If only we were told...
Development of a level 2 qualification in Promoting BME access to appropriate Mental Health Services
The Project picks up from an earlier project, "Talk to Us", conducted by the Sikh Community and Youth Service in 2007-8 at a time when the Mental Capacity Act, 2005 was being implemented, but in advance of the Mental Health Act 2007, amending the 1983 Act. It came at the time the Delivering Race Equality agenda had been launched in response to the concerns discussed in the Independent Inquiry into the death of David Bennett - Guardian.co.uk. Key figures relating to numbers of Black and Minority Ethnic groups were recorded in annual Count Me In Reports the last of which was 2010.
The earlier SCYS "Talk to Us" Project involved meetings with some 40 voluntary organisations across the West Midlands region of England. They all wished to increase their capacity to help with mental health need. As Ralph Hall of CSIP, an organisation, now disbanded, which considered mental health from a social perspective, commented these groups had come into being precisely because of unmet need.
While new and effective methods of supporting mental health needs are available they are not accessible to every one. As Primary Care Trusts begin to hand over to Clinical Commissioning Groups (CCGs) under the leadership of General Practitioners we are beginning to see what might emerge. There are promises that the new regime will not be "top down", given public involvement in CCGs and Health Watch. At present statutory organisations not only struggle to meet the volume of need but are able use their powers to make decisions that adversely affect patients and their families. It is not only the health authorities that come into daily contact with mental health need. Police, education, housing, employment can all be key factors in determining whether help is available.
Too often vulnerable people are abused and open to violence from officials. Between 2000 and 2010 there were nearly 6000 deaths of people in custody - held where we assume are places of safety. A large proportion are from Black and minority ethnic communities. Evidently the concerns and recommendations of the David Bennett enquiry, and many others, such as Stephen Lawrence, echoing Bennett on continuing racism inside and outside institutions, are falling on deaf ears. All this will be a requirement of a proposed syllabus to be followed by anyone wishing to work for improving access to mental health for bme communities.
1 The Proposal
This project will build on the results of our 'Talk To Us' project, which took place between 2007-8. However it is innovative and we consider that the work that we should like to do has considerable potential for improving access to mental health services by people from Black and minority ethnic groups nationwide. The Sikh Community and Youth Service (UK) based in Birmingham, UK, has been involved in improving access to mental health services for local residents through several projects and initiatives. Handsworth and the surroundings areas of North Birmingham and West Bromwich in the Black Country are composed of a rainbow of communities. The relatively cheap local privately rented accommodation has also led to an influx of refugees and asylum seekers since the turn of the 21st Century including many people from Eastern Europe.
Government policy provides people from different communities with considerably different entitlements to NHS and Social Services care when they are suffering from mental health problems. For people arriving from EU countries this is normally the same as that enjoyed by British citizens. On the other hand a large number of refugees and asylum seekers who were born in countries including Somalia and Kurdistan are only entitled to very basic emergency care which will only normally provide superficial treatment for their mental health problems. The Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) recognises that this is a problem and indeed it's also a professional dilemma for its doctors and nurses. However they are bound by the law and regularly audited so their hands are tied. In the areas where SCYS UK operates the stresses of life for people who are suffering from serious poverty, unemployment, social exclusion and who often live in overcrowded and generally very poor housing is often great. This is compounded by the challenges of coming to terms with life in a foreign country and the most serious recession since the World War 2 which is now leading many Public Sector service providers and charities to cut back on their activities. The underground (or black) economy was a big provider of jobs in Handsworth but the recession has cut these down considerably. Therefore families in the greatest need now have to cope with less than they had before.
In these circumstances the number of people who are developing stress related mental health problems continues to increase. Our previous mental health project was partly designed to encourage them and their families to seek help for these earlier, when the conditions are more easily treatable.
While many families still feel too ashamed to seek help because of stigma that are attached to mental health problems in their community's culture and tradition, SCYS UK is experiencing a steady flow of callers at our Information Advice and Guidance Centre from individuals and families who need to access NHS Mental Health Services. We havethought carefully about the best way that these needs can be provided for both by the NHS, Social Services Departments and by community organisations that operate in
very disadvantaged areas. We consider that it would be very helpful if there were far more Community Mental Health Workers who have received recognised introductory training in mental health problems, treatment and care pathways but who also have intimate understanding of the culture, traditions and religions of the communities that they are working in. We expect that the work of the newly qualified Community Mental Health Workers would include preventative health care so that they would also be ambassadors for maintaining good mental health and of ways of doing so. NHS and Local Authority budgets are going to be under a lot of strain for the next few years at least and so any new measures targeting Black and minority ethnic mental health problems are going to have to be low cost and have a good chance of success. We expect that the newly qualified Community Mental Health workers would have below average NHS salaries and they could also be affordable as employees of neighbourhood groups, local charities, Housing Associations, GP's Surgeries and similar organisations who draw funds from a range of sources to do work at the local level in mental health 'hot spot' areas. SCYS (UK) has managed a busy Information, Advice and Guidance Centre for a generation now and so we meet people who are looking for jobs all the time. This includes men and women who we think have all of the necessary people skills and general intelligence to train to become a Community Mental Health Worker but at present there is no suitable qualification that could be accepted and recognised by employers in a sector where the possession of qualifications is invariably a prerequisite to doing responsible health and social care work. We would like to plug this gap by developing a new Level 2 qualification in 'Promoting Mental Health and Well Being'.
