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Black and Minority Ethnic Mental Health
What Next after the Delivering Race Equality Programme?
Introduction and background
This is a brief report which emerged from a high-level roundtable event held on 9th
November 2012 convened by the Centre for Social Justice (CSJ), with sponsorship from
Partnerships in Care (PiC). HS Consultancy was a key partner in the design and execution of
the event. The CSJ is an independent, not-for-profit think tank whose mission is to put
social justice at the heart of British politics in order to alleviate poverty and reverse social
breakdown in Britain’s most deprived communities. Partnerships in Care (PiC) is the largest
independent provider of secure mental health facilities across the UK. HS Consultancy
specialises in mental health and social care, social justice and inequalities.
We three organisations, like many others in health and social care, remain concerned about
the persistence of ethnic variations and inequalities in experience and outcomes in mental
health care. Our aim was to convene a Black and Minority Ethnic (BME) mental health policy
and practice forum where ideas can be explored and ‘stress-tested’ with the Department of
Health, commissioners (local and national), service providers, experts and others.
The roundtable had three distinct phases:
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Reflections on the last Government’s initiative Delivering Race Equality in Mental
Healthcare (DRE) and lessons to be learned
Examples of progress towards improvements
Possibilities for future success – The Locked Hexagon Model
These provide the structure for this brief report.
Reflections on DRE and lessons to be learned
Delegates were given a brief overview of the content of DRE. There were three building
blocks, and 12 characteristics describing how services would look if the five year
programme achieved its aim of making significant reductions in ethnic inequalities in mental
health. The work of Focused Implementation Sites and community engagement projects
was applauded. The only concrete target of 500 community development workers (CDWs)
was recognised for having made a positive impact on the extent to which communities
trusted and engaged with specialist mental health services. At the highest point, 450 CDWs
were in post nationally, commissioned by Primary Care Trusts, with specific funding, which
was incorporated into core PCT budgets. Currently only a fraction of these posts remain.
There was a debate (including differing opinions) about the extent to which the good
intentions behind DRE were compromised by being unduly complex and ambitious. The
programme delivered some successes such as increased satisfaction with services but in
areas such as reducing deaths, the numbers were too small to draw meaningful conclusions.
Admission rates have not decreased (they have increased for Black groups) nor has
detention rates. Other targets, such as uptake of talking therapies, remains variable
according to ethnic group. There were successful initiatives delivered as Focused
Implementation Sites (pilots) and national measurement elements of DRE such as the Count
Me In census and the DRE dashboard we recognised as successes.
DRE was described as being front-loaded toward CDWs, with flawed terms of reference
that looked for success in the micro-level of community engagement and individual service
user stories of success. It was argued that the reform of leadership around race equality
was given less priority, and that there were no sanctions for trust Chief Executives who
failed to deliver.
It remains unclear why, given the overwhelming evidence that there is much more work to
be done in critical areas such as overrepresentation in admission and detentions, DRE ended
according to the predetermined timescale.
Wider contextual matters were discussed such as the tendency of the civil service to design
systems of measuring inputs and outputs in a way that leads to activity displacing objectives.
Different intellectual factions have led to a lack of consensus about what constitutes the
‘problem’; for example, whether causes of persisting inequalities rest in family and
community pathology or flaws in the mental health system and society. This has led to
some deadlock in finding solutions, worsened by heel-dragging by some leaders in mental
health, which was encountered when trying to encourage local buy-in of DRE. Professional
groups and managers in the mental health system found it hard to accept that there was
discrimination in the mental health system itself.
A number of possible learning points for the future were discussed. Most controversial was
the single equalities approach. This was seen both as a mechanism for both neutralising the
potency of the race agenda and also providing a mechanism for responding to the
complexities of people’s lives. Public health approaches and earlier intervention were
highlighted as critical to future success, as was the connectedness to Joint Strategic Needs
Assessment. Political drive was cited as a key requirement. The rising focus on the parity of
esteem for mental health was agreed to provide a lever for achieving a focus on BME mental
health. The new political positioning in relation to mental health generally, needs to be
capitalised upon to raise the problems arising from ethnic inequalities for individual, families,
communities and the mental health system.
Examples of Progress towards improvements
Two London Mental Health Trusts presented their respective approaches to trying to
achieve a reduction in the proportions of Black service users admitted. One had some
green shoots of success but the initiative ended before sustained improvement could be
achieved. Both of these NHS Trusts were Focused Implementation Sites under the DRE.
