The mental health of the African Caribbean community in Britain

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About this factsheet
Note on terminology
Introduction
Historical background
Population size
The African-Caribbean experience in Britain
African-Caribbean experiences with the mental health system
The criminal justice system
The David 'Rocky' Bennett story
The care of African-Caribbean women
Ethnic monitoring
Policy initiatives 1999 to 2006
The Mental Health Bill
Mind's Yellow Card scheme for reporting drug side effects
The Bennett Inquiry recommendations
Useful publications
Useful websites
Appendix: The NIHME Black and Minority Ethnic Mental Health Programme
Footnotes

About this factsheet

This factsheet aims to give an overview of how the mental health needs of the African-Caribbean community are negatively affected by many factors, including racism. It highlights examples of racism within society in general and the psychiatric system in particular. It is also provides much evidence to indicate that African-Caribbean people face disproportionate discrimination and disadvantage. These have a significant impact on their life chances and a detrimental effect on their mental health. The factsheet explores the very nature of mental health practice and places this into the wider historical and political context.

This factsheet is aimed at students, mental health professionals, carers, users of mental health services and the wider public. More statistical information can be found in Mind's Race, Culture and Mental Health factsheet (See 'Useful Publications').

Note on terminology

One controversial aspect when writing about race and mental health issues is the terminology used. The terms 'Black' or 'African-Caribbean' are used to describe people of African descent, wherever they were born. For the Black people who have adopted it, it is a term that underlies a unity of experience that includes discrimination and exploitation.

As Dominelli argues, the term Black refers to any person whose skin colour renders them liable to the application of racism irrespective of their ethnic background, linguistic or academic ability, country of origin and length of stay. [1]

In defining terms and groups, Parekh asserts that the term 'African-Caribbean' should not imply that this is a homogenous group. He indicates that African-Caribbean culture has numerous cross-cultural influences. These include Africans, East Indians, British, Spanish, French, Dutch, Portuguese and Chinese. [2]

No single term is completely acceptable to everyone, but by using both terms it is hoped that we include any individual who suffers from the effects of racism in whatever form.

When specific research studies are mentioned, or we use the terminology of psychiatric diagnosis, this is only to reflect the language of the sources referred to. The use of such language in no way implies Mind's unqualified acceptance of it.

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Introduction

The World Health Organisation (WHO) defines health as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity". [3]  In 1986, the Ottawa Charter for Health Promotion identified nine pre-requisites for health. These are:

1. peace
2. shelter
3. education
4. food
5. income
6. a stable economic system
7. sustainable resources
8. social justice
9. equal opportunity for all.

This factsheet illustrates the extent to which the African-Caribbean community is disproportionately disadvantaged in most, if not all, the domains of prerequisites for health.

To place this in a wider context, it is important to take into account the finding of the Acheson Report that persistent and entrenched inequality exist in the mental health provision for women, working class and old people. [4]  Acheson indicates that women have a higher rate of mortality from poor mental health and this is strongly influenced by socio-economic status. Working class men are three times more likely to commit suicide and old people are less likely to receive some health care services. [5]

Given that these entrenched inequalities already exist within the White community, it is not surprising then that the African-Caribbean community will face disproportionate disadvantage and discrimination within the mental health system. Consequently, the provision of mental health services to people from African-Caribbean communities has been the subject of growing concern, both within the African-Caribbean community, and the mental health field.

The National Institute for Mental Health in England (NIMHE) provides an excellent explanation as to why these inequalities persist given that the NHS has been in existence since 1948. [6] It points out that the British welfare state has ignored issues of discrimination. The assumption was that a range of standard services would be provided for those in need. However, evidence in reports by Townsend and Davidson and Acheson, [7] indicate that this is not the case. Both reports reveal that there are glaring inequalities in the provision of healthcare, particularly to women, old people, the working class and Black and ethnic minority groups.

NIMHE argues that this occurs because different groups of people do not start from a level playing field. [8]  We live in a society that categorises people according to a range of social divisions. These can be male, female, skin colour, age, sexual orientation or disability. It quotes Geoff Paynes who states that "it is impossible even to begin to think about people without immediately encountering 'social division.'"  We automatically perceive other human beings as being male or female, Black or White, older or younger, richer or poorer. In forming a perception of them, we place them in pigeonholes, adapting our behaviour and attitude to them in terms of the slots when we place them in.