The City and Guilds Institute has recently announced a new qualification in 'Promoting the Mental Health and Well Being of Older People' (Number 3062) which is targeted on the employees of nursing homes and domiciliary care workers with older people. We have discussed the labour market and social welfare requirements for the new qualification in Promoting Mental Health and Well Being with the City & Guilds and also with City College in Birmingham, which is our main FE partner. The process of getting a new NVQ approved is fairly complicated but at the heart of it is the development and prototyping of the course units that prospective students would have to study for. This includes how these would be delivered (e.g. training materials) and assessed (e.g. examinations and practical assignments). SCYS UK's role in this process would be to make sure that the units and both the accompanying training and assessment materials are BOTH (1) accessible to students who use English as a Second Language and (2) relevant to the special needs of Black and minority ethnic people who are suffering from mental health problems. The Level 2 students would receive training in counselling and advocacy skills as part of the course which will increase the range of valuable community based mental health oriented work that they can do. The Level 1 qualification is seen as an essential pathway to the Level 2 for people who have not studied for vocational qualifications in Britain before but not an employability qualification.
The developmental work is going to take 3 years and the key output at the end of this timeshould be a new Level 2 qualification which has the potential to improve the quality of life for Black and minority ethnic people with mental health problems for years to come.
2 Overview: "If only we were told...."
This was the cry from David "Rocky" Bennettʼs family when they understood too late what was happening to their beloved family member. David died, as have many others, in what should have been a place of safety. Too often institutions: care homes, mental health centres, police cells, have been places where vulnerable people with frail mental health "If only we were told....." end up dead. Then there is an enquiry which inevitably says "this need not have happened", the bereaved left agonising "if only we were told..."
In too many cases those in care, but at risk, are from black and minority ethnic communities. They end up disproportionally detained in hospitals or prisons. Many have ended up under heavy sedation, their quality of life extremely low. Count Me In reports recited figures annually up to 2010, although this was nothing new. Woeful provision for mental health has long been an issue which is well known and admitted. Appropriate provision for black and minority ethnic communities is high on the agenda but work to tackle issues dealing with vulnerability and racism is slow and patchy.
The view of the writer is that everyone has the same needs and experiences a common human condition with regards to mental health. The difference comes from both varying perceptions and interpretations of what a breakdown in mental health is and unique experiences in an unequal society where attitudes of others come into play. Appropriate treatment must take this into account, together with needs arising from diverse languages and cultures. The issues of racism has been explored in recent years during and since the Stephen Lawrence Enquiry and the report. An investigation into factors surrounding the death of another black person dealing with issues of racism, but specifically around mental health os found in the report on David Bennett. These are well documented cases which had tragic outcomes. The concern here is with many more situations which are not highlighted, but result in needless suffering by both patient and their wider network of family and friends. Indeed it is to look at cases where the outcomes have been wholly different and successful in either preserving or restoring mental wellbeing.
What do those charged with caring for others need to know and understand to prevent poor mental health developing or supporting where it has become a reality?
The David Bennett report makes recommendations, the first three of which are:
"1 All who work in mental health services should receive training in cultural awareness and sensitivity.
2 All managers and clinical staff, however senior or junior, should receive mandatory training in all aspects of cultural competency, awareness and sensitivity. This should include training to tackle overt and covert racism and institutional racism.
3 All training referred to in 1 and 2 above should be regularly updated."
Independent Inquiry into the Death of David Bennett, December 2003. p. 67.
"Inside Outside. Improving Mental Health Services for Black and Minority Ethnic Communities in England" is an NHS document also dating from 2003. It claims that this is the first attempt to co-ordinate a national service for mental health and declares:
Specific and co-ordinated action is required to:
• reduce and eliminate the current ethnic inequalities in mental health service
experience and outcome;
• develop the capabilities of the mental health workforce in providing
appropriate and effective mental health services for a multicultural population;
• invest in community development of minority ethnic groups aimed at
achieving greater community participation and ownership around mental
The Government responded with the Delivering Race Equality agenda with the aim by2010 of "more appropriate and responsive services - achieved through action to develop organisations and the workforce, to improve clinical services and to improve services for specific groups, such as older people, asylum seekers and refugees, and children; community engagement - delivered through healthier communities and by action to engage communities in planning services, supported by 500 new Community Development Workers; and better information - from improved monitoring of ethnicity, better dissemination of information and good practice, and improved knowledge about effective services. This would include a new regular census of mental health patients."
