MENTAL HEALTH

Published: 21/04/2005, Volume II5, No. 5952 Page 24 25 26

The inquiry into the death of David Bennett revealed an institutionally racist mental health service from which black and minority ethnic users were estranged. Now a new style of service is emerging, as Emma Forrest reports

When the inquiry into the death of a young black psychiatric patient, David 'Rocky' Bennett, concluded over a year ago that mental health services are institutionally racist, it triggered a debate that shows no signs of abating.

While the government has declined to accept the Blofeld inquiry's suggestions of institutional racism, the recommendation that racism in the service needs to be eliminated has been acknowledged as an urgent necessity.

How to achieve that, though, is a matter of further debate. The national service framework for mental health, published in 2000, outlined plans to recruit 500 community development workers specifically to work with black and minority ethnic communities by the end of 2006.

Guidelines on reducing the often-shocking health inequalities experienced by these communities were published in 2003 and the programme of work being undertaken by the National Institute for Mental Health in England on the issue is the largest it has ever conducted.

This includes the first ethnic census of inpatients, set to become an annual event, which was first carried out on 31 March. This joint work with the Healthcare Commission will also see about 2,000 patients interviewed.

Delivering Race Equality, published earlier this year by the Department of Health - in part as a response to the Bennett inquiry - set out an action plan for tackling discrimination for all BME patients (see box, opposite).

Errol Francis, manager of the Sainsbury Centre for Mental Health programme Breaking the Circles of Fear, describes the document as 'a very exciting prospect'.

'The five-year vision is the most ambitious of any government to date. There is real prospect for change, ' he says. 'We have been saying the same things for 20 years. The tragedy of David Bennett's death typified what needs to change, especially for Afro-Caribbean service users.' The issues are numerous and disturbing. Young black men in particular are far more likely to be diagnosed with schizophrenia and detained under the Mental Health Act than their white counterparts.

Anxiety and depression are far less likely to be diagnosed in BME groups, while high doses of medication are commonly prescribed and they have difficulties in accessing talking therapies. All this means the Afro-Caribbean community, in particular, says Mr Francis, are profoundly estranged from mental health services.

It is deeply uncomfortable for anyone working in health or social care to accept that the services they provide can be racist. But many of those working to improve care for BME communities say that shying away from the problem is not going to make it go away.

Breaking the Circles of Fear workforce development lead Joanna Bennett says recruiting people from ethnic communities to work within them does not automatically mean that care can be improved, particularly in view of the recruitment problems mental health trusts face.

Treating people with respect should be a given, regardless of the colour of the patient or care-giver, she says, and it is not enough to know something about a patient's cultural background.

'It is quite clear that racism and discrimination is the issue to address. I am not sure cultural awareness can address that. How can we expect one clinician to understand the culture of every individual they see? You cannot generalise culture.

A limited knowledge of cultural background moves us back into stereotypical assumptions, ' she says.

'Racism is something people feel uncomfortable talking about; it is easier to talk about the need to have Afro combs on wards. It is far less comfortable to consider issues such as diagnosis and risk assessment or the process of sectioning, things that are going wrong, and are nothing to do with what toiletries are available.' The voluntary sector is frequently relied on to provide the link with BME communities that statutory services fail to achieve, but most are relatively small, local projects. One national organisation, Rethink, has developed policies to ensure that race equality is a top priority, including setting targets on numbers of BME staff employed by organisations.

'It can be a slow process because [people from] BME communities are not used to having a voice, and users can require training for this. But I do think it is easier for us as a voluntary organisation, because It is easier for service users to access decision making [within a voluntary sector provider].

'Service users do sometimes feel that trusts are only paying lip service to involving them.

But neither side is used to BME involvement and it is going to take some time, ' says BME lead Claire Felix.

She believes mental health professionals' attitudes to treating people from BME backgrounds should be implicitly tested on a regular basis.

'It should be carried out in annual appraisals to ensure they remain culturally aware and are still using skills learned in training. Otherwise you get a scenario similar to the police, where members get training but are still implicitly racist. Processes are needed to weed them out, ' she says.