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Historical background

Black people have lived in England since 1554. Their presence was a reflection of the trading opportunities between Britain and West Africa at that time. [9]  By the middle of the eighteenth century, in London alone, there were 18,000 Black slaves, forming nearly three per cent of an estimated population of 650,000. The influence of slavery and colonisation has left an indelible mark on African-Caribbean people by familiarising them with many aspects of British life and institutions. [10]

Fernando points out that two historical pursuits brought Europeans into contact with people living in Africa, Asia and the Americans - slavery and colonialism. These pursuits were underpinned by the ideology of "national superiority" of white people and non-white people were seen as 'less  intelligent', 'under-developed', 'primitive' and 'lacking emotion'. [11] These social values and ideologies which were present during these times permeated into psychiatry and influenced its development in various ways.

Fernando felt the disciplines of psychiatry, psychology and sociology emerged during the times when colonisation and slavery were at the peak. The views that Black people are born with inferior brains and have limited capacity for growth and that their personalities tend to be abnormal due to genetic and environmental factors were considered normal. It is hardly surprising that these forms of racism have seeped, or were actively absorbed, into the theory and practice of psychiatry.

Indeed, Fernando quotes Thomas and Sillen [12] who indicate how observations by psychiatrists in the United States during the time of slavery left little doubt that psychiatry helped to reinforce racism and justify slavery. Slaves who ran away from captivity were diagnosed as having "draptomania". The treatment was their captivity and return to bondage.

In this country, under the British Nationality Act 1948, large groups of post-war economic immigrants came from the poorer Commonwealth territories, which included the Caribbean. Under this Act, citizens of the British Commonwealth were allowed to enter Britain freely in order to find work and settle. Many chose to take this option as a result of employers and government-led recruitment schemes by, for example, London Transport and the National Health Service. Many were soon joined by their families.

Even when immigration was encouraged for economic reasons, attitudes towards the newly arrived African-Caribbean people were inconsistent. [13]  Most memorable for African-Caribbeans today, was the arrival to Britain of the ship SS Empire Windrush, in 1948, which had 500 West Indian passengers on board. They came to start a new life in Britain but a large number of them returned immediately, due to finding a hostile environment that was ill-prepared for minority groups.

However, the McCarren-Walter Act (an American Immigration Act) passed in 1952, restricted the immigration of people from the West Indies to the USA and resulted in a further 50,000 West Indians settling in Britain by 1956.

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Population size

In the latest Census 2001 the UK population was estimated at just under 59 million. The size of the minority ethnic population was 4.6 million in 2001 or 7.9 per cent of the total population. Indians were the largest minority group, followed by Pakistanis, those of mixed ethnic backgrounds, Black Caribbeans, Black Africans and Bangladeshis. The remaining minority ethnic groups each accounted for less than 0.5 per cent each but together accounted for a further 1.4 per cent of the UK population. The African Caribbean population was estimated to be 1 per cent of the 59 million. [14]

The UK population: by ethnic group, April 2001

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The African-Caribbean experience in Britain

As WHO indicates, socio-economic political factors have direct implications for one's mental health. [15] This section summarises the experiences of African-Caribbean people in the UK.

Many studies from the 1970s, 1980s and 1990s have constantly highlighted that African-Caribbean people have experienced racist insults and abuse. It is estimated that up to 20,000 African-Caribbean people suffer a physical assault each year. [16]

In the criminal justice system, African-Caribbean people are treated differently in all stages of the criminal justice system. They are disproportionately affected by the 'stop and search' policy. [17] Black African suspects are more likely than white suspects to be arrested, tried by courts and six times more likely to be in prison and be given longer sentences. [18]

In education, serious inequalities have been identified since the Department of Education and Science (DES) published the Rampton Report in 1985. [19] African Caribbean children start school at the age of five at much the same standard as the national average. By the age of 10, however most have fallen behind. Governments own figures constantly indicate African-Caribbean students achieving fewer higher grades is "considerably less than the national average".

The Rampton report stated that the curriculum failed Black males in particular and teachers had low expectations of Black children. Black boys were, and still are, over represented in school expulsions.

Media coverage of the African-Caribbean people is still frequently negative, patronising or is completely ignored. [20]

In employment, many of the descendants of the original labour migrants continue to be employed in low paid and insecure jobs and have lower wages compared to the national average. Many individuals who are in work have good or excellent qualifications. Nevertheless, many have greater difficulty than their white counterparts with the same qualification in gaining the most sought after jobs.

All these forms of discrimination (and others not discussed in this factsheet) were reinforced in 1999 with the publication of the Macpherson Report. [21] The report conducted a detailed review of the circumstances surrounding the murder of Stephen Lawrence at the request of the Home Secretary. The report confirmed what was already well known and experienced by most African-Caribbean people - the existence of institutional racism.

The report considers the various forms and manifestations of racism. Macpherson defines it as "consisting of conduct or words or practices which disadvantages or advantages people because of their colour, culture or ethnic origin."

