Category Archives: Health

Improving access to appropriate mental health services for BME communities

Unit for a syllabus: Improving access to appropriate mental health services for BME communities

Year 3 Report of “If only we were told…” Project

Sikh Community & Youth Service (UK)
Information Advice & Gu
idance Centre
Serving All Communities
(Charity No. 518946)
75 Holyhead Road, Handsworth
Birmingham, B21 0LG, UK
Tel : 0044 (0)121-523-0147
Website : www.scysuk.info

Section 1

Year 3 of Project update 2013-2014

1.
1.1 Decision to provide a Unit resulted from discussions with staff of University Departments and Colleges offering courses in Mental Health say that syllabuses already exist for their purposes. Birmingham City University exemplify City and Guilds Level 3 Certificate in Community Mental Health (for people aged 18-65 years) (ref 3056-31). Earlier on in this Project a member of staff from the Metropolitan College, Birmingham, had indicated that they would find a Unit addressed to the issue of use to them.

1.2 Although there are existing syllabi addressing Community Mental Health knowledge and understanding of issues such as “cultural competence” are assumed. Evidence cited below shows that there is little coherence in the concept although ideas are emerging. On the other hand it is evident that inequalities persist in mental health provision. “No Health Without Mental Health” was the flagship of the coalition government’s approach when they claimed that mental health would be given parity of esteem with physical health. A recent report states that while mental health problems are set to exceed those of physical health adding that their effects are more debilitating and cost the economy huge sums many are getting no treatment.

“only a quarter of all those with mental illness are in treatment, compared with the vast majority of those with physical conditions. It is a real scandal that we have 6,000,000 people with depression or crippling anxiety conditions and 700,000 children withproblem behaviours, anxiety or depression. Yet three quarters of each group get no treatment. One main reason is clear: NHS commissioners have failed to commission properly the mental health services that NICE recommend. The purpose of this paper is to mend this injustice, by pressing for quite new priorities in commissioning. This might seem the worst possible moment to do this, but that is wrong……This is mainly because the costs of psychological therapy are low and recovery rates are high. A half of all patients with anxiety conditions will recover, mostly permanently, after ten sessions of treatment on average. And a half of those with depression will recover, with a much diminished risk of relapse. Doctors normally measure the effectiveness of a treatment by the number of people who have to be treated in order to achieve one successful outcome. For depression and anxiety the Number Needed to Treat is under 3. In the government’s Improving Access to Psychological Therapies programme, outcomes are measured more carefully than in most of the NHS, and success rates are much higher than with very many physical conditions.”

How Mental Illness loses out in the NHS, LSE pp1,2 2012.

1.3 The provision of IAPT needs to be coupled with the assurance that it will be available for all across language and culture so that practitioners are able to be culturally competent. An IAPT document spells out the principles but no guidance is given on how this is to be addressed practically.

1.4 This year there have been some key conferences addressing BME mental health.

1.4 (i) The Joint Commissioning Panel for Mental Health services for people from bme communities report was launched at the Botanical Gardens, Edgbaston, Birmingham. Launch attended.

1.4 (ii) Birmingham City Council put together a working party and produced a document: Mental Health: Working in Partnership with Criminal Justice Agencies. (Download). This provides a protocol where agencies work together to ensure that vulnerable people are taken to a place of safety rather than end up in a police cell. In the African Caribbean community individuals disproportionally end up receiving coercive treatment for mental health problems. Meetings attended and input made.

1.4 (iii) Birmingham and Solihull Mental Health Trust launched a project “300 Voices” aimed once again at African Caribbean men. This looks like a replay of actions taken following the David Bennett Report 10 years ago. Could it be that this is reinforcing stereotypical views by focussing on inedividuals rather than the agencies where there is lack of understanding leading to misdiagnoses. It may be that it is institutions and practitioners that need to change their practices. Meetings attended and input made.

1.5 My personal experience of applying cultural competence to cases is very disappointing given the high claims made. Staff appear to be tasked with severe budget reductions and have little time or inclination to get involved in furthering measures to combat inequality. Cultural competence appears to be a remote concept to many staff with much indifference and denial of need. This reflects the situation described in the Francis Report on Staffordshire Hospital and the Winterbourne View account of care practice.

Section 2

Rationale for the Unit

2.1 This additional separate Unit encompasses principles and actions governing other Units of a mental health syllabus. In this case reference is made to the City and Guilds (C & G) Certificate in Community Mental Health (for people aged 18 to 65 years) levels 2/3. The soundness of what is in the syllabus is not questioned, rather it is intended to add a dimension addressed at dealing with diversity which may well be implied but evidence shows cannot be taken as read.

2.2 The Philosophy underpinning the C & G syllabus states:
(6.3 Philosophy) “The content of the Certificate is underpinned by the philosophy that to provide effective mental health services, practitioners at all levels need to understand the service user’s perspective. They should respect diversity and deliver appropriate individualised responses to meet the needs of service users. Effective practice is centred on the user and recognises and values the experience and insight of the service user in respect of his or her own mental health. Workers should enable and empower service users to enhance the overall quality of their lives, and should promote partnerships that service users find helpful.”

2.3 Background. The David “Rocky” Bennett Report (2004) made findings and recommendations which were taken up by the Delivering Race Equality (DRE) agenda and the Count Me In annual statistics for much of the next decade. Inequality and injustice was to be given added weight and media coverage with the publication of the McPherson Report on Stephen Lawrence.

2.4 The effects of “Race” and “Racism” and on individuals are still hotly debated .Diverse views range from the denial that they have an effect to the belief that experiences are integral to the lives of individuals. As shown in the reports on Bennett and Lawrence they may have a profound effect on the individual’s mental health. Denial of such experiences by professionals lead to misdiagnoses. The incidence of schizophrenia diagnosed for African Caribbean men for example is 6 times higher in the UK than anywhere else, including Caribbean islands. David Bennett’s experience is just one example where the Report itself questions whether the “schizophrenia” was a medical condition he suffered from, or a either a misdiagnosis of a condition brought on by the use of Cannabis. It is clear that Bennett had to deal with racial abuse in the description of events leading to his death. He had deal with a level of provocation that could seriously affect anyone.

2.5 During the next 10 years there have been many repetitions of David Bennett’s experience when African Caribbean men have died in custody. Disturbingly there is little sign that his report had made an impact on those dealing with such cases. Regrettably deaths in custody and violence to individuals have continued since the Bennett Report. Deaths of Mikey Powell and Kingsley Burrell, both African Caribbean men, in Birmingham following police intervention have been followed by prolonged periods where families have been left in the dark about what happened, all reminiscent of Bennett’s death. There have been many other examples across the country. While Mikey was known to have a history of mental health problems before the highly inappropriate police involvement Kingsley Burrell did not until he was taken into custody at the Mary Seacole Centre in Winson Green and sectioned under the mental health act.

2.6 A characteristic of the decade following Bennett that the focus remains on the African Caribbean community. This has lead to the ignoring of trends in mental health in other communities, some of which may share similar experiences to the African Caribbean.The work of such authorities as Sashidharan, Bhui and Swaran Singh has shown that their are considerable anxieties in South Asian communities. The earlier SCYS “Talk to Us Project” showed that many others shared these anxieties and faced problems in accessing appropriate mental health services.

2.7 Misdiagnosis. The term “schizophrenia” is associated particularly with African Caribbean men. The question is raised in the Bennett report whether he was misdiagnosed as a result of stereotypical views held by clinicians. A report from the US asks questions. This is an experience shared by many in BME communities.

