The greater involvement of police services and the criminal justice system in "the management of black versus white patients" must be confronted before the Mental Health Act is reformed, argue the Synergi Collaborative Centre.
Ethnic minority people have a greatly increased risk of being detained under the Mental Health Act. For example, the most recent analyses by Synergi, which compiled data collected over several decades, showed that Black Caribbean people are almost three and a half times more likely than White people to experience compulsory admission under the powers of the Mental Health Act, over and above the more than five-fold greater risk of receiving a diagnosis of schizophrenia in the first place.
"The review mistakenly portrays the operation of ethnic inequalities within mental health services as of a similar nature and extent to that in other domains of life when this is simply not the case."
Similarly, Black African people are just over three times more likely to experience a compulsory admission than White people, again over and above their almost six-fold greater risk of receiving a diagnosis for schizophrenia.
These inequalities are extraordinarily large – there are very few other examples that even come close to this level of difference in risk of illness or in adverse pathways through care. (See for example the less than 50 per cent greater risk of heart disease that South Asian people are said to experience, and the great public health focus on this). And these inequalities have been persistent over many decades.
It is not surprising, then, that ethnic inequality was part of the context that motivated Prime Minister Theresa May to implement at the end of 2017 a review of the Mental Health Act, which reported just 12 months later in early December 2018. Indeed, these inequalities are something that the review described as ‘unacceptable’ with Simon Wessely, the chair of the review, describing the eight-fold greater likelihood of Black patients compared with ‘those of white heritage’ to be subjected to the relatively recently introduced Community Treatment Orders as a ‘painful expression’ of black people’s greater risk of compulsory treatment.
With this set-up to the review and its report claiming that its recommendations would help redress this inequality, it comes as a surprise to discover (on closer examination) that the recommendations contain nothing that is likely to make a difference to these ‘unacceptable’ inequalities.
False hopes raised
The review had the positive aspiration to move towards a rights-based approach, and its recommendations also contain many positive objectives, such as the provision of more patient-centred care, including rights to a second opinion, to appeal detentions, to have advance directives on treatment preferences, to challenge treatment plans and to have a nominated independent advocate.
However, the use of the ‘rights’ vocabulary here conflates an approach to care that promotes rights after detention with rights to not be detained in the first place and to have access to alternative forms of care - the former being the focus with nothing to address the latter. So, although appearing to be positive (if partial) moves towards a more therapeutic approach, none of this addresses the over-representation of ethnic minority people detained under the powers of the Mental Health Act. One commentator has claimed that ‘This Review has raised false hopes in the minds and hearts of many black people’.
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To make a difference to ethnic inequalities the review would have needed to thoroughly consider the causes for this inequality, something that it did not do. And although the review bravely raises questions of racism and discrimination, simply naming the problem doesn’t lead to an effective understanding of its nature, nor identify ways to address it. Indeed, the review does nothing meaningful to consider how racism within mental health services might be addressed.
This lack of consideration is reflected in recommendations that don’t move beyond existing widespread practices, with their focus on unconscious bias training and the development of competency frameworks and audits. Indeed, the review mistakenly portrays the operation of ethnic inequalities within mental health services as of a similar nature and extent to that in other domains of life when this is simply not the case.
It is within mental health services that these inequalities are most stark, even more so than in criminal justice. And the review’s suggestions in relation to staff training and monitoring will simply not address these fundamental issues. There is more than unconscious bias involved. Institutional racism and its relationship with broader, structural racism cannot be addressed by a focus on the individual practitioner who is working within these contexts.
It is of concern, to us at least, that some commentators have claimed that the final report of the review ‘ignores’ suggestions submitted in relation to the impact of racism on ethnic inequalities. Patrick Vernon is reported by Mental Health Today to have said “if we get the law right for black people, we get it right for everyone”. Unfortunately, the review has turned this on its head; the recommendations for everyone don’t address the inequalities faced by ethnic minority people. It avoids tackling structural and institutional sources of ethnic inequality.
Structural and institutional causes
In the process of taking the reform of the Mental Health Act to the next stage, we urge a thorough consideration of the factors that lead to the over-representation of ethnic minority people detained under the Act. Structural and institutional factors are fundamental causes of these inequalities, and investigating such causes requires a different approach to that taken by the review. This includes rethinking the limited time and resources allocated to the review, its objectives and terms of reference, which fail to consider wider determinants, and its recommendations, which fail to seek a preventive rather than ameliorative remedy.
This requires a careful conceptualisation of the problem, the systematic collection of comprehensive evidence and a wide and deep consultation with those ethnic minority people with lived experience who have expertise on how these inequalities operate within and outside of mental health systems. For instance, there is the greater involvement of police services and the criminal justice system in the management of Black versus White patients. Also, groups such as the National Survivor User Network (NSUN) have clearly indicated their willingness to constructively participate.
We urge that these factors are considered in the reform of the Act to directly address this profound and large inequality. Addressing them is a vital next step if the Prime Minister’s stated ambitions to address ethnic inequalities are to be achieved.