Delivering race equality in mental health care. An action plan for reform inside and outside services and the Government's response to the independent inquiry into the death of David Bennett. January 2005 p.3
The move to improving access to psychological therapies (IAPT) seemed a step forward with the debate centred on the use of "talking therapies" instead of, or in addition to medication. This is seen as a way forward on grounds of cost as well as benefits for patients. It challenges the (still?) dominant "medical model" of care in the health services against a "social model". In practice the one tends to centre on the patient and can leave out significant others while the other recognises the context in which people become ill and is more capable of taking wider factors into account. Stress, for example, is likely to arise from social rather than medical factors, so understanding this and being able to deal with maybe a range of complex issues can be helped by talking with others. Medication, while offering relief, explains nothing. It can impair the quality of life significantly over long periods of time. Statistics reveal that members of bme communities are more likely to have medication and to be assigned to hospital or other institutional care.
"2. Over the last 12 months, the demonstration sites for the IAPT programme (in
Doncaster and Newham) have provided evidence-based psychological therapy services
for over 4,000 people with depression and anxiety disorders - people who would hitherto have had limited access and choice. These services are beginning to address the psychological therapy needs of both these communities.
3. Newham is an area where over 50% of the community is from black and minority ethnic groups. There is very promising ongoing work engaging with local community leaders,encouraging access and providing evidence-based therapies that address diverse needs.
4. In Doncaster, the programme has focused on who delivers the psychological
interventions. By employing and training people from the local community to offer low intensity psychological interventions, the service has been able to offer a model of care integrating local IAPT Implementation Plan: National Guidelines for Regional Delivery Author DH/Mental Health Programme/Improving Access to Psychological Therapies February 2008. p 2.
The last Labour Government published New Horizons in 2009 building on the DRE agenda, but the new Coalition Government brought forward its own report in the context of sweeping changes to the NHS. In particular health services will be commissioned in a different way with Clinical Commissioning Groups (CCGs) having a role. These are intended to have public involvement and to move away from a "paternalistic" and remote approach adopted by some Primary Care Trusts (PCTs).
No Health Without Mental Health, published in 2011, superceded New Horizons but has links with issues raised in the earlier reports mentioned above:
"This strategy sets out our ambition to mainstream mental health, and establish parity of esteem between services for people with mental and physical health problems. It shows how Government is working to improve the mental health and well being of the population, and get better outcomes for people with mental health problems. "No Health Without Mental Health" is accompanied by the following documents, published individually:
• Delivering Better Mental Health Outcomes
• The Economic Case for Improving Efficiency and Quality in Mental Health
• Analysis of the Impact on Equality
• Analysis of the Impact on Equality - Evidence base
• Talking Therapies: A four year plan of action
• Talking Therapies: Impact Assessment
• Talking Therapies: Analysis of the Impact on Equality"
No Health Without Mental Health 2011 p1
This paper proposes a delivery system as follows:
Equality Delivery System (EDS): The Equality Delivery System is a new framework designed to support delivery equality in health care within a patient-led NHS. It is due to be rolled out from April 2011. This will involve commissioners and providers using local data and working with local user/interest groups to identify equality priorities on a four-year cycle.
There are a number of planned actions for the EDS:
• Gathering accurate data on local priorities, such as local need for mental health services - using channels such as the community and voluntary sectors.
LINks, and, in the future, HealthWatch;
• Establishing mechanisms that allow local user groups to engage with providers and
commissioners; empowering and supporting them to engage effectively; and
• Monitoring and evaluating effectiveness of service delivery and effective governance,
especially around equality needs.
The EDS aims to improve the equality performance of the NHS. NHS organisations will be graded. In partnership with local communities and the NHS, organisations will identify and agree one of four grades: excellent, achieving, developing and under-developed. Where organisations and local interests are unable to agree on a particular grade, the view of local interests will be prioritised. Based on this grading, NHS organisations will prioritise the areas that require improvement. This assessment will be undertaken annually to ensure that the grading accurately reflects organisations' achievements and areas that require further development.
Consultation, engagement and involvementThe Ministerial Advisory Group (MAG) on equality in mental health will continue to meet with the Minister of State for Care Services to monitor progress.