Both implemented a multi-component programme including workforce development, work
to develop Black service user engagement and community work. Both informed their work
with the Count Me In census data and had a clear intention that their programme would
lead to a reduction of admissions for Black people.
The programmes of work both started with a clear lead, applying project management
methodologies. Both suffered from a loss of the project lead, problems with generating
ongoing (modest) funding. One of the programmes was formally ended because as well as
the problems with funding and staff change, the array of projects within the programme was
just too complex to manage. In the other site, elements of the initiative continue to run and
individually are well received but no longer work together as a single programme with
rigorous monitoring of impact against the Trust’s performance on admissions.
The need for evaluation right from the outset was identified as a priority for any future
work programme, so that learning and impact can be well captured.
The roundtable discussion overwhelmingly identified the need for leadership. A clearly
defined project was seen as essential to embed a model but plans must be in place to make
the transition from project to local commissioning for success. The need to ensure the
capability of commissioners in the new architecture of the NHS was a recurrent theme.
Possibilities for future success – The Locked Hexagon Model
The Locked Hexagon Model (LHM) was presented (see Locked Hexagon Implementation
Toolkit here http://www.hsconsultancy.org.uk/resources). The Locked Hexagon is a model
for identifying a baseline level of performance and implementing coordinated action that
directly achieves demonstrable improvement in outcomes for people of Black and minority
ethnic backgrounds in secondary mental health care. It is predicated on the idea that there
are six key components required to create the conditions for demonstrable outcomes to be
achieved. The hexagon is locked because the model works only if all key components are
present. There is a disproportionately negative impact if even just one component is
missing. The six components are:
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Targets for improvement in key areas: These are defined locally in the service,
team or sector implementing the Locked Hexagon Model. The approach is to start
with the end in mind then ask “what do we need to be doing differently in order to
achieve this?”
Service users as experts in shaping services: Not traditional service user
involvement but imagining a (soon to be realised) world where service users are real
customers who chose whether or not to buy services.
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Use of Narrative Approaches: Along with explanatory models this draws
professionals into a focus on the story behind the presentation, the person and not
the symptoms. It is a redefining of a deficit model into a greater emphasis on the
capacities of people. Adverse life events are not seen as triggers for illness but as
having, to some extent, a causal relationship.
Promotion of employment, training, volunteering, and education: The
active support for BME service users to pursue structured activity is important as
the case has been made that this is a critical factor in developing and maintaining
good mental health.
Staff and Managers Knowledge and Skill Development: The focus is not just
on training but any mechanism that enables staff to enhance their knowledge and
skills to work creatively and in focused way with groups for whom variations in
outcomes persist.
Carer and Community Engagement: This is engaging carers in joint problem
solving about how to enhance the care and treatment provided and learning from
communities why some groups remain hidden or delay using services until a major
crisis occurs.
The roundtable discussion accepted the usefulness of the model. Suggestions were made
for modifications and inclusions and these have been taken into account. The main focus of
attention was on the implementation toolkit and how the model would be implemented in
the current busy austere climate. New possibilities were explored, such as applying the
model to a geographical area, using the Total Space model. Delegates felt that incentives
were needed to achieve buy-in from NHS Trusts and other sectors who might implement
the model. The learning from local area agreements should be identified and applied where
possible. If the model is to be successful it cannot be presented as a hugely bureaucratic
project. The project management sections of the toolkit need to reflect the intention that
local decisions are made about the level of resourcing. For example, a project may be
largely driven by a team manager of a Community Mental Health Team (CMHT) with
support from a diversity lead. Workstream leads may be team members (of the CMHT)
and meetings may be virtual. The LHM does not need to be run like a mini industry.
Recommendations
1. Some test sites should be encouraged to test the model.
2. Leadership needs to be clear. The NHS Commissioning Board is encouraged to
restate the need to tackle ethnic inequalities in mental health with renewed energy.
3. Timescales for change need to be more realistic. Major system change needed
longer than the five year allocated to DRE.
4. As mental health is achieving a higher profile in politics every opportunity should be
taken by all in the sector to raise issues of ethnic inequalities
5. The consensus that there needs to be a parity of esteem for mental health should be
exploited to achieve a focus on BME mental health.