Guidance for commissioners of mental health services for people from black and minority ethnic communities

Guidance for commissioners of mental health services for people from black and minority ethnic communitiesThis guide describes what ‘good’ mental health services for people from Black and Minority Ethnic (BME) communities look like.

While all of the JCP-MH commissioning guides apply to all communities, there are good reasons (see P9) why additional guidance is required on commissioning mental health services for people from BME communities.

This guide focuses on services for working age adults. However, it could also be interpreted for commissioning specialist mental health services, such as CAMHS, secure psychiatric care, and services for older adults.

Download Guidance for commissioners of mental health services for people from black and minority ethnic communities

Ten key messages for commissioners

  1. Regardless of their ethnic background, everyone who uses a mental health service (or cares for someone who does) should have equitable access to effective interventions, and equitable experiences and outcomes. Commissioners have a legal duty to ensure this.
    1. Commissioners have the opportunity and responsibility to tackle ethnic inequalities in access, experience and outcomes in mental health care. This involves improving the quality of mental health care. It also requires tackling inequality and structural discrimination within the NHS. Structural discrimination refers to policies and practices within institutions that are intended to be neutral, but which result in adverse outcomes for particular groups.
    2. Commissioners have a legal duty – under public sector equality duties – to consider the mental health needs and care experience of people from BME groups. These duties require care and treatment to be delivered to BME groups which will result in improved health outcomes, and the correction and removal of discriminatory patterns of care and treatment.
  2. Every commissioner should address ethnic inequalities in mental health. To do this, they will need to develop their knowledge, confidence and competences.
    1. Commissioners need to fully understand the mental health needs of BME communities, and their experience of the local mental health system. Commissioners also need to recognise that the organisational culture and structure of NHS care can act as a barrier to overcoming health inequalities among BME groups.
    2. To gain this understanding, a co- production model for commissioning, procuring, and delivering services should be used (please see the JCP-MH guide on ‘values-based commissioning’).
  3. Commissioners should identify and implement specific measures to reduce ethnic inequalities in mental health. These include collecting better data, specialist provision, enhancement or modification of existing services, and the scaling-up of innovations.
    1. Existing ethnic inequalities cannot simply be explained in terms of a ‘variable disease burden’. Therefore, commissioners need to collect and use much better data about the experience and outcomes of mental health treatment among BME groups. Ethnic variations in service experience and outcomes are not routinely collected, not bench-marked, and not available for progress or performance to be measured against. This should be rectified.
    2. The procurement and provision of mental health services should reflect a commitment to ensuring race equality. Progress in reducing such inequalities must be measured, as well as the quality and safety of mental health services for BME groups (which should include measurements from the perspective of BME service users, their carers, and their families).
    3. Commissioners need to play a key role in challenging (and supporting) existing mental health services to make the necessary improvements.
  4. Clinical Commissioning Groups and Health & Wellbeing Boards must develop local strategies and plans for improving mental health and wellbeing amongst BME communities.
    1. CCGs (and provider organisations) have a clear responsibility and accountability for BME mental health. Ultimately, they have the responsibility and are accountable for improving the quality and safety of mental health services for BME groups. When responsibility is diffused, it is not clearly owned: “with too many in charge, no-one is”.
    2. This should also include applying strategies aiming to promote health and wellbeing among BME communities. These should always include a commitment to address the social determinants of mental health that make BME communities more vulnerable to poor wellbeing (including the pre-determinants and antecedents of mental disorder and mental illness).
  5. There should be targeted investment in public mental health interventions for BME communities. This should focus on reducing/moderating the adverse impact of social and material adversities (including racism) on these communities. These should also include activities to raise awareness and reduce stigma.
    1. NHS England has the responsibility to promote and facilitate joint and collaborative commissioning by CCGs and Local Authorities. This should give priority to community development, mental health education, and awareness programmes amongst BME communities. Community development initiatives should always aim to (a) improve the ability of BME groups to deal with health or social care problems and (b) forge a more positive and trusting relationship between these communities and mental health/social care providers.
    2. Mental health commissioning should recognise the impact of racism, interpersonal violence and conflict on the mental health and mental wellbeing of people from BME communities. Plans must subsequently be developed to reduce the experience and impact of racism and stigmatisation in the community, as well as within mental health services. This is because such experiences can (a) aggravate the course of mental disorder in BME communities and (b) undermine the quality of care of BME patients and carers.
    3. Public health population programmes should be (a) suitable for all communities, and (b) not heighten or worsen inequalities among BME groups.
  6. From the outset, commissioners should involve service users, carers as well as members of local BME communities in the commissioning process. These individuals should be key in establishing the strategic direction and monitoring of mental health care and service outcomes.
    1. The principle of ‘no decision about me without me’ should be central to all commissioning activities.
    2. Clear guidelines on BME service user engagement, involvement, and co- production exist. The Dancing To Our Own Tunes guidance should be followed by CCGs and Local Authorities for every step of the commissioning cycle.