“Racialized experiences have long been linked with the mental health and illness of Black people (See Fanon, 1952; Grier & Cobbs, 1968; Pierce, 1970). At the same time, integration of non-White minorities into majority White populations (a common feature of multiracial societies) arguably results in an increase in racialized experiences, and exposure to White racism. Of particular interest is the case of the UK, a country where the integration and assimilation of the Black population is particularly intense. This paper considers the role of the UK racial situation in the very high rates of schizophrenia found in the UK African Caribbean population.
Schizophrenia is the most chronically disabling of all the major mental disorders and typically affects only one percent of any given population. However, there is a six- to eighteen-fold elevated rate of diagnosed schizophrenia in the UK African-Caribbean population compared to Whites (Hickling, 2005). Moreover, the Black incidence rate of schizophrenia is higher in the UK than anywhere else in the world (Cochrane & Sashidharan, 1996).
The issue of extremely high rates of schizophrenia in African-Caribbeans in the UK has been a topic of interest to British scholars since the 1960s. However, much of the British research has been criticized with regard to its preoccupation with biological explanations for this issue (See Sashidharan, 2001). Indeed, it is only recently that sociological factors have been given recognition with regard to the dynamics of ethnic schizophrenia in the UK (See Boydellet al., 2001, Mallett, Leff, Bhugra, Pang & Zhao, 2002; Whitley, Prince, McKenzie & Stewart, 2006). In 2001, Boydell et al. demonstrated that the incidence of schizophrenia in non-White ethnic minorities in London was higher when they constituted a smaller proportion of the local population, indicating that social factors were having an influence on the elevated rate of diagnosed schizophrenia. Additionally, in 2002, Mallett et al. found that the rates of schizophrenia among African-Caribbeans in London were significantly higher than those in Trinidad and Barbados, again suggesting that social factors played a key role in the Black incidence rate of schizophrenia. In a similar vein, Whitley et al. (2006) demonstrated that mental illness was greater among minorities in areas where they comprised a smaller proportion of the population.
While the above research studies indicate a willingness to consider how society may play a role in ethnic schizophrenia, there is a lack of discussion on how “racialized experiences” could be influencing the elevated rates of diagnosed schizophrenia. For example, while Mallet et al’s (2002) study draws attention to the importance of social factors in the high rates of schizophrenia in African-Caribbeans in the UK, there is little reference to African-Caribbeans as “racial minorities”, and the role that racism might play in the Black incidence rate of schizophrenia. While their research highlights the significance of “social disadvantage” as a cause of severe mental illness, Mallet et al. (2002) focus on issues such as unemployment, and on individuals who had been separated from one or both parents during childhood.
It is argued here that more attention needs to be given to the experience of African-Caribbeans as racial minorities with regard to this topic. As Jamaican scholar and psychiatrist, Frederick Hickling (2005) points out, the evidence regarding the Black incidence rate of schizophrenia is shifting in favor of factors of social alienation and racism experienced by Black people in the UK, and to misdiagnosis by White British psychiatrists. Hammack (2003) notes that an individual’s minority status represents an intrinsic stressor, and Bhugra & Ayonrinde (2001) draw attention to the idea that racism is likely to act as a chronic stressor, and that chronic racism may well precipitate psychiatric disorders. Moreover, it has been suggested that psychiatry as a discipline is inextricably linked with racism (See Littlewood & Lipsedge, 1982; Fernando, 1988; Sashidaran, 2001; Timimi, 2005); as such racial bias in psychiatric diagnosis might also be an important factor in the Black incidence rate of schizophrenia. For these reasons, racialized experiences (racial minority status stress, racism-induced stress, and racial bias in diagnosis) need to be seriously considered in the analysis of the elevated rate of diagnosed schizophrenia in the UK African-Caribbean population.”
Racializing Mental Illness: Understanding African-Caribbean Schizophrenia in the UK by Clare Xanthos, M.Sc., Ph.D., Senior Researcher National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia. Abstract.

Consideration must be given to institutionally racist views and practices in psychiatry. The following article discusses this:

“Although the debate about race and psychiatry is as old as psychiatry itself, it is only in the past three decades that the psychiatric institutions and practices in this country have come under critical scrutiny for their racial bias. During this period, much has been written about the experience of Black and other ethnic minority groups within psychiatry and the tacit acknowledgement that there is a problem about race within British psychiatry appears to be shared by psychiatrists in general. There have also been many attempts in recent years to make mental health services more culturally aware and sensitive. How we provide better services for Black and other ethnic minority groups has become a service priority in many areas.
Despite the commitment by both professionals and managers to provide ethnically sensitive and culturally appropriate services the overall experience of psychiatric services by Black and South Asian people in this country remains largely negative and aversive. The disparity between ethnic minority groups and White people in service usage, service satisfaction and outcome persists with little to suggest that the situation is likely to change. In fact, there is no single aspect of contemporary psychiatric care within which Black or South Asian people are not disadvantaged.
One conclusion that we can draw from all this is that the various changes and innovations around ‘ethnically sensitive services’ have largely failed to address problems with race and psychiatry. Perhaps the practical emphasis placed on improving services for particular ethnic groups has distracted us from the more fundamental but also the more difficult task of addressing racism within psychiatry. In other words, until we begin to address racism within psychiatry, in its knowledge base, its historical and cultural roots and within its practices and procedures, we are unlikely to achieve significant progress in improving services for minority ethnic groups.”
Institutional racism in British psychiatry †S. P. Sashidharan, Professor of Community Psychiatry and Medical Director

2.8 Experiences of Asian and other BME communities. The virtually exclusive focus on mental illness on African Caribbean communities ignoring the experiences of other groups has led to increasing assertion that much need is
not being met. The “Talk to Us” Project met with representatives of many other communities each of whom spoke of problems being faced by them. Somalian and Bosnian communities included many who had experienced the trauma of wars and forced displacement. Others, including South Asians, said that what was being said about the African Caribbean community was recognisable to them, including access to appropriate mental health services. This was discussed in the second year report of the current Project “If only we were told…” (a comment made by Dr Joanna Bennett, sister of David, echoed by many since). See section 4.

2.9 The history of “cultural competence” in relation to health care is coupled with a patient-centred approach in a brief history of this in relation to health care in the US. While these aspects are also familiar in the UK it is more difficult to trace a coherent approach.

2.10 A model showing an iceberg, with matters commonly regarded as being the essence of “Cultural Competence” reveals the complex nature of the subject, with the hidden aspects affecting an individual’s understanding of life being subject to self-concept, position in family, values etc. These aspects cannot be captured within formulae since they will be particular to the individual concerned, although within a framework of the specific culture, within its traditions and histories. This has at first to be recognised if not immediately understood. Understanding can only be gained by interacting with the individual, their family and community. While here may be factors presenting problems, there are also traditional support networks existing in communities which could provide considerable help.

2.11 Kamaldeep Bhui and others examined courses promoting cultural competence in 2007 and only found few courses in North America that met their criteria. They were looking for courses which had been evaluated to show that outcomes were effective in improving competence. Bhui cites the report into the death of David “Rocky” Bennett (download) as a call for training in cultural competence for health workers, but outcomes for BME communities remain the same as before. While there appear to be many scattered attempts at making improvements funding crises have led to statutory care agencies failing to act while many voluntary organisations (some 40 documented in the earlier SCYS “Talk to Us” Project report in the West Midlands) have lost the capacity to help if not closed. This is spite of the current Government’s “No Health without Mental Health” document which recognises the persistence of serious inequality in appropriate service provision affecting BME communities.

2.12 While “Cultural Competence” is widely spoken of but in reality there is little coherence in course provision with little evidence of their effectiveness, although there are individuals in the UK who are trying to change this. At present it is necessary to look to North America for a more sustained approaches, although “Cultural Competence” courses are coming into favour in the world of business. When it comes to the imperative of profit rather than health there appears to be a greater enthusiasm to grasp principles. Is there something to learn from this?