This AIE builds on work undertaken to develop the Equality Impact Assessment for New
Horizons: a shared vision for mental health, the previous Government's mental health
programme. As part of the development of New Horizons, equality screening was completed and the results of that screening were published within the New Horizons Equality Impact Assessment published in July 2009.1 A further Equality Impact Assessment was published in December 2009.
In June 2009 a public consultation on New Horizons was carried out. In order to avoid duplication of effort and resource a further consultation has not taken place. The issuescovered in the New Horizons consultation remain valid and the responses and conclusions have been used to inform this AIE. These are contained in the Evidence Base (Annex A). The complete consultation The complete consultation report can be found here: New Horizons consultation report available at:
1 New Horizons Equality Impact Assessment, July 2009 available at: http://tinyurl.com/
2 New Horizons Equality Impact Assessment, December 2009 available at: http://tinyurl.com/NewHorizonsEQIADecember2009
No Health Without Mental Health Analysis of Impact on Equality (AIE) p6
So it seems that the pilots in Newham and Doncaster are carried through to pilot and good practice with regard to ethnic diversity and community involvement. However this is a drop in the ocean with respect to pressing need. It has been reported recently that only 25% of those in need of mental health care are receiving treatment. We know that many who do need help don't present themselves and may end up when a crisis occurs.
In a meeting I attended in June 2012 concerning the CCG being set up for NW Birmingham and Sandwell I noted that one of the doctors is leading on mental health. He reports an advance of IAPT in the area of Sandwell where he practices himself, but while other GPs are aware of this psychological therapies appear not to have been rolled out in the wider area as yet. It is not clear to me if provision takes account of diversity of language, culture and belief and so there is access to appropriate mental health treatment for all.
The last ten years has then shown developments in awareness of mental health and diversity. It was acknowledged much earlier than this that Mental Health was a Cinderella service, underfunded and not touching many in need of help and support. More than that it is now agreed that choice is a critical factor since many people do not present themselves.
Fear of statutory service provision or finding centres where others do not share or understand your language and culture are not places you want to be confident that your problem will be understood and you will receive appropriate treatment and help. The report based on work in the West Midlands: "Breaking the Circles of Fear" was published just before the David Bennett Enquiry report. Its recommendations remain an issue and it will be referred to in more depth at the next stage looking more closely at developments in the West Midlands.
Two headlines in the Guardian of 18th June 2012 sum up where we are with mental health following a report from the London School of Economics:
"Scandal of mental illness: only 25% of people in need get help". It adds "Report urges appointment of special cabinet minister and says 'millions wasted' through lack of proper treatment."
"It is inexcusable that mental health treatments are still underfunded" pointing out that "Today's therapies are highly effective and save money. But attitudes to the sector remain stuck in the 1960s".
What happens to those who don't get appropriate help? A NACRO report from 2007 gives a report about then. Today's figures relating to deaths in custody are chilling and take us right back to the start with David Bennett where racism and discrimination continue to loom large for bme communities:
"Despite various policy initiatives in recent years, little progress has been made tackling...
(Black communities and the criminal justice system)......this important subject. Home Office statistics have consistently borne out the discrimination experienced by black people who come into contact with criminal justice agencies and the Department of Health had admitted that there is an undue emphasis on coercive models of treatment for black mental health patients, with organisational requirements often taking precedence over their individual needs." Black communities, mental health and the criminal justice system, NACRO 2007.
3 Addressing issues on BME Mental Health Provision and Access. Conclusions from the SCYS Talk to Us Project, 2007 - 8
While the debate on mental health provision has moved on in the past ten years since the David "Rocky" Bennett report the generality of appropriate and sufficient provision remains an issue. Increasing Access to Psychological Therapies (IAPT) is seen as a viable alternative to drugs with demonstrable success and affordability. However recognition that needs of people with diverse languages, cultures and consequently approaches to mental illness is extremely limited. In particular the persisting bureaucratic nature of statutory provision persists on clinging to professionalism with paternalistic attitudes to those the authorities are supposed to be caring for and supporting means for many added pressure and stress. A case in Birmingham has shown me how remote commissioners can be from those they provide for with inappropriate placement of people placed in alien environments estranged from culture, religion, diet and family at a time they need such support the most. Police deal with people they are called to deal with singularly inappropriately, physically and verbally assaulting them and in many cases, some of which have received front page coverage, people have received severe injury or died after being taken into custody. Nearly 6000 cases of death in custody were recorded between 2000 and 2010, many victims were known to be suffering from mental illness while others with no history of illness have ended up being told they are mad. Some have ended up being sectioned. Within this group there is an over-representation of black people. So much for understanding of key report such as that of David Bennett and the McPherson Enquiry into Stephen Lawrence's death. You get the impression that there are still areas of provision where the racism identified in those reports remains endemic.
