BMJ  2004;329:363-364 (14 August), doi:10.1136/bmj.329.7462.363

Editorial

Delivering mental health services for a diverse society

We need to marry policy and practice

The presentation, management, and outcome of mental disorders differ between ethnic groups.^{1-3 w1} The most consistent findings are that African-Caribbeans with mental health problems are disproportionately found in forensic, psychiatric, and prison populations and among compulsorily detained patients.^{2 3} They are more likely to receive antipsychotic medication and less likely to be offered psychotherapy.^{4-5 w2} Rates of suicide are also higher among some South Asian women and young people of Caribbean origin.⁶ These disparities have several causes, but it is difficult not to consider the lack of a coordinated and effective response to them as evidence of institutional racism in mental health and allied services.^{7-8 w3} In response to the disparities and the demands of service users for action,⁹ the Department of Health recently launched two policy frameworks: Inside Outside, a new strategy for England,¹⁰ and a consultation document, Delivering race equality: a framework for action.¹¹ Unfortunately these two documents differ in their focus and emphasis.

Two frameworks and two approaches

The publication of Inside Outside represents a landmark in mental health care in the United Kingdom and was developed over two years of extensive consultation with stakeholders. It takes an antidiscriminatory stance and aims to reduce and eliminate ethnic inequalities in the service users' experience of mental health services and clinical outcomes, develop a mental health workforce that is capable of delivering effective mental health services to a diverse population, and build capacity within communities for dealing with mental illness by deploying 500 community development workers. A cultural capability framework aims to tackle institutional discrimination while motivating and educating the workforce to improve clinical practice with diverse cultural groups.^w4

Delivering race equality was expected to be the implementation guide to Inside Outside. However, it has changed the emphasis from clinical effectiveness and equity to strategic and organisational change. In Delivering race equality, the need to be compliant with the Race Relations (Amendment) Act is expected to convince trusts to tackle disparities.^{11 w5} The document identifies three priorities as the building blocks for service change: ethnic monitoring, appropriate and responsive services, and community engagement. It also promotes training in race relations. The emphasis on race as a focus of reform may well cause problems. It could narrow the aspirations of service developers so that they target racial equality while ignoring the diverse needs of different cultural groups within a racial group. It may encourage outdated race based solutions where more subtle cultural interactions are the key to solving problems. It also runs the risk of excluding white minority groups such as the Irish. It provides no explicit guidance on how to improve clinical services. Stakeholders are requested to offer their opinions on barriers to improvement in care and the types of services they would consider helpful in three areas: acute inpatient care, pathways to care, and prevention of suicide.

During the preparation of Inside Outside, extensive consultations were completed. Delivering race equality therefore runs the risk of producing consultation fatigue and giving the impression that the views of ethnic minorities were not taken on board initially, as the findings of Inside Outside have yet to be implemented. Users of services who come from ethnic minorities want and demand change in NHS provision. They may see Delivering race equality as another strategic plan that fails to have any obvious clinical impact.

Clinical effectiveness and cultural capability

The surgeon general's report from the US Department of Health and Human Services gave recommendations for both policy and practice, based on comprehensive analysis of the international literature.⁵ In the United States policy moved towards a health promotion model and included culturally competent practitioners, integration between primary and secondary mental health care, and tackling stigma and discrimination.^{5 w4} Marrying the strategic direction of Delivering race equality with changes in organisation and clinical practice of Inside Outside is crucial. The organisational changes promoted by both policy frameworks and the drive towards better data on disparities in Delivering race equality are welcome. Better data on the effectiveness of different clinical approaches for distinct cultural groups are needed to support future policy and service initiatives. But how data or organisational changes will change practice without specific workforce development is difficult to see.

The cultural capability framework in Inside Outside could deliver this by promoting education and development of skills in the organisational context of antidiscriminatory practice. Cultural capability entails an antidiscriminatory approach to evidence based practice, development of clinical skills so that practitioners can work in culturally acceptable ways despite the absence of specific evidence, and the delivery of an organisational environment that does not promote institutional disparities. In this light an action plan to motivate and then equip professionals with the necessary skills seems vital in order to eradicate inequalities. Clear guidance on individual as well as institutional change will be required to translate both policy documents into action that addresses inequalities in provision of service.

Institute of Community Health Sciences, Queen Mary University of London, London E1 4NS (k.s.bhui{at}qmul.ac.uk)

Royal Free and University College School of Medicine, University College London, London NW3 2PF

Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT

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Additional references w1-w5 appear on bmj.com

Competing interests: KB was part of the external reference group for Inside Outside and contributed a paper on cultural capability but did not write the strategy.

References

1. Cochrane R, Sashidharan S. Ethnicity and health: reviews of the literature and guidance for purchasers in the areas of cardiovascular disease, mental health, and haemoglobinopathies. York: University of York, 1996: 105-26 (part 3).
2. Bhui K, Stansfeld SA, Hull S, Priebe S, Mole F, Feder G. Ethnic variations in pathways to specialist mental health care: a systematic review. Br J Psychiatry 2003;182: 5-16.[Free Full Text]
3. Coid J, Petruckevitch A, Bebbington P, Brugha T, Bhugra D, Jenkins R, et al. Ethnic differences in prisoners. 1: criminality and psychiatric morbidity. Br J Psychiatry 2002;181: 473-80.[Abstract/Free Full Text]
4. McKenzie K, Samele C, Van Horn E, Tattan T, Van Os J, Murray R. Comparison of the outcome and treatment of psychosis in people of Caribbean origin living in the UK and British Whites. Report from the UK700 trial. Br J Psychiatry. 2001;178: 160-5.[Abstract/Free Full Text]
5. US Department of Health and Human Services. Mental health: culture, race, and ethnicity—a supplement to mental health: a report of the surgeon general. Rockville, MD: US Department of Health and Human Services, Substance, Abuse and Mental Health Services Administration, Center for Mental Health Services, 2001.
6. Raleigh VS. Suicide patterns and trends in people of Indian subcontinent and Caribbean origin in England and Wales. Ethnicity Health 1996;1: 55-63.[Medline]
7. De Wildt G, Gill P, Chudley S, Heath I. Racism and general practice—time to grasp the nettle. Br J Gen Pract 2003;53: 180-2.[Medline]
8. Bhopal R. Racism in medicine. The spectre must be exorcised. BMJ 2001;322: 1503-4.[Free Full Text]
9. Trivedi P. Racism, social exclusion and mental health: a black user's perspective. In: Bhui K, ed. Racism and mental health. London: Jessica Kingsley, 2002: 71-88.
10. National Institute of Mental Health-England. Inside outside. Improving mental health services for black and minority ethnic communities. London: DoH, 2003. www.nimhe.org.uk/downloads/inside_outside.pdf (accessed 16 Feb 2004).
11. Department of Health. Delivering race equality: a framework for action. London: DoH, 2003. www.doh.gov.uk/deliveringraceequality/77951-del_race_equality.pdf (accessed 16 Feb 2004).

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This article has been cited by other articles:

• McKenzie, K., Bhui, K. (2007). Better mental healthcare for minority ethnic groups moving away from the blame game and putting patients first: Commentary on... Institutional racism in psychiatry. Psychiatr. Bull. 31: 368-369 [Full text]  
• Bouch, J., Jackson, R. (2005). Continuing professional development: the College and the members. Psychiatr. Bull. 29: 154-156 [Full text]  

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