Parekh elaborates on this definition and argues that racism involves stereotypes about difference, inferiority and the use of power to exclude, discriminate or subjucate. [22]

Macpherson [23] makes much reference to Lord Scarman's views of racism. [24] Macpherson defines institutional racism as "the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudices, ignorance, thoughtlessness and racist stereotyping, which disadvantages minority ethnic groups. Although this definition has its critics, it encapsulates the African-Caribbean experience in Britain.

African-Caribbean experiences with the mental health system

As indicated by the WHO's definition of health and the prerequisites for positive health, African-Caribbean people are disproportionately disadvantaged by most socio-economic factors. Furthermore, Fernando has already argued that the knowledge base of psychiatry grew at the same time when slavery and colonisation were at its highest. [25]

This section discusses the experience of African-Caribbeans within the mental health system.

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The criminal justice system

Under section 95 of the Criminal Justice Act 1994, the Home Secretary has a duty to publish annually any information that will enable criminal justice agencies in England and Wales to help prevent racial discrimination. Ethnic monitoring of key police activities, for example, of arrests and stop and search, became mandatory for all police forces from April 1996. [26]

In the 1980s several studies showed that Black people were more likely to be detained under section 136 of the Mental Health Act 1983. [27] By the late 1990s research into this issue, looking at both race and gender, discovered that similar worrying patterns had continued. The Mental Health Task Force Project  (a research project that was supported by the then National Health Service Executive -  a branch of the Department of Health) reported that African-Caribbean males were over-represented among those formally detained in acute inpatient units and were more likely to be 'taken to a place of safety' under section 136. It was also found that they were up to three times more likely to be sectioned than their white counterparts. [28] Black women also fare extremely badly, with a staggering 18 per cent likely to be held under this particular section, compared with just two per cent of their white counterparts. [29]

The police are involved in many mental health referrals, not just those involving section 136 of the Mental Health Act 1983 which allows them to arrest disturbed people in public places. Research has shown that the police are inconsistent in their use of this section and detain a higher proportion of Black people under it.

When asked about African-Caribbean people's entrance into hospitals on a section, in a minor survey that was carried out, consultants had responded that it was usually either through contact with the police, a general practitioner or the casualty department. This indicates that they would be placed on either a section 136 (admitted through the police) or a section 4 (as an emergency admission).
 
In contrast, Cole et al found that ethnic status did not determine whether police were involved as point of contact for people with a first episode of psychosis. [30] The significant factors associated with compulsory detention in this study were:

• living alone
• the absence of GP involvement
• the lack of a relative or friend in negotiating access to appropriate care.

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The David 'Rocky' Bennett story

David Bennett was an African-Caribbean man who suffered from schizophrenia and had been receiving treatment for his mental health for approximately eighteen years before his death. He was an inpatient at the Norvic Clinic in Cambridgeshire. As a young man, he was a talented footballer and musician. David became mentally unwell in the 1980s and was seen by a psychiatrist.

He was hospitalised on two occasions between 1980 and 1984. David had also had several episodes of being under probation, imprisonment and had a history of unprovoked assaults on both staff and patients. [31]

At the very outset of his contact with mental health services, the psychiatrist was dismissive of David and believed he was having problems due to 'cannabis intoxication'. Some years later, he was diagnosed with schizophrenia. No explanation was offered to the family to inform them of what schizophrenia was and his family was left to care for him.

David had many reports of being harassed and bullied by other patients. However, the inquiry revealed that there was no record of any action taken by staff. Black staff also experienced racism from white clients. The care David received in the community consisted only of injections. No interest was displayed by the authorities on his life, ambition, education, employment and how the family was coping.

While David was at Norvic Clinic in 1993 he wrote to the Head of Nursing Services to raise his concern about the lack of African-Caribbean staff at the clinic, as there were six or so clients on his ward during that time. He received a letter to say that there had been no application from any Black person for the previous two and a half years.

While at Norvic, David was over-medicated to an extent that his blood pressure was well below the level for his age. This got worse when David raised various issues. He was seen as a nuisance and his medication continued to be increased. His cultural, racial, social needs were not attended to. No attempt was made to engage his family in his care and treatment. No information was provided about his illness.

The staff were predominantly White and had not had much contact with Black people. Neither advocacy nor suitable recreational services were on offer.

On the evening that he died, David had been in an incident with another patient who was white. During that incident each man struck out at each other. David was also the recipient of repeated racist abuse from the other patient. After this incident, David was given some medication and moved to another ward. David questioned as to why he was the one being sent on to another ward. In an attempt to diffuse the situation, the staff nurse who was escorting him said "Well you need to."

