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Rapid Responses: Rapid Responses published:
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Institutional racism in mental health care: hitting the nail right on the head
- Charles Agyemang (31 March 2007)
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Institutional Racism in Mental Health Care: Editorial is unduly provocative and misses important points
- Cornelius Ani, Obeagaeli Ani (2 April 2007)
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Inside Outside
- Christopher L. Manning (2 April 2007)
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Article too strong? I think not
- Christopher L. Manning (2 April 2007)
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Focus on the Substance rather than the Provocative Delivery of the Editorial
- Babatunde Adetunji, Adegboyega Oyemade MD; Olusanya Rufai MD, Adedapo Williams MD & Oluyemisi Adetunji BSc, MSc, RN(UK) (4 April 2007)
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Institutional racism in mental health care: what about stigma, evidence base and consistency?
- Trevor Turner, Sue Collinson (10 April 2007)
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Count Me In Census provides no compelling evidence of Institutional Racism
- Paul Fearon, Robin Murray, Professor of Psychiatry, IoP, and Visiting Professor, University of the West Indies (18 April 2007)
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Institutional racism in mental health: another uncomfortable truth?
- Kwame McKenzie, Kamaldeep Bhui (25 April 2007)
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Institutional racism in mental health care
- Anthony Deery, Dr Veena S. Raleigh, Lead Methods and Research, Informatics, Healthcare Commission (1 May 2007)
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what stops us doing things about institutional racism in mental health care?
- Kamaldeep Bhui, Prof. Kwame McKenzie (9 May 2007)
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Institutional racism in mental health care
- Anthony Deery, Dr Veena S. Raleigh, Lead, Methods and Research, Informatics, Healthcare Commission (16 May 2007)
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Charles Agyemang, Research Associate Amsterdam Medical Centre, Department of Social Medicine, 1100 DD, Amsterdam
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Editor, I would like to congratulate Professors McKenzie and Bhui for hitting the nail right on the head on this topic.[1] Tackling the issue of institutional racism is difficulty because of the reluctance of accepting the reality of racism in society and the fear of being labeled as racist.[2] Those who are trying to address this issue also risk of being labeled as ‘trouble makers’. The lack of systematic evidence makes the issue even more difficult to address.[3] The ‘count on me’ findings clearly indicate that institutional racism is ‘alive and well’ and we can no longer afford to ignore it in society. These findings are worrying and raise many serious questions about the entire mental care for African and Caribbean origin people in England and Wales and beyond. While we cannot deny the fact that some groups suffer more from mental health than others, we can also not deny the fact that institutional racism in mental health is real. The legitimate questions we need to be asking now are: why are rates of admission lower than average in some groups but two to three times higher than average in others? Why are people from African and Caribbean origins more likely to be admitted involuntarily and receive suboptimal care? How can we address this issue seriously without resulting into the old style of ‘blaming games’? And how can we convince others that racism in mental health is real and is not just a matter of ‘self fulfilling prophecy’?[2] Evidence clearly indicates that experiences of racial harassment and discrimination are central to the lives of many minority groups and these contribute to ethnic inequalities in health.[4] As racism affects health, a further institutional racism (double racism) will lead to even poorer health among minority populations with huge consequences to the society. Tackling institutional racism is a major challenge, but a challenge that can be won if we approach this issue with open mindedness. Admission of the existence of institution racism in mental health will be a good starting point. There is also a need to assess the situation in other European countries especially in countries where information is lacking. This will help to develop the capacity to tackle racism more effectively.[3] References 1.McKenzie K, Bhui K. Institutional racism in mental health care BMJ 2007; 334: 649-650 2.Singh SP, and Burns T. Race and mental health: there is more to race than racism. BMJ 2006 333: 648-651. 3.Agyemang C, Seeleman C, Suurmond J, Stronks K. Racism in health and health care in Europe: where does the Netherlands stand? Eur J Public Health 2007 (in press) 4.Nazroo JY. The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism. Am J Public Health 2003;93:277-84. Competing interests: None declared |
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Cornelius Ani, Honorary Lecturer and Specialist Registrar in Child and Adolescent Psychiatry Academic Unit of Child and Adolescent Psychiatry, Imperial College, Norfolk Place, London W2 1PG, Obeagaeli Ani
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As black psychiatrists working in the NHS, we find McKenzie and Bhui’s editorial unhelpful and unduly provocative.[1] For instance, while it is possible that racism plays a role in increasing detention rates among black patients, the editorial ignores other well established, and in our view, more important factors. In our combined clinical experience, which includes acute adult, forensic, child and adolescent psychiatry and a large number of Mental Health Act assessments, one of the main reasons for increased detentions rates for black patients is insufficient community support network. Supportive intermediaries (like family members) can increase treatment adherence, detect early relapse signs and enable early non-coercive intervention. [2] In our experience, compared to other ethnic minorities, relative insufficiency of support networks predisposes black patients to adverse care pathways resulting in crisis and police intervention and disproportionate use of the Mental Health Act. This experience is supported by the AESOP study, which found that black patients were more likely to live alone. [3] We are neither blaming the victim nor shooting the messenger but blanket invoking of racism is too simplistic and fails to acknowledge other difficulties in black communities, some of which we can better address by reflectively looking inward rather than outward. 1. McKenzie K, Bhui K. Institutional racism in mental health care BMJ 2007; 334: 649-650 2. Singh SP, and Burns T. Race and mental health: there is more to race than racism. BMJ 2006 333: 648-651 3. Morgan C, Mallett R, Hutchinson G, Bagalkote H, Morgan K, Fearon P et al. Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission. Report from the AESOP study B J Psych 2005; 186: 281 -289 Competing interests: None declared |
