Health Inequalities

The ‘Northern Powerhouse’ is “the government’s vision for a super-connected, globally-competitive northern economy with a flourishing private sector, a highly-skilled population, and world-renowned civic and business leadership” and consists of the majority of northern England, including Manchester, Liverpool, Leeds, Sheffield, Hull, Newcastle, and many smaller towns and other cities.

However, the Northern Powerhouse does – on average – worse than the rest of the country with respect to both health and economic outcomes.

One of the major driving factors for the creation of the Northern Powerhouse was to build a joined-up north that could ultimately equal south/south-east England in terms of economic performance and productivity.

Regional differences in health

There are deep-rooted and persistent regional health inequalities within England. People who live in the north tend to have much lower levels of health than their counterparts elsewhere and there is a two-year gap in life-expectancy. One frightening result of this is that over the last 50 years, over 1.5 million northerners have died earlier than if they had experienced the same lifetime health chances as those in the rest of England.

Premature mortality rates in Manchester are 539 deaths per 100,000 population, compared to 241 deaths per 100,000 in Kensington and Chelsea.

It is not just length of life; there are also marked differences in the quality of health between the north and elsewhere. The ‘Due North Inquiry’ into health equity reported that a baby boy born in Manchester can expect to live 17 fewer years in good health than a baby boy born in Richmond Upon Thames. A baby girl born in Manchester can expect to live 15 fewer years in good health than a baby girl born in Richmond.

Regional difference in wealth

As well as stark differences in health, there are also large differences in wealth and other measures of economic conditions. For example, there is a £4 per-person-per-hour difference in productivity (measured using average Gross Value Added; GVA); the average GVA per-worker in the Northern Powerhouse is £28, compared to £32 nationally. If productivity in the Northern Powerhouse increased to match the UK average, it would equate to a potential £44 billion real terms gain to UK GDP.

The Northern Powerhouse also has lower levels of economic activity rates (implying higher rates of unemployment and economic inactivity), and even when in employment the average annual earnings in the Northern Powerhouse are 10% lower than the rest of England.

The relationship between the two

Given that both health and wealth are lower in the Northern Powerhouse, a natural question to ask is “Are these things connected?” with a follow-up question being “If we reduce the differences in health, will we benefit from higher productivity?”

In our recent report, funded through the Northern Health Science Alliance (NHSA), we answer exactly these questions.

First, at a local authority level, we show that there is a strong association between morbidity (ill health) and measures of economic performance (including GVA, employment rate, and the weekly wage). Decreasing the number of people with ill-health by 10% in the Northern Powerhouse will:

• increase rates of economic activity by 4 percentage points; the corresponding figure for the rest of England is 2 percentage points
• increase productivity by 4%; the corresponding figure for the rest of England is 0%

The economic gains associated with improved public health are much larger in the Northern Powerhouse than the rest of England.

Second, we show that increasing NHS budgets in the Northern Powerhouse by 10% will:

• increase the rates of economic activity by 3 percentage points (compared to 2 percentage points in the rest of England)
• increase productivity by 0.7% (compared to 0.4% in the rest of England)

Again, the returns are much larger for increases in NHS budgets in the Northern Powerhouse compared to the rest of England. These results, however, must bear in mind that average NHS spending is already higher, on average, in the Northern Powerhouse than elsewhere.

Finally, by analysing what causes the difference in productivity between the Northern Powerhouse and the rest of England, we show that around 30% of the productivity gap (of £4 per-person-per-hour, or £44bn per-year) can be attributable to worse health in the Northern Powerhouse. If we were to eradicate this gap, and make people in the Northern Powerhouse as healthy as their compatriots, a further £13.2bn could be added to UK GDP.

How to bridge the gap?

Throughout this report we make a number of recommendations to central government and regional stakeholders in the Northern Powerhouse. A selection of these is presented below.

Central government

• To improve health in the north by increasing investment in place-based public health in Northern Powerhouse local authorities.
• To improve labour market participation and job retention amongst people with a health condition in the Northern Powerhouse. For example, people with long-term conditions could be given extra assistance to enable them to maintain their job. This could include different working arrangements, easier availability of necessary equipment, and greater flexibility.
• To increase NHS funding in the Northern Powerhouse – to be spent on prevention services and health science research. The increases in spending could be brought about by, for example, giving a higher weighting to deprivation measures.
• To reduce economic inequality between the north and the rest of England by implementing an inclusive, green industrial strategy.

