Minds apart: race and differential outcomes

The stark and enduring inequality in mental health outcomes between black and white people is being addressed by two psychiatrists who want to tackle decades of unfounded assumptions. Keith Cooper reports

Location: UK
Published: Friday 9 October 2020
minds part

There is an awful inequality in healthcare and society with which doctors have grappled for decades to little avail: if you are of black African or Caribbean background, you are more likely to have a bad experience of mental healthcare than if you were born white British.

You are treated differently from childhood. The research shows that for bad behaviour, you get the social worker, not the child psychologist, and are more likely to be expelled. As an adult, you have less chance of accessing talking therapies.

If you do, you will face someone with whom you have little in common. You are more likely to be taken to hospital in a police van than ambulance, detained under the Mental Health Act, and end up in the forensic mental health system, with criminals, crushing your chances of getting a job.

The cost for patients, their families, the NHS, and to the economy is obvious. This stark and enduring disparity has been studied repeatedly, most recently in 2018 for the Independent Review of the Mental Health Act by Sir Simon Wessely, which admitted ‘little has changed’ in 30 years.

It’s about to be tackled again by a race equality taskforce set up by the Royal College of Psychiatrists, which will be focused on getting things done.

So how much of a difference will another initiative make?
Shubulade Smith and Rajesh Mohan, the two leading consultant psychiatrists heading it up, believe it can and the time is right. They admit, however, it may take generations to close the gap.

For in their sights are those difficult-to-pin-down, systemic, structural and institutional factors which have concreted racial inequality into healthcare for so long, as in so many areas of public life.

‘The death of George Floyd in the USA and COVID-19 have allowed people to accept racism isn’t simply about the overt, calling people names in the street,’ says Dr Smith. ‘People are open now to accepting there might well be institutional, systemic and structural factors that are long-standing, historical, and cultural, that disadvantage certain groups.’

Structural change

shubulade smith SMITH: 'Racism isn’t about the overt, calling people names in the street'

Dr Smith would like an end to all racism but is ‘more realistic than that’.

‘What we want to do is shift things so we introduce some structural change.’

Their taskforce will look at three areas: the college itself, ensuring its own house is in order, the needs of its members, 38 per cent of whom are from BAME (black, Asian, and minority ethnic) backgrounds, and the wider NHS.

With so much evidence and so many recommendations out there already, their focus is on getting things done. ‘There has been commission after commission, inquiry after inquiry,’ Dr Smith says. ‘We want to collate recommendations, group them and try to implement them rather than making new recommendations and talking about them again and again.’

People are open to accepting there might be institutional factors

Dr Smith

Dr Mohan admits structural and systemic factors are as hard to pinpoint as the evidence of their effect is clear. ‘Systemic racism in healthcare is the same as systemic racism elsewhere in society,’ he says. ‘Institutions or bodies have ways of working or systems that inherently disadvantage people in certain groups.

Dr Mohan says that the nature of structural racism is not well understood. ‘The systems we are working in have deeply entrenched processes and can perpetuate factors that can disadvantage certain groups,’ he adds. ‘We have to raise awareness of these systemic structural factors and actively work to address them to make health care systems truly equitable.’

This focus on structural and systemic issues is also informed by a 2019 research paper in Lancet Psychiatry with which Dr Smith was involved. This examined studies of racial inequality since 1970. It found almost half of a sample of 71 papers offered ‘no explanations’ or ones unsupported by the studies themselves. Unsupported explanations included those which entrenched ideas of ‘racial determinism’, that inequalities were due to patients’ lifestyle or cultures.

‘Over the last 35 to 40 years there’s been a propagation of explanations that have been taken as fact but are in fact based on assumption,’ Dr Smith says. ‘It’s amazing and it’s important because it means over the years nothing has changed.’

Experiences of racism

rajesh mohan MOHAN: ‘Systemic racism in healthcare is the same as systemic racism elsewhere in society’

Inequalities in mental healthcare cannot be addressed by the NHS alone, of course. ‘That wouldn’t be closing the tap that causes the flood,’ Dr Mohan says. ‘Mental health can be seen as a culmination of various unequal experiences over time.’

Dr Mohan and Dr Smith have, of course, experienced racism inside and outside of the workplace.

Dr Smith was born in the UK to Nigerian parents. She was subject to name-calling, doubts about her intelligence, questions as to whether she could be a medical student. She considered asking for ‘Dr’ to be removed from her credit card to clear supermarket checkouts quickly.

‘They look at you, look at the card, look at you, look at the card. It goes on for ages.’ After receiving a CBE in the 2019 Queen’s Birthday Honours, a colleague responded: ‘You’ve only got that because you are black.’

Dr Mohan talks of ‘unpleasant experiences’ and of being treated differently because of my ethnic origin’. He arrived in the UK in his late 20s from India, one year off from becoming a consultant but had to start again as a first-year trainee. ‘I trained until I literally couldn’t train any more,’ he says.

Cultural differences

Such experiences put Dr Mohan in a good position to argue for ‘decolonising’ the college’s curriculum and exams for trainee psychiatrists.

As in other specialties, international medical graduates are more likely to fail exams than those trained in the UK.

‘They are probably walking into them with a handicap that is unlikely to do with knowledge,’ says Dr Smith. ‘In certain societies, such as Nigeria or certain south Asian societies, it’s rude to look someone straight in the eye; it’s the opposite in Britain and Europe. It’s an important issue for clinical exams, when the actors who play patients give feedback and may mark candidates down because they didn’t look them in the eye.’

You’ve only got that because you are black

Dr Smith

Dr Mohan believes the college has a good track record on equality to build on. It carried out a gender pay gap review without having to; they’re only required for organisations with more than 250 employees.

But what of the seemingly intractable inequality in the wider NHS? How to shift those stubborn, structural, systemic, and institutional scaffolds?

A new framework

The solution, or at least the start of one, sounds, frankly, dry and bureaucratic. It’s a management tool – perhaps not the dramatic intervention which the stark effects of racial inequality seem to require.

What they’re keen to promote is the PCREF (Patient and Carers’ Race Equality Framework), a recommendation from Sir Simon’s review, in which Dr Smith played a role. The more you learn about PCREF, however, the more it makes sense. It’s a bureaucratic spanner to fix a healthcare bureaucracy which has failed for decades to fix itself.

It is being piloted by NHS England/Improvement in Manchester, Birmingham, and London, at the East London NHS Foundation Trust and SLAM (South London and Maudsley) NHS Trust, where they’re employed – Dr Mohan, as a consultant rehabilitation psychiatrist, and Dr Smith, as clinical director for the forensic service.

‘Everyone knows what the problems are, but people don’t talk about how you get there,’ says Dr Smith. ‘The PCREF is a way of supporting organisations to learn how to meet the needs of their local population.’

Rebuilding trust

At the SLAM, they’re beginning by building ‘meaningful connections’ with different communities through charities, churches, parenting, and foster groups. ‘That’s no mean feat, given the history,’ Dr Smith adds.

‘You need to find out who to speak to in every single community. What do they think the issues are? You then develop the competencies to meet the needs of that population, set targets with the local community, move things forward. Monitor. Modify each year until you’ve ironed out problems. It’s no quick fix.’

It could take NHS organisations five years to be classed as ‘competent’, she says, even longer for populations to feel comfortable about using their service. ‘It could be generations before we properly equalise out the system,’ Dr Smith adds. ‘It’s going to depend on people’s willingness to do this. To some extent, we are going to have to take a leap of faith.’

The success of PCREF, it seems, will depend, as with any other measure before it, on the commitment of those behind it.

Given the experiences of many in BAME communities, it may just be the leap of faith that is required.