In 2018, ethnic inequalities in mental health treatment led the Royal College of Psychiatrists to endorse the position that mental healthcare in the UK is institutionally racist. In this blog, Jamal Alston, Dr Henna Lemetyinen, and Professor Dawn Edge explain how these inequalities present themselves, and use their research to outline new policies for mental healthcare.

• BAME patients accessing mental healthcare in the UK face an overwhelmingly negative pathway compared to their White British peers.
• This includes more coercive forms of treatment, and a lack of culturally sensitive care.
• Following recommendations from NICE, the RCP, and NHS England, there is a need to develop a policy framework for evidence-based, culturally sensitive mental healthcare.

Health inequalities are unjust and preventable disparities in access to care, experience, and outcomes between different groups of people. At local, national, or global levels; inequalities in physical and mental healthcare are influenced by ‘social determinants’ such as age, socio-economic status, and ethnicity.

In the UK, individuals from Black, Asian, and Minority Ethnic (BAME) backgrounds experience ‘varied and pervasive’ inequalities in mental health and wellbeing.  We use ‘BAME’ here due to its familiarity. However, we recognise and urge others to reflect on how agglomeration of vastly different experiences can obfuscate meaning. One of the most consistent UK research is elevated rates of schizophrenia and related psychoses among people of Black African and Caribbean backgrounds, including those of ‘Mixed’ heritage, compared with White British peers.

No single cause accounts for these differences. Comparative studies have not found similar rates of morbidity in Caribbean countries like Jamaica, Barbados, and Trinidad. Racism, discrimination, migration, social and economic disadvantage are among contributory risk factors. Additionally, Black people’s inferior care (eg disproportionate rates of death in service and detention under the Mental Health) has led many observers to conclude that mental healthcare in the UK is institutionally racist, a position endorsed by the Royal College of Psychiatrists.

Tackling ethnically-based inequalities: ‘Too hard to do’?

Ethnic inequalities in mental healthcare appear intractable, despite a National Health Service (NHS) founded on the principle of equity and numerous policies and practice guidelines to tackle disparities.  After several decades of such strategies, research indicates that Black people continue to be less likely than other ethnic groups to receive timely diagnosis, treatment, and support. Instead, their experiences of mental healthcare is characterised by negative care pathways, often involving the police, and more coercive forms of treatment such as forcible injection of psychotropic medication and being held in isolation.

Black and other UK ethnic minority service users rarely receive culturally-sensitive care. For instance, faith and spirituality (which can buffer symptoms of distress and support recovery) are too often regarded as “irrelevant, harmful, and pathological” by practitioners. People of African and Caribbean origin are also less likely to receive psychological therapies. Those who do, report that their lived experiences and explanations for their difficulties are rejected, nullified or reframed as evidence of illness – particularly when these involve racialisation. Perceptions of practitioners’ lack of empathy and/or cultural awareness have detrimental effects, reinforcing mistrust and increasing the likelihood of disengaging from services; thus further increasing inequalities in access to evidence-based care.

Although various organisational bodies, such as the Royal College of Psychiatrists and NHS England, recommend culturally-sensitive care, there currently exist no clear national guidelines or regulatory standards for what evidence-based culturally-sensitive care looks like or how it can be implemented and evaluated. Research findings on the role, implementation, and results of ‘cultural-competency training’ in UK healthcare settings are ambiguous. Addressing consequential gaps in service provision is essential to tackling mental health inequalities that relate to ‘race’ and other Protected Characteristics as defined under the Equality Act, 2010.

Community Partnered Participatory Research (CPPR): A way forward?

The National Institute for Health and Care Excellence (NICE) highlight the urgent need to develop evidence-based, culturally-informed talking therapies to bridge the treatment gap experienced by the UK’s minority ethnic populations.

In response, people diagnosed with schizophrenia (and related psychoses), their families, healthcare practitioners, and community members have collaborated with us to co-produce Culturally-adapted Family Intervention (CaFI). Originally piloted with Caribbean-origin families in Manchester in 2013-2017, aspects of the CaFI therapy designed to maximise its utility and acceptability with families and mental health professionals included culturally-informed explanations of mental health problems (such as religion and belief) and improving CaFI therapists’ cultural competency. Service users and carer participants in the pilot study endorsed CaFI’s cultural acceptability and therapists reported increased confidence and competence in working with families of Caribbean origin.