Northern Powerhouse local and regional stakeholders

• Health and Wellbeing Boards and the emerging NHS Integrated Care Systems should commission more health promotion, condition management and prevention services.
• Local Enterprise Partnerships, local authorities and devolved northern regions should develop locally tailored ‘health-first’ programmes in partnership with the local NHS and third sector providers.
• Local Enterprise Partnerships, local authorities and devolved Northern regions should scale-up their place-based public health programmes across the life course: ‘starting well’, ‘living well’ and ‘ageing well’.
• Local businesses should support job retention and health promotion interventions across the Northern Powerhouse workforce and northern city regions and northern NHS integrated care systems should lead by example.

The COVID-19 pandemic has driven many of our activities online – including healthcare. While the digital revolution in the NHS has brought many benefits, further shifts such as remote consultations and monitoring during the pandemic, have the potential to leave people behind. Now, more than ever, digital skills are needed to navigate the world, especially while social distancing and restrictions mean that we spend more of our time online, but for many people this is not possible. The UK government aims to transform patient outcomes through technology, but does this benefit everyone equally? And who is left behind?

Digital access is not enough

Ensuring the whole population has access to the internet is vital in the technological age, yet access to digital services in the UK is deeply uneven. Currently, 4% of UK households do not have Internet access, 3.8 million people (7% of the population) have never used the Internet, and 9 million cannot use the Internet unassisted. The older and more deprived you are, the less likely you are to be digitally engaged, with lower socioeconomic groups more likely to face barriers to getting online and less likely to have the skills to use digital devices. People with disabilities are also less likely to be online. We know that these groups are disproportionately affected by ill health and are at more risk of complications related to COVID-19 and to suffer from social isolation – these differences have only been highlighted further by the pandemic. In light of this, the NHS should measure the use of digital health services by these groups and how this impacts on access to healthcare; after all, they are the biggest users of healthcare services. Digitisation of patient-facing services in the NHS needs to explicitly include strategies to engage these groups and ensure health inequalities are not widened even further.

The importance of access to the Internet is reflected globally in the United Nations (UN) Sustainable Development Goals (SDG 17.8). However, access is of no use if people don’t have the skills to make best use of the internet.

Improving digital skills in the clinically vulnerable

Digital literacy can be enhanced by targeting the most vulnerable with mass digital literacy programmes. This could be done through expanding projects such as the NHS Widening Digital Participation Programme which delivered digital skills training through local hubs working together with councils, libraries, community groups and volunteers thanks to a collaboration between the NHS and the Good Things Foundation. Scaling up this network further could help reach the estimated 23.5 million who have low to very low digital engagement according to the Consumer Digital Index.

Targeted skills training could begin by identifying clinically extremely vulnerable and shielding groups. They are at high risk of complications related to COVID-19 and isolation related to social and digital exclusion. This could also be led on a locality level such as the Greater Manchester Digital Inclusion Taskforce. This will allow for targeted skills training for those most in need. We should bear in mind that many older adults do use the Internet successfully and as many as 26% of those aged 70-79 consider themselves digitally skilled.

Ethical questions in digital healthcare

As we increasingly move more of our health services online, we should also consider the ethical implications: could we be widening health inequalities by moving more of our health service online? Is the increasing trend towards remote monitoring necessary? Who owns the data that is collected and how is privacy safeguarded? Will it result in a better experience of care and better treatment or will it compromise patient safety?

We must recognise the privacy concerns of patients. According to the Information Commissioner’s Office, healthcare accounts for the most personal data breaches, making up 19.7% of the total. Concerns around privacy became particularly prominent in the wake of the failed Care.data launch in 2013, along with more recent concerns surrounding the Test and Trace app. There is a growing concern around whether digital interventions can maintain the same level of ethical principles afforded to patients prior to these digital innovations. Respecting autonomy or ‘self-rules’ may not be achievable if individuals are implicitly coerced into accepting these changes against their will. Healthcare should be justly available to all and ensure access to care with digitisation is equal. Furthermore, it is those with the least digital literacy that we often exchange the most information about, such as those on the shielding list or in social care. This raises questions of power and control and whether digitisation and data sharing always really empowers the individual.

Digital literacy should not be viewed on its own – it intersects with many other aspects of health, and health literacy often overlaps with digital literacy. People with low literacy are more likely to experience increased hospitalisation or death and less likely to engage with preventative health, which is why health literacy campaigns need to run alongside digital literacy campaigns. Additionally, often the facilities available to people locally dictate what support and services they can access; ensuring there are facilities with free digital devices and support on how to use them, should be prioritised so that nobody misses out, including during lockdowns.

