By Professor Kamaldeep Bhui
The prime minister, Theresa May, has described shortfalls in mental health care as a “burning injustice” in our country. Her government has pledged to overhaul the Mental Health Act 1983 (MHA) after concluding that “discriminatory use” of the legislation is part of the problem.
The MHA is used more often for people of black Caribbean, black African and black British origin, with research showing a consistent threefold excess, even among those receiving early intervention services.
While the reasons for this have not been fully established, what is certain is that this issue is part of the wider intimate relationship between ethnic inequalities, multiple disadvantage and severe mental illness.
Higher incidence rate
Evidence collected over 50 years repeatedly shows that people of black Caribbean, black African and black British origin have around a five times higher incidence rate of severe mental illness than white people (the exact size of this estimation varies across studies and types of severe illness).
The challenges here are longstanding. The legacy is too often one of disappointment and unanswered questions. Now we have another question to add to the list – will a new MHA make a much-needed difference?
The first issue to consider is why ethnic groups are detained under the current legislation more often than others. Although part of the explanation for excessive detentions is down to age, diagnosis, risk and social support, it is also the case that pathways to care and patterns of seeking help in crisis are powerful influences on whether someone is detained.
These pathways vary across ethnic groups, with black patients more often receiving care following the involvement of the police and criminal justice system.
These inequalities were highlighted publicly when national data on ethnic differences in detention under the MHA were collected. However, the routine collection of data has been abandoned due to limited resources and the suggestion that other data sources are sufficient.
The lack of regular publications on ethnicity and use of the MHA nationally and locally since 2011 indicates that other data sources have not been anywhere near sufficient.
Nevertheless, there are local bottom-up interventions happening which consider urban environments, area deprivation and service resources, and better practice around the use of the MHA.
For example, street triage schemes seem effective at reducing section 136 emergency admissions at the behest of the police. This might make a difference to ethnic minority patients who appear more likely to have contact with criminal justice agencies, even on first presentation for psychosis.
Trying to understand ethnic inequalities in the use of the MHA and filling the data gap will be one of the roles of the Synergi Collaborative Centre. This five-year collaboration between Queen Mary University of London, the University of Manchester and Words of Colour Productions, is concerned with addressing the links between ethnic inequalities, multiple disadvantage and severe mental illness.
Developing this understanding may lead to less reliance on subjective judgments about insight, risk and dangerousness, and better standards of practice and service provision. Interventions to reduce these inequalities may also reduce inpatient cost and the loss of trust and disempowerment that compulsory treatment engenders.
Furthermore, it will provide an opportunity to explore the contributory factors in the local area, in service configurations and in individual attitudes and behaviours. This may help us to better understand the causes of both severe mental illness and the risk of compulsory treatment, and how to minimise the use of the MHA for different ethnic groups.
The reasons behind the growing use of the MHA have not been fully established, nor are we any clearer as to whether ethnic inequalities in the act’s use are explained by the structure of legislation. Reforming the code of practice alone may therefore not be sufficient, even if it addresses ethnic inequalities and standards of practice.
It is important to note that previous reform to the MHA in 2007 was brought in in the absence of evidence, yet despite the introduction of compulsory community treatment, it did not reduce readmissions. This provided an opportunity to introduce capacity-based legislation, but it was rejected.
Capacity-based legislation would offer a single legal framework that doesn’t offer extra powers to detain those with mental illness versus physical illness. For example, judgments about a lack of insight – leading to detentions – can be made, even when capacity is thought to be present. In addition, there was little emphasis or progress towards a rights-based approach in the 2007 reform, which would enable appropriately resourced, effective care pathways and human rights protections for those subject to detention.
A new act does, however, have the potential to improve the situation – if these issues are taken on board. They will need to be accompanied by the provision of extra funding for comprehensive and culturally capable community services, rather than being used as a rationale to further reduce them, or to distract from the existing knowledge base on tackling health inequalities and structural disadvantage.
So, if a new Mental Health Act is developed, it should be based on evidence that shows it can reduce ethnic inequalities. It must be a rights-based and capacity-based act to allow practitioners to balance their responsibilities to society and to the patient. It should not discriminate against those with mental illness by proposing special measures that are unnecessary for physical illnesses.
Such measures would reduce the reliance on risk avoidance and coercive care systems designed specifically to restrict freedoms of people who are mentally ill. They would empower patients to self-care for as long as possible and to seek help earlier, with clear provision of options.
It would also require practitioners to foster trust and positive therapeutic relationships as a means of providing care rather than rely on invoking the act to bypass the problems of poor trust and insufficient alternatives.
Part of the Synergi Collaborative Centre’s role, when it launches in November, is to assemble the views of stakeholders in policy and commissioning, alongside patient voices and hidden and unsought narratives from the communities, to inspire change.
The centre will help to co-produce and co-design better ways of providing care in services, care for each other in our communities and self-care in our homes and families. This kind of fundamental collaboration is the only way forward.
Kamaldeep Bhui is professor of cultural psychiatry & epidemiology, Queen Mary University of London, and consultant psychiatrist, East London Foundation NHS Trust.