Despite a concerted effort to clean up its act, race still plays a significant part in the quality of mental healthcare that patients receive, writes Mark Gould

Count Me In, the Healthcare Commission's 2006 annual snapshot of inpatient mental healthcare in England, painted a familiar and unfortunately bleak picture.

Its findings included overcrowded wards inhabited by a disproportionately large number of young black men, excessive lengths of stay and potential dangers in older institutions still without adequate segregation of the sexes.

While the commission itself says this was just one day in the life of trusts, so should be treated with caution, a random trawl around some of the larger mental health trusts shows little change so far.

Nottinghamshire Healthcare trust reports an average 100.49 per cent bed occupancy rate across the county for the 12 months to June.

In Nottingham itself, the trust reports some 26 per cent of inpatients are black Caribbean or black British and that, as revealed by Count Me In, these groups are three times more likely than whites to be sectioned under the Mental Health Act.

Elsewhere, acute mental health wards in Tower Hamlets are running at 121 per cent occupancy and 36.7 per cent of its patients are black, of whom 15.9 per cent are black Caribbean.

East London and the City Mental Health trust covers the three most deprived boroughs in London. Average bed occupancy across its City and Hackney locality to March last year was 109 per cent, and for Newham 104 per cent.

Manchester Health and Social Care trust reports that 29.4 per cent of its patients are from black and minority ethnic communities and that while average bed occupancy is an almost manageable 94 per cent, patients' average length of stay is a staggering 101 days.

Early diagnosis

A trust spokesman says such issues arise due to the fact that black patients only come into contact with services when they are in crisis.

'There are not sufficient services in communities that will pick up on mental health distress at an early stage and thus avoid problems becoming a crisis. Patients from BME backgrounds often feel their cultural needs will not be addressed,' he says.

At Tees, Esk and Wear Valleys trust, there is less pressure on beds and more demographically proportionate representation of black and minority ethnic patients on the wards. But it will not be until 2009 that it can say that all patients are being treated in single sex units.

A survey of mental health nurses by the Royal College of Nursing, published in early August, revealed that 42 per cent reported that low staffing levels compromised patient care at least once a week. And two-thirds did not consider that current numbers of staff were sufficient to meet patient needs.

With more treatment in the community, the threshold for admission is raised, creating an inpatient community with higher levels of acute illness - often in tandem with an addiction to illicit drugs or alcohol - being looked after by fewer experienced or specially trained staff.

Emily Wooster, policy officer for mental health charity Mind, says Count Me In underlined the findings of its own research. 'Race still determines the quality of care,' she says.

However, she adds that the Department of Health is making a concerted effort to change this situation via the Delivering Race Equality scheme, which calls for better and targeted health promotion and early interventions, such as offering counselling in primary and secondary care.

But there is still a lot to do.

Ms Wooster runs off a list of familiar issues: lack of talking therapies - some areas report a four-year waiting list; lack of green space around units; lack of choice or control of what you eat and drink; and lack of safety.

'The whole issue of mixed-sex wards is still a problem. Wards are neither complying with the letter nor the spirit of the law - people are still sharing washing facilities and that should not be happening. And when hospitals face capacity problems patients are squeezed in wherever they can,' she says.

Mind would have been happier if the£30m that was recently allocated to improve privacy and dignity had been given to the wards in most need, rather than asking trusts to submit a bid for their share.

Dr SJ Bamrah, chair of the BMA's psychiatry sub-committee, says that despite recent large-scale investment in mental health 'there is no evidence that inpatient care has improved as a therapeutic environment'.

He says the creation of some very large mental health trusts has seen new cash eaten up in management costs. 'Yes, some of the hospitals are cleaner, but we continue to have poor investment for inpatients so that staffing is poor, levels of aggression are higher and many wards are not able to offer recreation and rehabilitative therapies.'

He worries that mental health is always plundered when the NHS is balancing its books.

'[The BMA] wanted to have a meeting with the Department of Health to define the number of beds the NHS needs and exactly how many psychiatric beds a civilised country must have to provide proper services and they were not forthcoming.'

Dr Bamrah is concerned that the current wave of reconfigurations could lead to a situation where large psychiatric units are without A&E departments to support them.

'Mental health always suffers when trusts are trying to save money and BME is the group that always suffers the worst when this happens,' he says.

Head of mental health strategy at the Healthcare Commission Anthony Deery says hospitals are now populated by more seriously unwell people than they were even five years ago.

Fear of violence

'If you talk to clinicians they will say that 'ghettoisation' is happening. A lot more admissions are under the Mental Health Act, you get the feeling that there are fewer elective admissions, fewer planned moves into hospital care.

'In terms of the staff perspective, inpatient services are not seen as attractive parts of the system. You don't want fear of violence to be with you every day you go to work.'