After some time, another nurse informed David that the decision has been taken that he should stay on the other ward. David hit the nurse and was physically restrained by a number of nurses. He was taken to the floor and placed in a face down position. During the prolonged struggle he collapsed and died. David's sister Joanna Bennett launched a public campaign for a public inquiry.

The independent inquiry on David Bennett's death was set up by Norfolk, Suffolk and Cambridgeshire Health Authority after consultation with the Department of Health (DOH) in September 2002. The inquiry took detailed evidence from Norvic and from other specialists in the field of mental health. It made reference to the reports of the committee of inquiry into the death in Broadmoor Hospital of Orville Blackwood in 1993 and two other African-Caribbean patients, Michael Martin and Joseph Watts. Most of the recommendations arising out of the Orville Blackwood inquiry had simply not been acted upon.

The Bennett Inquiry made 22 recommendations. The key theme that underpinned most of these was that there should be ministerial acknowledgement of the presence of institutional racism in the mental health services and a commitment to eliminate it. [32]

The experiences of David 'Rocky' Bennett is encapsulated by the two year research conducted by the Sainsbury Centre For Mental Health. This study focussed exclusively on the mental health services received by the African-Caribbean people and is aptly named Breaking the Circles of Fear. [33] 

The study found that there are circles of fear that stop Black people from engaging with services:

1. Mainstream services are experienced as inhumane, unhelpful and inappropriate; that is, African-Caribbeans are not treated with respect and their voices not heard, services are not accessible, welcoming, relevant or well integrated with the community.
2. The manner in which African Caribbean people enter mental health services are problematic and influence the nature and outcome of treatment and the willingness of the communities to engage with services.
3. Primary care involvement is limited and community based crisis care is lacking.
4. Acute care is perceived negatively and does not aid recovery.
5. Different models of descriptions of 'mental illness' and other people's philosophies or world views are not understood or even acknowledged.
6. Service user, family and carer involvement is lacking.
7. The concept of 'culture' has been used to attempt to address some of these issues, but can divert professionals away from looking at individuals' histories, characteristics and needs.
8. Black community initiatives are not valued.

Inside Outside [34] supports most of the findings of David Bennett inquiry and Breaking the Circles of Fear. [35] It states that current mental health services place an over-emphasis on institutional and coercive models of care and professional and organisational requirements are given priority over individual needs and rights.

The above publications supported the Bennett's inquiry finding of the existence of institutional racism within mental health care. It highlights that there does not appear to be a single area of mental health care in this country in which Black people fare as well as, or better than, the majority white community. Mental Health outcomes for Black patients are shown to be poorer in terms of re-admission. GP's capacities to recognise psychiatric disorder in Black patients appear to be more limited than others. It supports other evidence, which confirms that Black groups are more likely than white people to go into specialist mental health care by coersion (that is, through either the police or the criminal justice system).

Black groups are more likely to be misunderstood and misdiagnosed and have more ECT (electro-convulsive therapy) rather than 'talking treatments'. Black clients are more likely to stay in hospital longer and less likely to have their psychological needs addressed. The rights and healthcare needs of this group are less likely to be taken seriously than white clients. Black clients are more likely to be under supervision, subject to physical treatment and are over-represented in high and medium secure settings. Their relatives feel unable to participate in treatment plans.

The census conducted by the Healthcare Commission concurred with most of the previous studies. [36] These are that African-Caribbean people are much less likely to be referred by their GP but twice as likely to be referred to mental health services by the police and the courts. This group is three times more likely to enter mental health system while detained under the Mental Health Act 1983.

Most of these findings have been highlighted by a series of research, some dating back to 1971. [37]

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The care of African-Caribbean women

African-Caribbean women often face several forms of discrimination, including sexism as well as racism. NIMHE and Parekh support this and argue that these forms of discrimination reinforce each other in a vicious circle to such an extent that it is not possible to disentangle them. [38]

Ahmed puts forward another argument. [39] He points out that white feminists have provided valuable and challenging research literature on gender in, among other areas, caring for the sick, masculanisation of medicine, the journey of being a mother and sexist nature of medical sociology. However, they are guilty of excluding the Black women's perspective.

African-Caribbean women bring distinctive insights and experience to both feminism and anti-racism. But Parekh argues that they frequently find that they have to struggle not only against sexism and racism within society generally, but also against racism within white feminists and sexism within anti-racist movements. He continues to argue that race equality initiatives benefit mainly Black men and gender equality initiatives benefit mainly White women. [40] More specifically, Women's Mental Health into the Mainstream, the latest policy initiative from the DH on women's mental health, makes only occasional reference to the views and experiences of African-Caribbean women in mental health services. [41]

Consequently, the mental health experiences of African-Caribbean women is not well researched and this group arguably finds itself being marginalised within an already marginalised group.

