Institutional racism in mental health careBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39163.395972.80 (Published 29 March 2007) Cite this as: BMJ 2007;334:649
- Kwame McKenzie, honorary consultant ()1,
- Kamaldeep Bhui, professor of cultural psychiatry and epidemiology2
- 1Barnet Enfield and Haringey Mental Health Trust, St Anne's Hospital, London N15 3TH
- 2Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary's School of Medicine and Dentistry, London EC1M 6BQ
Last week, the Healthcare Commission reported the findings of the “Count me in” one day census of National Health Service hospitals, private mental health hospitals, and learning disability units.1 It makes grim reading for people of African and Caribbean origin living in England and Wales.
The survey of 32 023 inpatients on mental health wards in 238 NHS and private healthcare hospitals reported that 21% of patients were from black and minority ethnic groups, although they represent only 7% of the population. Rates of admission were lower than average in the white British, Indian, and Chinese groups, but three or more times higher than average in black African, black Caribbean, and white and black Caribbean mixed groups. Not only were people in these three groups more likely to be admitted to hospital, but those in hospital were 19-39% more likely to be admitted involuntarily. Once in hospital, people who defined themselves as black Caribbean had the longest stay.1
Though high incidence rates of severe mental illness have been reported in people of African and Caribbean origin, admission rates reflect the prevalence of an illness. National community based prevalence studies have not found high rates of psychosis or other serious mental illnesses that could account for these findings.2 Moreover, increased incidence and prevalence of mental illness has been reported in some groups of South Asian origin,2 but the Count me in census does not report a corresponding increase in admission rates.
The survey of people with learning disabilities comprised 4609 inpatients from 124 hospitals. Only 11% were from black and minority ethnic groups. Rates of admission were lower than average in the South Asian, other Asian, white, and Chinese groups, but again they were two to three times higher than average in some “black” groups (black Caribbean, white and black Caribbean mixed, and other black groups). However, unlike inpatients with mental health problems, no ethnic differences were seen for involuntary admissions.1
The results add to the increasing evidence of ethnic differences in the treatment of mental illness.3 4 Some black and minority ethnic groups are less likely to be offered psychotherapy, more likely to be offered drugs, and more likely to be treated by coercion, even after socioeconomic and diagnostic differences are taken into account.5 6 7
These disparities reflect the way health services offer specific treatments and care pathways according to racial group, and therefore seem to satisfy the well established and widely known definition of institutional racism (box).
Definition of institutional racism
The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. This can be seen or detected in processes, attitudes, and behaviour that amount to discrimination through unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping which disadvantages people in ethnic minority groups8
The recent public discourse on institutional racism followed the inquiry into the handling of the murder of Stephen Lawrence by London's Metropolitan Police. The report found no evidence of direct discrimination, but it did find that police policies as a whole resulted in differential treatment for white and black people. The inquiry team offered the concept of institutional racism as a useful way of looking at and tackling racism at the level of individual organisations, and it challenged “every institution to examine their policies and the outcomes of their policies and practices to guard against disadvantaging any section of our communities.”8
This examination has been a painful process for some public services. For instance, in a recent discourse about institutional racism in mental health services, allegations of racism produced four stereotyped responses.9 They reflect the way that individuals and systems manage the emotions that the term engenders, rather than strategies to improve services for those faced with race based disparities.
The first response is to shoot the messenger. People who claim that institutional racism is rife in public services are considered to be overstating the problem because of a chip on their shoulder or to be seeking a privileged ethical position without the necessary evidence. The second response is to misunderstand the message. Despite well established guidance that institutional racism is about systems and not individual prejudice, some people respond by taking offence as if they are being called racists. The third is to focus discussions on whether racism is intentional rather than focusing on the disparities, thereby vindicating all inequity if no proof of intent is found. The last response is to ignore the urgency of the problem and to ask for more research, while proposing no remedial action for demonstrated disparities.
In contrast, once the existence of institutional racism in mental health care is accepted, progress can be made to understand and tackle the causes of racial disparities. For instance, it has led to the development of “Delivering race equality,”10 a systems level approach to improving mental health services.
Delivering race equality could improve services, but leadership is needed to ensure that it is taken up. A recent survey by the Healthcare Commission found that only a minority of trusts scored highly on its implementation.11 Moreover, fewer than half of the required number of community development workers—who were meant to be the backbone of improvement—have been recruited across the NHS, even though the money has been available since 2004.1 12
Delivering race equality may have some impact on disparities in involuntary admissions, but because such admissions reflect the combined actions of the criminal justice system, social services, and education, a strategy based in mental health services alone is unlikely to be sufficient. There is also a danger that its impact will be undermined by other government policy. The proposed amendments to the Mental Heath Bill that are making their way through parliament are likely to increase disparities in involuntary admission rates for black and minority ethnic groups, and the government has largely ignored its advisers on this subject.13
There are also wider questions about whether treatment is being offered and delivered effectively. It is surprising that, despite the race relations amendment act,14 National Institute for Health and Clinical Excellence guidelines do not have a formal impact assessment for race equality. It is unclear whether practitioners following these guidelines are offering culturally competent care.
The Count me in census and other research indicate that institutional discrimination does occur and that services have some way to go before they meet the challenges of our multicultural society. Delays in setting up ways to deal with disparities, delays in implementing guidance, and delays in developing appropriate and responsive services cause institutional racism.
People who think that claims of institutional racism may harm patient care should be aware that until disparities and remedial action were seen through this lens no strategy existed for improving mental health services for black and minority ethnic groups.3 9 10 If the concept of institutional racism had been more widely accepted and acted on, the Department of Health might not now be facing a formal investigation by the Commission for Racial Equality.15
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.