Response by the INForMHAA research project (https://sites.manchester.ac.uk/informhaa/) to the DHSC Call for Evidence: Mental health and wellbeing plan (https://www.gov.uk/government/consultations/mental-health-and-wellbeing-plan-discussion-paper-and-call-for-evidence)

The following responses were submitted by the INForMHAA research project from the perspective of the research project, not that of any individual members of the research group. This response is in line with the research project’s Knowledge Exchange, Information and Engagement plan which includes a commitment to contribute emerging evidence to policy and practice.

Promoting positive wellbeing

How can we support people that are more likely to experience poor wellbeing to improve their own wellbeing?

I am answering on behalf of the INForMHAA research project – a study funded by NIHR SSCR investigating the impact of interpreter mediation within formal Mental Health Act assessments. The group we wish to draw attention to is those who use a spoken language other than English or those who use a signed language – in this case BSL (British Sign Language). Minority ethnic groups and other groups that use a language different to that predominantly used to that of the host society are more likely to suffer poor physical and mental health outcomes which entails a degree of poor wellbeing – This might due to a situation of double vulnerability: social exclusion risk aggravated by language difference and poor wellbeing. We state that opportunities to access information and support if someone is not a fluent spoken English user are far reduced but moreover, additional complexities arise from needing more specialised interpreted interaction (rather than fixed written translations and also with a setting-specific focus) in order to receive information, understand potential actions to support wellbeing and contribute to such dialogue, social activity or other forms of support. Participation in activities to improve wellbeing are more limited for those who cannot access such activities directly in their own language. Same language support groups are much rarer and generally under-funded. Patient activation to self-manage and contribute to self-care and recovery are also more limited with limited access to information in a preferred language. Availability of interpreter mediated support to a professional standard might also be limited. Finally, the impact on equitable mental health assessment at time of crisis (which is the main focus of our work) is little understood and best practice guidance, training and resources for all parties is missing. Our current work is rectifying this.


How can we improve the wellbeing of people that are more likely to experience poor wellbeing?

Access to information routinely in languages other than English and in media other than the written word. e.g. spoken recording/video for those with limited literacy or who prefer to learn by listening rather than reading. Information on video in BSL which is a language with no written form. Funding for support and participation in activities to support wellbeing that are provided in community languages and BSL. Effective means of feedback to services of those who wish to do so in languages other than English or the written word (in any language). Funding for interpreter-mediated access and support for opportunities available through social prescribing (e.g. access to work funding for those who use BSL cannot be used for activities to support wellbeing that are socially prescribed) The development and support of community-led initiatives amongst community language groups in own language. Too much emphasis is being given to culturally matched activities and support without due attention to linguistically matched activity and support. Cultural diversity and language diversity are not synonymous. Attention to cultural needs is not in all cases attention to linguistic requirements.


How can we support different sectors within local areas to work together, and with people within their local communities, to improve the populations wellbeing?

Our research project is producing training guidelines and video resources to support professionals, service users and carers involved in interpreter-mediated interactions (in this case Mental Health Act Assessments) and making them freely available. We appreciate this is not the main focus of this consultation, which is not primarily about the assessment and treatment of severe mental illness. However, the principle of improving health and therefore wellbeing outcomes is transferrable. Interpreters do not in of themselves solve problems of interaction and understanding. All participants need to know how to work effectively with an interpreter in whatever roles and services they provide or use as a service user and carer. Specific funding and training should be available to improve uptake and effectiveness for those involved in any form of interpreter-mediated interaction associated with mental health and mental wellbeing.

Preventing the onset of mental ill-health

Please select the groups that you have suggestions for (you may choose more than 1 option)

People that are more likely to experience mental ill-health

What is the most important thing we need to address in order to reduce the number of people that are more likely to experience mental ill-health?

Effective information, service provision, recovery evaluation and ongoing support easily available in languages other than spoken English and where this cannot be managed directly in a common language, then effective, high quality and regulated interpreter provision that is paid for and is reliable and cost effective. Just because interpreter provision might be a reasonable adjustment or mandated legally does not mean it is always provided nor that it is effective. It is certainly not regulated currently within mental health services in the same way as other professional services are. This consultation in discussing equity and vulnerability does not mention linguistic diversity at all. We repeat, linguistic diversity is not synonymous with paying attention to cultural diversity.


Do you have ideas for how employers can support and protect the mental health of their employees?



Please select the groups that you have suggestions for (you may choose more than 1 option)

People that are at greater risk of suicide


What is the most important thing we need to address in order to reduce the number of people that are at greater risk die by suicide?

