Mental health services in England and Wales have been accused of being institutionally racist. In this week's BMJ, two senior doctors say that, although services are pioneers in moving towards equity, they have some way to go before they meet the challenges of a multi-cultural society.
The "Count me in" census, published last week by the Healthcare Commission, makes grim reading for people of African and Caribbean origin living in England and Wales, write Professors Kwame McKenzie and Kamaldeep Bhui.
The survey of 32,023 inpatients on mental health wards in 238 NHS and private healthcare hospitals reported that 21% of patients were from black and minority ethnic groups, although they represent only 7% of the population.
Rates of admission were lower than average in the white British, Indian, and Chinese groups, but three or more times higher than average in black African, black Caribbean and white and black Caribbean mixed groups.
Not only were people in these three groups more likely to be admitted to hospital, but those in hospital were more likely to be admitted involuntarily. Once in hospital, people who defined themselves as black Caribbean had the longest stay.
In a separate survey of people with learning disabilities, comprising 4,609 inpatients from 124 hospitals, only 11% were from black and minority ethnic groups. Rates of admission were lower than average in the South Asian, other Asian, white, and Chinese groups, but again they were two to three times higher than average in some "black" groups. However, unlike inpatients with mental health problems, no ethnic differences were seen for involuntary admissions.
These results add to the increasing evidence of ethnic differences in the treatment of mental illness, say the authors. For instance, some black and minority ethnic groups are less likely to be offered psychotherapy, more likely to be offered drugs, and more likely to be treated by coercion, even after socioeconomic and diagnostic differences are taken into account.
These disparities reflect the way health services offer care according to racial group, and seem to satisfy the well established and widely known definition of institutional racism.
In response, a systems level approach called "Delivering race equality" has been developed to improve mental health services. This could improve services but leadership is needed to ensure that it is taken up, say the authors.
But there is a danger that its impact will be undermined by other government policy, such as the proposed amendments to the Mental Heath Bill, and there are also wider questions about whether treatment is being offered and delivered effectively.
The Count me in census and other research indicate that institutional discrimination does occur and that services have some way to go before the challenges of our multicultural society, they write. "If the concept of institutional racism had been more widely accepted and acted on, the Department of Health might not now be facing a formal investigation by the Commission for Racial Equality," they conclude.