Count Me In: Racial inequalities in mental health services

The latest Count Me In survey shows that efforts to reduce the number of people from ethnic minorities in the mental health system are failing. Jeremy Dunning reviews the findings while Patrick Vernon and Steve Shrubb debate the way forward

Government targets to reduce the over-representation of people from ethnic minorities in mental health in-patient services are on course to fail, writes Jeremy Dunning. The Care Quality Commission’s Count Me In survey found 22% of the 30,500 people receiving in-patient care in England and Wales on 31 March last year were from ethnic minorities.

This is above the 20% admission rate in the first such survey in 2005.

Based on the 2001 UK Census, ethnic minorities form just 9% of the UK population. Count Me In was introduced to measure progress against targets to reduce disproportionate rates of in-patient admission and detention over the five-year Delivering Race Equality plan, also launched in 2005.

The CQC concluded that these targets were not being met, but emphasised that this did not mean that services were failing ethnic minority patients. It was a conclusion that echoed a review of Delivering Race Equality by its lead, Melba Wilson, which was published in December 2009.

“It is clear that admission and ­detention rates are not good indicators of quality in mental health services,” said Wilson. This is because the factors that cause mental ill-health are present more often in ethnic minority groups, leading to the higher rates.

Wilson and the CQC said reducing rates of admission and detention would only be achieved by tackling causal factors such as poverty and deprivation, a job for mental health services working in partnership with other agencies. This is the thinking behind the government’s vision for the future of mental health, New Horizons, which the CQC said had the potential to reduce the burden of mental illness and the need for secondary care services among ethnic minorities.

Wilson’s report emphasised that Delivering Race Equality had been successful in helping to make services more responsive to people from ethnic minorities and in raising awareness among commissioners of the need to tackle inequalities.

But Wilson said PCTs and providers needed to do more to take account of the particular needs of different ethnic groups, and variations in need between them.

Patrick Vernon, chief executive, Afiya Trust

The 2009 Count Me In Survey paints a bleak and depressing picture, and highlights how the Delivering Race Equality programme has not made a significant difference in reducing mental health inequalities.

Although there has been massive investment in mental health service provision and other programmes that contribute to tackling health inequalities – adult social care, housing, employment and regeneration – the lot of ethnic minority communities regarding mental health inequalities has not changed in real terms in the past 30 years.

I can remember Paul Boateng, then minister responsible for mental health, telling mental health trust chief executives that “heads would roll” if there was not a reversal in black over-representation in the mental health system. That was in 1998.

Several reasons have been posited for these ongoing inequalities, ranging from cultural behaviours and the impact of migration to social deprivation and exclusion.

However, mainstream researchers and policymakers fail to acknowledge the growing evidence and “real time” experiences showing how racism, racist victimisation and discrimination can affect the health and well-being of individuals and communities.

Everyday racism, fear of racial discrimination and lack of information about services are among the reasons people fail to access services when they need them most.

It is this situation that needs changing if people from minority ethnic communities are to have equal and equitable access to health and social care.

When the Department of Health’s national director for mental health, Prof Louis Appleby, says institutional racism is not a helpful term to apply to mental health issues, as he did in a recent interview, you can see why Delivering Race Equality has failed and that New Horizons will not deliver for ethnic minority communities in its current guise.

The CQC’s recommendations on the back of the Count Me In survey also miss the point on the nature of racism and discrimination in mental health services and its impact on ethnic minority communities in society.

The Afiya Trust wants to make sure that New Horizons provides a landscape that is visibly different with transparent and evidential step change.

More importantly, we want to see it make a connection with how mental health inequalities affect the over-representation in services among a number of ethnic minority communities and ensure there is real accountability and action.

The Afiya Trust believes that a key task is to empower ethnic minorities to encourage dialogue and engagement with local and cen­tral government and public sector agencies.

This has to be done through social marketing campaigns, good commissioning practices, rigorous and focused research and developing new approaches to understanding diversity and community issues.

Steve Shrubb, director, NHS Confederation’s Mental Health Network

As the latest Count Me In census results made clear, the over-representation of ethnic minority groups in mental health services continues to be a challenge for providers. They know they have to be more responsive to local cultural needs – to improve what you might call their cultural competences – based on the imperative to listen to and understand service users.

Listening to users is one of the founding bases for the work of the Future Vision coalition, which brought together service user, staff, provider, charity and third sector groups to shape mental health policy.

The coalition’s vision also made clear that good mental health and well-being was the responsibility of the full range of public services because we know the issues that users face do not stop at the doors of services.

If we are to successfully tackle many of the longstanding mental health issues that we face as a nation, such as child and adolescent mental health, care for older people, finding jobs for service users, dealing with stigma and tackling race equality, we need the full engagement of other public sector agencies.

Through the coalition, we were able to heavily influence the work of the Department of Health’s New Horizons strategy. It recognises the need for us all to work together, has been signed up to by government as a whole and is therefore a necessary and welcome step forward.

On the commissioning of services for ethnic minorities, New Horizons makes the points: “One of the most challenging and urgent tasks for those who commission and provide mental health care is to fully meet the needs of the increasingly diverse communities they serve”; and “the responsibility for remedial action extends to all the agencies that influence public mental health and well-being”.

Although this is correct, there is frustration at the lack of detail here. The overarching point to make is that New Horizons provides a vital road map for our public services to move forward. Last year’s document is also the first stage in a programme of action and other initiatives will follow.

Working together is the way forward, and together we need to challenge a future government to build on New Horizons. We also need everyone from service user groups through to the full range of public services to help put the flesh on the bones of this vision so we can finally get to the bottom of the most difficult issues we face in improving mental health.

Related items:

Wilson report

Count Me In 2009 results

New Horizons

This article is published in the 25 February 2010 edition of Community Care magazine under the headline Out for the Count