Mental health needs a lifeline

In September last year 200 delegates huddled together in a
crowded University of Manchester conference centre. They had been
told that one of the explicit aims of the conference was to
kick-start the creation of an ethnic minority mental health network
which could be a powerful voice in mental health reform. Today,
this embryonic network includes academics, service users,
front-line workers, voluntary organisations and NHS
practitioners.

The network’s genesis could not have come at a more critical time.
Mental health is in crisis and needs a lifeline. Not enough money,
not enough nurses, not enough psychiatrists, not enough social
workers, not enough of a priority. For the ethnic minority
community this has meant deaths in custody, high suicide rates,
inappropriately high doses of medication and polypharmacy – using
many medicines for the same disease.

In December, chief executive of the Commission for Health
Improvement Jocelyn Evans described mental health as “the poor
relation of the NHS” with mental health services being
“particularly poor at meeting the needs of black and ethnic
minority service users”. So what can a voluntary sector network
hope to achieve?

The ethnic minority voluntary sector has long been a mainstay of
the UK mental health system. Perhaps this is because it continues
to retain the trust and respect of service users. Voluntary
organisations often play an intermediary role between users of
mental health services and services themselves. They work as
advocates and legal advisers, as well as providing drop-ins,
assertive outreach and crisis intervention. Could a network use
this experience to shape the government’s plans for mental health
services? And is this something that ethnic minority service users
even want?

Delivering Race Equality¹ is the most recent
strategy, or draft framework as the government prefers to describe
it, to be touted as vanquisher of the many-headed hydra of inequity
in the mental health system. The National Institute for Mental
Health in England’s national strategic director, Kamlesh Patel,
believes the programme for change is unique and unprecedented in
the NHS in its focus on race.

Initial responses from the voluntary sector to the framework were
robust. Though welcoming key aspects, such as the emphasis on
suicide prevention and acute care, they considered that a strategy
was needed to tackle the structural inequalities within mental
health services through clearly specified targets, objectives,
rigorous monitoring and lines of accountability. A view was also
expressed for a greater emphasis on staff training, which would tie
into proposals in the framework around management and governance.
Many also felt there should be a greater emphasis on service users
and assessments.

However, it’s not all doom and gloom. There are progressive
elements, such as acknowledgement of the different ways in which
organisational cultures interact with the cultures of people who
use services. The consultation also indicates that the development
of staff from ethnic minorities is critical to enabling services to
meet the needs of patients from minorities. Overall, it is a
considered approach which recognises the need for a systematic
plan. So why are some still sceptical?

The question we must ask here is whether this will lead to a
sustainable transformation of mental health services for ethnic
minority communities. To which the answer must be, with the
framework in its current form, a qualified but clear “no”. But this
is not necessarily the disaster it seems, as we are still at the
consultation stage.

Does that mean that this framework merely reflects wider systemic
problems of poor funding? Probably, although in doing so it lets
the statutory sector off the hook. Responsibility for delivering
change is disproportionately placed on the voluntary and community
sector and communities themselves. A case of too much “outside”,
not enough “inside”. It allows mental health trusts to claim they
are fulfilling the requirements of the framework by doing two
things: gathering information on ethnicity and training staff in
the requirements of the Race Relations Amendment Act 2000. By
imposing so much of the responsibility for delivery on the
voluntary and community sector, the framework entices its readers
to believe the age-old fallacy that the problem is not with
services, but with the community.

The framework does not answer other, critical questions. How will
we address the continuing imbalance of power which exists between
patients and practitioners? How do we get money into mental health
and make sure it is spent there? How can we help statutory sector
services learn to work in partnership with, and respect the efforts
of, their voluntary and community sector counterparts? How can
statutory services regain the trust of the ethnic minority
community? Essentially, we are asking how transformational change
can be initiated and sustained in routine practice.

Mind believes that the solution lies in taking a more direct
approach, where the service user experience is central. This
involves staff, service users and management across the spectrum of
care, working with all mental health care professionals. Service
users must be involved in the planning and implementation of
services.

We need to ensure that the undergraduate, pre-registration,
post-registration and post-qualification stages of mental health
workers’ training routinely takes a self-aware, critical approach.
This should incorporate an understanding of:

• Critical approaches to psychiatric assessment and
  treatment.
• The history of the involvement of people from ethnic minorities
  with the psychiatric system and their over-representation in secure
  settings.
• The often coercive nature of ethnic minority people’s paths
  into care.
• Users’ personal preferences on how they could deal with their
  mental health issues.

The success of this work will depend on the ability of the
statutory sector, the voluntary sector and communities to forge a
lasting and trusting relationship. Mental health services will not
be transformed on a shoestring.

What must be realised is that, although the costs of the required
changes are significant, these are far less than the long-term
costs associated with piecemeal changes which lead to shattered
lives.

The painful truth about mental health services is that these costs
are being borne now, not by the state, but by communities and
service users, by virtue of their ethnicity, through destructive
experiences.

Mind’s proposals   

• Staff in the system must recognise this as a time of dramatic
  change. 
• Funding for community development workers must be ring-fenced
  within primary care trusts. 
• The work must involve rural, Irish and traveller
  communities. 
• One of the pilots for the scheme should include a high secure
  setting.

New approaches

Recent strategies from the National Institute for Mental Health
in England include Inside/Outside² 

This report advocated a three-part approach: 

• Reducing and eliminating ethnic inequalities in mental health
  service experience and outcome. 
• Developing the workforce. 
• Engaging the community. Delivering Race Equality 

This report details methods such as:  

• Better quality, more intelligently used information. 
• Appropriate and responsive services. 
• Increased community involvement.    

Shahid Sardar is editor of Diverse Minds, the
magazine of mental health charity Mind.

References  

¹ National Institute for
Mental Health in England, Delivering Race Equality, a
Framework for Action from
www.nimhe.org.uk 

² National Institute for
Mental Health in England, Inside/Outside: Improving Mental
Health Services for Black and Minority Ethnic Communities in
England, DoH, 2003, from
www.nimhe.org.uk