accessed at: https://www.rcot.co.uk/news/health-equity-whats-next  [Date accessed: 26/01/2022].

[27] Digital Health Wales, Over 250,000 video consultations delivered across Wales, 6th October 2021. Accessed at: https://digitalhealth.wales/news/250k-vcs-across-wales [Date accessed: 26/01/2021].

[28] NHS Wales, ACTivate Your Life, n.d. Accessed at: https://phw.nhs.wales/services-and-teams/activate-your-life/ [Date accessed: 26/01/2021].

[29] Powys Teaching Health Board, SilverCloud Wales Online Therapy, n.d. Accessed at: https://pthb.nhs.wales/services/adult-and-older-peoples-mental-health-services/silvercloud-online-cbt/#:~:text=SilverCloud%20Wales%20is%20an%20Online,to%20deal%20with%20life's%20problems. [Date accessed: 26/01/2021].

[30] Autistica, Autism and Mental Health: A Guide to Looking After Your Mind, n.d. Accessed at https://www.autistica.org.uk/downloads/files/Mental-health-autism-E-LEAFLET.pdf [Date Accessed: 26/01/2021].

[31] Welsh Government, Together for Mental Health: delivery plan 2019 to 2022, 24th January 2020. Accessed at: https://gov.wales/sites/default/files/publications/2020-10/review-of-the-together-for-mental-health-delivery-plan-20192022-in-response-to-covid-19_0.pdf [Date accessed: 26/01/2022].

[32] National Autistic Society, Left stranded: our new report into the impact of coronavirus, 7th September 2020. Accessed at: https://s4.chorus-mk.thirdlight.com/file/1573224908/63117952292/width=-1/height=-1/format=-1/fit=scale/t=444295/e=never/k=da5c189a/LeftStranded%20Report.pdf [Date accessed: 26/01/2021].