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Ethnic monitoring

Ethnic monitoring of hospital inpatients has only been mandatory since April 1995, and so there is currently a lack of statistics on the different treatments received by people from different ethnic groups. Outpatient monitoring is not mandatory but is encouraged.

Policy initiatives 1999 to 2006

Since the elections of the Labour Government in 1997 the Department of Health (DH) has consistently raised the profile of mental health services and published the National Service Framework (NSF). [42] Arguably, this was a momentous occasion for all those who worked and engaged with mental health services. The NSF had distinct standards. These are centred on mental health promotion, primary care and access to services, services for severe and enduring mental illness, caring for carers.

Nevertheless, this major initiative has its shortcomings. The Sainsbury Centre for Mental Health argued that the NSF was not fully resourced and paid too little attention to views of people from Black and minority ethnic groups. [43] This policy patently failed to take heed of a large amount of evidence available to them since 1971 which revealed glaring, persistent and unacceptable discrimination faced by African-Caribbean people.

In 2005, the DH released Delivering Race Equality in Mental Health Care (DRE). [44] This document draws on previously discussed publications, such as Inside Outside. [45] The key principles of DRE were threefold:

1. more appropriate and responsive services
2. community engagement
3. better information.

The DRE document states that it would support the implementation of Sir Nigel Crisp's 16-point race equality plan in the NHS. [46] This publication accepts most of the recommendations from the Bennett Inquiry but rejects the existence of institutional racism in the Mental Health Services.

The DRE relegates the existence of institutional racism to direct discrimination and indirect discrimination. By doing so, the DRE ignores the findings of Macpherson report [47] and most, if not all, the evidence available to the mental health services since the 1970s. Furthermore, the DRE fails to place into context the various forms of direct and institutional racism in the wider society.

The DRE talks about training, employment issues and the ways in which Black and minority ethnic people should be treated within mental health services. It fails to take on board the existence of institutional racism as the root cause of these deficiencies.

The DRE also implies that the very knowledge base of psychiatry is value free and culture free. It also fails to acknowledge Fernando's views that most of the values and beliefs systems inherent in psychiatry are steeped in euro-centricity. [48]

Another flaw in the DRE is that it relies heavily on the Race Relation (Amendment) Act 2000. While this may improve some of the issues faced by African-Caribbean people, there is little evidence to suggest that the Race Relations Act 1976 had any impact on clinical experience of this group within mental health services. A report form the University of Central Lancashire argues that the Race Relations (Amendment) Act 2000 has no bearing on clinical decisions. [49]

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The Mental Health Bill

The groundwork for the Bill began in 1998 with the appointment of the Richardson Committee. The Mental Health Bill was part of the government's strategy of modernising mental health law. The Bill proposed a wide definition of mental disorder, medical treatment and the definition of people suffering from "severe and dangerous personality disorder".

However, most stakeholders (most of the voluntary sector organisations, the Black mental health network, the community at large and the Royal College of Psychiatrists) criticised the Bill, and it was dropped in June 2006. The question remains as to why such a Bill would be proposed in the first instance, despite all the serious concerns that have been articulated since the 1970s. Most criticisms put forward were centred on the view that BME groups would be even more disadvantaged by the Bill than by the current Mental Health Act. [50]

The DH is currently planning to amend the existing Mental Health Act. There are anecdotal concerns that the worst elements of the Mental Health Bill could be introduced into the 1983 Act.

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Mind's Yellow Card scheme for reporting drug side effects

Mind's Yellow Card scheme was based on the official scheme used by doctors, dentists, pharmacists and nurses to report suspected adverse drug reactions to the then Medicines Control Agency, the UK regulator. Mind introduced their own scheme for people taking psychiatric drugs rather than health professionals. It invited people to report side effects and other aspects of their treatment. The scheme showed how unpleasant, disabling and in some cases even life-threatening the side effects of psychiatric drugs can be. It highlighted the need for better information provision, more say for people in their treatment, and support for managing withdrawal.

