June 1, 2005

The government says it is committed to rooting out racism in mental health services. It has drawn up a five year action plan and is to establish "hothouses of reform" services to drive forward change. But will this all be enough? Adam James investigates.

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It is now seven years since black Rastafarian David Bennett lay dead on the floor in Norvic psychiatric clinic in Norwich.

The 38-year-old, diagnosed with schizophrenia, had punched another patient who, in turn, called him a "black bastard". After hitting a nurse David Bennett was restrained. He suffocated after being pinned down by around four nurses for at least 25 minutes.

After the shock and outrage came inquiries and government responses. First an internal Norfolk Mental Health Care Trust inquiry, then a government report, entitled Inside Outside, which laid out initial ideas on how to improve mental health services for black and minority ethnic (BME) people. In December 2003 an independent inquiry into David Bennett's death highlighted a "festering abscess of institutionalised racism" in NHS mental health services. Finally, in January of this year, the government issued a five year action plan - Delivering Race Equality In Mental Health Care - detailing how it plans to root out anti-discriminatory practice.

The action plan wants service providers to reduce the disproportionate rate that BME people are treated and detained in hospital. It also laid out how to create a workforce capable of delivering "appropriate and responsive" mental health services to BME people.

Statistics reveal that black people represent 30% of patients in medium secure services and 16% of high secure services. They are more than six times likely than white patients to be detained. Women born in India and East Africa have a 40% higher suicide rate than those born in England and Wales.

However, the time has now come for the aspirations within the action plan to be realised. The ball began firmly rolling at the end of last month when 17 strategic health authorities - "implementation sites" - were due to submit details for pilot projects which the government wants to pave the way in creating non-discriminatory mental health services.

"I want the implementation sites to be hothouses of reform, and to bring about innovation and new thinking," says professor David Sallah, the National Institute For Mental Health's director of BME mental health programme.

Yet, already there are strong concerns as to whether the action plan has the teeth to enforce such innovation.

For example, no specific targets - such as by how much to reduce rates of detention of BME people - have been set. Target-weary service managers may be relieved, but critics are dismayed. They fear a lack of targets issues a green light for providers to get away with not ensuring real change.

Prof Sashi Sashidharan, chair of the expert group which drew up Inside Outside, fears the lack of targets indicates government reluctance to tackle full on racism in mental health services.

"It's welcome that people say they are all for action," says Prof Sashidharan. "But where do you focus your action? The action plan does not commit services to specific action. 'Target' is a bad word these days. But nevertheless there should be clear benchmarks."

Prof Sallah disagrees, emphasising the Healthcare Commission, backed up by the Race Relations Act, will be a "lever" for implementing the action plan.

This is despite the commission deciding to drop 18 "prompts", as laid out in the action plan, which were to be a means to monitor race equality performance. The prompts were too prescriptive, said service providers.

Instead, measures for assessing the action plan have now been subsumed into general "must do" measures for assessing how providers meet core standards throughout the NHS. This document - entitled Criteria for Assessing Core Standards - was emailed to service providers at the beginning of May with more detailed guidance on mental health to follow.

"The whole idea of targets is highly disparaged in the public sector," says Prof Sallah, also director of research, ethics and consultancy at University of Wolverhampton's school of health.

"To me it is about working with people to reach a level of change rather than trying to set targets…It can be demoralising for those who do not get there [reach targets]."

Short on targets it may be, but the action plan has set primary care trusts (PCTs), SHAs and other providers a raft of initiatives to implement.

For example, all mental health staff should be trained in "cultural sensitivity", PCTs must create BME befriending schemes on psychiatric wards, the needs of asylum seekers and refugees must be met, and PCTs must ensure that BME inpatients have culturally appropriate services.

These initiatives are supported by PCT funding for 500 community development workers. Their role is to help harness existing expertise and knowledge within BME communities.

At the last count, 100 of the 500 were already in place. Two, for example, are already working for a pioneering Bradford City Teaching Primary Care Trust-funded project called Sharing Voices. For two years Sharing Voices staff have been successfully working with BME community organisations to use their "untapped expertise" in endeavouring to mould culturally-sensitive mental health services in an inner city with a 60 per cent BME population.

A good start, perhaps. In the bigger picture, however, the draft mental health bill is looming.

Mental health professionals have condemned as "draconian" plans laid out in the draft bill - also criticised in March by a joint parliamentary committee. They fear it will widen conditions under which people can be detained. Psychiatrists will be jailers as much as doctors, they say.

Moreover, Mike Shooter, president of the Royal College of Psychiatrists, called the planned legislation "one of the most racially discriminatory laws ever seen in the UK" because Afro-Caribbean men in particular face a disproportionate risk of mistaken diagnosis and detention.

Prof Sashidharan asks how can this be squared up to the aspirations within the action plan. "The draft bill is a very serious matter for BME communities," he says.

Prof Sallah, however, is more tight-lipped. "The government needs to respond to the parliamentary committee. It's best to wait and see what comes out of that response," he says.

David Bennett's death may have focussed minds pushing for change. But these minds have strong differences of opinion on how to implement it.

A shortened version of this article appeared in Public Servant magazine

* Government's Delivering Race Equality in Mental Health Care Action Plan (pdf)

See also:
April 4, 2005: Planned services heralded to be "hothouses of reform" in rooting out racism in mental health - announcement of new projects comes on heels of census to establish extent of discrimination against black and minority ethnic patients in NHS and private hospitals
Jan 11, 2005: We'll cut rate that black and ethnic minority people are detained in psychiatric hospital, vow ministers - promise unveiled in government five-year anti-racist action plan for mental health services
March 29, 2005: Government again under fire over plans to change mental health law - parliamentary committee warns that planned legislation would erode civil liberties

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