Digital, health and financial literacy

The pandemic has highlighted the gap in achieving equal access to education for children who do not have digital devices and we know that education and health are intrinsically linked. We also know that globally there is a gender digital divide, with girls and women having less access to technology and the Internet. Without a combination of digital, health and financial literacy it will be very difficult to break out of a cycle of poverty and ill health. To study the best ways to tackle this and co-produce a solution with local communities, we are working with communities in Doncaster, West Cheshire and Manchester alongside academics from across the country to identify research questions that matter most to them and co-produce solutions to the above. We hope that by taking a collaborative approach we will be able to achieve lasting solutions that work for the most deprived communities in our towns and cities.

Digitising health services should be more than just putting services online. Many communities will require access to free-to-use digital devices, the Internet, and active support, and it is likely that a large campaign will be needed to improve digital literacy for all. Particular attention should be paid to ensuring that an ethical approach is taken and patients and the public are involved in leading the design of digital health projects, to ensure their specific needs are met.

This article was originally published in On Digital Inequalities, a collection of thought leadership pieces on how to address the inequalities we are seeing in the digital space, published by Policy@Manchester.

Health inequalities are unjust and preventable disparities in access to care, experience, and outcomes between different groups of people. At local, national, or global levels, inequalities in physical and mental healthcare are influenced by ‘social determinants’ such as age, socio-economic status, and ethnicity.

In the UK, individuals from Black, Asian, and Minority Ethnic (BAME) backgrounds experience ‘varied and pervasive’ inequalities in mental health and wellbeing.  We use ‘BAME’ here due to its familiarity. However, we recognise and urge others to reflect on how agglomeration of vastly different experiences can obfuscate meaning. One of the most consistent UK research is elevated rates of schizophrenia and related psychoses among people of Black African and Caribbean backgrounds, including those of ‘Mixed’ heritage, compared with White British peers.

No single cause accounts for these differences. Comparative studies have not found similar rates of morbidity in Caribbean countries like Jamaica, Barbados, and Trinidad. Racism, discrimination, migration, social and economic disadvantage are among contributory risk factors. Additionally, Black people’s inferior care (e.g. disproportionate rates of death in service and detention under the Mental Health Act) has led many observers to conclude that mental healthcare in the UK is institutionally racist, a position endorsed by the Royal College of Psychiatrists.

Tackling ethnically-based inequalities: ‘Too hard to do’?

Ethnic inequalities in mental healthcare appear intractable, despite a National Health Service (NHS) founded on the principle of equity and numerous policies and practice guidelines to tackle disparities. After several decades of such strategies, research indicates that Black people continue to be less likely than other ethnic groups to receive timely diagnosis, treatment, and support. Instead, their experiences of mental healthcare is characterised by negative care pathways, often involving the police, and more coercive forms of treatment such as forcible injection of psychotropic medication and being held in isolation.

Black and other UK ethnic minority service users rarely receive culturally-sensitive care. For instance, faith and spirituality (which can buffer symptoms of distress and support recovery) are too often regarded as “irrelevant, harmful, and pathological” by practitioners. People of African and Caribbean origin are also less likely to receive psychological therapies. Those who do, report that their lived experiences and explanations for their difficulties are rejected, nullified or reframed as evidence of illness – particularly when these involve racialisation. Perceptions of practitioners’ lack of empathy and/or cultural awareness have detrimental effects, reinforcing mistrust and increasing the likelihood of disengaging from services; thus further increasing inequalities in access to evidence-based care.

Although various organisational bodies, such as the Royal College of Psychiatrists and NHS England, recommend culturally-sensitive care, there currently exist no clear national guidelines or regulatory standards for what evidence-based culturally-sensitive care looks like or how it can be implemented and evaluated. Research findings on the role, implementation, and results of ‘cultural-competency training’ in UK healthcare settings are ambiguous. Addressing consequential gaps in service provision is essential to tackling mental health inequalities that relate to ‘race’ and other Protected Characteristics as defined under the Equality Act, 2010.

Community Partnered Participatory Research (CPPR): A way forward?

The National Institute for Health and Care Excellence (NICE) highlight the urgent need to develop evidence-based, culturally-informed talking therapies to bridge the treatment gap experienced by the UK’s minority ethnic populations.