Turning Point chief executive and Department of Health BME steering group co-chair Lord Adebowale has stressed the importance of leadership in trusts to prioritise equality and make sure resources are available to fund it.

'Ultimately race equality training has to be mainstreamed, the same way that race equality issues have been mainstreamed. It is not enough to bolt it on.

'I can only hope that it will be a given in the future, part of continuous professional development, ' says Ms Bennett. .

DELIVERING RACE EQUALITY AN 11-POINT PLAN

Although Delivering Race Equality does not contain specific targets, its vision is 'a service characterised by':

Less fear of mental health services among BME communities.

Increased satisfaction with services.

Reducing admission of BME patients to psychiatric units.

Fewer violent incidents.

Reduction of use of seclusion in BME groups.

Prevention of deaths following physical interventions.

More BME service users reaching selfreported recovery.

Reduction in the ethnic disparities found in prison populations.

A more balanced range of therapies.

A more active role for BME communities in the training of professionals.

A workforce capable of delivering mental health services to BME communities.

www. dh. gov. uk

CARES OF LIFE BREAKING THE CYCLE

The Cares of Life project (see pictures, left and overleaf) in Peckham, south London, is unusual for many reasons. It is aimed solely at AfroCaribbean and African people, and is based in a building where it is surrounded by voluntary organisations.

It is run by Dr Dele Olajide, who is also a consultant psychiatrist for the South London and Maudsley trust.

Originally funded by a research grant, it has just received primary care trust funding.

'There is fear from the community [of using NHS services for mental health problems]. They only access care when forced, which means we section them and inject them. We want to break that cycle, ' says Dr Olajide.

'We needed something that could harness work in a community that did not access mainstream services. The community uses support networks; it goes to barbers shops, churches, hairdressers.

We took on this reality and that meant moving out of the hospital.' Clients are not seen at the project's offices; rather the scheme's workers go to them.

Interventions can last up to three months and can involve project workers acting as advocates to resolve problems with housing, benefits or other agencies.

Clinics are also held in non-health environments, such as the Damilola Taylor Centre for Young People, where clients feel more comfortable. The project also runs a health bus, which does mental health promotion and physical health checks.

Seventy per cent of clients self-refer. Now the project is working with local doctors to adapt their way of questioning patients about symptoms in an effort to ensure all relevant clients find their way to the service.

'We take a wholesystems approach.

Rather than prescribing Valium and sending them off, we will look at why someone is not feeling right.' Dr Olajide has spent the past three years building up a level of trust with the local community.

'People think they will die if they go into hospital or are given injections. As one of the people giving the injections I can explain that we only do this when people are very ill, ' he says.

MERSEY CARE TRUST 'ASSUMPTIONS CAN OFFEND'

Equality and diversity lead at Mersey Care trust Scott Durairaj cautions against jobs such as his being tagged on to another role.

'Usually it is given to human resources, which can be seen as a dumping ground. But it is actually principally a serviceuser issue and only 5 per cent HR.' Race equality training has been mandatory at the trust for over a year.

'A lot of psychiatry and psychology is based on Euro-centric models; we are introducing an ethno-centric model to avoid misdiagnosis because of cultural differences, ' says Mr Durairaj.

The trust consults local groups representing people with disabilities and gays and lesbians as well as those for ethnic groups.

'We want to expand the net of culture beyond that of race; race is a facet but there can be other considerations, such as if a service user is Muslim and gay.

'There is a misconception that staff do not want these changes, that It is political correctness gone mad, but That is not the issue. It is about respect, ' says Mr Durairaj.

He says that fear of saying the wrong thing is widespread.

'I always tell people that I am not going to start calling Blackpool an ethnic background swimming facility.

Things like that take away the impact of discrimination.

'People are never offended by questions, but they are by assumptions.'

Key points

Black and minority ethnic patients are more likely to be diagnosed with schizophrenia and detained, more likely to receive high doses of medication and less l ikely to have access to talking therapies.

Input from voluntary organisations and monitoring staff attitudes are crucial factors in tackling the problem.