The World Health Organisation see depression as of epidemic proportions and as the most seriously debilitating human condition. Yet many find help unavailable, rather they face stigma from uncomprehending societies, exclusion, beatings and confinement in appalling conditions. They recognise on the other hand that a transformation is possible if more were involved. This means a demystification of clinical practice and a sharing of expertise. People can be helped by talking with understanding family, friends or any other person. David Bennett's family remarked "if only we were told", but thy failed to understand and recognise David had a problem. They wanted to know how they could have helped.
Of the 6000 deaths in custody many had associations with mental illness and/or Black people. In 2003 Mikey Powell's mother called the police from her home in Handsworth in Birmingham. This was the response: "Mikey died after police knocked him down with a patrol car, discharged more than four times the recommended amount of CS spray on both Mikey and his friend, and hit him with a police baton. Up to eight officers held him down on the ground for at least 16 minutes and then took him to a police station and not a hospital.|
"Talk to Us” was the title of the earlier Project meaning those in need of support are asking for someone to talk to them. Medication may have sedated them, but that has not helped in dealing with the cause or causes of their anxiety or stress. Many have testified to the effectiveness of talking through their difficulties. We need many more people to do this, but they will need training to recognise signs that the individual concerned will need more specialist help. The NHS has long recognised the need to work closely with people in the community to be effective in meeting the widespread need with schemes such as the Expert Patient. It also needs to be recognised that this is essential for dealing with diversity where "cultural competence" is required. It appears that pilot projects in Newham (diversity) and Doncaster (community involvement) address the issues. What the timetable is for rolling out good practice is unclear.
I have found the emerging Clinical Commissioning Groups are useful fora for discussion and General Practitioners are aware that the PCTs have often been patronising and top down. One GP said that thos would not happen with the CCGs although that remains to be seen.
The earlier SCYS Project "Talk to Us" (2007) was aimed at building capacity of voluntary organisations. As Ralph Hall of CSIP remarked these had come into being because of unmet need. The organisations I visited, around 40 across the West Midlands, represented a wide diversity of origin and background. There were well established communities from Asia: Indian, Pakistani, Bangladehsi, Chinese, Vietnamese; African (including Somalian) and Caribbean; Eastern European (including Bosnian). Some had people suffering trauma as a result of experiencing war in their home countries. Other temporary migrants working in the orchards of Herefordshire and Worcestershire were not finding support for mental health needs until they reached crisis point.
Changes in funding arrangements and cuts in expenditure has meant that many of the organisations identified as helping specific cultural groups, with deep knowledge of language, culture and religion, have little or no funding. Many are existing on a voluntary basis but have had to dispense with paid staff. They are not able to offer services or compete easily with large established organisations in getting commissions for services. More and more there is a need to rely on statutory services, themselves experiencing swingeing cuts, which to many are alien offering inappropriate services to them, unable to meet their needs.
Change Up Conference at Aston Villa, June, 2007. l to r Dr Safi Afghan, Ian Fellowes, Sukhwinder Stubbs (Chair) and Sundeep Singh, Manager SCYS.
In June 2007 the SCYS organised a Change Up Conference at Aston Villa, chaired by Sukhwinder Stubbs of the Barrow Cadbury Trust and addressed by a range of experts on key issues concerning mental health and then current legislation. Ian Fellows, the first speaker, referred to the partnership with the funders, Capacity Builders, and its aim to support the voluntary sector organisations in building capacity in order to take advantage of commissioning opportunities arising from the introduction of mental health legislation. At this time the Mental Capacity Act was being implemented, the Mental Health Act was still at a discussion stage and much about that remained unclear. Dora Jonathan, a national trainer and consultant, outlined the Mental Capacity Act and the intentions of the Mental Health Act with their proposals for independent advocates.
Dr Safi Afghan, consultant psychologist from Walsall spoke of the need for accessible community-based services promoting good mental health. He said that many had been unable to access statutory provision. They then became prey to bogus practitioners who exploited their vulnerability resulting in a further deterioration in their condition.
Following speakers, Gilbert George of Capacity Builders and Sharon O'Brien of Future Builders, underlined how they saw the voluntary sector as key to improving community health. Since that time the virtual ending of grant funding coupled with the introduction of commissioning has greatly disadvantaged voluntary organisations which have not had the means of dealing with the complexities and demands of commissioning. The Talk to Us Project brought organisations together with the idea of building a network of providers. Conditions of funding from both commissioning and grant giving bodies militated against this.
Staff at the voluntary organisations were invariably keen to be able to offer improved services to their clients and so the prospect of improving their capacity was warmly welcomed by everyone I met. Among the organisations there was the prospect of providing for the diverse needs of people with a variety of languages, cultures and beliefs so that individuals could choose to go where they felt most comfortable.