In response, people diagnosed with schizophrenia (and related psychoses), their families, healthcare practitioners, and community members have collaborated with us to co-produce Culturally-adapted Family Intervention (CaFI). Originally piloted with Caribbean-origin families in Manchester in 2013-2017, aspects of the CaFI therapy designed to maximise its utility and acceptability with families and mental health professionals included culturally-informed explanations of mental health problems (such as religion and belief) and improving CaFI therapists’ cultural competency. Service users and carer participants in the pilot study endorsed CaFI’s cultural acceptability and therapists reported increased confidence and competence in working with families of Caribbean origin.

Subsequent to the successful pilot in Manchester, our team of national academics have secured £2.5 million of National Institute of Health Research (NIHR) funding to further refine and evaluate CaFI with people from Sub-Saharan African and Caribbean backgrounds. This involves evaluating CaFI’s clinical and cost-effectiveness in a randomised controlled trial (RCT).

Our research will also identify barriers to implementing the therapy across a number of mental health NHS Trusts in England and solutions to overcome them.  We anticipate that ensuring service users and carers are integral to research design, delivery, and evaluation will lead to more holistic mental health care, which service users and their families find acceptable. Accordingly, our work strives to amplify African and Caribbean communities’ voices in informing CaFI therapy resource development, therapist training, research management and dissemination.

Through meaningful collaboration with service users, their families, and healthcare professionals, we are learning valuable lessons that we intend to share with the wider research community and mental health services. We hope that these insights will inform strategies for increasing the participation of BAME populations in clinical trials, as well as shape policy and commissioning decisions. Effectively tackling inequalities in mental healthcare provision and outcomes will enable us to confidently assert that ‘Black mental health matters’. This is especially pertinent in preparing to adequately address the potential mental health crisis during and after the COVID-19 pandemic.

Policy recommendations

We propose the following policy recommendations for tackling long-standing inequalities in mental healthcare experienced by Black and other UK minority ethnic groups in the UK.

1. Cultural competency and inclusive service delivery should be standardised in healthcare practice and curricula across the NHS to ensure that diverse groups receive high-quality, holistic care.

It is imperative for healthcare professionals to challenge their assumptions in care delivery, which if unchecked, could inadvertently reinforce institutional practices that produce mental health inequalities. We must also develop diverse versus ‘one size fits all’ approaches; thereby promoting understanding of how factors such as membership of LGBTQ+ communities, age, and disabilities intersect with race/ethnicity to magnify inequalities.

Comprehensive, standardised, and evidence-based cultural competency training could enable healthcare professionals to work more effectively and confidently with diverse cultures and experiences. This includes enabling healthcare professionals both to understand how issues like racism detrimentally impact mental wellbeing and equipping them to maximise mental wellbeing and help-seeking for UK-minority people both within and outside the NHS. For example, even though spiritual wellbeing can be crucial for healing and recovery, it is often neglected in mental healthcare. In addition to providing more holistic care, working with faith leaders could help to reduce stigma and promote understanding and timely access to care. Representation of BAME people in key leadership roles in healthcare and policy must also be improved to better inform inclusive mental health provision.

2. Monitoring and evaluation of UK mental health services by regulatory bodies must incorporate assessment of workforce capacity to deliver holistic care and service users’ rating of their experience.

The Care Quality Commission (CQC) and the National Clinical Audit Programme should develop criteria to assess service user satisfaction, safety, and the availability of culturally-sensitive care against benchmarked regulatory standards. Patient satisfaction criteria alongside Workforce Race Equality Standards (WRES) should be used routinely to drive up Equality, Diversity & Inclusion (EDI) standards within services and should be mandatory components of statutory inspection reports and service rating. Clinical Commissioning Groups (CCGs) and Health and Wellbeing Boards should be held accountable for filling gaps in mental health provision for all people thus, ensuring that inequities are eradicated.

3. Mental health services should actively work with service users, their families and community groups such as faith-based organisations at ‘a grassroots level’ to better understand their needs and co-produce solutions.

Collaboration of this kind provides opportunities for bi-directional learning about:

• culturally-based conceptualisations of mental health and how these might inform both hospital and community-based treatments
• developing and evaluating initiatives to dispel stigma about mental health
• more inclusive and novel public health education approaches to, for example, identifying and responding to early warning signs of poor mental wellbeing to facilitate more timely access to care and support

We believe that more effective partnership working will enable a plurality in service provision, which is necessary for optimising patient choice, for example, multiple entry points into specialist NHS mental health services. Meaningful engagement with diverse communities also fosters the potential for co-producing more culturally-informed psychosocial interventions by mobilising ‘citizen scientists’ and providing under-served communities with opportunities to become more actively involved in research.

