A missed opportunity to address ethnic inequalities

In the foreword to the highly anticipated 2021 White Paper on Reforming the Mental Health Act, the Secretary of State for Health and Social Care and the Secretary of State for Justice and Lord Chancellor state: ‘We will take action to tackle the disproportionate number of Mental Health Act detentions of people from BAME backgrounds.’

We welcome the recognition of these large and persistent inequalities as a major area of concern and one that requires action as part of the reform of the Mental Health Act. Yet closer inspection reveals that there is little of substance in the White Paper supporting this commitment. Recommendations for actions to make this happen are virtually non-existent.

The evidence to demonstrate why action in this area is essential is well known and, sadly, easy to recite. One example is that compared with White people, Black people:

  • Are more than five times as likely to receive a diagnosis of schizophrenia;
  • Over and above this increased risk of diagnosis they are more than three times as likely to be detained under the Mental Health Act;
  • Are around three time much more likely to have police contact prior to admission
  • Are around half as likely to have GP involvement prior to their admission;
  • Have a much lower chance of referral to counselling services; and
  • Are more than eight times as likely to be given a Community Treatment Order after being detained for treatment in hospital.

Significantly, the evidence shows that these inequalities have persisted over many decades despite previous attempts to tackle these them.

So why are we again faced with a partial and inadequate response? In part this is a result of the failure of the work on the independent review that informed the White Paper to engage with evidence on the fundamental drivers of these inequalities This meant that the paper’s authors did not have the necessary framework in place to draw out appropriate recommendations.

Disquietingly, throughout the White Paper, the question of inequality becomes reduced to questions of cultural difference. This includes the concern that health professionals may not adequately understand the needs and circumstances patients from ethnic minority backgrounds face, and the entirely speculative claim that ‘cultural factors’ may underlie the fact that ‘People from BAME backgrounds (sic) may engage with services later, because of perceptions held within their communities for example around recognising mental health problems early, on levels of associated stigma, as well as a distrust of service’.

The White Paper does not sufficiently discuss the evidence illustrating how ethnic minority people’s mental health concerns are more likely to be overlooked by GPs than White people’s, and that they are less likely to be referred to secondary services such as counselling.

What is also absent is any consideration of the possibility that a long-held distrust of mental health services can largely be explained by repeated discriminatory treatment from a wide range of state institutions, such as schools, health care and the police service, as well as mental health institutions.

The poorly evidenced nature of the White Paper’s analysis of the causes of these inequalities results in recommendations that focus on addressing these supposed cultural deficits, such as the use of advocates to ‘help patients under the act voice their needs’ on the assumption that ‘poor cultural understanding can worsen outcomes for patients from BAME backgrounds and compound other inequalities’.

Of course, such recommendations may well carry benefits. There is no harm in having strong, effective and independent advocacy for patients’ rights which reflect their context and preferences. Yet, advocacy would be more powerful if there were well resourced alternatives to detention long before a crisis ensues. Preventive action needs to be timely and which is why the recommendation to increase ethnic minority representation among mental health practitioners and in mental health research is also welcome.

However, this in of itself will not produce the seismic shift that is required to change the way ethnic minority people with experience of mental health problems are negatively viewed by many of those in the workforce. This requires something much deeper, a cultural shift in the way mental health services operate, which addresses institutional racism, and includes developing and resourcing alternatives to detention in crisis, alternative models of care, and more rights to not be detained alongside enabling rights once detained.

We are beginning to see commitment to tackle racial inequalities in mental health by senior level individuals working in mental health systems, not least via the National pledge to reduce ethnic inequalities in mental health systems launched by Synergi in August 2020. The challenge was, and has always been, to have this commitment mandated throughout mental health institutions and systems, and this is where the White Paper has failed to provide a meaningful action plan.

Similarly welcome are the recommendations around developing and implementing the Patient and Carer Race Equality Framework (PCREF). This has the potential to centre the question of ethnic inequalities among providers of mental health care, particularly if the bodies established have appropriate levels of responsibility and accountability, have national as well as local reach, and adequately represent the interests of those with lived experience.

Despite some signs of promise, what is entirely missing from the White Paper is any consideration of how the principles that underlie the Mental Health Act and how the use of the Act relates to institutional racism.

Any legislation that deprives people of their liberty must be better evidenced. It is deeply disappointing that the White Paper does not engage with the extensive evidence illustrating how ethnic inequalities in relation to the use of the Mental Health Act relate to processes of structural, interpersonal and institutional racism (racism does not gain a single mention in the White Paper).

The failure to engage with this critical evidence results in the White Paper setting out to address ethnic disparities (sic) in the use of the Act without considering the fundamental causes of these inequalities.

A starting point for impactful reform that addresses ethnic inequalities in the operation of the Mental Health Act would be to take a human rights-based approach to compulsory detention that acknowledges how racism operates within and across mental health institutions.

Without this, we are creating opportunities for ethnic minority people to be failed – yet again.