While it may well be the case that the service provider's knowledge and culture would align with the service user this was not always the case. The Afro-Caribbean Millennium Centre partnered with the Health Exchange in Birmingham. The service provided was intended to help people with a range of social problems including housing, benefits, debt etc. which might cause stress and impact on health. Each client was assessed for their feelings about being stressed both before and after the interview. When a client was advised to see her doctor she replied that she preferred to come here. She explained that there was more time for her. She herself it emerged was not Afro-Caribbean but of white British or Irish origin.
The importance of the voluntary sector and local communities involvement in dealing with what WHO describes as "an epidemic" with the "most debilitating" consequences has been restated endlessly, not least by governments and the NHS itself. It appears however that the ideals expressed in schemes such as the "expert patient" are overwhelmed by enduring professional often informed by outmoded policy and practice. The "we know best" approach needs to be replaced with "we should know better". The failure to come down from ivory towers results in patients and their families getting services unrelated to their real needs and actually leads to heartache and misery: it contributes to stress, depression and mental breakdown. We do know better so let's make the changes.
Statutory service providers ensure us that they are able to provide for diversity, and many examples can be shown where that claim is substantiated. Diversity and demand means that statutory services are unable to meet need anywhere near adequately. A recurring comment from voluntary organisations was that people came to them because they were unable to access help where and when it was needed. This resulted in getting treatment at crisis point, if at all. Today Increasing Access to Psychological Therapies (IAPT) is being rolled out. Access is limited, limited maybe by location, but limited widely by failure to consider the variations within diversity which results in the situation that Dr Safi Afghan describes above.
The "Talk to Us" Project received support and advice from a number of experts and resulted in 8 people training as Independent Mental Capacity Advocates (IMCA). However bureaucracy and procedures meant that this wasn't followed through to allow this diverse group to practice. An IMCA must assess someone's capacity to make decisions if close friend or family member is not available. The question arises how it is possible to do this without knowledge and understanding of that person's background particularly if there are variations in language, culture and belief.
Next Steps. Plans for years 2 and 3 of the Project
The Report on Year 1 is being circulated to those involved in providing services to bme communities in mental health and to training providers. A questionnaire is provided below (pages 15 -20) inviting responses to what is written here and for views on the current situation in provision and access to mental health services.
Included in the circulation will include Birmingham and Solihull Mental Health Trust (BHSMHT), Birmingham City Council Social Care and Health, Dr David Eccleston, Handswortb Wood Medical Centre, Dr Nick Harding Chair of Sandwell and West Birmingham Clinical Commissioning Group (SWBCCG), Dr Ian Walton, Mental Health Lead, SWBCCG, Prof Swaran Singh, Univesity of Warwick, Tari Atwal, Asian Rationalist Society (Britain), Birmingham Metropolitan College, Birmingham MIND, Ashraya House.
I have been invited to join the LINk Mental Health Group with a first meeting in September, 2012. I understand that this group is interested in IAPT developments.
A draft of a syllabus, or unit for inclusion in existing schemes of work will be completed for offering to training establishments for evaluation.
Investigating what is currently happening in the West Midlands.
Apart from following developments in moving towards CCGs and their role in mental health developments, the consultation document "Better Mental Health for Birmingham 2010 - 2015" will be considered to see how its plans reflect the developments of the last decade. For example it is possible to see a move towards a social model of care which looks at supporting people with debt, housing, employment with advice and talking therapies, including self-help.
At least some of the 40 or so voluntary organisations will be contacted to assess how changes in funding and spending cuts have affected their ability to support those they were set up to help. There appears to be a huge contradiction in intentions to involve communities and continued support for the agencies on which they depend. This is particularly marked when dealing with diversity and choice of places to go to for help and feeling comfortable that the provider can address cultural and linguistic while being competent in dealing with social and/or medical needs.
Other statutory agencies persist in being monolithic and impose their solutions often with far reaching and extremely damaging outcomes for patients and families. Key staff will be interviewed in health, police, prison and education services. Many will have responded to the questionnaire.
Draft material will be completed to offer to training providers.
Will focus on disseminating draft material to colleges and other training providers. This will be principally in the West Midlands.
Further work on considering who will benefit from such a scheme of work will continue, including the health services, the police service, the criminal justice system, schools and colleges, social services. employers and anyone who might be involved with people in need of mental health support.
Meetings and conferences during year 1
Sikh Community and Youth Service Project meeting At SCYS, Soho Road, Handsworth. November 2011.
This was attended by Dal Singh Dhesy, Chair of SCYS, Sundeep Singh SCYS Manager, two lecturers from Birmingham Metropolitan College, a member of staff of MIND in Birmingham, the Manager of Ashraya House in Handsworth and John Tyrrell, Project Manager.