The impact of housing on health and wellbeing is now widely recognised. Good quality, affordable housing improves personal and social wellbeing, creates sustainable communities that attract investment and jobs, and can reduce our carbon footprint and improve the environment. However, delivering healthy homes still remains a big challenge. It requires urgent action involving all sectors of the built environment, but how can we rise to the challenge and create homes and places where it is possible to live a happy, healthy life?

Housing and health inequalities

The COVID-19 pandemic has exposed how housing inequalities can inhibit the capacity of households to adequately respond to lockdowns and changed patterns of work and leisure. Overcrowded households, defined as having more than one person per room in a household excluding bathrooms and kitchens, is a major factor for the spread of COVID-19. Poor house ventilation, which is a major cause of indoor air pollution and already has a disproportionate impact on low-income houses, is another major factor driving the virus’s spread. The quality of design and the built form as a determinant of health and wellbeing have a lot of potential to improve health and wellbeing if the quality of buildings and open spaces is high. Good housing is key, but the planning for the area must also allow better access to employment, leisure and recreation opportunities to positively impact health and wellbeing.

Unhealthy homes and neighbourhoods

The UK doesn’t have the best track record of high-quality house and neighbourhood design conducive to healthier lifestyles. Far too many new housing developments are car-dependent, lacking sustainable modes of travel or adequate open and recreational space. They are often not walkable and have a poor sense of place, leading to unattractive and unfriendly environments that make it difficult to be physically and socially active, and that don’t support wellbeing and mental health. In fact, the Building Better, Building Beautiful Commission, which advised government on how to promote and increase the use of high-quality design for new build homes and neighbourhoods, found that housing developments of the last century were often less beautiful than that of Georgian, Victorian and Edwardian periods in terms of settlement pattern, place-making, and building design. The National Housing Audit revealed that there are also long-standing inequalities within the housing system, which have led to an uncomfortable trend towards delivering less healthy developments for less affluent communities.

What can housing developers do?

Both developers and local planning authorities need to work together to deliver healthy homes and neighbourhoods for everyone. Developers can incorporate health and wellbeing into housing developments by preventing bad health outcomes such as reducing air pollution, and promoting good health outcomes such as encouraging active travel. By doing so, developers can also contribute to redressing long-standing health inequalities such as increasing accessibility for disabled people. Developers cannot dictate how people should live their lives, but can manipulate the shape of the built environment to remove barriers to healthier lifestyles, discourage unhealthier habits and encourage good behaviour towards happier and healthier lives.

The real estate consultancy Knight Frank found that high-quality housing that promotes health and wellbeing does not necessarily erode returns and, in fact, can provide up to 15% value at the upper end of the market. At the lower end, where financial viability of the project is compromised, long-term investment in the area and close collaboration with local authorities on the matters of planning risk, planning costs, and infrastructure costs can deliver positive public health outcomes. For example, a mixed-use development delivering strong place-making and retail environment can bring huge return on business rate and council tax revenues for the council, which could justify some level of public subsidies to deliver health benefits in challenging locations.

The role of local authorities

However, the onus is on local authorities to set high health and wellbeing aspirations for housing developments. Judging by the most recent large scale housing developments and when the demand for housing remains exceptionally high, developers have very little incentive to promote health with their schemes. The primary concern of most house builders is to deliver profits for their investors. However, local authorities can motivate and inspire developers to work together and create healthier places. For example, local authorities can ask all major developments to demonstrate a health net gain with their development, provided that local evidence substantiates such a requirement. If a development demonstrates health net gain, for example, the local authority can grant an accelerated planning permission, which would lead to huge cost savings and contribute positively to the viability of the proposal. Health net gain can be adaptable to locality and it could refer to any acute local health issues such as respiratory diseases or obesity.

Furthermore, local authorities can set robust design standards, which are now strongly supported by the National Planning Policy Framework, to positively influence design quality. These could include a well-connected network of attractive, safe, convenient transport corridors with separated pedestrian and cycle routes, high-quality open and recreational green spaces, and decent homes built to the highest standards, such as BREEAM of which health and wellbeing are part.