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The Bennett Inquiry recommendations

The inquiry has made a number of recommendations in its report. [51] The main ones are:

1. All who work in mental health services should receive training in cultural awareness and sensitivity.
2. All managers and clinical staff, however senior or junior, should receive mandatory training in all aspects of cultural competency, awareness and sensitivity. This should include training to tackle overt and covert racism and institutional racism.
3. All training referred to in points 1 and 2 above should be regularly updated.
4. There should be Ministerial acknowledgment of the presence of institutional racism in the mental health services and a commitment to eliminate it.
5. There should be a National Director for Mental Health and Ethnicity similar to the appointment of other National Directors, appointed by the Secretary of State for Health to oversee the improvement of all aspects of mental health services in relation to the Black and minority ethnic communities.
6. All mental health services should set a written policy dealing with racist abuse, which should be disseminated to all members of staff and displayed prominently in all public areas under their control. This policy should be strictly monitored and a written record kept of all incidents in breach of the policy. If any racist abuse takes place by anyone, including patients in a mental health setting, it should be addressed forthwith and appropriate sanctions applied.
7. Every Care Programme Approach care plan should have a mandatory requirement to include appropriate details of each patient's ethnic origin and cultural needs.
8. The workforce in mental health services should be ethnically diverse. Where appropriate, active steps should be taken to recruit, retain and promote Black and minority ethnic staff.
9. Under no circumstances should any patient be retrained in a prone position for a longer period than three minutes.
10. A national system of training in restraint and control should be established as soon as possible and, at any rate, within twelve months of the publication of this report.
11. The Department of Health should collate and publish annual statistics on the deaths of all psychiatric inpatients. This should include ethnicity.
12. All medical staff and registered nurses working in the mental health services should have mandatory first-aid training, including CPR training.
13. Records should be kept of all psychiatric units use of control and restraint on patients. The Department of Health should audit the use of control and restraint.
14. There is an urgent need for a wide and informed debate on strategies for the care and management of patients suffering from schizophrenia who do not appear to be responding positively to medication and the inquiry recommend that the Department of Health monitor this debate in order to ensure that such strategies are translated into action at the earliest possible moment.
15. All medical staff in mental health services should have training in the assessment of people from the Black and minority ethnic communities with special references to the affects of racism upon their mental wellbeing.
16. All patients in the mental health services should be entitled to an independent NHS opinion from a second doctor of their choice, in order to review their diagnosis and/or care plan. If a patient, by reason of mental incapacity, is unable to make an informed decision, their family should be entitled to make it for them.
17. The question of detention in, and treatment of, patients in secure accommodation should be reconsidered in order to ensure that no patient is detained in such accommodation unless it is necessary, and that the period of each detention and the treatment be kept constantly under review.
18. The Department of Health should examine, with the Department of Social Security, possible modifications to State financial assistance from the state.
19. All psychiatric patients and their families should be made aware that patients can apply to move from their current hospital to another one for good reason, which includes such matters as easier access by their family, a greater ethnic mix, or a reasoned application to be treated by other doctors. All such applications should be recorded. They should not be refused without providing the applicant and their family with written reasons.
20. There is a need to review the procedures for internal inquiries by hospital trusts following the death of psychiatric patients with emphasis on the need to provide appropriate care and support principally for the family of the deceased, but also for staff members.
21. There is a need for medical personnel caring for detained patients to be made aware, through appropriate training, of the importance of not medicating patients outside the limits prescribed by law and the need for more regular and effective monitoring to support the work undertaken by the Mental Health Act Commission in this field.
22. It is vital to ensure that the recommendations of this inquiry inform all relevant parties, including the development of a Black and minority ethnic mental health strategy.

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Useful Publications

Mind factsheets
Available from www.mind.org.uk or call the MindinfoLine for a printed copy.)

The Mental Health of Chinese and Vietnamese People in Britain
The Mental Health of Irish-Born People in Britain
The Mental Health of the South Asian Community in Britain.
Public Attitudes to Mental Distress
Statistics one: How common is mental distress?
Statistics two: Suicide
Statistics three: Race, culture and mental health
Statistics four: The Mental Health Act 1983
Statistics five: The financial aspects of mental distress
Statistics six: The social context of mental distress
Statistics seven: Treatments and services for people with mental health problems
Statistics eight: The Criminal Justice System

Useful websites

www.cre.gov.uk
The Commission for Racial Equality

www.nimhe.csip.org.uk
National Institute for Mental Health

www.yellowcard.gov.uk
Medicines and Healthcare products Regulatory Agency site for anyone to report side effects of medicines.

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Appendix

Black and Minority Ethnic Mental Health Programme

The NIMHE Black and Minority Ethnic Mental Health programme is the largest of NIMHE programmes. The programme aims to improve the mental health care of all people of Black and minority ethnic (BME) status, including those of Irish or Mediterranean origin and east European migrants. This action plan has the potential to improve the care for any group affected by disparity in health and healthcare, including BME older people, children and adolescents, refugees and asylum seekers.

The aims of the NIMHE BME programme are to:

• Enhance the quality of life, challenge exclusion through improved mental health services and health outcomes.
• Develop appropriate training and support to staff to deliver culturally competent services, with confidence.
• Enhance, or build capacity within, Black and minority communities and the voluntary sector to deal with mental health and mental ill health.
• To ensure compliance with statutory obligations: RR(A)Act 2000, Human Rights Act 1998.

