7 Ethnicity and the use of the Mental
Health Act
Disproportionate representation
of minority ethnic groups
108. The CQC found in 2011-12 that there was
a "continuing trend in high rates of detention amongst certain
black and minority ethnic groups."[140]
The general trend for hospitalisation and detention under the
Mental Health Act 1983 is at disproportionately high rates amongst
minority ethnic groups. Rates of detention were 2 to 13 times
greater than was expected[141]
and this particularly applies to the Black and Black British population.[142]
109. We heard evidence about the experiences
of minority ethnic groups within the mental health system and
the reasons which explained much higher rates of detentions amongst
these groups. The MHA have found that Mixed, Black and Black British
groups are "40% more likely than people in the White group
to be using mental health services, with or without compulsion."[143]
In oral evidence Alison Cobb expanded on this and told the Committee
that it might be the case that:
people from black communities may be afraid of services
and have fears around being detained, medication or how they might
be treated. The impact of that results in damaged trust and people
not wanting to engage with services and, perhaps, delaying making
contact with services until really late in the piece, when it
may be more likely that the Act will be used.[144]
110. The Department of Health accepts that there
is:
long-standing concern about the disproportionate
numbers of people from minority ethnic groups, particularly Black
Caribbean, Black African and other Black groups, using in-patient
mental health services and detained under the 1983 Act.[145]
Bruce Calderwood spoke in more detail about this
concern, saying that this problem was specific to migrant communities.
Specifically discussing detention, he said:
There are higher rates here than there are in either
the Caribbean or in Africa, so there is something around the experience
of black and Afro Caribbean people in this country as opposed
to where they, their parents or grandparents come from, which
actually is helping to cause much higher levels of psychosis than
in the general population.[146]
Dr Griffiths added that this was not simply a problem
which England or the United Kingdom must address and that "It
is a phenomenon all over the world that migrant populations have
higher rates of mental illness."[147]
Bruce Calderwood told the Committee that there was also a 'London
effect' whereby:
The pattern of detention due to the Mental Health
Act in London is very different from the rest of the country,
and that seems to be, again, to do with social isolation, homelessness
and people not having anyone to look after them. It is very difficult
to disentangle race effects from the London effects.[148]
Anne McDonald told us that social factors attached
to living in London along with the city being a major transport
hub might be part of this phenomenon. Interestingly, she said
that:
if you present for an assessment under the Mental
Health Act, the [...] likelihood of actually being detained are
very similar between Birmingham and Oxford but much higher in
London.[149]
111. Bruce Calderwood and Dr Griffiths argued
in their evidence that the disproportionate detention of people
from black communities could not be attributed to institutional
racism in the system. They accepted that, inevitably, racism would
occur and acknowledged that racism in society might be a driver
of mental health problems.[150]
Overall, however, they concluded that "it looks as if the
much higher rate of the use of the Mental Health Act can be explained
to a considerable extent by some of these demographic characteristics."[151]
Effect of the 2007 Act
112. We did not take any evidence which claimed
that the 2007 Act was inherently weighted against certain people
or communities or had exacerbated the problems identified within
the system. It is telling, however, that 15% of CTOs issued between
2008-2011 were for Black or Black British patients.[152]
This group represented approximately 3% of the population in 2009
and it demonstrates that even the most recent innovations in care
have not managed to overcome the ethnic imbalance. The extent
to which CTOs are issued to Black patients is even more disproportionate
than the rates of detention under the Mental Health Act. Bruce
Calderwood explained to the Committee that when a patient is detained
under the Mental Health Act:
it is not just about diagnosis and whether you have
a mental disorder; it is about risk. There are many determinants
of risk, some of which are contained in your social circumstances.[153]
Naomi James told us that some patients subject to
CTOs had reported elements of risk being too heavily weighted
in their care plans.[154]
The evidence presented to the Committee demonstrated that societal
factors which create risk will influence clinical decisions regarding
treatment.
113. Alison Cobb emphasised the significance
of delivering advocacy services to detained patients and those
on CTOs. In Chapter 2 we identified the problem that those most
in need of advocacy were least likely to be able to access it.
The University of Central Lancashire found that this problem is
apparent for minority ethnic groups.[155]
This is a failing in the system which we believe can be resolved.
114. Introducing the Bill to Parliament, Lord
Warner said that decisions around treatment must consider whether
services are "culturally appropriate".[156]
This is a vital consideration and it is right that the legislation
should address this point. It is, however, the responsibility
of NHS England and clinical commissioners to commission and construct
mental health services that make the legislative intent a practical
reality.
115. Effective commissioning
of advocacy by local authorities can begin to tackle the failure
to provide minority ethnic patients with a robust advocacy service.
Anne McDonald said that it is important to commission in a way
"which improves quality and access"[157]
and this should be a priority in relation to advocacy. Helping
Black patients to use and exploit their rights would be a small
but important step in begin to address the disproportionate number
of Black patients subject to the provisions of the Mental Health
Act.
140 CQC, January 2013, p 16 Back
141
Ibid, p 17 Back
142
Q 170 Back
143
Mental Health Alliance, May 2012, p 18 Back
144
Q 63 Back
145
Department of Health, July 2012, p 13 Back
146
Q 170 Back
147
Ibid Back
148
Q 173 Back
149
Q 175 Back
150
Q 170 ff. Back
151
Ibid Back
152
CQC, January 2013, p 89 Back
153
Q 170 Back
154
Q 45 Back
155
Department of Health, July 2012, p 18 Back
156
HL Deb, 28 November 2006, col 658 Back
157
Q 179 Back
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