Delivering healthy homes and high-quality neighbourhoods requires a strong steer from local leaders, who are responsible for establishing a unifying vision for their area and helping planning departments and public health teams inside local authorities work together to implement the shared vision. At a minimum, local authorities’ corporate strategies should outline how they address local health and wellbeing needs with the help of their housing strategies.

This article was originally published in Building Utopia, a collection of thought leadership pieces and expert analysis on urban development, published by Policy@Manchester.

In the UK around 50 Sexual Assault Referral Centres (SARCs) provide support for survivors of sexual violence. Largely operated by the NHS, they offer medical, psychological and legal assistance for victims. While centres like these can be excellent at meeting the immediate needs of assault victims, how well equipped they are to deal with the long-term needs of survivors is less known, and are not well recognised in government policy or well documented in recent research.

Between 2019 and 2022, with funding from the Violence and Mental Health Network, we created and piloted a questionnaire designed to learn more about what sexual assault survivors need in the longer-term so that services can be better equipped to deal with them. The self-report questionnaire is accessed online and is designed to be completed at multiple time points – three, six and twelve month intervals following an assault – so that changing needs can be tracked. It asks respondents about the affects they suffer from the assault, what types of support would be helpful to them. It also measures their mental health using widely accepted measures of anxiety, depression and Post Traumatic Stress Disorder (PTSD).

Despite a small sample of 18 respondents, constrained to some degree by the impact of the pandemic, initial results confirm the need for further research and interventions that address sexual assault survivors’ longer term needs. Three months after the assault:

• 13 of the 18 respondents suffered from moderate or severe anxiety, 7 of which suffered from severe anxiety
• 15 suffered from moderate or severe depression
• 7 had both severe anxiety and depression
• 12 had Complex Post Traumatic Stress Disorder (CPTSD), all of whom also had both moderate or severe anxiety and depression

Based on these results, it is unsurprising that, when survivors were asked what support would be ‘essential’ to them, they rated ‘emotional and psychological support’ the highest. Over two thirds said psychological support through counselling was essential and wanted emotional support specifically during the court process. Support in the legal process features routinely in the long-term needs of sexual abuse survivors because court hearings typically take several years.

Another key long-term need is support in stopping further abuse. Half of the sample had been sexually assaulted more than once, and just over a fifth had suffered attacks at least ten times. It is no surprise then that, when asked about the specific effects of the assault, 78 per cent cited frequent fear of being assaulted again. Other commonly cited consequences were ‘anger’ (67 per cent), ‘difficulties with sexual intimacy’ (56 per cent), ‘avoiding travelling alone’ (50 per cent), ‘problems with physical health’ (44 per cent) and ‘avoiding family and friends’ (44 per cent).

The vast majority – 85 percent of the sample – who had accessed support from the Sexual Assault Referral Centre said they were ‘very satisfied’ with the service they received. Assessments of other sources of organisational support were more mixed. Nevertheless, the question remains whether SARCs are well equipped to deal with the ongoing issues that survivors of sexual assault have to contend with, in particular complex psychological ones. There can be no quick fix for victims of sexual abuse who need ongoing support to redress emotional needs that are amplified both by legal processes that rarely secure convictions and by the ongoing threat of repeat victimisation.

While our study gives some insight into the type of long-term support sexual abuse victims need, it also shows just how difficult it is to gather survey data about these needs. The questionnaire we designed is a powerful tool that service providers are welcome to use to assess whether the needs of those they serve are being met. However, recruiting representative samples of sexual assault survivors – a population which is both vulnerable and largely hidden – is incredibly difficult. Considerable care needs to be taken to maximise inclusivity among prospective participants who are often unable to decide whether to engage with research in the aftermath of trauma. Service providers and researchers must work together to overcome these difficulties so that long-term needs can be tracked, and the appropriate support given to those who need it.

Supporting sexual assault survivors

We make the following policy recommendations utilising the responses gathered from our questionnaire.

• The needs of sexual assault survivors are varied and complex. Local Authorities must invest in coordinating the efforts of the various actors involved in meeting those needs. These include health and social care services, the criminal justice system and the Voluntary, Community and Social Enterprise (VCSE) sector. We are delighted to see such an approach adopted in the Greater Manchester Gender Based Violence Strategy.
• Psychological and social support must be provided for survivors before, during, and after the court process, meaning this support could extend for several years.
• Services offering support to survivors must anticipate the ongoing threat of further victimisation client groups face and have strategies in place to maintain contact with those at risk.
• Further research into the long term impact of sexual abuse on victims’ health, wellbeing, and everyday lives must be funded. As our study has shown, conducting research in a sensitive, confidential manner, that respects and protects participants, can only be achieved through sustained collaborations between researchers and those providing frontline services for survivors.