The focus of the Black and minority ethnic mental health (BME MH) programme is Delivering Race Equality (DRE)

Delivering Race Equality (DRE) in Mental Health care is a five year action plan for achieving equality and tackling discrimination in mental health services in England. Equality in mental health services is not a new requirement. Many of the actions described in DRE have their roots in existing legislation, guidance or initiatives. DRE pulls them all together, sets them in a mental health context, and adds the key, focused activity that is needed now to ensure rapid delivery. Specifically Delivering Race Equality is designed to deliver on three key aims:

• equality of access
• equality of Experience
• equality of outcomes.

The five year vision

The five year vision for DRE is that by 2010 mental health services should be characterised by:

• less fear of mental health services among BME communities and service users
• increased satisfaction with services
• a reduction in the rate of admission of people from BME communities to psychiatric inpatient units
• a reduction in the disproportionate rates of compulsory detention of BME service users in inpatient units
• fewer violent incidents that are secondary to inadequate treatment of mental illness
• a reduction in the use of seclusion in BME groups
• the prevention of deaths in mental health services following physical intervention
• more BME service users reaching self-reported states of recovery
• a reduction in the ethnic disparities found in prison populations
• a more balanced range of effective therapies, such as peer support services and psychotherapeutic and counselling treatments, as well as pharmacological interventions that are culturally appropriate and effective
• a more active role for BME communities and BME service users in the training of professionals, in the development of mental health policy, and in the planning and provision of services
• a workforce and organisation capable of delivering appropriate and responsive mental health services to BME communities.

Key people
Programme Director: Professor David Sallah
Project Support: Martin Teff

Race equality leads
New regional race equality leads will provide local leadership for the DH and NIMHE BME programmes, including this action plan. They will develop and implement race equality within NIMHE and regional and local services, as well as providing leadership and mentoring to community development workers in their areas.

