Delivering race equality in mental health services
‘Delivering race equality’ is a 5-year action plan for tackling race inequalities in mental healthcare in England and Wales, based on the main themes of improved services, better community engagement and better information. The perception is that clinical teams have not been sufficiently engaged with the plan and progress is slow. This article shares insights from the author’s work across government departments over the past 2 years and explores the potential for linking up different initiatives across the patient care pathway in support of the plan’s delivery. A summary of conclusions from a pilot survey of consultant psychiatrists, commissioned by the Department of Health in June 2007, addresses the main controversial areas in the action plan, with suggestions for improvement. Areas for clinical engagement are identified that exploit new funding, investment and policy initiatives. Examples of good practice are offered.
In 2006, I was the Medical Advisor in Mental Health in the National Specialist Services Commissioning Advisory Group (NSCAG), Department of Health. I was also invited by Kamlesh Patel, National Strategic Lead, to work across government departments to support the Department of Health’s Delivering Race Equality agenda, working mainly with the Home Office and the Department of Education and Skills. The work on Delivering Race Equality is ongoing. This article arose from insights and information gained during this time.
The main goals of the Delivering Race Equality in Mental Health Care Action Plan{dagger} for England and Wales (Department of Health, 2005) are more appropriate and responsive services, community engagement and better information. The plan sets out 12 characteristics of a reformed service which should be in place by 2010.
A key outcome measure for the programme is route of admission to hospital. The results of the 2005 and 2006 Count Me In census in England and Wales (Healthcare Commission, 2005, 2007), show Black (African–Caribbean and other African) and ‘White/ Black Mixed’ service users to be three to four times more likely to enter the in-patient care pathway through detention under the Mental Health Act 1983. To obtain a more comprehensive picture of the care pathway of Black and minority ethnic service users, the Department of Health recognises the need to monitor their experience using community, primary care and offender population surveys.
Case for clinical engagement
How can psychiatrists and their teams most usefully engage with this agenda? There has been much heated debate, most recently in the Psychiatric Bulletin (McKenzie & Bhui, 2007; Singh, 2007), on whether psychiatric services are institutionally racist, and where the fault lies with regard to poor access to and experience of mental health services by Black and minority ethnic service users and families. ‘Whole system’ changes are needed at a number of different levels and across organisations. As clinical leaders we need to reach out and engage with others prepared to make those changes. We need to harness the energies of new policies and invest in new services. We need to challenge our teams to think and act differently (Box 1Go) and work with our partners in health and social care.
Box 1 London initiatives to change attitudes
* Tower Hamlets Primary Care Trust in east London has set up a series of educational events for general practitioners to promote cultural competency and improve access to mental health services in the Bangladeshi community.
* Rabishikha, a cultural organisation in north London that promotes the work of Rabindranath Tagore, encourages awareness of mental health issues through dance, drama and music. Their dance production Maya (presented at the Bloomsbury Theatre in 2003–2004) carried an anti-stigma message and was part of the Royal College of Psychiatrists’ Changing Minds campaign.
Improving access
Tackling inequalities is a focus of recent health policy and of Lord Darzi’s (2007) report on the future of the National Health Service (NHS). It is also a key objective of primary care trusts (PCTs). Tackling inequalities translates to access across the entire patient care pathway (primary care, secondary services in mental health trusts, specialist tier four services). It also involves reducing stigma and fear of services in the community, as these stand in the way of access. Art, poetry, music, drama and dance can all be used effectively to normalise mental distress, as part of the universal human journey (Box 1Go).
I believe that the move towards better integration of primary and secondary care in enabling access, as in the polyclinics proposed by Lord Darzi (2007), may offer new opportunities for better sharing of knowledge and skills and better communication across organisational interfaces in healthcare. These new centres may be perceived as less stigmatising by Black and minority ethnic communities and, as such, more accessible.
Informed PCT commissioning of services
The Department of Health’s Care Quality Commission will include commissioning standards in its regulatory portfolio and rate PCT commissioning skills. Clinicians can work with PCT commissioners so that appropriate services are established, with recognition of the needs of Black and minority ethnic service users throughout the health and social care system. The growing consensus is that ‘world-class commissioning’ (Department of Health, 2007) will mean input from a range of providers, including the voluntary sector. What is important is that service input is integrated and coherent across the entire care pathway, and that it manages to secure service user confidence. Secondary services will need to work with the voluntary sector to ensure that the needs of Black and minority ethnic service users are met along the entire care pathway, including social inclusion and recovery. Primary care counselling should focus on quality and outcomes, not just case-load targets and number of contacts.