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Christopher L. Manning, CEO Primhe TW11 9HG
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Dear Editor I would also like to place Primhe's support right behind this essential article. The charity's supporters all around the country regularly report the disproportionality of admissions and approaches involved in the management, rather than optimal intervention for, people of Afro-Caribbean and Afrikan origin. A few years ago, when I served on the National (England)Mental Health Taskforce, these very issues were 'fudged', in my opinion, when the report "Inside Outside" was published. There had been design meetings prior to its release when the issues of Instituional(-ed and -ing) Racism were hotly debated (at issues, not personal, level) as being vital to the remit of that Report and there was a strong commitment to the Authors that the final report would be uncompromising and honest. It was also mentioned, and unanimously agreed as I recall, that the consultation undertaken in connection with it, should not be yet another token exercise, raising false hopes in these vital communities, who have had their hopes raised and dashed so often before. To be frank, I felt ashamed when the final and, as I saw it, "gagged" report, was published. I am grateful to Professors McKenzie and Bhui for soothing my conscience on this matter and for placing the issue right back on the centre of the table. England is no longer a 'developed' country really and, if the imminent MH Act is passed (and we need to recall that only a recent amdendment removed the opportunity for locking away people whose political views are uncomfortable - to say nothing of the recent changes to the Freedom of Information Act)as is, then the issue will deepen further. It will merely act as a catalyst for institutionalising further existing racist attitudes and practice. It is much harder to affect behaviours when they are behind various walls and Governments are implicilty supporting them, rather than 'out there' where we can continue to bring positive influence to bear on them? This also aligns to Dr Iona Heath's article in this same Journal issue. Doctors and teachers have massive daily contact with the public and (especially) this Government are almost addicted to the need for controlling their lobbying voice and wearing them down. Racism and creating 'common enemies' by purpose, or by default, should be not part of the practices of this increasingly Blighted Isle....unless you move to Scotland? Yours Sincerely Dr Chris Manning Competing interests: None declared |
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Christopher L. Manning, CEO Primhe TW11 9HG
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Dear Editor Whilst I can completely understand the results of AESOP and the logic of Dr Cornelius Ani's argument, I fail to see how a lack of community supports can be allowed to justify restraint or the ill-informed ethno- centric malbehaviours of the NHS (or any institution that claims to care). Unless and until every potential confounder to providing a healthy intervention is rooted out, then nothing will change. After all, if hospitals, in Ani's view, continue to support lack of community or family cohesion (and do we really understand how best even to engage these aspects of care and change them towards the positive?) by admitting people becuse of inadequate support, what will ever happen to change those very communities and families in a more positive direction? Perhaps they are in the state they are in precisely because those folk feel so systematically enfeebled. And,surely, this is how we help to "make mental health everyone's business"? Yours Sincerely Dr Chris Manning Competing interests: None declared |
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Babatunde Adetunji, Clinical Assistant Professor of Psychiatry, Drexel University College of Medicine, Philadelphia, USA MHM Services, 8001 State Road, Philadelphia 19136, Adegboyega Oyemade MD; Olusanya Rufai MD, Adedapo Williams MD & Oluyemisi Adetunji BSc, MSc, RN(UK)
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It would be a great disservice to the editorial by Kwame McKenzie and Kamaldeep Bhui (1), if we focus mainly on the provocative delivery of their article rather than the content. The editorial is not meant to only generate intense emotional responses but rather to challenge the medical community at large to acknowledge that the problem exists and to institute corrective measures. The tenet of modern day medicine is to seek evidence and to put in corrective measures based on the evidence. Constructively putting such measures in place will not happen if the focus is on the provocative delivery rather than the substance of the editorial. The key question therefore is: Are there racial inequalities in mental healthcare delivery in UK and indeed in the USA? Based on multiple studies, the answer is undoubtedly yes. However, since most people misperceive racism as deliberate actions, it makes them recoil in horror, whenever it is mentioned around them. Yet, we need to educate people that this term can also include actions that are inadvertent. These inadvertent racial actions could range from, global superimposition of western psychiatric concept to other cultures who do not view illness as in the body and mind alone, to individual practitioners who are simply untrained and unsympathetic to the possible role of communications in the expression of psychopathology. For example, while a study showed that in the USA, African Americans were significantly less likely to receive a second-generation antipsychotic than whites (2), it was found that this may be due to differences in symptom expression and presentation between different ethnic groups.(3). Such misunderstanding and miscommunication across cultures may facilitate improper diagnosis and treatment choices. (4). Even among members of the same race, there could be sub-cultural misconception among the well educated ‘minority’ versus those that are poor and live in the ghettos. Consequently, what we should learn from the editorial is that such racial differences in service delivery exists and continuously work towards reducing the incidences and the impact. Remedial measures could include usage of interpreters, teaching trans-cultural psychiatry in the medical school, regular audit as well as fostering exchange medical programs. 1). McKenzie K, Bhui K. Institutional racism in mental health care BMJ 2007; 334: 649-650 2). Opolka JL, Rascati KL, Brown CM, Gibson PJ.: Ethnicity and prescription patterns for haloperidol, risperidone, and olanzapine. Psychiatr Serv. 2004 Feb;55(2):151-6. 3).Jeste DV, Lindamer LA, Evans J, et al: Relationship of ethnicity and gender to schizophrenia and pharmacology of neuroleptics. Psychopharmacology Bulletin 32:243–251, 1996. 4). Adebimpe VR: Race,racism, and epidemiological surveys. Hospital and Community Psychiatry 45:27–31,1994 Competing interests: None declared |
