Delivering race equality in mental health services
Early intervention in psychosis
Implementation of early intervention in psychosis (EIP or early intervention) teams is now mandatory in all mental health trusts in England. Where properly funded and resourced, these teams are not only reducing the duration of untreated psychosis, but are also returning young people to meaningful social roles in the family and community, and getting them back into school, college, training and employment. Early findings (as yet unpublished) from a London-wide survey of which I am Project Lead suggest good uptake of early intervention services by Black and minority ethnic users, but this needs to be documented by ethnic monitoring.
The Learning and Skills Council (2006) is committed to improving services for people with mental health difficulties by building service capacity, boosting the demand for learning, monitoring quality and raising achievement levels. Over the next 2 years, nine regional networks in England will work to promote and improve access to learning and skills for people with mental health difficulties, including those with intellectual disabilities. Mental health professionals need to take up the opportunity for partnership with further education providers, given the political will that now exists. There is a particular focus on training that can lead to employment. If early intervention services engage effectively and consistently with local further education colleges, the trend noted in recurrent census surveys of adverse care pathways for Black and minority ethnic service users may well be reversed.
Improving access to talking therapies and safe in-patient environments
Access to talking therapies should be a matter of right for all service users, but shortages of psychotherapists and counsellors are common on mental health units. The government has signalled new investment (?170 million; Her Majesty’s Treasury, 2007) in England and Wales to shorten waiting lists, with PCTs acting as centres of excellence and local demonstration sites (‘beacon sites’) for the provision of cognitive–behavioural therapy (CBT) (http://www.mhchoice.csip.org.uk/psychological-therapies.html). This should lead to better provision of psychological therapies for Black and minority ethnic groups, but current research shows that adequate access to services does not suffice. For example, the evidence shows low engagement and high drop-out for Black service users diagnosed with schizophrenia who are offered a brief CBT package (Rathod et al, 2005). The reasons for this are currently being evaluated, but all clinicians need to contribute to documenting which therapeutic interventions are most effective in engaging patients from Black and minority ethnic groups. I wonder whether brief (six-session) focused CBT would be sufficient to address the more complex needs of some of these patients. I would suggest that successful treatment also requires connection with the patient’s value and meaning systems, including religious belief.
Good practice identified in acute care forums in NHS trusts should be harnessed and cascaded (Box 2Go). For example, all in-patient nurses should be expected to use therapeutic observations of patients at clinical risk, and also have access to regular supervision.
Box 2 Nurse therapists
In Enfield, a skilled nurse therapist runs cognitive–behavioural therapy training groups for nurses from in-patient units in Chase Farm Hospital. Nurses that have taken up these skills have been empowered to engage much more successfully with patients, including those from Black and minority ethnic groups, improving their treatment experience and outcomes.
L. Parry, Barnet Enfield Haringey NHS Trust, personal communication, 2008
The pathway to forensic care
As Medical Advisor in Mental Health in NSCAG in 2006, I had responsibility for the national adolescent forensic mental health services, and liaison work with the Youth Justice Board of the Home Office. I have become increasingly aware that individuals in young offender institutions, prisons and probation services, where Black and minority ethnic groups are overrepresented, still have inadequate access to good mental healthcare. Services exist in ‘silos’, often with barriers to good communication. These organisational barriers, and a lack of appropriate resources to ensure continuity of care plans, make transitions between services, particularly between different age groups, fraught with risks for patients. In interdepartmental meetings, I was informed that senior Home Office staff feel that health and social care services do not provide good aftercare for offenders, regardless of their ethnicity, following discharge from custody. As a result, people get sucked back into old patterns that lead to a return to offending behaviour.
Adult medium secure services find it difficult to offer timely in-patient assessment and treatment of offenders with mental illnesses, as beds are blocked by a lack of step-down high-dependency units in the community to which patients still requiring high levels of supervision and support can be appropriately and safely discharged. Also, the Policy Division of the Youth Justice Board identified a pattern of more punitive sentencing by the judiciary of young Black men, given similar patterns of offences (Bill Kerslake, Head of Policy, Youth Justice Board, personal communication, 2006). In this context, the needs of Black and minority ethnic offenders tend to get lost. Good practice examples are, however, to be found (Box 3Go).
Box 3 Taking a stand against stereotyping
At a care programme approach (CPA) discharge planning review meeting for a young Black man who had turned 18 and was to leave a forensic secure adolescent unit, the clinician noted that her team wanted to assign a high-risk rating, despite the fact that the man had displayed no aggressive behaviour during his 3-year stay. He had also made good educational progress. She argued for a more realistic, and lower, risk rating. She believed that her staff had been unjustifiably intimidated by the man’s large build and ethnicity.