Our analysis highlights the impact of both additional long-term conditions and deprivation on people with depression and/or anxiety. We find a higher proportion of people with long-term conditions, more complex prescribing and higher rates of unplanned care use among people with depression and/or anxiety living in more deprived areas. However, rates of primary care consultation and planned secondary health care are not higher in more deprived areas than less deprived areas. This suggests people with more complex needs in more deprived areas may not be using the most appropriate care.
There are a number of potential reasons for this. Barriers to the most appropriate care may include the availability of services (for example long waiting times), their suitability for patients (for example based in locations that are difficult to reach by public transport), or treatment-seeking behaviours (for example expectations around the efficacy of treatment). Designing services that tackle these barriers to the most appropriate health care is key to addressing these inequalities.
This analysis used data from before the pandemic, yet COVID-19 is forecast to have a substantial impact on the mental health of the population, which could disproportionately affect certain groups including those with long-term health conditions and those living in more deprived areas of the UK. It is important that we understand the health care use of these populations as pre-existing disparities are likely to be exacerbated by the pandemic. Early evidence of the pandemic’s impact indicates significant issues in accessing mental health services and a sharp rise in the number of patients needing emergency mental health care for services that were already lacking resources. We know that patients with long-term conditions have faced particular issues around accessing health care. As services plan how to tackle these challenges, support is needed to ensure they can deliver health care to those that need it most.
Supporting health care services within the areas of greatest need
A number of factors suggest a strong rationale for targeting more support towards primary care services in more deprived areas. Much of the health care supporting people with depression and/or anxiety is delivered via primary care and those living in the most deprived areas have more additional conditions. Greater investment in primary care in these areas may help to reduce the higher rates of emergency care that we observed, including mental-health related A&E attendances. Further, the number of patients per GP is 15% higher in the most deprived tenth of clinical commissioning groups than in the least deprived tenth. The known shortage of GPs, especially in more deprived areas, presents a real challenge to providing care impacting both access to and quality of care. The time that GPs can spend with their patients is shorter in more deprived areas meaning there is lesser opportunity to engage patients in conversations around strategies for managing multiple conditions as recommended in clinical guidelines. An additional challenge revealed in recent Health Foundation analysis is that these areas are more likely to have GPs who are themselves at high risk of serious illness from COVID-19, and may need additional support to provide core services.
In addition to these pressures, treatments for depression and anxiety are less accessible and effective in deprived areas. Over 1 million people begin treatment via IAPT services per year, but despite higher referral rates, access and symptom improvement rates show systemic disadvantage among those in more socioeconomically deprived areas. The COVID-19 pandemic may worsen challenges in access to psychological therapies. Early analysis indicates that there were substantial reductions in the number of patients able to access IAPT services during the national lockdown. There will be a likely backlog among already overstretched services that will be critical to address going forward.
Person-centred service configuration
Though the NHS long term plan acknowledged the need for greater integration of physical and mental health care, current service configurations can mean that patients with more than one condition often have each treated separately, requiring them to manage multiple appointments across multiple clinical services. This analysis shows that the treatment burden can be greater for people with more conditions, especially if patients are living in more deprived circumstances. Here, we have not considered the chronology of conditions, but previous evidence indicates that mental health may be an important precursor to a cascade of physical health conditions, and that early intervention could be an effective strategy for reducing inequalities. Integrated care approaches tackling mental, physical and social needs, such as the 3DLTC or IMPARTS programmes, can be impactful, and may facilitate earlier interventions for patients by considering all of their health needs. But there is still a lack of widespread accessible solutions for patients living with multiple conditions.
The shift to remote consultations for many health care services in response to the pandemic may have reduced the burden of travelling to multiple health care appointments for some patients with multiple conditions. However, it is critical to ensure that this rapid adoption of remote care delivery is appropriate for all. For example, our data show that 13.6% of all patients with depression or anxiety have hearing loss, which may make clear communication in a remote consultation more challenging. Work is needed to identify groups who may be excluded by this transition and to put quality improvement approaches in place that tackle these barriers to access.