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Trevor Turner, consultant psychiatrist East London and the City Mental Health Trust, Sue Collinson
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The somewhat strident tones of McKenzie and Bhui, describing the 'Count me in' census of mental health wards as 'grim reading' for African- Caribbeans in England and Wales, is quite extraordinary in starting a priori from stigmatising assumptions. If institutional racism - an essentially undisproveable concept similar to Freudian pseudoscience - is defined as a 'collective failure...which disadvantages people in ethnic minority groups', why is actively treating people for severe illness seen as evidence of such? Were this treatment for hypertension, diabetes or sickle cell anaemia, it would be considered a well-targetted intervention. Admission rates and length of stay in mental health do not reflect illness prevalence, they reflect the severity and social disruption generated by that illness. Delays in seeking care (and increased Mental Health Act usage) reflect both social isolation (e.g. the AESOP study) and stigmatised attitudes (e.g. denial or fear of mental illness)[1]. And were institutional racism the dominant engine of admission, why is it so differentiated in the races it selects? Furthermore, did the survey collect ethnicity data on the mental health staff on the wards and in the community teams, where there is a high rate of black and minority ethnic employment? Would that be indicative of institutional racism, or would it be indicative of culturally competent care? On our East London acute wards over Easter, it was noted by the duty consultant psychiatrist that at least 80% of the staff were not white British. In a thoughtful editorial 11 years ago, McKenzie outlined the problem of 'describing race, ethnicity and culture in medical research', eschewing 'politically correct terms'[2]. However, he and Bhui now resort to 'institutional racism', 'community development workers', 'race impact assessment' and 'culturally competent care', as if these were evidence- based concepts [3]. In itself the 'Delivering race equality' paper, while well-intentioned, derived from a single, deeply flawed homicide inquiry (David Bennett); developing policy from a single case study is hardly scientific. If there is anything to be understood from this editorial, it is that severe mental illness, requiring hospital care, remains deeply stigmatised; that intervention is presented as coercion; and that those working in mental health, whatever their own ethnic background, should argue vociferously for proper funding for wards, community teams and the promotion of mental health for all. 1. Morgan C, Mallett R, Hutchinson G, Bagalkote H, Morgan K, Fearon P et al. Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission. Report from the AESOP study. BJPsych 2005;186:281- 289 2. McKenzie KJ, Crowcroft NS. Describing race, ethnicity and culture in medical research. BMJ 1996;312:1054 (27 April) 3. McKenzie KJ, Bhui K. Institutional racism in mental health care. BMJ 2007;334:649-650 Competing interests: None declared |
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Paul Fearon, Senior Lecturer & Hon. Consultant Psychiatrist Insitute of Psychiatry & Maudsley Hospital, London SE5 8AF, Robin Murray, Professor of Psychiatry, IoP, and Visiting Professor, University of the West Indies
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Editor, We are disappointed that McKenzie and Bhui wrote such an unbalanced piece in support of the Institutional Racism (IR) paradigm. In our view, far from providing evidence of IR in mental health services as McKenzie and Bhui claim, the 2006 Count Me In (CMI) report, in common with other recent evidence, undermines it. The two main pillars upon which the IR argument has been built are: 1) the higher rates of admissions of Black people to mental health inpatient units, and 2) the higher rates of compulsory detention of Black people. The authors acknowledge that the incidence of severe mental illness (SMI) in Black people living in the UK is genuinely raised. However, then, by selectively quoting evidence (and misinterpreting it) [3], they argue that since ‘national community prevalence studies’ show no evidence of higher rates, therefore the higher inpatient rates provide evidence of IR. This is incorrect. First, Nazroo[4], found almost a twofold difference in prevalence of non-affective psychosis (White rate 8/1,000; Black Caribbean rate 13/1000), and the author himself stated that the study was underpowered to detect modest rate differences for these disorders and pointed out that one should therefore not take the lack of statistical significance of his findings as evidence of a lack of a true difference in rates. This study was based on a national household survey (thus excluding those in hospitals, prisons and other institutions), had a low response rate in general, but particularly from the Caribbean group and did not use the same criteria for assigning diagnosis as is used in modern incidence studies or indeed in clinical practice. It thus almost certainly underestimates the true prevalence of SMI in the community as a whole and in Black Caribbeans in particular. Furthermore, the authors fail to mention 2 other reports [5,6] (one of which McKenzie co-authored) using the same sample which show a twofold excess in psychotic symptoms in Black people in the community. Do McKenzie and Bhui not believe that Black people in mental health inpatient units are ill and require inpatient treatment? The routes into an inpatient psychiatric bed are complex and often involve factors outside the control of services (as this years CMI census confirms). However, our clinical experience, especially in this time of acute bed shortages, is that the overwhelming majority of people (regardless of ethnicity) are admitted for appropriate reasons. Do the authors have evidence to the contrary? The authors are more circumspect when discussing the raised detention rates in Black people, and with good reason. Even a cursory glance at the executive summary of the CMI census revels why. On page 3, the report concludes that the raised rates of detention in the Black Caribbean and Other Black groups ‘was largely