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Mental healthcare: change is needed at the top to address care inequalities

Having more black and minority ethnic mental health nurses and leaders could improve patient outcomes

Having more black and minority ethnic mental health nurses and leaders could improve patient outcomes


‘We need to establish more community-based BME mental health groups’
Picture: iStock (posed by models)

Black and minority ethnic (BME) people are four times more likely to be detained under the Mental Health Act (NHS Digital 2108a) than white people, and nearly one in four (23%) admissions to mental health hospitals involve people from a non-white background, even though they represent only one in seven (14%) of the UK population (Institute of Race Relations 2019).

Furthermore, while BME people are more likely to be diagnosed with mental health disorders, they are also less likely to obtain treatment than the white British group and less likely to experience positive outcomes after mental health service care (Wessely 2018).

Sadly this is not a new phenomenon, but surely in 2019 this is unacceptable. 

Much has been done in recent years to tackle the long-standing stigma associated with mental ill health, but the issue of why BME people are most likely to be detained for their mental health, and least likely to have access to the right counselling, therapy and medication remains a deep concern. 

Not only does this inequality come at profound personal cost to the individuals not receiving the treatment they need but, with people remaining in the healthcare system for longer than they need to, it also has a significant impact on strained NHS resources.

Why is this still prevalent?

The answer to why this inequality exists is complex. One important factor is the negative perception of mental ill health among many BME people. Culturally, and particularly among African-Caribbean communities, there remains a strong stigma attached to mental illness that can prevent them from seeking timely help.

BME groups can also be reluctant to engage with traditional health services and healthcare professionals (Bhui et al 2007), which means the window to catch mental health issues early is diminished. This is a significant reason why African-Caribbean people are more likely to enter the mental health services system through the courts or the police than through a primary care pathway, and therefore finally receive treatment only at times of crisis or breakdown.

Additionally, Sir Simon Wessely, chair of the Independent Review of the Mental Health Act, noted in his review that ‘we have to accept the painful reality of the impact of that combination of unconscious bias, structural and institutional racism, which is visible across society, also applies in mental healthcare’ (Wessely 2018).

'There needs to be more senior BME leaders at the decision-making table, bringing their personal experiences of their own ethnic minority community into the mental healthcare provision framework'

What can be done?

So how can we tackle some of these seemingly intractable issues? One solution, I believe, lies in encouraging more BME people to work in mental health services. If people feel alienated from services due to their cultural background and cannot relate to the caregiver, whether this is a nurse, doctor or community support staff, they may be more likely to avoid seeking help. 

Perhaps most importantly, however, change must start at the top. 

There needs to be more senior BME leaders at the decision-making table, bringing their deep, personal experiences of their own ethnic minority community into the mental healthcare provision framework. Seeing more BME people operating at a senior level and making a positive difference, will encourage others from a similar background to enter the sector.

Current figures show that 19.8% of the NHS workforce is from a BME group (NHS Digital 2018b) and in London this figure rises to 43%, but only 14% of senior board members are from an ethnic minority background (Randhawa 2018). Correcting this imbalance is crucial to reduce inequalities in care.

To tackle cultural stigma, we also need to establish more community-based BME mental health groups, such as Find a Balance, a service providing practical and culturally relevant support for people, specifically from BME communities, with mental health problems.

'14% of senior board members are from an ethnic minority background'

One size fits all does not apply

And we must look more broadly at how we deliver care. The paradigm of care for mental health conditions is still largely based on a ‘one size fits all’ system that sometimes fails to take into account many of the subtle cultural nuances crucial in dealing with vulnerable patients. Having a more dynamic, fluid and culturally flexible system, and with respected BME leaders at its helm, is one way to produce improved outcomes.

We need practical ideas and solutions, a mental health system that is more culturally receptive, and aware of taboos relating to BME communities.

Innovation in community, primary and secondary mental healthcare is crucial to ensure sustainability, and funding is not the only answer; the important driver here is diversity at all levels and at all stages.

If we continue with the same people making the same decisions, we will continue to get the same outcomes, and change is needed.

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About the author

Ian Nnatu is medical director of Cygnet Hospital Harrow, Middlesex, and consultant psychiatrist at Charing Cross Hospital, London. He has a master of science degree from the NHS Leadership Academy and is among the 100 most influential UK British men and women of African or African-Caribbean heritage as featured by Powerlist 2019

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