While many trusts feel they know where the problems are, Mr Deery says Count Me In was just a snapshot. 'At present nobody can quantify what an acute inpatient spell provides,' he says, adding that a better picture will come out of the commission's acute inpatient survey, which is due to be published early
next year.

Mr Deery hopes the survey will be able to quantify exactly what services inpatients are getting and accordingly make recommendations to government. This means addressing major concerns, such as over representation of BME patients, overcrowding, delayed discharge, mixed wards, the availability of a therapeutic environment, violence levels, safety overall and environment.

Yet there is a lot of positive activity in the sector, including patient and staff collaborations, such as the innovative Star Wards project created by Marion Janner, a social entrepreneur and mental health service user.

Some 150 wards in England, a quarter of the total, have so far signed up to the scheme, which allows staff and patients to rate wards based on 75 criteria, such as having daily papers available, internet and e-mail access and a choice of fresh fruit and vegetables, entertainments and activities.

Executive director of local services for Nottinghamshire Healthcare trust Simon Smith agrees that there are good things happening and that services know where the problem areas are and so can start putting them right.

The trust is working with a local charity, Amaani Tallawah, which supports and promotes the well-being of Afro-Caribbean people who use mental health services.

The two organisations are launching a 'delivering race equality in mental health' strategy in the autumn with a keynote speech from mental healthcare lecturer Dr Joanne Bennett.

Dr Bennett has deep personal awareness of the sometimes-tragic consequences of racism in the NHS. The investigation and report into her brother David 'Rocky' Bennett's death in 1998 during a struggle with NHS psychiatric staff was a watershed in NHS race-relations akin to the McPherson report on the racist murder of Stephen Laurence.

Mr Smith does not think that many NHS employers would say that they are providing the very best in this respect.

'We are doing our best to improve that; we are employing a number of clinical nurse specialists from an Afro-Caribbean background with a specific brief to work with this client group.'

A recent trust audit of inpatient acute, residential and forensic units revealed that 55 per cent of service users had current or past drug or excessive alcohol problems. Given the extent of the problem Nottinghamshire units operate on a controlled access basis to physically exclude drug dealers.

Mr Smith says wards have developed close relationships with beat police officers who attend inpatient and residential areas on request to discuss any issues relating to drug taking and dealing and will also speak individually to service users if necessary.

A specialist county-wide dual-diagnosis consultancy service visits inpatient units twice weekly to ensure that patients and staff receive the appropriate support for positive therapies.

Claire Murdoch is chief executive of Central and North West London Mental Health foundation trust, an organisation that covers communities as diverse a Soho in London's West End to the outer suburbs.

The trust is one of 12 DRE focus implementation sites which are described as 'hothouses' of identifying and spreading best practice in delivering race equality.

Tools for communication

Ms Murdoch says simple things like language and communication are vitally important. 'In Westminster there are 160 languages spoken so we need to offer internet and e-mail for everyone. They are a vital way of communicating and making patients feel less alienated. And if you are from some remote region it's nice to be able to Google away and download your local paper.'

The organisation's Faith and Spirituality initiative, involving faith groups from outside the hospital coming onto wards, helps ensure patients are treated in a culturally appropriate way. 'It's about inreach as well as outreach. It means that people can hook up with their community and it really helps on discharge,' says Ms Murdoch.

It is working with voluntary groups and the London borough of Brent on the Boys to Men project aimed at getting black men to be positive role models for teenagers. Its aim is to tackle some of the problems that might be at the root of a potential acute admission and prevent them.

'In a lot of cases by the time we as an NHS inpatient unit become aware of these young men they are in real trouble. They may have had terrible experiences, heartbreaking lives, so a lot has gone on upstream before we see them.'

Court diversion schemes work together to provide services for offenders with mental health problems; another area where young black men are over represented. 'We want to make sure that hospital is the appropriate place for the courts to send young men in the first place.'

While she feels that the proper mix of experience and training is vital to ensure a safe and therapeutic environment, Ms Murdoch is also keen to ensue that her wards are places of sanctuary in its literal sense. 'It's about having the right ethos and attitude as well as training. Some patients complain that they simply weren't treated kindly. So you need to create a place that is very much a sanctuary - it has got good food including nice fruit and veg, it is clean and welcoming.'

The trust is also keen to instil a sense that patients are valued. Ms Murdoch says: 'People complain that nurses were too busy coping with crises or in their office doing paperwork to be bothered with them. So we introduced protected engagement time; for two hours in the afternoon the ward is virtually closed to social workers or rounds.

'It is protected time for nurses and patients to spend talking and listening to each other. It is really pleasing - on one ward a senior manager was visiting and the nurses told him to go away as they treat protected time so seriously.'

And while over representation of some ethnic groups is seen as the biggest problem Ms Murdoch warns of a worrying flip side. 'While the main over representation is young black Afro-Caribbean men, by the same token the Chinese community is really unrepresented so there are concerns from both perspectives,' she says.