Exclusive: Mental health ‘tsar’ admits services suffer from institutional racism

It is almost five years since David Bennett died after being
restrained by staff in a psychiatric unit in Norwich. The final
evidence session of the inquiry into his care and treatment is due
to take place at the end of the month.

Bennett, a 38-year-old African Caribbean, died in The Norvic
Clinic, a medium secure unit, at the end of October 1998. At the
inquest into his death, the coroner found that the cause was
“accidental death, aggravated by neglect”.

Following this, an independent inquiry was set up under health
service guidelines to look at the circumstances surrounding
Bennett’s death and to examine mental health services generally.

Bennett was by no means the first black person in psychiatric care
to die in such a way. Mental health charity Mind believes that at
least 27 have done so since 1980. However, as it stands, there is
no central database that records serious incidents or deaths.

Consultant psychiatrist Sashi Sashidharan is the medical director
of Birmingham and Solihull Mental Health NHS Trust and a member of
the inquiry panel. He is also the author of Inside Outside, a
report on mental health services for people from ethnic minorities
published earlier this year (news, page 6, 13 March). He describes
mental health services for people from ethnic minorities as
“absolutely appalling”.

“There is no aspect of mental health services in this country in
which people from ethnic minority backgrounds do as well as white
people or better,” he says. “Not only are the inequalities
persisting, but all the evidence shows that they are getting
worse.”

And problems run right through the system, says Sashidharan. Not
only is access to services problematic, with GPs failing to help
black people as effectively as they do white people, but once they
have navigated the “tortuous routes” to specialist services they
are often subject to misdiagnosis, poorer standards of hospital
care and higher levels of discrimination. Furthermore, once they
are discharged into the community, their follow-up care is often
inappropriate, with many ending up with a “medication supervision
service” rather than a more holistic care package.

But these problems are neither new nor unrecognised. Sashidharan
says there is 50 years of evidence from research studies, patients,
and people within the system.

“It’s a scandal as far as I’m concerned. We collectively –
psychiatrists, clinicians, nurses, doctors, social workers and,
more importantly, policy makers and government – have got so used
to it we do nothing about it. There’s a sense of inaction not
because we don’t know what to do but almost because we are prepared
to tolerate this,” he says.

During the Bennett inquiry, Anthony Sheehan, the chief executive of
the National Institute for Mental Health in England (Nimhe),
admitted that parts of the NHS were institutionally racist, and
promised “a strong and visible black presence” within Nimhe.

Mental health “tsar” Louis Appleby told Community Care that he
agreed institutional racism was present within mental health
services “as long as what is meant by that is that the service
doesn’t operate equally to the benefit of all ethnic groups, so
some people are disadvantaged by the way the system works”.

However, he does not think there is “overt and deliberate racism”
within mental health services.

“The problem is how the system works, and whether we can put our
hand on our heart and say we provide care that is equally
appropriate for all ethnic, cultural and religious groups, and I
don’t think we can sensibly say that we do,” he confesses.

Appleby says that, after admitting this on television, he received
more mail than in relation to any other issue. Most of it came from
people pleased about his openness towards the problem, but two
clinicians wrote that what he had said was disgraceful, and gave
the impression that nobody cared about the issue.

Several things need to happen in order to improve services for
people from ethnic minorities, says Appleby. With evidence
indicating that people from ethnic minorities prefer to be treated
at home rather than in hospital, he says that services need to be
less conventional. More support should be given to the voluntary
sector, which he says has performed better than the statutory
sector on this issue and deserves proper status “so it’s not seen
as providing an alternative”. In addition, trusts should have
someone on their boards who can represent ethnic minority views, he
says.

One way to ensure trusts take the necessary steps would be to
include ethnicity in their assessment criteria. Appleby admits
that, at the moment, there is not an adequate performance indicator
on the subject. He explains that one had been wanted this year but
the information systems were not suitable. Instead, it was made a
requirement for trusts to record patient information, which they
will be assessed on in this year’s star ratings. A better ethnicity
indicator will be introduced, he promises, but doing so “takes a
frustrating amount of time”.

“My guess is that it might be another two years before we’ve got a
pure ethnicity indicator. That’s because a lot of the indicators
that will be judged next year are already planned,” he
explains.

A possible contender is an indicator based on the number of people
from ethnic minorities detained under the Mental Health Act 1983,
but there are worries that this could create “a perverse incentive”
not to use the act when necessary, such as where someone is at risk
of suicide.

Control and restraint have been key topics during the Bennett
inquiry, given the circumstances in which Bennett died. The Mental
Health Act Commission told the inquiry that, around the time that
Bennett died, control and restraint may have been a factor in the
deaths of 22 detained patients. After this, the number of deaths
rose to 24 in 2000 before falling to 10 in 2001 and seven in 2002.
Appleby says that national guidance and training are needed, and
says that the National Institute for Clinical Excellence is
preparing guidance on the management of violence.

He says that, throughout his professional life, it has been clear
that there have been problems in providing satisfactory mental
health care for people from ethnic minorities. Little progress in
addressing the issue has been made because the NHS has not
responded appropriately, he says, with mental health failing to
reach the top of the priority list.

But Sashidharan takes a stronger view of why there has been so
little progress. “The Department of Health and the NHS are
paralysed in relation to race and ethnicity,” he says. “Whatever
might be the recommendations arising out of major events or
investigations, institutions that have no commitment to challenging
and eradicating ethnic inequalities will not be able to implement
them.”

The report resulting from the David Bennett inquiry is expected
towards the end of the year, and the government has a duty to
respond.

“Why will it happen differently this time? Because we won’t allow
it to drift this time,” says Appleby. He is aware that his personal
reputation is at stake should mental health services for people
from ethnic minorities fail to improve.

“It goes beyond being a health issue. It’s a social and moral
issue,” Appleby says. “There probably isn’t a single area of mental
health that is more important to get right. There will come a time
when I will hang up my Department of Health boots, and I want to be
able to say several important things have changed as a result of my
time in the DoH. And one of them has got to be this.”