In December 2021, documentary series Panorama broadcast a programme outlining the damaging impact of profit-driven care companies on care provision for older people. This was foreshadowed by academic research 20 years prior which identified an association of poor outcomes with private-sector care. In 2019, data from the Institute for Public Policy Research and Future Care Capital found that 84% of beds in care homes were owned by private companies.

Regulating Profit-Making in Institutional Care

As a consequence of the downward squeeze on local authorities’ revenue spending, these companies have increasingly relied on ‘self-funders’ to remain in business. The profit-driven marketisation of care homes is characterised by the Chair of the Health and Social Care Select Committee, as the “unacceptable face of capitalism”. Since the Panorama broadcast, a number of organisations have called for care to be provided by not-for-profit organisations. The actions of the private sector in health and social care generate concern in light of scandals in private care homes and hospitals such as Cawston Park, which resulted in the deaths of three adults with learning disabilities; Winterbourne View where 11 staff members were convicted of offences of ill-treatment and wilful neglect; and Whorlton Hall, where nine members of staff are due to stand trial in 2023 for ill-treatment and wilful neglect.

Since corporate structures in the care sector are complex and likely to be fragmented, it is increasingly difficult to identify all corporate bodies that derives financial benefit from neglectful or abusive care provision. This poses very significant difficulties for the CQC. It is unable to take enforcement action or investigate multiple providers which are owned by separate legal entities, regardless of whether they are closely connected. Life-altering abuses and neglect are often found at multiple care homes of providers owned by the same company, such as in the case of Operation Jasmine in South-East Wales and Atlas Homes in Devon.

However, financial transparency is not presently required under the CQC’s regulatory scheme, even though immediate implementation of this by the Department of Health and Social Care was strongly advised by the Equality and Human Rights Commission in 2020. Although the CQC has powers to determine the financial efficiency of many NHS Trusts and the financial viability of large, independent sector adult social care providers, its assessments do not currently permit a focus on or consideration of the financial gains secured by providers, their shareholders or their parent companies; or the extent to which companies’ assets and resources are moved beyond UK jurisdictions.

Relatives: The undervalued regulatory agents

The CQC relies on strategies of registration audit, inspection and enforcement of care standards. Those strategies are reliant on the insights and observations of CQC professionals and inspectors. A lay perspective also informs the work of the CQC in the form of recruiting ‘experts by experience’ in inspections, engaging with family members and residents who report poor and insensitive practices, plus opportunistic discussions with residents and their family members as part of the inspection process.

Elsewhere, health and social care policy expressly acknowledges the crucial role of family members in decision-making, for example the Mental Capacity Act Code of Practice and the Care and Support Statutory Guidance. Although families are critical to safeguarding their relatives, they are used to being distanced and ignored by services that are performing poorly, even though their perspectives in care decision-making are foregrounded in the right to respect for private and family life under Article 8 of the European Convention on Human Rights (G v E (By his litigation friend the Official Solicitor), A Local Authority, F [2010] EWHC 621 (Fam); Glass v United Kingdom 61827/00). Without an understanding of people’s lives, services cannot adopt a meaningful life course perspective, since it takes time and trust to gather information about a person’s life. By creating distance between residents and their families, it becomes difficult to truly integrate health and social care with a rounded understanding of the person.

Knowing residents as loved family members, with roles within and outside their families, is critical to the provision of valued care and support. Families have developed skills, expertise and powerful advocacy over time and yet these are rarely perceived as complementing those of professionals, untrained and unsupervised support workers, or even the ‘experts by experience’ commissioned by the CQC. The confident knowledge of families that things are ‘not right’ often begins when placements are being considered, at the outset of these placements and during reviews when marginalisation is commonplace. Families have a deep desire to demonstrate the worth of their relatives to hospital and care home staff and to ensure that they are not harmed.