attributable to higher than average rates of detention under Section 37/41-where a person is sent to hospital for treatment by the courts, under a restriction order by the Home Office. In contrast, detentions under the civil sections of the Act were either lower than average in these groups (Section 2) or no different from average (Section 3)’. Since these latter 2 sections (2 and 3) are those in which psychiatric services are most likely to take the initiative, this argues against IR in mental health services being central to this phenomenon. Further, the transfer of people with a serious mental illness from the criminal justice system to mental health care is surely a good thing. McKenzie and Bhui go on to claim that ‘some black and minority ethnic groups are less likely to be offered psychotherapy, more likely to be offered drugs..’, but the papers they reference do not provide any mention of the latter, and they misquote the paper that does mention psychotherapy [7] (which is curious, as it was written by McKenzie). His paper stated that Black patients were less likely to receive psychotherapy. In our Trust, the early intervention services routinely offer Cognitive Behaviour Therapy (CBT) to all referrals. It is striking that, while a clear majority of white and other groups accept this offer, just over half of Black patients refuse it. Understanding the reasons behind these phenomena are likely to be more complex that the overly simplistic and all-embracing IR paradigm that the authors suggest. McKenzie and Bhui assert that ‘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’ and state that it has led to the development of ‘Delivering Race Equality’ (DRE) [8]. While DRE offers a plan to tackle the observed differences between groups in MH care, its weaknesses lie in its assumption that these inequalities have their roots primarily in discrimination within services. To take but one example from the 12 targets set by DRE: ‘A reduction in the rate of admission of people from BME communities to psychiatric inpatient units’. If this target was set for any other disorder known to affect BME groups (eg hypertension or diabetes in African Caribbean people, or coronary artery disease in South Asian men), such a target would be regarded as discriminatory. We agree that services need to strive to deliver the best possible treatment to all those who present to them. Unlike McKenzie and Bhui, we feel that viewing these issues through the distorting ‘lens’ of Institutional Racism obscures the reality that the causes of these phenomena are more complex and in many cases lie beyond the control of mental health services. 1. McKenzie K, Bhui K. Institutional racism in mental health care BMJ 2007; 334: 649-650 2. Healthcare Commission. Count me in census 2006. London: HC, 2007. www.healthcarecommission.org.uk/_db/_documents/Count_Me_In_2006.pdf 3. Nazroo J, King M. Psychosis—symptoms and estimates rates. In: Sproston K, Nazroo J, eds. Ethnic minority psychiatric illness rates in the community (quantitative study). London: Stationery Office, 2002. 4. Nazroo JY. Ethnicity & mental health. Findings from a national community survey. Policy Studies Institute, London, 1997 5. Johns LC, Nazroo JY, Bebbington P, Kuipers E. Occurrence of hallucinatory experiences in a community sample and ethnic variations. Br. J. Psychiatry, 2002; 180: 174 - 178. 6. King M. Nazroo J. Weich S. McKenzie K. Bhui K. Karlsen S. Stansfeld S. Tyrer P. Blanchard M. Lloyd K. McManus S. Sproston K. Erens B. Psychotic symptoms in the general population of England--a comparison of ethnic groups (The EMPIRIC study). Social Psychiatry & Psychiatric Epidemiology 2005; 40(5):375-81 7. McKenzie K, Samele C, van Horn E, Tattan T, van Os J, Murray RM; on behalf of the UK700 group. A comparison of the course and treatment of psychosis in patients of Caribbean origin and British whites. Br J Psychiatry 2001;178:160-5 8. Department of Health. Delivering race equality: an action plan for improving services inside and outside mental health care and the government's response to the independent inquiry into the death of David Bennett. London: DoH, 2005. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4100773 Competing interests: None declared |
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Kwame McKenzie, Professor of Mental Health and Society University of Central Lancashire, Kamaldeep Bhui
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We are pleased that so much interest and public debate has been promoted by the editorial on the important topic of institutional racism in mental health care (1). We said that institutional racism is not simply a statement of the fact that disparities exist between ethnic groups in treatment, but also reflects the priorities that services ascribe to dealing with these disparities, the processes that generate disparities and those that inhibit effective actions to remove disparities. Rather than discussing this central theme critical responses have focussed on one aspect; the high admission rates in people of Caribbean and African origin with psychoses. The fact that the Count Me In Census was published led to us highlight this issue but we made it clear that disparities in treatment and outcome cover a range of ethnic minority groups and mental illnesses. That ethnic minority groups do not get equitable treatment compared to white groups is agreed by the Department of Health & NHS (2), the Royal College of Psychiatrists (3) and the voluntary sector. We could produce a list of disparities, for example, the fact that limited access to interpreting services means that non-English speaking groups do not get equal treatment or that race equality impact assessment are not routinely undertaken by the National Institute for Clinical Execellence (NICE) so that services offer a ‘one size fits all’ approach. Clinicians working in the UK will have witnessed such problems first hand and will have found that they are unable to do anything about them because they need solutions at an institutional level. The Tsar, Louis Appleby, has publicly stated there is no higher priority in mental health care than improving services for BME groups(4). It is why all groups supported the development of Delivering Race Equality (DRE)an institutional response. The Audit Commission has noted that the Race Relations Amendment Act and the acceptance of the institutional racism paradigm are vital for public services striving to deliver equitable services (5). There is a literature on the emotional response that the issue of institutional racism engenders which we alluded to in our editorial (1). These are demonstrated in the correspondence and may explain urgency and tone in responses and the errors of logic in the arguments proffered. We could argue that there is no better example of ideologies and values expressed as