The UK’s mental health services are failing. Right now, two-fifths of patients waiting for mental health treatment are forced to resort to emergency services and we’ve seen record numbers of people – 400,000 children and 2.2 million adults – seek help for conditions including anxiety, depression and eating disorders in lockdown. But with big reforms announced around the 1983 Mental Health Act, will services improve? And how will the changes affect people of colour?
What are the proposed Mental Health Act reforms?
The Mental Health Act is a piece of legislation which, among other things, allows the state to detain people in crisis. Now the government has announced its reform, with a specific aim to “tackle racial disparities in mental health services” and give individuals “greater choice and autonomy” over their care.
One of the main proposals is a pilot of “culturally appropriate advocates” so that patients from all ethnic backgrounds can access support from people who understand their needs. Furthermore, sectioned people (those who are detained in hospital and given treatment whether or not they agree to it) will be allowed to nominate friends or family members to guard their interests if they are unable to do so themselves.
Reforms will also introduce a new competency framework for NHS trusts, referred to as the ‘Patient and Carers Race Equality Framework’. The idea is to make sure trusts know what specific steps they need to take to improve mental health outcomes for Black and ethnic minority communities. This will be done by working closely with community members, patients and carers to understand their experiences and offer services that better respond to their needs.
Other recommendations include a right to appeal against treatments as well as an end to the use of police cells in detention and police vehicles for transporting individuals to the hospital.
For people of colour, these are desperately needed changes. Evidence shows ethnic minority individuals are at a higher risk of mental ill health than white people, yet they’re less likely to get help through their GP and more likely to end up in crisis care. The care experience of ethnic minority service users is likely to vary in quality too; research has found Black African Caribbean patients undergoing psychosis treatment are more likely to be prescribed medication than be offered talking therapies. Even more worryingly, police are far more likely to be involved in admissions for Black African Caribbean psychosis patients than white patients.
As it stands, Black people in the UK are over four times more likely to be detained under the Act than white people and over ten times more likely to be subject to a Community Treatment Order (CTO) – a legal order which releases a person from detention but places strict conditions on further treatment and their life. Although CTOs are supposed to prevent people from being readmitted to hospital through methods like requiring them to see a therapist, their strict conditions often go much further.
Under CTOs – nicknamed “psychiatric ASBOs” – people can be forced to live in a certain area and even prevented from leaving their house without an escort. They deprive individuals of their liberty and their widespread use, particularly against people of colour, has been a cause for extreme concern for many.
Yet, despite the knowledge that CTOs are used disproportionately against people of colour, the government’s aren’t proposing to scrap them but instead tighten the criteria for their use. Under the new look Mental Health Act, CTOs will only be used “where there is strong justification, and a clear therapeutic benefit to the individual”. They will also be reviewed more often and by more professionals, and are limited to two years.
Scope for change
While the proposals have been welcomed by mental health advocates and organisations, many remain sceptical as to whether these changes will have a tangible impact on mental health outcomes for people of colour.
Mind, the UK’s largest mental health charity, has expressed its disappointment that CTOs aren’t being removed altogether, pointing out that they haven’t reduced hospital readmissions and that they are a coercive practice, often causing lasting trauma and damage to people subject to them.
The Royal College of Psychiatrists have also briefed that raising the threshold for people to be detained or placed on CTOs will not eliminate ethnic inequalities in the use of CTOs, as this does not address their root cause nor unconscious bias in risk assessments.
For Alfred Oyekoya, founder of Bame Mental Health Support (BMHS), a major concern is the lack of culturally appropriate interventions. He warns the reforms will have “zero impact” for ethnic minority groups if more culturally sensitive measures aren’t included.
“Not only do BAME (Black, Asian and minority ethnic) individuals often show different signs of mental illness, evidence shows community support is much more effective for these groups than mainstream services,” Alfred explains.
“A lot of BAME groups are reluctant to reach out for help due to fear of how they will be treated and because culturally appropriate support is not available,” he continues. “It’s vital they can access the care they need at an early stage, before they reach crisis point.”
Subject to funding
There’s no getting away from the fact that the proposed reforms come with a hefty price tag. Ensuring they are successful will require substantial investment in mental health services, services that have been chronically starved of funding over the last ten years.
According to Professor Kamaldeep Bhui, director of Synergi Collaborative Centre, detentions under the Act will only decrease if community-based alternatives such as support groups and crisis cafes are readily available. But a decade of spending cuts as a result of austerity means these services are seriously lacking at present. Mental health trusts suffered real-time funding cuts of eight per cent each year since 2011, 6,800 mental health nurse posts have gone and almost a third of mental health beds have been lost during this time.
Worryingly, the white paper states that a number of measures, including access to culturally sensitive advocacy, which would benefit communities of colour, are “subject to future funding decisions”. It raises questions around the purpose of the reforms if there’s no money to ensure their implementation as without adequate funding, they will, inevitably, fall far short of their promises, as has been witnessed in the past.
The bigger picture
But are these reforms enough to help people of colour, when racism impacts on their mental health in ways that go beyond discriminatory treatment experienced once using support services? Everything from financial inequality to experiences at work impacts on mental wellbeing – and we already know people of colour are at disproportionate risk of inequalities – due to racism – in a range of spaces.
“It’s not until wider societal injustices are tackled that we will see a reduction in the use of the mental health act,” says Ian Hamilton, a senior mental health lecturer at the University of York. According to him, the reforms will do little to address the over-representation of people of colour who are detained while racism is so ingrained in British society. He believes systemic discrimination and stress they are subject to significantly contribute to the mental health problems.
While the reforms could be a tentative step in the right direction – so long as funding promises are upheld – updating the Mental Health Act alone is nowhere near enough to significantly improve mental health outcomes for ethnic minorities. The government must commit to addressing deeply embedded inequalities everywhere from the labour market to the criminal justice system if we are to truly see significant reductions in the number of Black and brown individuals falling afoul of the legislation that is supposed to aid them.
This article was updated on 28 May 2021 to amend a statement from The Royal College of Psychiatrists.