  7. Commissioners should ensure that service providers collect, analyse, report, and act upon data about ethnicity, service use, and outcomes. This should be part of a systematic attempt to mobilise local evidence in relation to ethnicity and mental health.
    1. The health care needs of BME communities vary in different parts of the country. Although national surveys and monitoring still provide helpful information, data on local service outcomes, their effectiveness, quality, safety, and service user/carer satisfaction is essential.
    2. There is a pressing need for annual audits in local mental health services that focus on service experience and outcomes by ethnicity. Such audits should be made public and easily accessible. They should include data on the quality of mental health care as measured against coercive interventions, and include measurements based on service user experience.
    3. Providers should be mandated by commissioners to complete Mental Health Minimum Data Sets, and to collect relevant ethnic data to determine whether high-quality, safe, and non-discriminatory care is provided to BME groups.
    4. The Evidence and Ethnicity in Commissioning (EEiC) project has highlighted all of the above problems, and is a useful resource for commissioners. (http://research.shu.ac.uk/eeic)
  8. To create more accessible, broader, and flexible care pathways, commissioners should integrate services across the voluntary, community, social care and health sectors.
    1. Multiple points of entry into specialist mental health assessment/care are needed. This will require direct access through non-clinical routes such as community agencies, places of worship, the educational and social welfare system, housing providers, criminal justice and the voluntary sector (including BME agencies).
    2. In doing this, commissioners should invest in youth services targeted at BME groups, as this will help facilitate the early detection of mental health problems and appropriate interventions.
    3. Some BME groups, such as people of African and African Caribbean origin, may engage better with services specifically designed and delivered to address their needs, and prefer services delivered through community agencies such as BME third sector organisations. Consequently, mental health commissioning strategies should recognise the importance of increasing choice and the plurality of service provision available for BME communities.
  9. Every mental health service should be culturally capable and able to address the diverse needs of a multi-cultural population through effective and appropriate forms of assessment and interventions.
    1. Mental health services tend to follow uniform models of care that assume that ‘one size fits all’. However, mental health service experiences and outcomes are powerfully influenced by the ethnic and cultural background of patients (and arguably more so than in other aspects of health care).
    2. The quality of mental health care experienced by BME groups depends on the cultural capability of mental health services. Commissioners must ensure that mental health services that they commission are ‘culturally capable’, in that the service and workforce are able to deliver high-quality care to every patient, irrespective of patients’ race, ethnicity, culture or language proficiency. A personalised service response is essential to achieve this objective.
    3. Such competencies and skills should exist within all mental health services (doing this means mainstream care will help attend to the cultural, religious and ethnic needs of people, and help meet the principle of equality of care which is a core value of the NHS).
    4. Where the level of need, risk, or exclusion of generic services raises serious concerns about equity and equality, it is appropriate to provide specialist short- term or alternative care for particular marginalised groups. (This will also help optimise choice, as well as opportunities for individuals and groups from BME communities to become centrally involved in service provision.)
    5. A long standing concern reported by BME groups is about the disproportionate use of control and coercion within mental health services. Addressing this is key and requires both culturally competent staff and organisations/systems. Training courses or initiatives on recruitment (ensuring diversity within the workforce) cannot by themselves ensure clinical cultural competency skills. Other methods must be considered including cultural mediation and cultural consultancy services; the ‘co-production’ of services; development of alternatives to institutional care and increased involvement of BME peer workers and user involvement in the planning and delivery of care; and the presence of spiritual care teams in mainstream services.
  10. Coercive psychiatric care is experienced disproportionately by some BME groups, in particular people of African and African Caribbean origin (black and mixed race origin). A number of strategies are required to reduce coercive care. These should include a greater focus on patient safety, greater plurality and choice of service providers to reflect the ethnic and cultural backgrounds of service users/local communities and more investment in patient advocacy.
    1. Commissioners should take practical actions to expand community residential alternatives to hospital admissions, and also increase community services that support psychosocial rehabilitation of BME service users. This means expanding community residential alternatives to hospital admissions, reviewing the use of Section 136 provisions, accelerating discharge from inpatient settings, and expanding step-down options from custodial care (especially where it is targeted at individuals in long-term and, often, forensic mental health care).
    2. Procurement and delivery of such services through third sector organisations from BME communities should be prioritised. Where such services already exist they should be enhanced. Where they do not exist, commissioners should explore, pilot and commission these options in co-production with BME communities and service users.
    3. Peer support services and advocacy services specific to the needs of BME communities should be an integral part of mental health service provision in diverse communities. Advocacy services should be commissioned in a way which improves quality, patient safety and access. Helping patients to use their rights would be an important step in addressing the disproportionate number of black patients currently subject to the provisions of the Mental Health Act and managed in restrictive settings5.

Related Top tips

Related FAQs