scientific facts when Fearon and Murray (6) over interpret non-significant statistical findings to support fixed a priori views. We understand how challenging some find this and so are not surprised that Ani and Ani (7), Turner & Collinson (8), and Fearon & Murray (6) criticise the paradigm but offer no alternative for improving services for BME groups. The only other paradigm offered to date is by the Department of Health which is currently repositioning itself and has stated that “We just don't believe that "institutional racism" would be a helpful label to apply - the solutions lie in the hands of individuals, not institutions.” (9) Which individuals? We believe that clinicians are trying to do their best in difficult circumstances and should not be blamed for systemic problems. The part they have to play in tackling institutional problems is to commit themselves to the systems approach that DRE proposes (2). This will mean looking beyond only one part of the mental health care system and trying to influence other parts of the system - something that not all critics appear able to do. DRE is a complex strategy which tries to improve mental health services by community engagement, the development of appropriate and responsive services and the intelligent use of improved information and research and the development (2). It should be remembered that DRE was developed over years and included academic literature reviews, all the UK’s specialists in BME service development, the voluntary sector, UK charities and widespread public consultation. Therefore, Turner & Collison are incorrect to state that DRE was a response to the death of Rocky Bennett alone. Furthermore, Turner & Collinson are incorrect to suggest that a workforce representative of the population it serves can by itself achieve equitable services. If the ethnic minority workforce is trained similarly and subjected to institutional constraints and incentives to sustain pre-existing models of care there may be little benefit (10). Fearon and Murray did not participate in the work leading up to DRE. It is disappointing that only now, two years into the programme and over five years since the process began, they are voicing disquiet. This disquiet is not based on any data and they have not waited for evaluations of the policy to be published. Disparities in admission rates for mental illness are different to admission for many illnesses. This is to do with the general thrust of mental health policy and service development, the need to listen to users and the difference between voluntary and involuntary treatment, as well as our complex packages of care which rely on trusting relationships with clinicians. The general thrust of policy is to close asylums, reduce inpatient beds and treat people as much as possible in the community in new crisis intervention, assertive outreach and community care teams. The aim is to reduce disempowerment, institutionalisation, the trauma of hospital admission and increase choice of treatment for people with mental illness. People from BME groups want to be able to avail themselves of these improvements. Because of this, disparities in hospital admission rates are seen negatively. We hope we have misunderstood Fearon & Murray’s argument (6) which implies that community care is good for some but not for other racial groups. The Count me in Census gives comparative proportions of sectioned inpatients and not population rates of detention for African or Caribbean people. When looking at comparative section rates, it fails to take account of the fact that people of African and Caribbean origin are over- represented in the inpatient group. It is important not to mis-represent these data as Fearon and Murray have (6). Moreover, involvement of the prison justice system and detention of people with mental illness under section 37/41 is considered by many as a negative service outcome, and not something to be celebrated. The evaluation of interventions is indeed necessary, but Turner & Collinson must surely know that health policy is always based on the best available evidence, and the absence of evidence should not delay ethical imperatives and obvious actions to provide more humane care. The evolution of mental health care to a more choice based system has relied on this. It is important to understand disaffected communities and develop culturally competent, effective and equitable care (10). The term institutional racism must be used with care. It needs further unpacking in terms of specific processes and actions, and their benefits to the public rather than an ideological objection to its use, or indeed the use of the term without understanding or commitment to tackle disparities (10). It would be fanciful to propose that all health policy be censored of terms like discrimination, racism, inequality, and disparity because they upset clinicians and academics. Health policy ignorant of these important processes would rightly fail race equality impact assessment - which is law. Everybody wants decent and high quality care with respect and maximum choice. If they received it we would welcome the abandonment of the term institutional racism and the paradigm it represents. In the meantime, however, we should continue to employ it as a way of understanding disparities and developing equitable sevrices - unless, of course, others can come up with a useful paradigm which is enshrined in law, is an effective driver in producing equitable public services, does not blame hard working clinicians who are doing their best, understands the connectedness of mental health to other services that produce disparities and is accepted by the communities that it hopes to serve. 1) McKenzie, K., Bhui, K. Institutional racism in mental health care BMJ 2007 334: p. 649-650 2) Department of Health. Delivering race equality: an action plan for improving services inside and outside mental health care and the government's response to the independent inquiry into the death of David Bennett. London: DoH, 2005. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4100773 3) Royal College of Psychiatrists. Response to consultation on DRE http://www.rcpsych.ac.uk/pressparliament/collegeresponses/nimhe_framework.aspx 4) Appleby L, Impact of Racism on Mental health Guardian letter Wednesday April 4 2007 5) Audit Commission, The Journey to race Equality 2003 Audit Commission available at http://www.audit- commission.gov.uk/reports/accessible.asp?ProdID=EA59CF1B-0157-4cdb-BCA5- D9579C4DBFE5#sect5 6) Fearon P and Murray R Count Me In Census provides no compelling evidence of Institutional Racism BMJ, 18 Apr 2007 http://bmj.com/cgi/eletters/334/7595/649#164000 7) Ani, C., Ani, O. Editorial is unduly provocative BMJ 2007 334: p. 761-761 8) Turner, T., Collinson, S What about stigma, evidence base, and consistency? BMJ 2007 334: p. 814-814 9) Department of Health Position on Institutional racism in mental health care; personal communication 10) Bhui K. Racism and Mental Health; prejudice and suffering 2002 Jessica Kingsley Publishers London and Philadelphia Competing interests: authors of the article |