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Footnotes

[1] Dominelli, L, 1988, Anti-racist social work, London: McMillan.
[2] The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books.
[3] World Health Organisation (WHO), 1986, Health and Welfare, Canada: Canadian Public Health Association.
[4] Acheson, D, 1998, Independent Inquiry into Inequalities in Health Report, London: The Stationery Office.
[5] Acheson, D, 1998, Independent Inquiry into Inequalities in Health Report, London: The Stationery Office.
[6] National Institute for Mental Health in England (NIMHE), 2002, Anti-discriminatory practice, London: NIMHE.
[7] Acheson, D, 1998, Independent Inquiry into Inequalities in Health Report, London: The Stationery Office; Townsend, P and Davidson, N, 1979, (ed), Inequalities in Health: The Black Report, London: Penguin.
[8] National Institute for Mental Health in England (NIMHE), 2002, Anti-discriminatory practice, London: NIMHE.
[9] Fryer, P, 1984, Staying Power: The History of Black People in Britain, London: Pluto Press.
[10] The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books.
[11]  Fernando, S, 1989, Race and Centre in Psychiatry, London:Tavistock/ Routledge.
[12]  Thomas, A and Sillen, S, 1972, Racism and Psychiatry. Brunner/Mazel, New York.
[13]  Hiro, D, 1991, Black British, White British: A History of Race Relations in Britain, London: Grafton.
[14] http://www.statistics.gov.uk/cci/nugget.asp?id=273 Accessed 10/08/2006.
[15]  World Health Organisation (WHO), 1986, Health and Welfare, Canada: Canadian Public Health Association.
[16] The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books; Modood, T and  Berthoud, R, 1997, Ethnic Minorities in Britain - Diversity and Disadvantage, London: Policy Studies Institute.
[17]  Mooney, J and Young, J, 1999, Social Exclusion and Criminal Justice: Ethnic Communities and Stop and Search in North London.
[18] The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books.
[19]   Department of Education and Science 1985, Education for all: The report of the Committee of Inquiry into the Education of Children from Ethnic Minority Groups, Cmnd 9453, London: HMSO.
[20] The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books.
[21]   Macpherson of Cluny, Sir William, 1999, The Stephen Lawrence Inquiry, London: The Stationery Office.
[22] The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books.
[23]  Macpherson of Cluny, Sir William, 1999, The Stephen Lawrence Inquiry, London: The Stationery Office.
[24] Scarman Report, 1981, The Brixton disorder 10-12 April 1981, London: Penguin Books.
[25]  Fernando, S, 1989, Race and Centre in Psychiatry, London: Tavistock/ Routledge.
[26]  CRE, 1997, Criminal Justice in England and Wales Factsheet, London: CRE.
[27]  Department of Health and Home Office, 1992, Services for people from Black and Ethnic Minority Groups - Issues of Race and Culture: A Discussion Paper, London: DOH.
[28]  Smaje, C, 1995, Health "Race" and Ethnicity: Making Sense of the Evidence, London: Kings Fund.
[29] Browne, D, 1997, Black People and Sectioning - The Black Experience of
Extension under the Civil Sections of the Mental Health Act.
[30] Cole, E, Leavey, G, King, M, Johnson-Sabine, E and Hoar, A, (1995) 'Pathways to care for the patients with a first episode of psychosis: a comparison of ethnic groups', British Journal of Psychiatry, 167, 770-776.
[31]  Norfolk, Suffolk and Cambridgeshire Health Authority, 2003, Independent Inquiry into the Death of David Bennett. Cambridge. Cambridgeshire Health Authority.
[32] Norfolk, Suffolk and Cambridgeshire Health Authority, 2003, Independent Inquiry into the Death of David Bennett. Cambridge. Cambridgeshire Health Authority.
[33] Sainsbury Centre for Mental Health, 2002, Breaking the Circles of Fear, London: SCMH.
[34] National Institute for Mental Health in England (NIMHE), 2003, Inside Outside: Improving Mental Health Services for Black and Minority Ethnic Communities in England, London: NIMHE.
[35] Sainsbury Centre for Mental Health, 2002, Breaking the Circles of Fear, London: SCMH.
[36] Healthcare Commission, 2005, Count me in - results of a national census of inpatients in mental health hospitals and facilities in England and Wales, London: Healthcare Commission.
[37] Bagley, C, 1971, 'Mental Illness in Immigrant Minority in London', Journal of BioSocial Science, Vol 3 (449-59); Browne, D, 1997, Black People and Sectioning - The Black Experience of Extension under the Civil Sections of the Mental Health Act; Cochrane, R and Bal, S, 1989, 'Mental Hospital Admission Rates for Immigrants to England: A comparison of 1971 and 1987', Social Psychiatry Vol 24 (11); Fernando, S, 1989, Race and Centre in Psychiatry, London:Tavistock/ Routledge; Harrison, G et al. 1988, 'A prospective study of service mental disorder in Afro-Caribbean patients', Psychological Medicine, Vol 18, pp 643 - 657; Littlewood, R, Lipsedge, M., 1988, Aliens and Alienists, Ethnic minorities and Psychiatry, London: Unwin; McGovern, D and Cope, R, 1987, 'The compulsory detention of males of different ethnic groups, with special reference to offender patients', British Journal of Psychiatry, Vol 150, pp 505-512.
[38] National Institute for Mental Health in England (NIMHE), 2002, Anti-discriminatory practice, London: NIMHE; The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books.
[39] Ahmed, WSU, (ed.), 1993, 'Race and Health in Contemporary Britain, Buckingham: OU Preston.
[40]  The Parekh Report, 2002, The Future of Multi-ethnic Britain, London: Profile Books.
[41] Department of Health (DH), 2002, Women's Mental Health: Into the Mainstream Strategic Development of Mental Health Care for Women, London: DH.
[42] Department of Health (DH), 1999, National Service Framework for Mental Health, London: DH.
[43] Sainsbury Centre for Mental Health, 1999, The National Service Framework for Mental Health: An Executive Briefing 8, London: SCMH.
[44] Department of Health (DH), 2005, Delivering Race Equality in Mental Health Care: An Action Plan for Inside and Outside Services, London: DH.
[45] National Institute for Mental Health in England (NIMHE), 2002, Anti-discriminatory practice, London: NIMHE.
[46] Department of Health (DH), 2005, Delivering Race Equality in Mental Health Care: An Action Plan for Inside and Outside Services, London: DH.
[47] Macpherson of Cluny, Sir William, 1999, The Stephen Lawrence Inquiry, London: The Stationery Office.
[48] Fernando, S, 1989, Race and Centre in Psychiatry, London: Tavistock/ Routledge.
[49] University of Central Lancashire, 2000, Mental Health Act National Consultation on Mental Health Issues and Black and Minority Ethnic Communities, Regional Report for Greater Manchester, Preston, University of Central Lancashire.
[50] Foolchand, M.K, 2004, 'Equality before the law', Community Care 22-28, January. Community Care Journal. London. See Appendix 1 for more information on DRE.
[51] Norfolk, Suffolk and Cambridgeshire Health Authority, 2003, Independent Inquiry into the Death of David Bennett. Cambridge. Cambridgeshire Health Authority.

This factsheet was written by Navin Foolchand, November 2006.