2.13 Talking Therapies
Many people from BME communities have said that they have been unable to access key developments on mental health, including talking therapies such as Cognitive Behavioural Therapy. Governments have shown interest since early findings were that such therapies could be as effective as medication in appropriate cases. It was announced that Newham would be the place where developments would be trialled on giving access to BME communities. This was 2006-7. Newham’s current website gives information on their Talking Therapies services but it is not immediately apparent how accessible it continues to be in addressing equality. The one aspect which stand out as important in the ability to make self-referrals, a declared barrier in the past.
As with other treatments it is necessary for practitioners to be fully aware of cultural understandings relating not only to individuals but to families and community because of a key difference between nuclear and extended family practices and understanding. In the west it is usual for individuals to decide on action they take without necessarily referring to anyone else, whereas in Asian cultures, for example, actions are taken within the context of family and may impinge on relationships with a number of people, all of whom have beliefs and expectations. It is often assumed that those expectations may be negative and unhelpful, but it is wise to consider whether traditional support may be just what is needed by the individual concerned. In this respect agencies, families and communities need to work together.

A report on BME counselling in Devon is worth consulting as it appears to promote a considered approach.

2.14 What is on offer here is a unit considering factors which will act as a guide to ensuring that groups identified as receiving less favourable, or no treatment, can be directed to appropriate services that meet their needs and help their families and communities develop support networks in partnership with statutory bodies. Earlier reports “If only we were told” (Year 1) and “Cultural Competence” (Year 2) made links to many reports and articles relevant for students following this Unit. The two reports can be seen at the Project website with the warning that some of the links need updating where reports have been removed.

2.15 The Unit is modelled on City and Guilds Level 2/3 Certificate in Community Mental Health Care (for people aged 18-65 years).
Level 2:
Level 3:
The Unit however may be regarded as stand alone or be used with other courses for training, particularly with regard to Cultural Competence.

Section 3

Unit: improving access to appropriate mental health services for BME communities.
Level 2/3

Outcome 1 To consider how diversity in language, culture, ethnicity and experience vary individual and community’s concepts and understanding of mental illness.
The candidate will be able to
1. understand how the experiences of BME communities affect their lives and particularly how this can be a factor in mental illness
2. understand recommendations of key reports on those who have had poor experiences of living in Britain because of their “race” and ethnic origins eg David Bennett and Stephen Lawrence
3. consider their own beliefs and values regarding “race”. ethnicity and religion, recognising stereotypical views and ideas resulting from our colonial history
4. listen to the experiences of individuals from diverse background non-judgmentally.
Outcome 2 For providers to recognise the need for understanding the aspects of cultural competence essential for providing an appropriate service
The candidate will be able to
1. know with actions which followed for 10 years following the David Bennett Report in 2004
2. assess factors for failures to fundamentally alter the situation of intractable inequalities continuing after 10 years addressing the issues raised
3. understand the views and feelings of other members of BME communities and their ability to access appropriate and effective mental health services
4. understand what aspects of “cultural competence” need to be recognised and understood i.e. in the “iceberg model” is hidden factors which are crucial for consideration rather than superficial knowledge about different cultures

recognise why many from BME communities don’t come forward for help, or are unable to access appropriate services
Outcome 3 To assess how developing talking therapies such as CBT can be accessed by and delivered to people across languages and cultures.
The candidate will be able to
1. consider how effective talking therapies can be offered to those with different languages, cultures, religions etc.
2. take account of involving family members and communities in helping deliver support to individuals in need
3. examine cultural assumptions underlying such burgeoning remedies as Cognitive Behaviour Therapy (CBT) and be prepared to modify their approach
General outcome: The candidate will be able to apply principles appropriately throughout the syllabus. (City an Guilds Community Mental Health Certificate level 2/3)

Sports centre in Handsworth up for asset transfer

Once upon a time when we lived in a fairly civilised society we had a wooden hut which served as changing facilities for a range of sporting activities. The hut was available to us in the community, With Ernie in charge it was made available when needed. From 1990 onwards the ward changed from being represented by Tory councillors it transformed in three years to having three Labour councillors with the largest majority in Birmingham. After elections we would return to Laurel Road to tune into the election results late into the night.

One day came the news of a fire. Our precious centre had burned down due to an electrical fault in a drinks machine. What would happen to the site. We wrote letters to Pepsi-cola, or whoever owned the drinks dispenser to see if they would help sponsor a rebuild. Eventually we learned that we would get a new building which we were asked to comment on. I remember we were told we couldn’t have a clock tower (don’t remember anyone asking!) Sports England came on board to help out and gave us funding for upgrading the facilities including a climbing wall (instead of the clock tower I suppose).

On the downside Ernie disappeared to look after another centre nearby. African Caribbean himself he was popular with local youth and could reach out to young people with excellent results. The centre became managed with a new staff. We could hire the building for meetings but it had to be cleared by 9.00pm.

Last Wednesday a large group of people assembled at Hamstead Hall School from the Handsworth Against the Cuts Campaign with banners and songs led by Dave Rogers of Banner Theatre. Laurel Road was a candidate for asset transfer. It was the Handsworth Wood Ward Committee meeting at which the three Labour councillors were present. A request had been made for Laurel Road to be an agenda item. This had not happened but I suppose because of the size of the protest group discussion was grudgingly allowed. We were promised that our views would be taken back to the City Council. The councillors said they were on our side, but in view of the draconian cuts in funding there was little they felt could be done.

The question remains why the Labour Party, now in control, acquieces to everything thrown at it. Handsworth Wood Ward may have continued with its Tory representation. The question is whether the three Labour Councillors oppose the transfer of assets and privatisation. The sad fact is that they do having openly supported first Academies and then Free Schools. While Labour brought in academies their stance of Free Schools has been oppositional. At least of two of the Councillors actively supported Free Schools in Handsworth set up by the Nishkam Centre. Do these councillors not understand that asset transfer and privatisation is the handing over of public money for the purpose of making the now private assets profitable to an unaccountable group of people? How will they support us when they believe in asset transfer etc?

Food Aid Britain

Hunger is a major issue in Britain. Food poverty added to fuel poverty add up to a threat to life in a wealthy nation where its leaders have more pressing priorities. The dismantling of a welfare state and redistributing wealth to an already overfed elite.

Food is something we can take control of and grow our own – as happened in war time. Havana in Cuba, struggling from an embargo imposed by its mighty imperial neighbour, has created a means of helping to feed its population. Havana can provide for about 50% of its population. Which other city in the world could approach anything like that? If we ask how many of its population of around 1 million could Birmingham in the UK support a target of 10% would seem daunting. Yet a sizeable number of people demand allotments and use leisure time to cultivate food for themselves. Rules for allotments, set years ago, do not allow for a system which, as in Cuba, brings about a market where food grown is sold to the community at affordable prices.

Much is happening at the Uplands Allotment in Handsworth, Birmingham UK to enhance urban living. They note that fruit is lefty to rot on trees in gardens across the city. THeir response is an urban harvest where volunteers will collect the fruit. They have introduced bees to ensure the fertility of crops.

On the other hand big business has other ideas claiming that it has the solution the world hunger. This involves the seizure of land displacing peasant farmers, many of whom committed suicide, and introducing genetically modified crops. Food is a commodity to produce maximum profit.

Food waste is a huge issue with about half of that expensively produced wasted. Supermarket chains have become aware with some produce, just a little, ending up in food banks. Much of this is tinned and processed so does not provide the healthy nutrition that the growing number of people with families need to keep healthy. THe potential cost to society and its services is enormous. Yet a poor country like Cuba can keep its population healthy and educated. What can we learn?

