Mental health providers are working to tackle the problems of over-occupancy, length of stay and over-representation of black and minority ethnic groups. But are they doing enough, asks Stuart Shepherd

It seems unthinkable that in the 21st century NHS mental health services should still be having to send one patient on leave before they can admit another in crisis. Especially when other patients who are ready for discharge cannot be moved on for want of an appropriate facility.

Even more alarming is that patients face an increased chance of being compulsorily detained under the Mental Health Act by virtue of their ethnicity.

Two documents published earlier this year - the Care Services Improvement Partnership toolkit A Positive Outlook, and the Healthcare Commission's 2006 Count Me In report - suggest that mental health providers must continue work to address the challenges of over occupancy, length of stay and over-representation of black and minority ethnic groups.

Count Me In 2006 reports the findings of the second national annual census of mental health inpatients. The work is one of the three key building blocks of the Delivering Race Equality five-year action plan to improve mental health services for BME communities.

Focus implementation sites (FIS) - there are 17 across England - are described by Delivering Race Equality as hothouses for identifying and spreading best practice that will improve access, experience and outcomes for mental health service users from the BME communities. These include tackling disproportionate rates of admission and compulsory detention, increasing satisfaction and diminishing fear and inform what more equitable mental health care should be like by 2010.

'After the 2005 [Count Me In] census, for the first time we had a very clear picture of who was using our services,' says FIS project manager for Bradford Salma Yasmeen.

'However, that was not enough on which to base significant planning decisions, so we now repeat it on a quarterly basis, helping to identify recurrent patterns and target groups that we want to address.'

With 23 per cent of Bradford's population of South Asian origin, and concentrations of people from Africa, the Caribbean and China, providing equitable mental health has been a concern of Bradford District Care trust for several years. Established home-treatment services were more recently followed by the community development mental health project Sharing Voices.

'This scheme engages with people's awareness of the issues they face and gets them involved in developing meaningful solutions,' says Ms Yasmeen. 'Delivering Race Equality has been a lever to progress that work and commission it at arm's length from statutory services. The real benefit of the Sharing Voices community development workers is that they have good relationships within the different ethnic groups and give us lots of opportunity to talk about Bradford's mental health services.'

Other initiatives focus more directly on the district's inpatient facilities, where a disproportionate number of young South Asian men are being admitted under the Mental Health Act. A pilot scheme on two wards sees local voluntary-sector organisations working alongside staff with service users from admission to identify patients' fears and concerns and broker a culturally sensitive and appropriate care package.

Another pilot project, now completed, brought a spiritual healer onto some of the care trust's wards to work with young South Asian men with religious concerns based around being possessed by spirits. The successes of this programme, and its potential for feeding into a more holistic care planning process, are now being evaluated.

The Hampshire and Isle of Wight FIS team serves a large geographical area, stretching from Basingstoke in the north, with a 4 per cent BME population, down to Southampton, where the figure rises to 8 per cent. Having examined initial service-user data, recommendations from the delivery group focused on over-representation and length of stay.

'We started by developing some work with the gatekeepers of the inpatient services - our crisis resolution and home treatment teams. We drafted in Rameri Moukam from Pattigift, an African-centred mental health service in Birmingham, to look at issues of risk,' says Beverley Meeson, FIS coordinator, Hampshire and Isle of Wight FIS team.

'Having DRE around seems to have concentrated people's minds and improvements have been measured,' Ms Meeson continues. 'It may not be FIS that is doing it but as a proportion of the total number of compulsory admissions to all our units we have seen the figures for black Caribbean and black African patients drop from 80 per cent to 55 per cent.'

Staff on inpatient wards are being made more aware of the particular needs of some of their BME patients, as a result of a two-year cultural assessment pilot project led by Kirpal Vedwan.

'Within 48 hours of their admission the project team talk with the patient about key aspects of culture and from a personalised narrative,' says Ms Vedwan. 'We identify three areas that offer therapeutic potential and can be incorporated into the care plan. Exit interviews with staff and the patient are helping us evaluate its impact and what might be modified.'

Central and North West London foundation trust operates across some of the most ethnically and faith diverse boroughs in the country - Westminster, Brent and Hillingdon among them.

'It is early days but in some of our services it looks like we have BME over-representation at two times the percentage of levels in the local population,' says David Truswell, FIS project manager.

However, data from crisis resolution, early intervention and assertive outreach teams suggests that the site is seeing a statistical reduction in admission rates for its BME communities.

'We need to look more closely at the long-term impact of these teams on people's mental health careers,' says Mr Truswell, 'to identify clinical practices that generate positive outcomes so that these can be transferred across the board.'

Published in April, A Positive Outlook spares no time in reminding its readers of the consequences of overcrowding. An identifiable feature of far too many acute mental health wards, it leads to stressed patients, overstretched staff and an increased risk of a serious incident occurring.

Case studies, such as the use of 'lean thinking' at Cumbria Partnership trust, however, point the way to whole systems solutions fit for replication across many other services.

'Two of our acute wards were running at 130 per cent occupancy levels,' says Karen Holt, trust head of operations for acute services. 'There was a constant struggle for beds and a heavy reliance on leave.'

Ward and community managers joined Ms Holt on a lean thinking event facilitated by GE Healthcare to look at the influence of systems and processes on a patient journey - and came up with a 48-hour assessment pathway.

'The ward, crisis resolution and community staff now meet every day to review inpatients admitted two days earlier,' explains Ms Holt. 'They might stay on the acute unit, move to a needs-led assessment unit or be discharged back to the community. This is about changing a culture and empowering a patient from the start of the acute care journey.'

Since its introduction, the trust has seen a 40 per cent fall in length of stay and a 36 per cent reduction in acute bed numbers.

A similar whole systems approach on wards at the Salford locality of Bolton, Salford and Trafford Mental Health trust brings acute and community managers together for twice weekly reviews. Occupancy on all wards has dropped from 96 to 85 per cent - producing a net saving of 960 bed nights.

At Cheshire and Wirral Partnership trust, acute bed closures were matched by increasing levels of disturbance among the patients. Trying to meet the needs of 12 consultants attending the ward compounded this stressful situation further.

'It was untenable,' says clinical services manager Nigel Crompton, 'so we changed the model and now there are distinct community consultants, an inpatient consultant who also treat crisis resolution home treatment patients, and an assertive outreach consultant.'

The rationalisation means the consultant has a greater presence on the ward - and a client-activated appointment system can be introduced to replace the weekly ward round.

'The team talk about a greater fluidity to the decision making,' says Mr Crompton. 'There is also bed capacity that we never had before and we can provide protected therapeutic time for psychological interventions.'

Job sharing: healthcare benefits

'It was the clinical director looking to reduce his caseload and my need for some clinical input to complement my primary role as an academic that prompted us to job-share,' says senior lecturer and consultant psychiatrist at Bolton, Salford and Trafford Mental Health trust's Meadowbrook Unit Dr Peter Talbot.

'So I became the dedicated inpatient consultant to the unit with my colleague taking responsibility for the community services. Comparing the 12 months since my appointment with the previous 12 months, and despite a similar admission rate, the average length of stay has fallen from 39 days to 25.5 days.'

Dr Talbot thinks this has been achieved because, despite being part time, he is now on the ward more often than before.

'I can support the nursing team more readily and effect prompter assessments, diagnoses and - for those patients deriving no therapeutic benefit from being in hospital - discharges,' he says.