An extra £1 billion a year by 2020-21 and a pledge from NHS England to help a million more people facing mental health problems was announced earlier this year. Recommendations included the appointment of an “equalities champion”. But, argues Dr Dharmi Kapadia, while racial inequalities in mental health treatment are apparent, how can they be tackled if they’re not even measured properly?
If you’re from an ethnic minority group and suffering from a mental health problem, chances are the treatment you’ll get from the NHS will be different from (and probably more harmful) than if you’re White.
We know this from decades of research that has shown that mental health treatment is not the same for people of different ethnic groups in England. To point out a few of these inequalities, Black Caribbean and Black African men are more likely to be sectioned (admitted to an inpatient mental health unit involuntarily), or enter treatment via the Criminal Justice System than White men.
Pakistani and Bangladeshi women are less likely to be referred for specialist mental health treatment when in need than White women. And overall, most ethnic minority groups report lower satisfaction with their mental health treatment than the White British population.
So, what’s being done about these harmful inequalities?
Delivery and data
Well, to be fair, there was a large scale programme, Delivering Race Equality (DRE), rolled out by the NHS between 2005 and 2010 to make sure that NHS services were equitable amongst all ethnic groups. As part of this, there was fairly comprehensive data collection on mental health inpatient and outpatient stays, broken down by ethnic group and gender, with minimal missing data on people’s ethnic group. To stress, these data were not collected routinely before and these new statistics were important for highlighting the scale of the problem.
But since the DRE programme ended in 2010, there has been no real attempt by the Department of Health to instigate a new race equality initiative for mental health services, and the quality of the statistics, now provided by The Health and Social Care Information Centre (HSCIC), has taken a nose-dive too.
There are three main problems with these new statistics. First, for most mental health services, HSCIC does not give figures separately for men and women; this is a major flaw because we know that ethnic inequalities for men follow a different pattern than for women.
On top of this, none of the figures provided by HSCIC are standardised to the population nor do they adjust the figures for the level of mental illness in the population. This means that we have no idea from looking at the raw data, how this relates to the age structure of the population. Nor do we know if the number of people in each ethnic group using services bears any relation to the number of people that are thought to be suffering from mental illness. This is pretty important because even though some Black ethnic groups have higher levels of mental illness, their levels of incarceration in secure psychiatric units are still higher than would be expected.
Finally, there are high levels of missing data on ethnic group; the most recent report (2015) on the use of secondary care mental health services shows that 17% of people who had contact with mental health services did not have their ethnic group recorded, and it was lower for outpatient services than inpatient services.
All in all, this is pretty worrying. If we can’t even get accurate data to evidence how bad the problem of ethnic inequalities is, how can we begin to tackle it?
Not good practice
What is more worrying, is that the recent publication (February 2016) by the Independent Mental Health Taskforce to the NHS in England, stated that “the national data on access to psychological therapies for common mental health problems are robust” (p.50). However if we look at the most recent statistics on the usage of services provided by the NHS under the umbrella of Improving Access to Psychological Therapies (IAPT), ethnic group data was missing for 23% of all referrals received to this service. Can we really count these as “robust” statistics?
Even with these levels of missing data, ethnic inequalities are apparent, so supporters of the HSCIC statistics in their current form may wonder what critics are moaning about. But, the point is we shouldn’t be using these statistics as robust evidence to base national and local decisions on mental health service planning. It doesn’t make for good evidence based practice.
And it looks like the quality of statistics may become worse. HSCIC have recently opened a consultation on changes to the statistics they will provide over the next three years. They say that this “comes at a time when spending on central services are being squeezed, and [they] must better prioritise [their] current services”. How long before ethnic group recording is given such little importance that the statistics fail to provide policymakers, researchers and service managers with any usable information on ethnic inequalities?
If we are to really tackle racial inequalities within mental health services, reporting accurately on which ethnic groups are using services would be a good place to start.
Without this, there is a danger that the true extent of the problem will remain hidden, and racial equality in mental health services will not be achieved.