Chapter Two: Population factors

Some populations are at a higher risk of experiencing poor mental health; of being underserved by mental health services and requiring targeted support to ensure that their needs are met. To identify inequalities in prevalence of mental health problems, access to services and outcomes it can be helpful to look at population sub-groups. The main findings have been summarised as an infographic.

It has five main sections, which cover the following topics:

Each of these topics is covered in the following local data packs: demographics and population groups

The Public Mental Health Implementation Centre of the Royal College of Psychiatrists has produced a free learning module on health inequalities, marginalisation, trauma informed approaches and physical & mental health.  The learning from the module supports this chapter.

Priorities for future work

A key output from this needs assessment was the identification of priorities for future work. These are listed below:


  • Review barriers to accessing services across mental health providers including reviewing the range of digital options available for different services and, information on routes in. Ensure this includes a focus on inequalities for populations that are under represented in their access. Work with local communities to ensure barrier to access for any part of the community are identified and addressed.
  • Did Not Attend (DNA) and no-contact rates for services are an indication of barriers to accessing services. Build a picture of DNA and no–contact rates across services and use quality improvement methodologies to try out interventions to reduce these.  There may be resource implications in the work that is needed to ensure services are equitable and investment needed to improve system efficiencies in the longer term.
  • Map local assets in the community for ethnic minority groups and support building those up
  • How are the needs of ethnically and gender diverse individuals  interpreted by health and mental health care professionals?
  • Promote disaggregation of mental health inequalities beyond broad ethnic categories. Improve detailed data and insights to better recognise, understand and reflect the experiences of different minoritised ethnic groups.
  • What are local waiting times for interpretation services?
  • Explore inequalities in the prevalence of mental health conditions, and in mental health services, for people with physical disabilities.
  • Explore inequalities in the prevalence of mental health conditions, and in mental health services, for people with brain injury.
  • Develop local estimates of SMD at district level
  • Go through with partners whether the system meets the NICE quality standard for Integrated health and social care for people experiencing homelessness
  • Develop understanding of potential mental health inequalities faced by people living in rural areas in Cambridgeshire and Peterborough.
  • Promote and share analysis of Did Not Attend (DNA) rates across services, segmented to highlight inequalities.

Comorbidity and health behaviours

  • Update data on the prevalence of physical and mental health comorbidity in C & P.
  • Do people with SMI who attend physical checks get referred to, and complete, health interventions as a result (such as smoking cessation interventions)? Does attending a physical health check improve health outcomes for people with SMI?
  • Understanding the health needs of people who take antipsychotics but are not eligible for the SMI register
  • Exploring reasons why some people on the SMI register do not receiving health checks
  • Understanding if everyone who is eligible is included in the SMI register; and if not, what the reasons are behind this
  • Map GPs signed up to the active practice charter

Substance use

  • Go through with partners whether the system meets the NICE quality standard for assessment, management and care for people who have coexisting severe mental illness and substance misuse
  • Continue developing local estimates of severe multiple disadvantage, working with local PHI team
  • Investigate shared patient records across agencies for mental health, drugs, alcohol use and contact with primary, secondary care and police services. Look at possibility within the Shared Care record programme.
  • Exploring the elements of the Stepped Care Community Mental Health programme and ensure they are replicated in the roll out across the county.
  • Build understanding/relationships between CGL and mental health services (e.g. workshops), including with core CPFT services like adult locality teams.
  • Exploring the potential for ‘joined-up’ commissioning between substance use and mental health services.
  • Developing systematic training on co-occurring conditions for staff in CGL, primary care and CPFT.
  • Investigating follow-up support for people with co-occurring conditions who present in crisis
  • Use the CPFT data warehouse to estimate levels of drug and alcohol use amongst people using mental health services