“IF ONLY WE WERE TOLD” REPORT YEAR 2: CULTURAL COMPETENCE

Overview. Key Reports on Health Care 2012-3
“Compassionate Care”
1.1 Key recommendations of the report into the death of David Bennett, which appeared at the beginning of 2004, emphasise training in cultural competence. They state:

(i) All who work in mental health services should receive training in cultural awareness and sensitivity.
(ii) 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.
(iii) All training referred to in 1 and 2 above should be regularly updated.

1.2 The Government initiative “No Health Without Mental Health” 2011 also reports that BME communities across the UK request increased cultural competence in services. All participating Black and minority ethnic communities point to a strong need for greatly increased cultural competency in mental health services. Study participants highlighted the need for practical improvements in language (interpreting, translating, literacy support), meeting faith-related and religious needs, culturally appropriate food, gender-specific services and staff, increasing the ethnic diversity of staff, and action to tackle racism.” No Health Without Mental Health 2011
1.3 The first year report “If only we were told” looked at mental health initiatives over a decade. The David “Rocky” Bennett report led directly to key initiatives in equality in mental health provision. particularly “Delivering Race Equality” and “Count Me in” statistics. These annual reports gave evidence of marked and unacceptable differences in equality in access to appropriate services.
“If only we were told report -year 1
1.4 New programmes of treatment, such as “Increasing Access to Psychological Therapies” were thought to be major advances, yet BME communities are saying that they have not benefitted from them.

1.5 Evidence shows that different sections of the community are likely to follow different paths in accessing mental health treatment. More African Caribbean people access mental health treatment through the criminal justice system ending up in secure units and prisons. Asian communities say they too find difficulty getting treatment that recognises different cultural, religious and linguistic understanding of mental health.
Improving Access to Psychological Therapies. A review of the progress made by sites in the first roll‐out year
1.6 A consequence of failure to address cultural competence can be misdiagnosis. This, according to practitioners such as Dr Aggrey Burke continues to be a hazard between clinician and patient where there is cultural confusion. This is compounded by commonly held ideas and beliefs about black people and mental health and applying labels as a result of stereotypical understanding of conditions such as schizophrenia.
1.7 Different traditions may have their own ways of dealing with well being, Much is made of reporting the widespread existence of stigma and fear, and supposed cultural shortcomings, much less attention is given to different coping strategies which if understood and taken up by professionals could greatly help improved well being of patients.
1.8 In 2012-13 health care issues were dominated by two reports of major failures in care. The Francis Report into failings at the Staffordshire Hospital Trust was followed by the Winterbourne View report of abuse of patients in care homes. Resulting from these and other reports of breakdowns in care to vulnerable people came a response from the Government with the call for “Compassionate Care”.

The failure to deal with inequalities in mental health
Increasing Access to Psychological Therapies (IAPT)

1.9 While there have been significant advances in mental health treatment over the last decade, similar advances in addressing equalities have stayed stubbornly static with identifiable pathways to services differing between cultural groups. One major initiative has been the IAPT (Increasing Access to Psychological Therapies) but feelings of many are that they have been excluded from benefitting from these treatments and are consigned to medical remedies, coercion and detention. While there has been a move away from a medical model of care competence in recognising varying perceptions of mental health according to culture is still largely missing. Whether this is due to absent mindedness or more deliberate racist attitude it is necessary to create a climate of understanding and refusal to tolerate willful acts of violence by agency staff serving the public.
Coercion in Mental Health
1.10 Referrals to mental health services will likely be from various other agencies and sources for a variety of reasons. Social services, police, prison services, schools and colleges all deal day to day with people and it is expected that within their training they will be competent to recognise those at risk from difficulties such as poor mental health. A number of questions arise.
1.11 If cultural competence is missing from the range of competencies needed in working in a diverse community then there is added risk. Even within the health service people can be labelled and prejudice results. This we know that black men in particular are associated with “schizophrenia”. The case of Kingsley Burrell who died while being held in a secure mental health unit in Birmingham in 2010, was taken there by police after he had called them for support when he felt under threat from a group of youths. The police judged him to be paranoid, beat him according to his young son who was with him, and he was sectioned as a result. His family say there was no previous knowledge of mental health problems. He later died in mysterious circumstances that have still to be explained. 10 years on from the David Bennett Report and cases of many people with or some without mental health histories and a high proportion of black men have died in custody. No reports have been commissioned and indeed in many cases there are suspected cover ups.
1.12 It is of deep concern that threats of “sectioning” is used as a weapon when dealing with people as some black women in the West Midlands have alleged in their dealings with police. In one case the threat was carried out, the family unable to find her whereabouts.
1.13 In some of these examples it appears that racism may be a factor for those dealing with people using mental health issues improperly. Of course in order for this to work institutional back up is essential. Police superiors, courts, prison officers and even trained clinicians seem happy to oblige. This matter is in urgent need of independent investigation.
2. Cultural Competence – some definitions
The importance of cultural competence

2.1 In 2007 Professor Kamaldeep Bhui et al surveyed the availability of courses of study addressing cultural competence. They discovered only 9 programmes of study with outcomes evaluated to demonstrate they had been effective:
2.2 Abstract of research programme
“Background: Cultural competency is now a core requirement for mental health professionals working with culturally diverse patient groups. Cultural competency training may improve the quality of mental health care for ethnic groups.
Methods: A systematic review that included evaluated models of professional education or service delivery.
Results: Of 109 potential papers, only 9 included an evaluation of the model to improve the cultural competency practice and service delivery. All 9 studies were located in North America. Cultural competency included modification of clinical practice and organizational performance. Few studies published their teaching and learning methods. Only three studies used quantitative outcomes. One of these showed a change in attitudes and skills of staff following training. The cultural consultation model showed evidence of significant satisfaction by clinicians using the service. No studies investigated service user experiences and outcomes.
Conclusion: There is limited evidence on the effectiveness of cultural competency training and service delivery. Further work is required to evaluate improvement in service users’ experiences and outcomes.”
Source
2.3 The research paper looks at the selected papers to see if a pattern emerges to say what cultural competence is. The conclusion they reach is that it is about practitioner and patient understanding each others cultural viewpoints, the absence of which can lead to misdiagnosis, or mismanagement of care provided. It is extremely complex in practice and subject to oversimplification and misconception. It is not, for example, just a matter of knowing about different faiths and cultures, their symbols and practices, rather it is coming to an understanding of how cultural difference can lead to different concepts of mental illness. It is understanding how different family structures and traditions affect individuals. Different individuals within any one cultural will vary so no formulae are likely to help. There are differences between age groups.
2.4 A model developed by BEWEG likens “cultural competence” to an iceberg where the visible tip is what is commonly accepted as its meaning while what really matters is what lies out of sight below the surface. The authors also point out that there is often an expectation of having practitioners and patients with common cultural backgrounds is the answer. This is unrealistic because the practitioners will most likely have been trained in the same way.
2.5 The following is from a source in the United States talking about cultural competence and why it is of fundamental importance:

“Cultural competency is one of the main ingredients in closing the disparities gap in health care. It’s the way patients and doctors can come together and talk about health concerns without cultural differences hindering the conversation, but enhancing it. Quite simply, health care services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients can help bring about positive health outcomes.”

Source
2.6 The Government’s “No Health Without Mental Health” stresses in the foreword under the names of David Cameron and Nick Clegg:

“The Prime Minister, David Cameron, and the Deputy Prime Minister, Nick Clegg, have made it clear that the Coalition Government’s success will be measured by the nation’s wellbeing, not just by the state of the economy. The public health White Paper Healthy Lives, Healthy People is the first public health strategy to give equal weight to both mental and physical health.This Government recognises that our mental health is central to our quality of life, central to our economic success and interdependent with our success in improving education, training and employment outcomes and tackling some of the persistent problems that scar our society, from homelessness, violence and abuse, to drug use and crime.”

