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A new report finds that mental health services for people from ethnic minorities are not meeting targets set out in the National Service Framework. Derren Hayes reports.

Mental health services have had their share of political attention over the past five years. The government has published no less than six policy papers since 1998 on how health and social services should be working with adults with mental health problems.

The most significant was the National Service Framework for Mental Health in 1999, which set out how high-quality mental health services should be developed and delivered. One of its key themes was for services to be non-discriminatory and to focus on the needs of ethnic minorities.

Despite this, a recent report by the Social Services Inspectorate, based on a study of 19 councils between June 2000 and September 2001, shows that mental health services across many areas of the country are still poor.

The report finds that although some of the targets set out in the NSF are being achieved, services are poorly co-ordinated and not well publicised, managed or delivered. Also they are not focused enough on rehabilitation and joint working across health and social services is not happening.

One of its most significant findings is that mental health services for ethnic minorities are not improving quickly enough. It says mental health services do not understand the needs of different communities, do not engage them enough in service co-ordination and provision, and that there is an over-reliance on voluntary and independent service providers.

The importance of this issue is made even clearer in the light of the large number of people from ethnic minorities, particularly African-Caribbean men, who are diagnosed with mental health problems. In England, several studies have shown that African-Caribbean people are between five and 10 times more likely to be diagnosed with schizophrenia than the national average.

The report says that in some councils corporate targets on race are reflected in social services plans but are rarely seen in mental health services plans.

Claire Felix, services development manager for Rethink, formerly the National Schizophrenia Fellowship, says it is taking time for the two sectors to formalise joined-up strategic thinking.

She believes that a national mental health strategy, along with national targets and penalties for not meeting them, would help to formalise what services need to achieve.

Compulsory training in race-equality issues from the top down would also enable the statutory sector to gain the knowledge and skills needed to make services more responsive, she adds.

More support networks, developing a diverse workforce, and better monitoring of services, treatment pathways and the needs of clients would also help.

"Change needs to happen so that councils' cultural competences are developed," Felix says. "The voluntary sector and local authorities should come together, and service users need to be encouraged to be involved in the shaping of services."

Errol Francis, programme director of the Frantz Fanon Centre, part of Birmingham Mental Health Trust, believes the problem lies with service guidelines being too vague.

"Managers of services need a clear message of what it is they must change and what defines a good service," he explains. "We need to have more detail of what goes wrong when services are below par."

The report says that mental health strategies lack understanding of the demographic population they serve, the way different cultures regard mental illness and how services should respond to this.

Francis believes this doesn't go far enough. He says that monitoring of diagnoses, treatments and outcomes of users of mental health services, aligned with national benchmarks based on percentages of population, need to be introduced.

This lack of understanding, combined with a health system that he believes is institutionally racist, is the major cause of the difficulties ethnic minorities face with mental health services.

This isn't down to cultural differences," Francis argues. "There's some type of stereotyping that has crept into the assessment process."

The report finds that specialist services have been developed in most local authorities, but that the majority of these are being done by small, independent and voluntary organisations.

Ratna Dutt, director of the race equality body REU, says these services - many of which are developed by local communities and ethnic minority front-line staff - are more attractive to users than services provided by the statutory sector.

"t's a service that many feel more comfortable with because they see people who come from their own background, who they can share experiences with and who understand them better," she says.

Dutt adds that, in areas with large ethnic minorities, local authorities should be looking to work with the independent sector to bring those services into the mainstream.

A survey of ethnic minority users of mental health services by the Mental Health Foundation that is not yet published also finds that the voluntary sector scores highly with this group.

The findings of the study will be revealed in a MHF report due out later this year, which will also make recommendations on how statutory bodies can learn from the voluntary sector to make services more responsive

However, the SSI report says the success of the independent sector has created a "reliance" on these organisations, many of which lack resources and support, and that there is a tendency to refer patients to them based on ethnicity rather than need.

While much can be learned from the experience of the independent sector, Kiran Juttla, Diverse Minds development manager at mental health charity Mind, says ethnic sensitivity alone will not change practice.

"Outreach teams must ensure they have the right staff balance in terms of ethnicity, skills, experience and knowledge, and that they recruit staff with a track record of positive work with ethnic minority mental health service users," she says.

This is another criticism the report makes, which is because of the absence of workforce profiling across the whole health and social services. In addition, anti-discriminatory and equal opportunities training, while being offered by many local authorities, is still not mandatory and is taken up by less than a third of staff.

Dutt says all this information points to a need to break down what a "culturally competent" workforce actually means. "Just because I have information about somebody's culture doesn't make me culturally competent," she warns. "It's about how you use that information to inform your practice."

'Modernising Mental Health Services: An Inspection of Mental Health Services' from

www.doh.gov.uk/ssi/modernisingmhs.htm

Case Study - ENFIELD

In Enfield, voluntary organisation the Ebony People's Association supports African-Caribbean service users, carers and families, and promotes a better understanding of mental health issues in the community. The project is part funded from Enfield social services mental health grant allocation and by Enfield Primary Care Trust. Steve Tall, the borough's joint commissioning manager for mental health, explains: "The organisation is represented on our major planning and development forum and on our Mental Health NSF team. We involve them in key discussions as we work towards social inclusion, but we still have some way to go."

In 2000, the council organised a training event for social and health workers in Enfield. "It raised awareness, educated and provided information about ethnic minority groups and their mental health needs. It can be very challenging for social workers to work in that environment, and they were able to discuss and learn from their experiences."

Case Study - LEEDS

Leeds Community and Mental Health Trust is highlighted as achieving best practice in community profiling. Julie Sutton, carer development worker for ethnic minority communities, says of its community involvement work: "Our aim is to develop a culturally sensitive service for carers of people with mental health problems. I spent three months in consultation with carers about what their needs and those of the community were. I found that a lot of carers weren't accessing services and weren't meeting other carers in a similar role.

"The consultations were a way of giving them a voice and will enable us to provide culturally sensitive care packages for carers and those they care for. They felt that because of the system and racism they had lost their voice and this was a way of making them heard."

Sutton has set up the black and ethnic minority advisory group to support her in her work. The group consists of carers, statutory organisations and voluntary organisations, and ensures that projects are appropriate and people with all type of experiences and skills are involved in their development.