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Anthony Deery, Head of Mental Health Strategy Healthcare Commission EC1 8TG, Dr Veena S. Raleigh, Lead Methods and Research, Informatics, Healthcare Commission
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To: BMJ editor (rapid response) Date: 1 May 2007 Dear Sir This subject has been discussed extensively in the BMJ, following the articles by Singh and Burns1, and McKenzie and Bhui2. The prompts for these articles were the 2005 and 2006 “count me in” census reports respectively.3,4 The census was designed by the Department of Health to provide organisations with baseline information against which to monitor progress against Delivering Race Equality.5 It has proved very useful in this. However, the census was not designed as an epidemiological tool, and the census reports contained significant caveats that need to be considered in interpreting the results. Further, we stated that the results should be interpreted in the light of research evidence, which indicates that there are a multitude of factors that affect both the levels of mental illness and subsequent pathways of care for certain black and minority ethnic groups. As with many other areas of health, these frequently differ, and often significantly, between ethnic groups. Levels and patterns of health service usage need to be interpreted in the light of epidemiological evidence, as is customary in other aspects of healthcare, where ethnic difference is not in the main ascribed to institutional racism. Interpreting difference as disproportionality per se is not helpful in identifying preventive strategies for ways forward and could compromise patient care. The census data do not of themselves lead to a conclusion that mental health (or any other) services are institutionally racist or discriminatory, nor do they provide evidence of ethnic differences in the treatment of mental illness. It is not helpful to healthcare professionals and service users for the census to be interpreted in this way, especially when there is a pressing need for securing early and more effective engagement of African-Caribbean communities with primary care and mental health services. The Joint HC/CSCI review of specialist community mental health services, which took place 18 months into the lifetime of the DRE action plan found that progress was poor in respect of appointing community development workers, however, there was encouraging progress around agreeing their strategy and delivery plans with 70% of Local Implementation Teams (LITs) reporting that they had comprehensive systems and strategies (including a formal Race Equality Scheme) in place. At publication of the 2006 census report, Professor Sir Ian Kennedy said “the marked ethnic differences shown again by the 2006 census need to be understood and acted upon appropriately in the light of evidence about the factors causing these differences.”4 Delivering race equality in mental health is very complex and it is clear from the evidence that the solutions do not rest with any one organisation or agency. Arguably, much of what can be done to improve the situation lies outside the power or responsibility of secondary mental health services. Strategies are needed for addressing (a) primary prevention ie tackling the larger upstream non- health related factors eg education, social support, housing, employment, substance misuse, crime and disorder, social exclusion and racism, and (b) secondary prevention ie promotion of primary and community care in black and minority ethnic communities. Whilst health certainly has a duty to ensure that it provides an equitable and culturally sensitive service, it will always be in a position of having to react if those who are responsible for other parts of the system are not obliged to also take action. The Healthcare Commission is working with the Department of Health and others to promote coordinated action by statutory organisations, working in partnership with the voluntary sector and minority ethnic communities and service users, to address the factors contributing to these ethnic differences. In the meanwhile, it is important to ensure that the care provided to every mental health service user is appropriate to individual need and properly reflects the available evidence. In a follow-up letter6, McKenzie and Bhui state that “the Count me in Census gives comparative proportions of sectioned inpatients and not population rates of detention for African or Caribbean people. When looking at comparative section rates, it fails to take account of the fact that people of African and Caribbean origin are over- represented in the inpatient group”. It is standard epidemiological practice to measure, where possible, events in terms of the population at risk rather than the general population. Estimates of black and minority ethnic minority people with mental illness are not available. In the absence of this, and as detention is associated with admission to hospital, this was used as the base - as in many studies to date. As an analogy, rates for coronary artery bypass grafts (CABG) in South Asians should be based on the South Asian population with coronary heart disease (CHD) rather than the general South Asian population. However, in the absence of data on the former, hospital admissions among South Asians for CHD are used as an acceptable proxy for assessing CABG rates in this group7. Anthony Deery Head of Mental Health Strategy Dr Veena S Raleigh Lead, Methods and Research, Informatics Healthcare Commission References 1. Singh SP, Burns T. Race and mental health: there is more to race than racism. BMJ 2007;333:648-651. 2. McKenzie K, Bhui K. Institutional racism in mental health care. BMJ 2007;334:649-651. 3. Count me in: results of a national census of inpatients in mental health hospitals and facilities in England and Wales. Healthcare Commission, Mental Health Act Commission, National Institute for Mental Health in England, 2005. http://www.healthcarecommission.org.uk/assetRoot/04/02/18/30/04021830.pdf 4. Count me in: results of the 2006 national census of inpatients in mental health and learning disability services in England and Wales. Healthcare Commission, Mental Health Act Commission, National Institute for Mental Health in England, 2007. http://www.healthcarecommission.org.uk/_db/_documents/Count_Me_In_2006.pdf 5. Delivering race equality in mental health care: an action plan for reform inside and outside services. Department of Health, 2005. 6. McKenzie K, Bhui K. Institutional racism in mental health: another uncomfortable truth? BMJ 25 April 2007. http://www.bmj.com/cgi/eletters/334/7595/649#164363 7. Indications of Public Health in the English Regions 4: Ethnicity and Health. Association of Public Health Observatories, 2006 http://www.lho.org.uk/Download/Public/9841/1/Ethnicity%20Exec%20Summary.pdf Competing interests: None declared |