Comprehensive assessment in the person’s chosen (or only) language and if this requires the use of an interpreter, that the interpreter is specifically qualified to work with serious mental health conditions and that all professionals involved have undergone comprehensive training in how to work with an interpreter – whether a signed or spoken language interpreter. That such linguistically accessible assessment is available swiftly. Face to face interpretation in person is usually the most desirable form in situations of extreme distress (rather than telephone or online interpreting).That any tools that are used are validated within the language in which they are used, not just ad hoc translated at the time. This requires investment but more importantly it requires a fundamental recognition by service providers that there is nothing straightforward or easy about effective co-working with an interpreter and just because someone is registered with an interpreting agency does not mean they are qualified to undertake such serious mental health work nor that they are supervised. At present only voluntary regulation is in place for interpreter services across all service sectors. People at a time of crisis deserve the very best opportunity for their needs to be recognised, assessed and preventative services delivered. In health and social care services, as in other services, this requires a national regulator for interpreters There is no national regulator for interpreters working in the health services or social care services. A central point is that failure to provide access to communication in a person’s own language is discrimination on the grounds of origin-language and contrary to the Equality Act 2010. 

Intervening earlier when people need support with their mental health

Where would you prefer to get early support for your mental health if you were struggling?

Voluntary and community sector, Workplace, Digital based support or advice, Private sector for example by paying for counselling


Please select the groups that you have suggestions for (you may choose more than 1 option)

Groups who face additional barriers to accessing support for their mental health


What more can the NHS do to help groups who face additional barriers to accessing support for their mental health?

Targeted investment in IAPT in languages other spoken English rather than assuming an interpreter mediated course of support is equivalent enough. Information that is in a form that is not reliant on literacy in the written word through video, audio for spoken languages and BSL for signed language. Funding for a course for interpreters, whether signed or spoken, who support those with mental health needs at whatever stage of the journey/degree of seriousness that provides a means of certification that they are especially trained in mental health. Widening of access to interpreters, whether spoken or signed, for people seeking support, participation, activities and involvement that may be socially prescribed.


Do you have any suggestions for how the whole of society (beyond the NHS) can better identify and respond to signs of mental ill-health?



How can we ensure that people with wider health problems get appropriate mental health support at an early stage if they are struggling?

For anyone accessing health services through an interpreter, there may be limits experienced in what is possible to bring up in the conversation or add to an assessment because interpreter-mediation to a large extent formalises an interaction and can limit it. Greater awareness by health and mental health practitioners of this effect should be encouraged so that a more deliberate approach may be taken to exploring mental health related concerns when exploring health problems more widely.

Improving the quality and effectiveness of treatment for mental health conditions

Please select the groups that you have suggestions for (you may choose more than 1 option)

Groups who report worse experiences and outcomes from NHS mental health services


What needs to happen to ensure the best care and treatment is more widely available within the NHS for groups who report worse experiences and outcomes from NHS mental health services?

More treatment available directly in languages other than English that is not reliant on interpreter mediation. This refers to spoken and signed languages. Where treatment uses an interpreter: specifically qualified and certified mental health interpreters should be available. This requires specialist courses that are built on evidence from projects such as the current INForMHAA project (funded by NIHR SSCR). Where treatment uses an interpreter: specific training for health and social care professionals on how to work effectively with interpreters. This is not self-evident and as a result patients receive a non-equitable service of poorer quality in many cases. Greater investment in multi-lingual research in mental health from a service user/carer point of view as well as a practitioner and interpreter perspective. Take seriously the fact that treatment in a language other than your own is a fundamental issue of equality and ensuring that the course and availability of that treatment is equitable with others treated directly in their own first language. Better consultation with PPIE and other patient/SUC groups where there is a significant number of members who are not first language English users.  These ‘voices’ are not well heard. Greater efforts to work in partnership with specific grassroots groups to ensure information on available services is made available in the most relevant group languages.


What is the NHS currently doing well and should continue doing, in order to support people struggling with their mental health?

Investing in research for better practice through NIHR. Seeking to change to become more responsive to the linguistic diversity of the country, not just the cultural diversity. There is a long road still to travel on this one but the first steps are clearly being made.


Please select the groups that you have suggestions for (you may choose more than 1 option)

Those who have worse experiences in NHS mental health services and or often do not experience good outcomes


Please suggest priorities for future research, innovation and data improvements in relation to people who have worse experience in NHS services, and or often do not experience good outcomes.

NHS digital minimum data set currently does not require that the language of a MHA assessment is uploaded nor details of whether an interpreter is used within that assessment (even if it might be documented on a local/regional/service level). Consequently, central data do not record or report linguistic diversity in MHA Assessments therefore there is no evidence base to improve practice. Cultural/ethnic group/heritage is recorded – why is language not? The welcome reforms to the Mental Health Act have quite rightly paid attention to the disproportionate outcomes/detentions experienced by some cultural groups. Almost no attention whatsoever has been paid to potential inequalities in outcomes concerning those who undergo assessment with an interpreter. The INForMHAA project (NIHR SSCR funded) on whose behalf this contribution to the consultation is being made is seeking to provide the first evidence base on that. Much more research is needed to understand this issue and to fund translational research that makes a real difference in practice for this overlooked group. Such research requires cross disciplinary experience in social work and interpreting/translation as our project has done.


What should inpatient mental healthcare look like in 10 years’ time?