On inequality the report has this to say:


“Critically, not all groups have benefited equally from improvements – for example, many
people from black and minority ethnic communities. Access to services is uneven and some people get no help at all. This contributes to health inequalities within and between groups with ‘protected characteristics’ “

No Health Without Mental Health p 8. 1.11
2.7 However good intentions are evidence of the present state of mental health provision is of a crisis. Since the Talk to Us project, 2007, many of the voluntary sector organisation “set up because of unmet need” (Ralph Hall of CSIP) have lost key staff. “Delivering Race Equality and the Count Me In statistics have been archived as if no longer relevant. While it is clear that the programmes failed to meet expectation the knowledge gained needs to be developed, not discarded.
3. David Bennett: the report 10 years on
3.1 While the present Government’s plans make it very clear that the same issues continue to exist it is as if they are treating the efforts to deal with it as political. Two issues illustrated here by case studies show that:
(i) Issues of Mental Health in the African Caribbean community continue to feature, although they fail to get the public attention that followed the death Stephen Lawrence, if not that of David Bennett. Of deaths in custody since the David Bennett report a significant number have been African Caribbean. Far from getting reports written they have characteristically been followed by cover ups. Many have been related to mental health issues, although some of the victims were not known to have a prior history of illness. This prompts the question of diagnosis and understanding when terms like “schizophrenia” are routinely attached in a way that becomes stereotypical. The question arises are members of this section of the community at risk from being mistreated based on prior assumptions and racist attitudes? The cases of Mikey Powell and Kingsley Burrell in Birmingham and police practice in Wolverhampton will be considered here.
(ii) Members of Asian communities have noted that the Delivering Race Equality agenda highlighted the failure of services to offer effective mental health services to the African Caribbean community. They feel that the characteristics of this failure are increasingly applicable to them, but with important differences. In particular advances in treatment such as IAPT it is felt have not been readily available, and may not take account of cultural or linguistic differences. The question of “cultural competence” is highlighted, with doubts that while it is said to be important it is widely misunderstood, dealing only with the visible tip of the iceberg model rather than underlying factors.
3.2 Cases in Birmingham and Wolverhampton over the period since the Bennett Report question what, if anything, has been learned? What has improved?
The death of Mikey Powell in 2003 when the ink on the David Bennett Report was not yet dry. It then took 6 years to decide that he died as a result “positional asphyxia”.
Now 10 years on the family has received an apology from the police. On the other hand no one has been called to account. As usually happens officers involved have retired from the police force and just faded out of sight.
The following is an account from the Friends of Mikey Powell Campaign for Justice.

“Mikey Powell was 38 years old when he died after being detained by West Midlands Police on 7 September 2003. He had three children. He had a mental health crisis and smashed a window at the home he shared with his mother. His mother called the police for help, assuming they would take him to hospital.
During the incident that followed, the police drove a car at Mikey as fast as they could, claiming they thought he had a gun, which he did not. Mikey was injured but survived the collision. He was then sprayed with four times the recommended amount of CS gas, hit with a baton and restrained for at least 16 minutes. No ambulance was called. Mikey was put on the floor of the police van and taken to the police station and into a ‘drunk cell’. It was only then officers noticed that he was not breathing.
The inquest jury found that Mikey died of positional asphyxia in the back of the police van while he was being taken to the police station.
Many issues were raised by the inquest into his death, including questions around possible assumptions made by police about Mikey, based on the area he was living in and the colour of his skin. The family made several recommendations following Mikey’s death, including training for officers to avoid these kinds of assumptions being made.”

Mikey Powell was not a criminal, He lived in the Lozells district of Handsworth which itself has a history of associations with black people. While events in 1981 and 1985 received sensationlised media coverage, attributing “rioting” to the black population, those seen in court came a variety of backgrounds, age groups and areas outside both Handsworth and Birmingham. As one resident said at the time, the impression was given that “we routinely had drugs with our cornflakes”. Mikey was a much loved family member but who was experiencing a mental health problem. It was his Mother who called the police for assistance, hardly expecting the response described above. She continues to regret her decision that day in September 2003.
As stated it took years to establish the cause of Mikey’s death: that it was not being hit by a police car, using excessive amounts of CS gas, being hit repeatedly with police batons or being sat on by a number of police officers. It has taken longer for an apology, but as yet no one has been called to account and held responsible. The family have made recommendations, but it is not clear if these have been accepted an shared. Meanwhile the recommendations of the David Bennett enquiry remain together with information now archived.
3.3 On 27th March, 2011 another member of the African Caribbean community died while in custody. He had no previous history of mental illness but ended up being sectioned and detained at the Mary Seacole Centre in the Winson Green area of Birmingham. On this occasion he himself had called the police when he felt that he and his young son were being threatened.
Kingsley Burrell, 29, dialled 999 after being threatened by a group of men while with his young son in Icknield Port Road, Birmingham, on March 27 last year.
But when officers turned up they detained the trainee security guard under the Mental Health Act – despite his family saying he had no history of mental illness.
Within hours Mr Burrell was sectioned and taken to a mental health unit in the city, where his family claim he had mysterious physical injuries and was not allowed to speak to them.
Three days later, police were called to the Mary Seacole mental institute in Winson Green after an “incident” involving the dad-of-two and he was transferred to the Queen Elizabeth Hospital, where he died on March 31.
The Independent Police Complaints Commission immediately launched an inquiry and has now asked Dorset Police to begin a further investigation into the death.
Last night Mr Burrell’s sister, Kadisha Brown-Burrell said the family still had no idea how he had died – and could still be months away from having a funeral.
She said:

“How can they keep a body for a year? It’s been more than a year now and they are dragging their heels.
”We are still grieving and need closure but have been told the Dorset Police investigation will take at least take another six months.
“We’re angry and frustrated and don’t know what is happening.
”It’s been painstakingly difficult, frustrating, and emotionally overwhelming for the family to begin to come to terms with his death. Especially, not being able to lay his body to rest, not knowing the sequence of events that led up to his death and how he died.”
Mr Burrell was dad to five-year-old son Kayden – who was with him when he was detained by police – and 10-year-old daughter Travita.
Student Miss Brown-Burrell regularly visits her brother’s body, which is being held at the mortuary at Sandwell Hospital.
She added: “I personally don’t have much confidence in the IPCC investigation and we have not been kept informed.
“The family has now attended eight or nine pre-inquest hearings, yet still nobody can tell us what or who killed Kingsley.
”It’s not fair on his children, especially his little boy who can’t stop thinking and talking about what happened that day.”
A spokesman for the IPCC said investigators have interviewed four West Midlands police officers under criminal caution and a further 10 officers as witnesses.
He added: “In total, more than 100 witness statements have been obtained from police officers, medical professionals, ambulance staff and members of the public.
”Footage from CCTV cameras at four locations has been recovered and reviewed and hundreds of documents have been seized as part of the independent investigation.
“Earlier this year, after liaison with HM Inspectorate of Constabulary, Dorset Police were requested by the IPCC to begin an investigation into the actions of non-police personnel who had contact with Mr Burrell and they continue to undertake enquiries.
“The IPCC has provided regular updates at HM Coroner’s pre-inquest hearings and to the family and interested parties.'”