Subsequent to the successful pilot in Manchester, our team of national academics have secured £2.5 million of National Institute of Health Research (NIHR) funding to further refine and evaluate CaFI with people from Sub-Saharan African and Caribbean backgrounds. This involves evaluating CaFI’s clinical and cost-effectiveness in a randomised controlled trial (RCT).

Our research will also identify barriers to implementing the therapy across a number of mental health NHS Trusts in England and solutions to overcome them.  We anticipate that ensuring service user and carers are integral to research design, delivery, and evaluation will lead to more holistic mental health care, which service users and their families find acceptable. Accordingly, our work strives to amplify African and Caribbean communities’ voices in informing CaFI therapy resource development, therapist training, research management and dissemination.

Through meaningful collaboration with service users, their families, and healthcare professionals, we are learning valuable lessons that we intend to share with the wider research community and mental health services. We hope that these insights will inform strategies for increasing the participation of BAME populations in clinical trials, as well as shape policy and commissioning decisions. Effectively tackling inequalities in mental healthcare provision and outcomes will enable us to confidently assert that ‘Black mental health matters’. This is especially pertinent in preparing to adequately address the potential mental health crisis during and after the COVID-19 pandemic.

Policy recommendations

We propose the following policy recommendations for tackling long-standing inequalities in mental healthcare experienced by Black and other UK minority ethnic groups in the UK.

1. Cultural competency and inclusive service delivery should be standardised in healthcare practice and curricula across the NHS to ensure that diverse groups receive high-quality, holistic care.

It is imperative for healthcare professionals to challenge their assumptions in care delivery, which if unchecked, could inadvertently reinforce institutional practices that produce mental health inequalities. We must also develop diverse versus ‘one size fits all’ approaches; thereby promoting understanding of how factors such as membership of LGBTQ+ communities, age, and disabilities intersect with ‘race’/ethnicity to magnify inequalities.

Comprehensive, standardised, and evidence-based cultural competency training could enable healthcare professionals to work more effectively and confidently with diverse cultures and experiences. This includes enabling healthcare professionals both to understand how issues like racism detrimentally impact mental wellbeing and equipping them to maximise mental wellbeing and help-seeking for UK-minority people both within and outside the NHS. For example, even though spiritual wellbeing can be crucial for healing and recovery, it is often neglected in mental healthcare. In addition to providing more holistic care, working with faith leaders could help to reduce stigma and promote understanding and timely access to care.  Representation of BAME people in key leadership roles in healthcare and policy must also be improved to better inform inclusive mental health provision.

2. Monitoring and evaluation of UK mental health services by regulatory bodies must incorporate assessment of workforce capacity to deliver holistic care and service users’ rating of their experience.

The Care Quality Commission (CQC) and the National Clinical Audit Programme should develop criteria to assess service user satisfaction, safety, and the availability of culturally-sensitive care against benchmarked regulatory standards. Patient satisfaction criteria alongside Workforce Race Equality Standards (WRES) should be used routinely to drive up Equality, Diversity & Inclusion (EDI) standards within services and should be mandatory components of statutory inspection reports and service rating. Clinical Commissioning Groups (CCGs) and Health and Wellbeing Boards should be held accountable for filling gaps in mental health provision for all people thus, ensuring that inequities are eradicated.

3. Mental health services should actively work with service users, their families and community groups such as faith-based organisations at ‘a grassroots level’ to better understand their needs and co-produce solutions.

Collaboration of this kind provides opportunities for bi-directional learning about:

• culturally-based conceptualisations of mental health and how these might inform both hospital and community-based treatments
• developing and evaluating initiatives to dispel stigma about mental health
• more inclusive and novel public health education approaches to, for example, identifying and responding to early warning signs of poor mental wellbeing to facilitate more timely access to care and support

We believe that more effective partnership working will enable a plurality in service provision, which is necessary for optimising patient choice, for example, multiple entry points into specialist NHS mental health services. Meaningful engagement with diverse communities also fosters the potential for co-producing more culturally-informed psychosocial interventions by mobilising ‘citizen scientists’ and providing under-served communities with opportunities to become more actively involved in research.

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