Patient Network Meeting, 25th April 2012. Transition from Patient Network to Care Commissioning Groups (CCG).
The meeting of the Patient Network Group was informed at the meeting that they would become part of the Clinical Care Commissioning Group for Sandwell and West Birmingham. We were told that Dr Ian Walton who practiced in the Rowley Regis area of Sandwell was the lead practitioner on Mental Health
The Five Ways to Well Being. Mental Health Awareness Training, 6/2012 Birmingham MIND at Birmingham Voluntray Service Council, Digbeth
A useful refresher session on recognising mental health issues and opportunity to make valuable contacts.
Community Partners for Health, 23/6/2012 Saffron Centre, Birmingham. Health Exchange
Am event organised by the Health Exchange developing links between organisations. Useful in its essentially social approach to mental health and stress. To be followed up,
Strengthening the Patient Voice. Patient Summit Meeting 5/7/2012, West Bromwich Albion Football Club. Changes in NHS services of Sandwell and West Birmingham CCG.
A key meeting to introduce the Sandwell and West Birmingham CCG with a number of GPs present, including the lead on mental health who told me that IAPT was being introduced in his area. How this will be rolled out remains to be seen.
LINk Heart of Birmingham Action Group member. Monthly meetings.
A link had been made with the Mental Health Group through this channel.
“Sarbat Dha Bhalla”: Individual and Collective Wellbeing for All. 14/9/2012 Sikh Health at Tower Ballroom, Edgbaston, Birmingham
The Conference focussed on "attitudes to mental health and well being within the Sikh. Punjabi and South Asian communities ..... aimed at understanding and addressing the issues that often affect access to Mental Health services such as stigma, superstition and shame that are known to exist within these communities". A desired outcome was "the development of a national prevention and early intervention strategy for addressing mental illness in these communities .......to develop best practice in mental health intervention for these communities". (from Conference brochure).
The feeling seems to be that there is too little research into the situation concerning people originating from the Indian Sub-continent. A report "Mental Health care 'fails' Asians" based on Leicester believed that lack of involvement of the health authorities with the community was allowing an increase of suicide among women in particular. Lord Kamlesh Patel expressed the fear that mental health patterns would grow to resemble the situation for African, African Caribbean and dual heritage. He had found a stark lack of basic knowledge and understanding of languages, cultures and religions of Asian people he had spoken to, people who had been in care for many years. How, he asked, could a package of care be put together if this was the case? He noted that care pathways typically differed between different groups.
At the conference speakers referred to the "duty of care" that faith leaders had in educating themselves about mental illness and ns how it affects the community. It was acknowledged that 1 in 4 people were affected from all sections of the community, but cultural patterns of family life in Asian communities require understanding because of the barriers of stigma, superstition and shame stopping access to appropriate treatment: "The Eurocentric model of psychiatrically based mental health services need to fully appreciate and incorporate race, culture, faith and spiritual factors into their formulation of mental health difficulties." (Sachdev Singh Sayan}.
Kamel Kaur Chahel spoke of current NHS provision in a group of London Boroughs with the introduction of talking therapies. There needs to be a partnership between the Health Service and community "to ensure they are more meaningful and effective to and for these communities".
Professor Swaran Singh referred to the social context of mental health. Both he and the earlier speaker pointed out the differences between cultural concepts based on the individual in European societies and family structures in Asian societies, pointing out that they had different coping strategies. These are also present in Asian communities and factors exist that can help facilitate recovery as well as hinder.
The issues raised will be looked at in greater depth in the next stage of the Project.
If only we were told...
Development of a level 2 qualification in Promoting BME access to appropriate Mental Health Services
- The David Bennett enquiry made recommendations on publication in January 2003. Have these in your experience been effectively implemented?
“The Inquiry has made a number of recommendations in the report. Here we highlight the main ones.
1 All who work in mental health services should receive training in cultural awareness and sensitivity.
2 All managers and clinical staff, however senior or junior, should receive mandatory training in all aspects of cultural competency, awareness and sensitivity. This should include training to tackle overt and covert racism and institutional racism.
3 All training referred to in 1 and 2 above should be regularly updated.
4 There should be Ministerial acknowledgment of the presence of institutional racism in the mental health services and a commitment to eliminate it.
5 There should be a National Director for Mental Health and Ethnicity similar to the appointment of other National Directors, appointed by the Secretary of State for Health to oversee the improvement of all aspects of mental health services in relation to the black and minority ethnic communities.
6 All mental health services should set out a written policy dealing with racist abuse, which should be disseminated to all members of staff and displayed prominently in all public areas under their control. This policy should be strictly monitored and a written record kept of all incidents in breach of the policy. If any racist abuse takes place by anyone, including patients in a mental health setting,it should be addressed forthwith and appropriate sanctions applied.