Kingsley Burrell’s funeral was eventually held on 31st August 2012, well over a year after his death occurred and during which time there appeared a great reluctance to give any information or account for how he came to die. Kingsley was taken to a unit with the name of Mary Seacole, which itself associates the African Caribbean community as a whole with mental illness.
3.4 In the past ten years black women and men have been subject to brutal treatment from police officers in Wolverhampton, Bilston Street Police Station being the centre of focus. While some of their victims have no records of mental health problems officers have resorted to threats of sectioning telling them “you are mad”. They have been taken to police cells or mental health institutions and held in custody.
3.5 So ten years on from a land mark report what has changed, especially for African Caribbean citizens. They remain vulnerable from a whole spectrum of inequality from individual attitudes to the institutional racism highlighted by the Stephen Lawrence enquiry. What the “cultural competence” recommended by the David Bennett report is remains unclear. Although widely referred to in the context of addressing mental health it requires a thorough going appraisal in order for it to become central to the training the report, and many others now recommend.
3.6 The NHS offers a guide for good practice in prisons. While it speaks of addressing inequality it confines itself to mentioning gender but avoids reference to the inequalities described above. The ratio of black people in jail proportionally was given as 7:1 in the Guardian, compared to 4:1 in the United States.
3.7 Evidence shows that black people are much more likely to be detained either in prison or secure units where they are likely to encounter heavy sedation.
4. The Asian community’s concerns over access to appropriate services
4.1 While the focus of the last 10 years has been on the African Caribbean community, albeit with little, if anything, to show for it apart from continuing restraint and incarceration measures with further deaths in custody of those with mental heath problem and those assumed to have because of prevalent stereotyping and racist attitudes, members of the Asian community are asking if they too are being excluded from advances in treatment for mental health issues in the community. Lord Kamlesh Patel of the Mental Health act Commission speaks about a “hidden plague” affecting them and fear of a trend which is leading to them finding themselves in a comparable position to the African Caribbean community within 10 to 20 years.

“People of South Asian origin with mental health problems are missing out on treatment, the BBC has been told.
Experts warn it is contributing to the high suicide rate among Asian women.
The chairman of one NHS Trust says he blames “institutional racism” for the “lack of engagement” with the South Asian community.
And Lord Kamlesh Patel, of the Mental Health Act Commission, warned the “hidden plague” would grow if the problem was not tackled urgently.”

4.2 In describing a failure to address need in the Asian community, itself diverse in respect of religious affiliation and variations between generations settled in the UK, attention is regularly given to social pathology or attributing blame to victims of failure to get support. Clearly features of differences such as family structure, values, beliefs and perceptions are important, but it can result in less attention being paid to ways in which traditional support mechanisms operate. This results in inappropriate intervention by clinicians making decisions without possessing the necessary cultural competence.
Case study
4.3 A Hindu man living in Birmingham suffered a brain haemorrhage in 1999 while in his early forties. He had a young family who were left deeply traumatised. He received remarkable care and treatment to bring him back to life, but an existence that required full time care. He had an uncle in India who had experienced a similar occurrence and in which case the family expected his wife to act as his main carer. Although widely spread his large extended family had similar expectations of his wife, faced with the daunting task of keeping his immediate family, a son of 11 and daughter of 19, together. He meanwhile was placed variously in highly successful rehabilitation followed by disastrous periods in homes totally unprepared and unsuited to his complex needs. Family and friends rallied together and devised a structural programme to stimulate him with the aim of allowing him as full a life as he could achieve.
4.4 Life for him in a care home quickly proved totally inappropriate with their inability to recognise his cultural, spiritual or social needs. Not that they were competent in other spheres of care in which they laid claim to expertise. The Primary Care Trust continued to proceed on a medical model of care based on the diagnosed medical condition of the patient and totally neglecting him as a human being. The possibility of him retaining his traditional position as head of his family was effectively removed, the family portrayed as a problem to the “care” they believed they needed to give.
4.5 The failure to comprehend cultural traditions leads to severe and potentially damaging consequences which can be very costly in terms of human suffering to the patient and their family but also financially for the health authority. The development of cultural competence is an essential component for a just, compassionate care system. Misconceived ideas of what this is are common, concentrating on known “facts” and possibly stereotypical ideas of other lifestyles. It is not just a matter of reading up about Hinduism, Sikhism, Islam or whatever, it is understanding how individuals relate to their wider family and how matters like mental illness are understood and the consequential decisions made, often by other family members, about necessary action. There is no solution other than for health professionals to work closely and co-operatively with family and/or community to be able to provide care which encompasses the range of need of the patient.
4.6 In more than a decade of care provision for their Hindu patient, the officers of the Primary Care Trust have failed to learn lessons from experience. In their retention of an outmoded medical model of care there has been a concentration on his medical condition coupled with a complete failure to account for cultural, spiritual and social requirements. This has led to frustration and ongoing battles with family members who have become vilified and labelled as problems who threaten their patient’s well being and best interests.
4.7 From early on after a period of intensive support and rehabilitation this patient made an amazing recovery to the extent he regained ability to walk and speak. It was necessary for him to have 24/7 care and family and friends rallied round devising stimulation to aid a return to a life as fulfilling as possible. This was his wife’s wish.
4.8 What the family were aware of and attempted to achieve owed much to their understanding of the situation. As husband and father he was regarded as head of the family and the change in his health and ability didn’t change that. His carers however did not even imagine the possibility of other ideas based on their experience of life as Hindus, shared by an extended family spread across continents, all with their own beliefs and expectations within the shared culture. They had their own beliefs that religious acts would be beneficial and had high expectations that the family would continue their duty to a beloved family member. Unfortunately that was not so simple.
4.9 An initial period in institutions and care homes ranged from disastrous to a period of rehabilitation which once more regained progress damaged by life in alien institutions where their patient lost his identity. His behaviour deteriorated seriously during such periods. His immediate family continued to give support battling against uncomprehending bureaucracies. Their health suffered as a consequence although the care agencies failed to notice. Rather the family continued to be regarded as a source of irritation. This culminated in an attempt by the Primary Care Trust to get a protection order issued against the family. This failed when they couldn’t produce evidence for the allegations made without any reference to the family.
4.10 Cultural competence, it is clear from this family’s experience, has to do with an understanding of family dynamics, quite different in Asian culture to western tradition. Whereas in a western cultural model care staff routinely expect to be dealing with an autonomous individual in Asian families individuals have a place and role which cannot be overlooked and discarded. To vary this will ultimately be damaging and counterproductive. This understanding is chiefly located in the submerged bulk of the iceberg model. It is complex and requires carers to develop their understanding. This is only achieved by working closely with family and community.
4.11 A solution to the care in this case was to provide a bungalow with full time care. The family lived over a shop so the possibility of returning there was not an option. However the care company commissioned to provide the care were located in Telford. They were selected by the PCT and were not familiar with the needs and expectations of an Asian family. When problems arose the PCT regarded it as matter between the family and care company. The family wished to recreate family life as far as possible which would mean having family and friends round regularly. It soon became clear that the carers saw the bungalow as primarily a place of work, so what would have been a dining room became their office. Care staff brought in their own food, stored in in the family’s fridge and used available utensils to prepare it. When beef products were brought in the family found it necessary to take action to say that could not be allowed. Furniture provided was dilapidated, and according to one of the relief staff an infection hazard, yet neither PCT nor the nurse in charge saw a problem. The family asked if they could bring in their own furniture, which was at first agreed. It was then pointed out to the family that if any items they brought in was the cause of an accident then they would be liable. They then had to pay for the furniture to be put in storage. The more the family tried to bring problems to the attention of the care provider, and when that failed the PCT, the more they were perceived as problematic.
4.12 Eventually the Primary Care Trust made a decision to change the care provider. They told the family it would be necessary for their patient to go into a care home for no longer than three months while they made necessary preparations. The family were unhappy with this but were given no choice. They wished to help with the transition and take their family member to his new temporary – they thought- home. The PCT disregarded their wishes and advice and a van driven by staff from the care home arrived and collected him. They disrespected both him and his daughter as they took him away from her treating without concern for either him or his family. The next time they saw him they were in for a shock. He was found to be inactive, confined to a wheel chair. He appeared uncared for with long hair and nails. Uncut toe nails meant he found it difficult to walk. He was wearing other people’s clothes, having promised to label the new clothes the family supplied. A mixture of his and other clothes were found bundled in a heap in a wardrobe. The family found it hard to find the courage to visit. When they did they discovered a note on file warning staff about them and advising them to contact police if necessary. Although staff had acknowledged and apologised for their lack of care, the family remained the one regarded as at fault.
4.13 The family then raised their concerns with Birmingham Social Care and Health and so another meeting was called to consider protection issues this time at their request. There was still the belief that a return to the bungalow would happen, but it was agreed that another care home could be found in the meantime.
4.14. At the new care home family and friends attempted to help the new care providers understand their new resident’s needs. However they were alarmed when they found information accompanying him had him classed as a Muslim and as having diabetes. It had been assumed that those responsible for his move would have monitored information on file. Surely records would accompany him from placement to placement. It seemed there was marked reluctance to listen to his family, but finally his religion changed to Hindu/Sikh whatever that means. While there were assurances that he had not been diagnosed with diabetes without the family’s knowledge he was still tested for this on a visit to the dentist, apparently because it was still on the records.
4.15 It finally emerged that the decision to return home was changed by the PCT. In making their decision they failed to follow the Mental Capacity Act and consider the family’s view on Best Interest. This means that those most likely to know what the patient’s own views were likely to be on deciding where to live were ignored. It also means that a chance to demonstrate cultural competence was once again missed. It has been left for a court to make the final decision.
4.16 In her talk to a Sikh health conference in 2012, Kamel Chahal, Chartered Clinical Psychologist working in a London Health Authority, made the following points about menbers of the Asian community following Lord Patel’s concerns in 3.1 above:

Women trapped in situations of domestic violence are well documented
Women (ages 15-34) are 2-3 x suicides than British peers
Self-injurious behaviour is increasing in young women
High levels of alcohol use and dependence in men
Frequent presentations at GP surgeries with physical complaints

4.17 Those involved in delivering services to members of the Asian community need to be sensitive to the cultural perspectives and understanding of their patients. They have been identified as obstacles to individuals and families seeking help at a critical time. While these will vary between individuals and families western family patterns and traditions are vary from the characteristics of Asian families. As has been noted above it is important not to make assumptions, and there are likely to be variations between first, second and third generations settled in Britain.
4.18 Kamel Chahal refers to Rethink reports of work within the Sikh, Punjabi South Asian communities in Harrow, North West London
Research conducted by Rethink Mental Illness revealed six key findings;

1. Shame, fear and secrecy surround mental illness
2. The causes of mental illness are often misunderstood
3. The family can be both caring and isolating
4. Social pressure to conform
5. People with mental health problems are not valued
Marriage prospects can be damaged by mental illness
Extended family and wider community were felt by people with mental health problems to
have most impact on their lives.
The key learnings from the project are:
1. It’s important to embrace the power of the community, its networks and local knowledge.
2. Pay attention to cultural dates of interest as hooks for PR and local activity.

5. IAPT – increasing access to psychological therapies. Source of equality or further discrimination?
5.1 One major advance in recent years is the understanding that the use of psychology can be effective in treatment of mental illness, which is as likely to stem from social factors as from physical illness. The development of such treatments is becoming a growing industry with universities like Chester setting up departments and publishing journals. I attended a conference to discuss the present state of affairs, but was concerned to see no contribution to the issue of diversity and a recognition of how cultural competence will be necessary for practitioners in the development of their skills. The question has to be asked whether this will intensify the situation where many will be denied a choice in their treatment on the basis of their ethnicity and culture. A current NHS document on IAPT acknowledges diversity and the requirement of cultural competence. Sections on this, while acknowledging complexity, are extremely brief.
5.2 Concern that much more needs to be done to ensure equal access across cultural groups appears to be shared by professional groups such as the Royal College of Paediatrics and Child Health
5.3 Kamel Chahal enumerated blocks within NHS services to Asian families accessing talking therapies:
Blocks within NHS Services:
Obstacles to Accessing Talking Therapies – Ethnic monitoring within psychology services shows:

“Less access to talking therapies (although often requested by communities in reports)
Less referrals from GP’s & CMHT’s
Less take-up of therapy when offered
Higher & earlier drop-out rates Issues related to cultural competence
Confidentiality fears – Major taboo to talk about problems outside home
Self-esteem built through different mechanisms – “we want” rather than “I want”
Value system and rules of living can be very much in conflict with “host” society
External & Internal Pressure to comply with cultural norms of: Impacted on by 1st,2nd, 3rd generational differences & ensuing cultural conflicts
Family structures & familial expectations – e.g. Marriage
Rules & subtleties in managing immediate and extended relationships
Folk-lore understanding of metal illness
Superstition, jinns, past lives, bad blood, not curable – passed on through families
Spirituality / Religious philosophy ignored.”

Kamel Chahal 2012
6. The Voluntary Sector’s role in supporting mental health needs of a diverse community

6.1 The “Talk to Us” project involved visits to some 40 voluntary organisations across the West Midlands. They typically involved enthusiastic and in many cases staff with long experience in working with sections of the community. These were usually those known to be at risk of failing to get appropriate, if any, help from the statutory sector. The organisations in the words of Ralph Hall of CSIP were “set up because of unmet need”. Most expressed a wish to build their capacity to develop their services professionally to be able to deliver a high standard of care in partnership with health service professionals. Now in 2013 most are struggling to exist. They have to compete for contracts with large well-staffed organisations. While they have the knowledge and experience to deal with what matters to the communities they have sprung from and serve, they are often unable to contend with the bureaucratic requirements of complex contracts. This has become even more difficult in a period of transition for commissioning bodies as Primary Care Trusts (PCT’s) end and Clinical Commissioning Groups (CCG’s) evolve.
6.2 Professor Kamaldeep Bhui of Queen Mary College, University of London, argues the importance of the voluntary sector in addressing detention of those with mental health need. Professor Bhui has set up a Cultural Consultation Service (hear a podcast on the link provided) intended to address cultural factors in mental health services.
7. The Development of a Level 2 Syllabus to Improve Access to Appropriate Mental Health Services

7.1 While the first year report looked at key reports and recommendations following the David Bennett Report, 2003, the current report for year 2 considers the present position nationally, while drawing on case studies within the West Midlands where the SCYS Project is centred.
7.2 The headings above serve to signal key issues which seem essential for those serving a diverse community. The first thing to recognise is that mental health is a world wide problem which the World Health Organisation has described as “the silent epidemic” growing so that by 2020 it will be one of the largest and the most debilitating ailments facing human beings. There is no difference in the condition between diverse groups, but there is a difference of how it is understood according to cultural understanding and consequent approaches to help and support. On the one hand this can lead to a failure to take appropriate action to get help for self or other, on the other the views and lack of cultural understanding by health providers lead to a failure to provide appropriate services. This encompasses ignorance leading to misdiagnosis and willful racist attitudes. The David Bennett Report recommended thoroughgoing and continuous training in cultural competence and this has been retained through the previous government’s Delivering Race Equality (DRE) agenda, backed by Count Me In statistics to present recommendations in “No Health Without Mental Health”. While the DRE and Count Me in statistics have been archived they are by no means irrelevant. The decision to stop collecting is apparently because they repeat the same pattern, not because they have shown that matters are improving. Figures found elsewhere suggest that far from it detention of those with severe need are on the increase and need addressing. Professor Bhui states the importance of the voluntary sector in addressing this.
7.3 Outline of syllabus proposed based on sections discussed above.