An agenda for legal and policy reform

Given our research and experience in informing safeguarding adult reviews, we propose that the following have promise:

• There is impetus for an ethically-informed model of care commissioning such as that advocated by Hudson that takes seriously the commitment to service user dignity, sustainability and community benefit.
• Powers of enforcement and sanction are needed against parent companies that are organisationally, legally and functionally distinct from their care providers. Such powers would significantly enhance the CQC’s current regulation of ‘complex providers’.
• There is merit in expanding criminal law to address the most egregious instances of weak corporate governance; an issue which is currently under consideration by the Law Commission.
• The perspectives of relatives on their loved-ones’ experience of poor institutional care require enhanced recognition in policy and legal frameworks. Significantly increased engagement by CQC with relatives is required to ensure institutional compliance with regulatory standards around safety and service user dignity.

With thanks to our academic contributors;

Omer Ali
Dr Omer Ali is a clinical informatics fellow and junior doctor at Lancashire Teaching Hospitals, and a lecturer in public health at The University of Manchester.

Jamal Alston
Jamal Alston is a Research Assistant working at Greater Manchester Mental Health (GMMH) NHS Foundation Trust on the Culturally-adapted Family Intervention (CaFI) study. Jamal has research interests in reducing mental health inequalities through an intersectional approach.

Sheena Cruickshank
Professor Sheena Cruickshank leads The University of Manchester's Public Engagement with Research activities, and lectures in gastrointestinal immunology.

Elizabeth Dalgarno
Dr Elizabeth Dalgarno is Lecturer in Healthcare Sciences and an NIHR Fellow at the Integrated Interdisciplinary Innovations in Healthcare Science Hub at The University of Manchester.

Dawn Edge
Dawn Edge is Professor of Mental Health and Inclusivity at The University of Manchester’s Division of Psychology and Mental Health, and the University's Academic Lead for Equality, Diversity & Inclusion (EDI) with a specific focus on race and students. Her research focuses on improving health outcomes and reducing inequalities in underserved populations. She is Chief Investigator for a £2.5M National Institute of Health Research (NIHR) funded, multisite study to evaluate Culturally-adapted Family Intervention (CaFI) with African and Caribbean people diagnosed with schizophrenia and related psychoses and their families.

David Gadd
David Gadd is Professor of Criminology at the Centre for Criminology and Criminal Justice in The University of Manchester. He is currently working on two major research projects related to modern slavery and domestic violence.

Kirsty Keywood
Dr Kirsty Keywood is a Senior Lecturer in Law and a member of the Centre of Social Ethics and Policy at The University of Manchester. She teaches and researches the law relating to adult safeguarding and has been involved in a number of safeguarding adult review.

Caglar Koksal
Dr Caglar Koksal is a Research Associate and Lecturer in Planning at The University of Manchester. He investigates how health matters can be factored into the complex urban development decision-making process.

Henna Lemetyinen
Dr Henna Lemetyinen is a Research Associate of the Culturally-adapted Family Intervention (CaFI) study. Henna works in the Research & Innovation department at Greater Manchester Mental Health NHS Foundation Trust (GMMH).

Luke Munford
Dr Luke Munford is a Research Fellow in Health Economics at The University of Manchester. His research has focused on applying econometric and statistical methods to existing secondary data to investigate the wider determinants of health and to investigate the consequences of health.

Maria Pampaka
Dr Maria Pampaka is a Senior Lecturer in Social Statistics and in Manchester Institute of Education and is a co-Investigator on the Development of Measures to Assess the Long-Term Support Needs of Adult Sexual Assault Survivors project.

Pamela Qualter
Pamela Qualter is Professor of Psychology for Education at The University of Manchester. Her research explores child and adolescent peer relationships, including their experiences of loneliness and its impact on mental and physical health and social functioning.

Matt Sutton
Matt Sutton is Professor of Health Economics, joint lead of the Health, Organisation & Economics research group and Deputy Director of the NIHR Applied Research Collaboration for Greater Manchester.

Filippo Varese
Dr Filippo Varese is a Clinical Senior Lecturer in Psychology and an NIHR Advanced Fellow at The University of Manchester. He has researched extensively on the topic of trauma and how it impacts mental health.

Arpana Verma
Professor Arpana Verma is Head of the Division of Population Health, Health Services Research and Primary Care. She is Director of Manchester Urban Collaboration on Health (MUCH), a WHO Collaborating Centre, and an honorary Consultant in Public Health at PHE.

Laura Watt
Dr Laura Watt is a Research Associate at The University of Manchester and a sociology lecturer at Manchester Metropolitan University. Her research is focused on intimate relationships, including how attitudes towards them can be measured via social surveys.

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September 2022

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