Tackling societal inequalities and institutional discrimination in mental health systems

A recently published BMC Medicine article investigates the inherent inequality in the mental health service care received by patients from minority ethnic groups. Here, Dr. Kamaldeep Bhui discusses his team's findings.

Health systems exist within specific political and societal contexts, and so it is no surprise that societal inequalities are in fact reproduced in health systems that are operating within the same structures and values. Decades of research have shown ethnic inequalities in the experience and outcomes of severe mental illnesses, which may now be worsening.

One of the worries that troubles health professionals and the public is that black patients in mental health services in the UK more often receive care through the powers of the Mental Health Act (MHA) than white patients; that is, black patients are more often detained against their will and forcibly given treatments. Why one ethnic group should need more coercive care than another is not clear.

The Count Me In Census (CMIC) monitored care under the MHA during a national policy implementation to deliver race equality between 2005 and 2010. The data showed no reductions in use of the MHA for black patients, and subsequently data on ethnicity and MHA have not been annually reported as was originally intended. Thus good information of research quality is needed.

In an article published in BMC Medicine, my team and I investigated ethnicity and severe mental illness, to look at pathways to care taken by people from specific ethnic groups and whether this picture had worsened since austerity policies and more recently. In the article we show that black Caribbean and black African mental health patients are more likely to encounter the police and the criminal justice system, but are less likely to receive care through their GPs and primary care services. Likewise, black Caribbean and black African and South Asian people are more likely to be assessed for care under the powers of the MHA.

These findings show that the systems of care are still not operating in a fair and equitable manner, and that some ethnic minority groups can expect to receive less primary treatment, and less voluntary care. The causes of these variations are under investigation, although evidence from other research undertaken on psychoses show that violence, personality disorders, and substance misuse did not account for the variations in criminal justice system contact.

It is likely that the factors leading to inequalities in society are structured and replicated in our health systems, hence a careful and searching inquiry is needed of the structural sources of inequalities, and how factors such as multiple disadvantage, poverty, poor education, excessive criminal justice system contact, more experiences of racism, and discrimination can ultimately be replicated in our health systems.

This is a bittersweet pill that health services need to accept. Rather than continue to operate in crisis as the end point of care systems, which are under strain, we need better prevention and community alternatives. Professionals, politicians, and policy makers need to show compassionate, collaborative, and emotionally intelligent leadership that does not duck these difficult issues. We need to create the conditions in which we can join forces to re-think the sources of structural and institutional disparities, and follow through on the findings of the Race Disparity Audit and our research with actions to reduce ethnic inequalities in severe mental illness in health systems, as well as in society more widely.

Improving the wider health system to reduce the reliance on MHA as a cornerstone of care and investment in prevention, public health, and community-based care has to be culturally competent and cognizant of the principles by which discriminatory practices can unwittingly enter health systems and for which the strongest remedy is the highest standards of professional clinical and managerial practice that is reflective, responsive, motivated, and culturally capable.

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