Understanding of developments over last 10 years. The significance of the David “Rocky” Bennett report, it’s recommendations. Setting up of the Delivering Race Equality agenda and collection of statistics annually in “Count Me In” reports. Appraisal of outcomes of legislation (see If only we were told Year 1 Report).
(ii)The current situation. Publication of Francis and Winterbourne View reports on care and recommendations for “compassionate care”. what would this look like taking into account diverse needs of BME communities?
Cultural Competence. Iceberg model showing common understanding and failure to understand complexities of hidden (vastly greater) part required to address appropriate care provision. This is itself in need of developing and refining, particularly on the basis of experience of cases of care, including where there has been a significant lack of understanding of different expectations base on cultural differences in understanding of mental well being.
Advances in mental health treatment: IAPT and differential access. Factors preventing access and ways in which community engagement can help.
Working with statutory and voluntary agencies. Partnerships, discrimination and injutice, the voluntary sector and its role in the community.
Compassionate care – what this looks like for BME communities where cultural competence is put into practice

Food Sovereignty

There is an over production of food globally but around half, much expensively produced cost wise and environmentally, goes to waste. This adds to the cost. Locally produced food can be beneficial since it is easier for the consumer to identify the producer and transport costs are reduced as are CO2 emissions. It is not always the case that local produce is cheaper since it may be cost effective to transport out of season produce than store it in warehouses which may be at a distance from the producer, only to be transported to supermarkets again at a distance.
Struggling countries like Cuba may face huge bills importing food so they encourage more and more people to use unused space to grow crops. Havana, it is estimated, can supply food to about 50% of her people. For most cities a target of 10% would be a huge achievement.
In March 2012 a delegation from the Socialist Labour Party in the UK visited Cuba and saw local initiatives to grow organic crops for food and medicine. In January that year the SLP had put a resolution to the Party’s Triennial Congress in Blackpool which was remitted for further consideration. Four members of the SLP delegation: Andrew Jordan, President, Shangara Singh, West Midlands President, John McLeod, Brighton and John Tyrrell, West Midlands had a discussion on a site just outside Havana.
More recently the SLP held a day school at the Uplands Allotments in Handsworth, Birmingham, led by Malcolm Currie whose wife, Balbir, is Secretary of the Allotment Association. We discussed local initiatives on food issues, including local production and supply.

Mental Health and the South Asian community in the UK

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.

Police and mental health

DSC03349.JPGYesterday, 18th August 2012, saw the second march to protest at the non-action since the death in Birmingham of Kingsley Burrell. This happened at the Mary Seacole Centre. Kingsley had called the police when he and his young son were threatened by a group of youth on Icknield Port Road. The police decided to detain him and he was taken to the mental health hospital and sectioned. His family say he had no record of mental health. A few days later police were called to the centre. Kingsley ended up in hospital where he died. After a year the body is only now being released. The family and we are none the wiser how and why he died. He is one of a large number of statistics of deaths in custody, many of which involve mental health issues.
I met Jenny Cooper and her family at the march. She was beaten up by police in Wolverhampton two years ago and remains severely disabled. The police say they have held an enquiry, but they haven;t release their findings to Jenny. She and her family have been continually harassed over many years, and police have raided her house and the homes of her daughters on numerous occasions. On one occasion an officer told Jenny “she was mad” and he would have her sectioned. Another black Wolverhampton woman told me that she had been brutally treated by police and on occasions taken into cells and beaten or taken to a mental health institution. She complained but got no satisfaction. Both prisons (7 black people to one white person in UK) and mental health secure institutions show black over representation. This is how it happens. There needs to be a police watch, starting with Wolverhampton’s Bilston Street Station in the West Midlands.
If someone is thought to hav a mental health problem, then why are hey given a beating? It happened to Mikey Powell in Handsworth district of Birmingham in 2004. Aljazeera talks about people being caged or bound and badly treated in the third world. Not much progress here after the David Bennett report and the Lawrence enquiry.

If only we were told…..

Development of a level 2 qualification in Promoting BME access to
appropriate Mental Health Services

Summary
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” which appeared in 2003. 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 Overview section of the report covers the period since then encompassing the legislation and national agendas of National Government. On the one hand there appear to have been significant advances in treatment, particularly with the Increasing Access to Psychological Therapies (IAPT) initiative. The problem of increasing levels of stress and depression, described by the World Health Organisation as a “silent epidemic” of world wide proportions, cannot be met by statutory provision in either the “first” or “third” worlds. WHO describes depression as one of the most debilitating illnesses the world faces and will be the 2nd most prevalent health issue by 2020.They propose a much wider community involvement in tackling need. Their proposals single out areas they see as most in need, i.e. what is characterised as undeveloped areas. I would suggest that significant sections of the so-called developed world require similar measures particularly where there is diversity and inequality.
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 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
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
health.”
“Inside Outside. Improving Mental Health Services for Black and Minority Ethnic
Communities in England” p.36.
The Government responded with the Delivering Race Equality agenda with the aim by
2010 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
5.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
Impact Assessment
• 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 involvement

The 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 issues
covered 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:
http://tinyurl.com/NewHorizonsConsultationReport

1 New Horizons Equality Impact Assessment, July 2009 available at: http://tinyurl.com/
NewHorizonsEQIAJuly2009

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.”
and
“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 bacause 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.
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 in order to assess the person’s best interest. 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.
4. Next Steps. Plans for years 2 and 3 of the Project
Year 2.

This 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 will be attached 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.
Year 3.
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.

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The Silent Epidemic

Aljzeera discusses at length in “the stream” the “world’s silent epidemic” echoing the British Government’s “there is “no health without mental health”. There is. in my view, a false dichotomy in dividing the world into “first” and “third” components when the characteristics of inner cities and rural communities within the first share the same effects of poverty with the third world. We are talking about a truly global problem, but some of the solutions envisaged for the “third world” are equally applicable to the rest. The World Health Organisation describes depression as the most debilitating illness. In all parts of the globe only a minority of those in need get help with the “third world” sections within the “first” again resembling the other.
“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.” Source Aljazeera “The World’s Silent Epidemic”
In the Birmingham in the UK the Sikh Community and Youth Service carried out a project visiting around 40 organisations in the voluntary (or “third” sector – yes it says it all) which were set up for “unmet need” and covered diverse communities settling in the West Midlands region of the United Kingdom. The Project “Talk to Us” produced a website in 2007 intended as a toolkit to help the kind of organisations visited build capacity for dealing with mental health issues.

Cuba brings hope to Haiti

Fidel Castro reports the success of the medical brigades working in earthquake, hurricane, and now, cholera ridden and tormented society. The news is astounding. Cuba, small and restricted as it is, is able to treat cholera patients and prevent deaths occurring.
Cholera, it has been reported, was introduced from outside from among the legions who turned up to give aid. Haiti’s people have suffered from years of exploitation leaving poverty while surrounded by unparalleled wealth creation.
While Castro reports Cuba’s achievements in his low key article in Granma are his claims substantiated elsewhere? According to a Reuters Report, on the ground it is the Cubans that others turn to first, although this is not made known widely. The world of wealth is not about to admit that it might just have some things like it’s values and ideology all wrong. Keep up the profits by exploiting the likes of Haiti (which Cuba has successfully resisted for over 50 years and inspired others in the southern parts of the Americas) while these lives, the poor, are expendable.
Those Haitians who have encountered Cuban care recognise who their carers are.