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Kamaldeep Bhui, Professor of Cultural Psychiatry & Epidemiology & Hon. Consultant Psychiatrist Barts & The London, Queen Mary's School of Medicine & Dentistry & ELCMHT, Prof. Kwame McKenzie
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Dear Sir Important clarifications are sought by Deery and Raleigh. (1)We proposed that a wide body of data and knowledge support the fact that institutional racism as an organisational process is a reality. The processes that led to Inside Outside and the Delivering Race Equality action plan were comprehensive; they considered clinical and epidemiological data and other forms of evidence including the views of service users, carers and the public.(2)We are not relying only on the Census. When is an ethnic difference a disparity and when is it a need? A disparity is suggested when the outcome is a negative one; for instance when the intervention is ineffective, deprives some of effective treatment, enforces ineffective treatment or provides less choice than is possible or desirable. There also has to be the possibility of innovation to deliver treatment in a manner that can reduce this disparity. In mental health we have a situation where some ethnic minority groups have less access to psychotherapy though they want it, where there is more reliance on pharmacological treatment and ultimately more use of admissions and detentions to deliver treatment that might be delivered by other pathways with more choice. We understand this as a disparity. As clinicians we fully endorse the value of admission and detention where absolutely necessary. However, differences in admission are modifiable as we have seen with trends over the last two decades because of the impact of specialist services and more flexible community approaches to treatment. Differences in admission rates, section rates and pathways to care between ethnic groups are similarly modifiable by the development of targeted services, which is why the Department of Health launched the delivering race equality action plan. Why should people of Caribbean origin need more admission and detention under section? To date this has not been explained by differences in the diagnosis, prevalence of illness or disability or by any biological factors. Social causes and systems of health care delivery are a possible social cause. They need to be investigated. We do not think that the analogy for CABG is reasonable. In CABG, the intervention is considered desirable and wanted by patients, and they feel denied an effective intervention; this not always the case with admission for treatment of mental health problems and detention in hospital. Institutional paradigms are applied to other health conditions and can be beneficial in mental health services.(3,4,5) To fund and orchestrate a national census designed to support the evaluation of DRE but not to consider causes and remedies and take notice when it shows disparities is disquieting. Everyone agrees that when one sees a disparity the first question to ask is why? The second question may be - what we can do about it? We are simply asking the question - what stops us doing things about it? Unless we understand the barriers to change, including attitudes and prioritisation, it is difficult to move forward. We have not seen any evidence offered that the institutional racism paradigm is harmful to patient care. We fail to understand how this can be stated when the paradigm aims to improve patient care and Inside Outside and DRE policies have taken account of service user, carer and community views. We have found that being frank, honest and confronting our problems is respected by BME groups and improves engagement. We have aimed to move away simply from the subject of the admission and section rates in people of African and Caribbean origin as there are many groups who suffer from disparities in care. However, we are concerned about the rates analysis, and the proposal that the denominator should always be admissions to hospital rather than the population at risk. Our reference to this issue was to point out the error in Fearon & Murray’s interpretation of the data as population admission rates rather than what they are: proportional admission rates. Admission to hospital under section is the outcome of an assessment in a clinic, in primary care, in prison, in police cells, in the community, at home or on the streets. These assessments are undertaken by social workers, doctors or by the police. They may result in involuntary or voluntary admission or no admission at all. Therefore the “at risk” group includes those at home, on the street, in the prison justice system or in contact with mental health services. For most short-term sections the population at risk is arguably the general population as these are sections that tend to be used for people with no current diagnosis and perhaps little insight to the fact that they have symptoms. The population at risk for longer sections section is the population with a mental illness. There are a number of national studies which have been undertaken to assess cross ethnic mental illness rates in the community. If these had been used to help calculate all section rates rather than the admission population we would have a better idea of the population section rates which is what communities are concerned about. Deery and Raleigh suggest that “strategies are needed for addressing primary prevention ie tackling the larger upstream non-health related factors such as education, social support, housing, employment, substance misuse, crime and disorder, social exclusion and racism”. They suggest responsibility for this lies outside of services, echoing comments by Fearon & Murray, that those working in services have no responsibility for addressing disparities. We would argue that these issues are health related, and are in fact a more important indicator of functioning and quality of life than a narrow symptom or disease based model of mental illness. Mental health services and public mental health departments do already research these risks and clinically intervene when these factors are evident. Most psychiatrists and providers work in partnership with housing, forensic, employment and voluntary sector agencies. Transforming this good clinical practice into an organisational approach and a systems approach requires a paradigm that enables more of this practice to flourish, and to be taken up.