Mental Health Act overhaul will not tackle racial disparities without societal change, experts warn

Proposals to reform the Mental Health Act to tackle racial disparity and lower rates of detention and community treatment orders among Black Asian and Minority Ethnic (BAME) groups will be futile without systemic, societal change, experts have warned.

The long-awaited Mental Health Act (MHA) White Paper, published last week, pledged “decisive action” would be taken to cut disproportionate use of the act among certain groups. Black people are over four times more likely than white people to be detained under the act and over 10 times more likely to be subject to a community treatment order (CTO) – under which people are discharged from detention but placed under conditions on their lives and treatment.

Part of this would be achieved by tightening conditions for people to be detained or subject to a CTO, while the paper also sets out plans to subject mental health trusts to a patient and carer race equality framework (PCREF) designed to improve their response to Black and ethnic minority communities and improve access to culturally appropriate advocacy.

Scope for change limited without addressing ‘racist society’

But Hári Sewell, a social worker by background, former mental health trust director and now a consultant in mental health and equalities, said he was sceptical about the scope for change “while Black people are still living in a racist society”.

“Think of the response to an impoverished community drinking contaminated water because there is no clean water supply, if you improve your treatments and service structures, the experience of crisis may be less problematic but the number of cases coming through will not significantly reduce,” he said.

Furthermore, Sewell said the underlying principles of mental health meant that the focus on looking for signs and symptoms of an illness could lead to “inattentional blindness to the role of racism in people’s presentations”, exacerbated because many forms of racism were invisible to many in the profession.

“Racism is thought of as racist attacks, poo through the letter-box-type racism rather than the weathering that occurs from living with constant stereotyping and negative images of self and othering, often under the guise of benevolent racism,” said Sewell, who is director of HS Consultancy.

Race equality ‘left to the charity sector’

Professor Kamaldeep Bhui, director of Synergi Collaborative Centre, which studies ethnic inequalities in mental health, echoed Sewell’s concerns, and said that while the government’s commitment to tackling racial inequality was welcome, more work was needed to “really unpack, expose and remove drivers of race equality in care systems”.

“[This] means tackling racism more generally and the legacy of heritage and life course adversity, all the pathways that lead to a detention decision not only the decision to detain alone,” said Bhui, a professor of psychiatry at Oxford University

While examples of good practice existed, Bhui said these had been under-resourced and disbanded, “leaving race equality to the charity sector and on an ad-hoc basis”. While there was an opportunity to embed it in the NHS, this needed “a total revolution in training”.

‘Discrimination will change form’ with CTO targets

The government proposes to reform CTOs so that they can only be used where there is a strong justification, they are reviewed more frequently and by more professionals, are time-limited (to two years unless the person has relapsed or deteriorated), and that people subject to them really need them to receive a genuine therapeutic benefit.

Sewell warned that, while this would likely reduce numbers on CTOs and the proportion of Black and ethnic minority people placed on them, though perhaps only slightly in the latter case, “it is also more likely than not that the discrimination [will change form] will show up elsewhere”.

“In future, if CTO data ‘improves’ we are likely to see higher proportions of detentions for people from BAME backgrounds and longer lengths of stay,” he added.

Lack of alternatives to CTOs and detention

Meanwhile, Bhui said that raising the threshold for people to be detained or placed on CTOs could only work if there were community-based alternatives; however, these were severely lacking due to service cuts over many years.

“Proposing a change in threshold for detention (as a progressive response) to apply only in the face of more serious or significant risk of harm to self or others, and that there is benefit to the patient for recovery, assumes existing decisions are made with significant scope for alternatives.

“At the moment there are few alternatives such as crisis houses, community supports, and a range of different levels of supported care, many community services have been reduced in size and capacity and focus on those with the most severe illnesses, and less is preventive at earlier stages of the pathways,” Bhui said.

He urged the government to publish specific examples on applying the proposed and current thresholds for detention, adding: “Legislation alone will not lead to reduced detention, but a total systems culture change is needed with more investment in care systems and more opportunity for people to choose alternatives to support recovery, as long as people understand the risks and agree to them.”

Reforms ‘subject to funding’

Steve Chamberlain, chair of the AMHP leads network, echoed Bhui’s concerns about the availability of community alternatives to detention and said “the most telling” paragraph in the White Paper was one which said its proposals would be “subject to future funding decisions”.

“To provide more effective community support, better crisis responses and alternatives to admission, and also improve conditions for psychiatric inpatients, there needs to be more resources available and changing the law is not going to solve many of the issues which have developed and become more severe during the past ten years of austerity,” Chamberlain said.

Bhui also questioned the evidence base for the patient and carer race equality framework (PCREF), which is currently being piloted in some mental health trusts.

“As far as I’m aware the evidence that PCREF will work to reduce race disparity is lacking,” he added. “At the moment this title compels Trusts and organisations (along with an OCF) to measure, review, and implement processes to change the disparities. Again, this lacks any empirical evaluation or clear logic model, although the shift to an organisational and structural framework is important and welcome.”

AMHP role expansion must be ‘adequately resourced’

The White Paper proposals would involve an increased workload for approved mental health professionals (AMHPs), particularly through more involvement in renewals of CTOs, and also moots a new role for AMHPs in managing transfers of people from prisons or immigration removal centres to hospitals. The impact assessment on the White Paper states that, by 2023-24, the full-time equivalent AMHP workforce would need to grow by 7% above current projections to take on their proposed responsibilities –  and this excludes the suggested prison transfer role.

AMHPs are already due to take on a new role later this year, assessing people receiving mental health crisis services who are in debt so they can gain access to a freeze on their debt repayments and any enforcement action for the duration of their treatment plus a month.

Chamberlain said it was widely acknowledged that the AMHP workforce was considerably stretched across much of the country, with a 4% fall in numbers from 2018-19. In November 2019, the Department of Health and Social Care and other organisations issued an AMHP workforce plan to improve recruitment, retention and development, including by tackling salary disparities, workloads and stress, and developing national education and service standards for the role.

Chamberlain said that, while these were welcome, any expansion of the role would need to be adequately resourced.

“The White Paper helpfully states that adequate resources are needed in order to deliver some of these developments and their success will, without doubt, be dependent on those resources.”