7 Every CPA care plan should have a mandatory requirement to include appropriate details of each patient's ethnic origin and cultural needs.
8 The workforce in mental health services should be ethnically diverse. Where appropriate, active steps should be taken to recruit, retain and promote black and minority ethnic staff.
9 Under no circumstances should any patient be restrained in a prone position for a longer period
than three minutes.
10 A national system of training in restraint and control should be established as soon as possible and,at any rate, within twelve months of the publication of this report.
11 The Department of Health should collate and publish annually statistics on the deaths of all psychiatricin-patients, which should include ethnicity.
12 All medical staff and registered nurses working in the mental health services should have mandatory first-aid training, including CPR training.
13 Records should be kept of all psychiatric units' use of control and restraint on patients. The
Department of Health should audit the use of control and restraint.
14 There is an urgent need for a wide and informed debate on strategies for the care and managementof patients suffering from schizophrenia who do not appear to be responding positively to medication and we recommend that the Department of Health monitor this debate in order to ensure that such strategies are translated into action at the earliest possible moment. (See term of reference 10).
15 All medical staff in mental health services should have training in the assessment of people fromthe black and minority ethnic communities with special reference to the effects of racism upon their mental well being.
16 All patients in the mental health services should be entitled to an independent NHS opinion from a second doctor of their choice, in order to review their diagnosis and/or care plan. If a patient, by reason of mental incapacity, is unable to make an informed decision, their family should be entitled to make it for them.
17 The question of detention in and treatment of patients in secure accommodation should be reconsideredin order to ensure that no patient is detained in such accommodation unless it is necessary, and that the period of each detention and the treatment be kept constantly under review.
18 The Department of Health should examine, with the Department of Social Security, possible modifications to State financial assistance so that patients do not leave resident hospital care in order to obtain adequate financial assistance from the State.
19 All psychiatric patients and their families should be made aware that patients can apply to move from one hospital to another for good reason, which would include such matters as easier access by their family, a greater ethnic mix, or a reasoned application to be treated by other doctors. All such applications should be recorded. They should not be refused without providing the applicant and their family with written reasons.
20 There is a need to review the procedures for internal inquiries by hospital trusts following the death of psychiatric patients with emphasis on the need to provide appropriate care and support principally for the family of the deceased, but also for staff members. (See term of reference 9).
21 There is a need for medical personnel caring for detained patients to be made aware, through appropriate training, of the importance of not medicating patients outside the limits prescribed by law and the need for more regular and effective monitoring to support the work undertaken by the Mental Health Act Commission in this field. (See term of reference 11).
22 It is vital to ensure that the findings and recommendations of this Inquiry inform all relevant parties,including the developing black and minority ethnic mental health strategy. (See term of reference12).”
This report, together with its findings and recommendations, was presented by the Inquiryto the Secretary of State for Health and the Norfolk, Suffolk and Cambridgeshire StrategicHealth Authority on Wednesday, 17 December 2003.
Sir John Blofeld, Chairman of the Inquiry Pan
- The second recommendation refers to “cultural competency, awareness and sensitivity”. What do you understand this to mean?
2. What are the implications for access to appropriate mental health servic
3. Can you give examples (re. question 3) of good practice in your experience?
4. Have you experience of Increasing Access to Psychological Therapies (IAPT)
5.How widely are these available in your area of activity?
6. Is IAPT inclusive in your opinion? ie does it take account of different languages, cultures and understanding of mental health?
7. The World Health Organisation proposes “task shifting” or “task sharing” in order to better meet need. Is this an appropriate strategy here in the UK given diversity and failure of many in need to present themselves?
“Although treatment is available for some, many suffering with mental illness in certain low-income countries lack access to healthcare or do not seek help because of the stigma associated with it. In fact, a multi-country survey in 2008 revealed 35 to 50 per cent of people suffering mental health problems in developed countries and 76 to 85 per cent of those in developing countries did not receive any treatment in the previous year. To tackle this crisis, some mental health experts are promoting task-shifting—or task-sharing—where local people in the community can provide the same emergency health services as medical doctors.” Al Jazeera
8. How, in your view, can members of communities get involved to help meet need of those at risk of stress leading to depression?
9. Does a social model help in understanding mental health needs?
10. What in your view are barriers to people seeking help for their mental wellbeing?
11. Who would benefit from the kind of training being proposed here?
i) among staff or colleagues working with you
ii) among the wider community?
Please add any other observations
John Tyrrell - Project Manager
SCYS UK - Community Mental Health Support Services (CMHSS)
Sikh Community & Youth Service (UK)
Open To All Communities
(Charity No. 518946)
348 Soho Road, Handsworth
Birmingham B21 9QL, UK
Tel : 0121-523-0147