(2,3,4,5) The institutional racism paradigm enables this but we all have to be less defensive, focus on what our service users and the communities we serve want, and then positively and confidently respond to the challenge.(6) This requires ownership of responsibilities and leadership to improve service user experiences and outcomes. 1)Deery, A. Raleigh, V. Institutional Racism in Mental Healthcare. BMJ, rapid responses, May 1 2007. http://www.bmj.com/cgi/eletters/334/7595/649 2) Bhui K, McKenzie K, Gill P. Delivering mental health services for a diverse society. BMJ. 2004; 329(7462):363-4. 3)Elkan R, Avis M, Cox K, Wilson E, Patel S, Miller S, Deepak N, Edwards C, Staniszewska S, Kai J. The reported views and experiences of cancer service users from minority ethnic groups: a critical review of the literature. Eur J Cancer Care (Engl). 2007; 16(2):109-21. 4)Lipscomb HJ, Loomis D, McDonald MA, Argue RA, Wing S. A conceptual model of work and health disparities in the United States. Int J Health Serv. 2006;36(1):25-50. 5) Corrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004;30(3):481-91. 6)Cox, JL. Institutional racism in British psychiatry Psychiatric Bulletin (2001) 25: 248-249 Competing interests: Authors of original editorial |
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Anthony Deery, Mental Health Strategy Lead Healthcare Commission EC1Y 8TG, Dr Veena S. Raleigh, Lead, Methods and Research, Informatics, Healthcare Commission
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Dear Sir We would like to correct some inaccuracies in the response by Bhui and McKenzie(1) to our letter(2), and to add some clarification. 1. Our letter did not imply that the current hospital admission and detention rates among some black and minority ethnic groups are non- modifiable. On the contrary, the count me in census report advocated action to reduce the need for detention and admission to hospital, where possible and without compromising patient care.(3) And that improvements in primary and community mental health care have a key role to play in this process. 2. Bhui and McKenzie indicate that those responsible for undertaking the census fail to consider the causes for differences and the remedies. This misrepresents what was said in the census reports and in our letter, both of which addressed the need for primary and secondary prevention. In the foreword to the 2005 census report Professor Sir Ian Kennedy said the census “demands an explanation”.(3) 3. As Bhui and McKenzie have cited selectively from our letter, we remind readers of what we said: “Strategies are needed for addressing (a) primary prevention ie tackling the larger upstream non-health related factors eg education, social support, housing, employment, substance misuse, crime and disorder, social exclusion and racism, and (b) secondary prevention ie promotion of primary and community care in black and minority ethnic communities.” While mental health services of course have a key role to play, the widespread evidence to date suggests that interventions need also to go beyond the health sector, to address the upstream factors that we referred to, and which have been shown to impact on mental health, pathways and outcomes. 4. Bhui and McKenzie say we “suggest responsibility for this lies outside of services” and that “those working in services have no responsibility for addressing disparities”. This is an inaccurate representation of what we said.(1) Please refer 1-3 above. 5. Our example of CABG rates by ethnic group was intended to demonstrate the data constraints applying to epidemiological analyses by ethnic group, and of the approaches used to circumvent them, which are widely accepted. We do not agree that detention rates should be calculated using the general population as denominators rather than the population at risk, as it implies that the risk of detention (including for those on short sections) is equal between those with a mental illness and the significantly greater proportions of those without. 6. Further, Bhui and McKenzie state that community-based surveys of mental illness should be used to derive estimates of ethnic populations with mental illness ie the population at risk. There are significant problems with this. First, such surveys do not provide population-based prevalence, as they do not include the significant number of people with mental illness who are not in private households ie those in other forms of housing (social services etc), hospital, prison, the homeless, etc. Second, it would entail applying estimated prevalence rates by ethnic group from such surveys to the ONS census of the general population to derive numbers of people with mental illness by ethnic group. For example, EMPIRIC was a sub-sample of the Health Survey for England 1999, designed to estimate levels of mental illness by ethnic group.(4) It had a sample of 4281 adults, with a response rate of 68%. Such surveys are designed to estimate the prevalence of psychiatric morbidity in the community, however, they are not designed to generate absolute numbers of people with mental illness (and these numbers would be needed by age and gender, in order to produce standardised detention rates). As with any surveys, the results are inevitably subject to margins of estimation, and do not provide a robust basis for extrapolation to reliable national denominators. Further, the ONS 2001 census estimates of ethnic group populations themselves had significant caveats (ONS is also due to issue revised 2001-census based population estimates later this year; the impact on numbers by ethnic group is not known). Hence the approach proposed would involve multiple levels of estimation, with potentially significant margins of error. We do not consider this a robust basis for analysis. We hope this sets out our perspective on this issue and avoids further misunderstanding. Anthony Deery Mental Health Strategy Lead Dr Veena S Raleigh Lead, Methods and Research, Informatics Healthcare Commission References 1. Bhui K, McKenzie K. What stops us doing things about institutional racism in mental health care. BMJ, rapid responses. http://www.bmj.com/cgi/eletters/334/7595/649#165189 2. Deery A, Raleigh VS. Institutional racism in mental health care. BMJ, rapid responses. http://www.bmj.com/cgi/eletters/334/7595/649#164706 3. Count me in: results of a national census of inpatients in mental health hospitals and facilities in England and Wales. Healthcare Commission, Mental Health Act Commission, National Institute for Mental Health in England, 2005. http://www.healthcarecommission.org.uk/assetRoot/04/02/18/30/04021830.pdf 4. Ethnic minority psychiatric illness rates in the community (EMPIRIC). National Centre for Social Research, 2002. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4005698 Competing interests: None declared |
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