The UK is at a cross roads in terms of BME mental health policy. Sadly the recommendations made by the Centre for Mental Health report ‘Breaking The Circle of Fear’, (launched over 10 years ago), many of which contributed to the development of Department of Health policy around ‘Inside Out’ and ‘Delivering Race Equality’, are yet to be fully adopted. However, the report was influential in other ways, such as playing a role the development and launch of Catchafiya the national black service user led movement supported by the Afiya Trust. The fact of the matter is, that in spite of their age, the Breaking the Circle report along with other reports (such as the Race Equality in Mental Health report from the NHS Confederation) are still highly relevant today. This demonstrates the lack of meaningful progress in addressing issues of BME inequality in mental health provision. The energy and leadership for transformation and change feels light years away as many of the home truths of the black community are still routinely ignored.
We require a major rethink on policy development in racial inequalities, and we need to acknowledge that mental health is one aspect of many wider issues affecting BME communities. Issues of racial inequality and structural inequality are intermixed, we cannot address one without addressing the other, since to do so is to only address half of the problem.
There is no consensus or collective approach to tackling racial inequalities in mental health services, meaning that politicians and policy makers are easily influenced by clinicians in seeking solutions and answers. The current mainstream discourse presented by psychiatrists and academics suggests that you cannot blame mental health services for the over representation of black people, as they are simply responding to issues of structural rather than racial inequality, (this view is clearly articulated in the AESOP research project looking at mental illness within the Caribbean community). Although this is an important point, just like the racialised politics of policing and the lack of minority representation in Parliament, the Judiciary and the board room, it nonetheless lets everyone off the hook!
Similarly, we have to look at the impact of discrimination and racism against BME staff in the NHS workforce, particularly at senior management and board level which has a correlation with the experiences of service users (see the recent report from Roger Kline)
We had over 30 years of race equality training, strategies, pledges, and indicator sets which have failed to shift the agenda, much to the dismay of many service users, front-line staff, senior system leaders, activist and politicians. This further adds to the malaise and perception that ‘BME mental health’ is an intractable issue that is impossible to address.
In the meantime, new trends in psychosis and mental ill health are emerging within the BME communities. Current austerity measures will only serve to exacerbate these trends, as the marginalised are pushed to the extremes in all aspects of their lives. Thus we need to create a new agenda by exploring structural racism in society and its impact on services by coming to terms with many of these historical inequalities. This is needed in order to create the right conditions of reconciliation and trust that have the potential to transform policy making and services development. The Tutu Foundation concept of Ubuntu that Nelson Mandela and Bishop Tutu promoted in South Africa with the formal ending of legal apartheid and introduction of The Truth and Reconciliation Commission provides an example of the sort of conditions required for this transformation.
We also need impact assessment, particularly within African and Caribbean communities on the legacy of enslavement that continues to influence our personal and family relationships, and cultural identity. Furthermore we have to counter the stigma, stereotypes and misunderstanding which are built into mainstream thinking from the media, policy makers and service providers that mean black people are still seen as Mad, Bad and Dangerous. The ingrained prejudice and stigma against the Mad, Bad, Dangerous and Black presents a massive challenge to the BME community involved in the mental health system.
There needs to be mainstream delivery and accountability of services as part of an affirmative action programme or a distinctive race equality strategy to target and make direct action across how services and the care pathway and other stakeholders can be held to account.
In the context of tackling mental health and the concept of parity of esteem the equality agenda is absent (despite the legislation). This should be extended beyond physical and mental health but also incorporate race, gender and LGBT equality as a mantra to tackle over-representation in inpatient care, extend culturally relevant talking therapies, revisiting commissioning models and empowering service users, carers and the wider community around leadership and accountability.
About the author: Patrick Vernon (OBE) is the founder of Every Generation Media (www.patrickvernon.org.uk), and an Associate Fellow at the Centre for History of Medicine, Warwick University