Freely available, high quality, well trained health/social care professionals and psychologically minded and specifically trained interpreters who work comfortably and effectively together and can be relied upon for service users and carers who require them. Service users, patients, carers and members of the public experience a linguistically accessible mental health care provision without being regarded as exceptions to normal practice and provision.


What needs to change in order to realise that vision?

Greater investment in research on interpreter mediated professional practice in mental health care that translates into improved practice outcomes. Formal regulation of interpreting in mental health care to ensure quality and safeguard all who are involved. Mandatory and regular professional training on how to work effectively with an interpreter. Greater involvement of service users and carers from a wide diversity of language backgrounds able to contribute effectively to mental health care reform. For the NHS and social care providers to stop behaving like the world is monolingual and include diverse linguistic access as standard in whatever component of mental health prevention, information, support, treatment and care.

Supporting people living with mental health conditions to live well

Please select the groups that you have suggestions for (you may choose more than 1 option)

Working age adults


What do we (as a society) need to do or change to improve the lives of working age adults who live with a mental health condition?

Given we are answering from within our research project perspective, we are repeating the same issues – to ensure easy linguistic diversity of access as standard at whatever stage of mental health provision.


What more can we do to improve the physical health of people living with mental health conditions?

This is not a focus of the research project perspective from which we are responding to this consultation.


Please select the groups that you have suggestions for (you may choose more than 1 option)

Groups who face additional barriers to accessing support


How can we support sectors to work together to improve the quality of life of groups who face additional barriers living with mental health conditions?

Provide funding to voluntary and third sector groups to fund interpreting provision where required to ensure that groups are accessible to a wide diversity of language users. Currently groups either suggest that service users/carers bring their own interpreter and fund it (mostly impossible) or say they cannot afford to fund interpreting provision (understandable but not acceptable). Provide more funding to language-based groups that unite individuals who share a common language alongside mental health difficulties to participate in support without the assistance of interpreter provision. Ensure that training is provided to professionals to qualify in service delivery/treatment in their own language even if that is initially expensive for trainers rather than just default service provision to the same providers plus an interpreter. BSL IAPT is a good example of this and the associated NIHR funded study of effectiveness. There is a massive difference between experiencing support and treatment directly in your own language and experiencing it through an interpreter.


What can we change at a system level to ensure that individuals with co-occurring mental health and drug and alcohol issues encounter ‘no wrong door’ in their access to all relevant treatment and support?

no comment

Improving support for people in crisis

Please select the groups that you have suggestions for (you may choose more than 1 option)

Groups who face additional barriers to accessing support


How can we improve the immediate help available for groups who face additional barriers in crisis?

We are commenting from the perspective of the INForMHAA research project (NIHR, SSCR funded). Better joint training between AMHPs and interpreters to deliver effective MHA assessments derived from an evidence base. Our project is the first to start to develop this specific evidence base with the support of service users and carers who have experience of assessment with an interpreter as well as AMHP and interpreter trainers (both signed and spoken languages).


Please select the groups that you have suggestions for (you may choose more than 1 option)

Groups who face additional barriers to accessing support


How can we improve the support available for groups who face additional barriers after they experience a mental health crisis?

For those detained under the MHA, better access to information and support to understand their rights in their own language. Continuity of interpreting provision and interpreters during detention who are well trained in mental health and the training of professionals in how to work effectively with interpreters. There remains a persistent belief that no such specialist training is required.


What would enable local services to work together better to improve support for people during and after an experience of mental health crisis?

For those who do not use spoken English, continuity and availability of high quality interpreting provision.

Next steps and implementation

What do you think are the most important issues that a new, 10-year national mental health plan needs to address?

Early intervention and service access, Treatment quality and safety, Crisis care and support


Please explain your choices

As we have done throughout our contribution, we would like to emphasise the significance of availability of support to those who use a language other than spoken English, preferably within own language but if interpreters are required that these are highly trained and those who work with them are also trained in how effectively to work with interpreters. There is an invisibility throughout mental health services and also the current reforms and documentation surrounding them, to the significant barriers faced by those who are not fluent English users or who require interpreters to access services. The current and correct focus on cultural diversity and awareness is in fact covering this up because people erroneously assume that cultural sensitivity will include where required linguistic sensitivity and provision. This is just not the case. A glance at this document introducing the 10 year plan and the documents surrounding the reforms to the MHA demonstrate this clearly.


What ‘values’ or ‘principles’ should underpin the plan as a whole?

Equality of access and provision regardless of preferred language use.


How can we support local systems to develop and implement effective mental health plans for their local populations?

A mapping of the linguistic diversity of a locality and taking this seriously within resource allocation would be an essential component.  An audit of staff language skills and professional qualifications undertaken in a language other than English.


How can we improve data collection and sharing to help plan, implement and monitor improvements to mental health and wellbeing?

Put preferred and chosen language use in everything and record it always. Put interpreter provision required and provided in all data requirements. This should be as routine as asking about gender and ethnicity. Until it is, the true picture of the requirements and resources needed will not be known. Ensure parity between spoken languages and British Sign Language within this data recording.