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Lord Phillips of Sudbury: My Lords, I am grateful to the Minister for that careful reply and to his civil servants. They have been extremely courteous and helpful in engaging with me on this difficult issue. I am particularly obliged for a letter written on 17th June, which to some extent the noble Lord has reiterated today.

I suppose that I feel a little sad that this issue cannot be made a little plainer in the language of the Bill. It is so esoteric. I have to say that the Bill as a whole strikes me ever more as being a bounty for my profession that it does not deserve. I understand what the Minister says. I am at least reassured by his affirmation of what he said on 3rd June that the provisions of Clause 261 are in addition to the general requirements of Clause 260. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 133B had been withdrawn from the Marshalled List.]

[Amendments Nos. 133C and 133D not moved.]

Clause 266 [Enforcement of public service remits]:

[Amendment No. 133E not moved.]

Lord Evans of Temple Guiting: My Lords, I beg to move that further consideration on Report be now adjourned. In moving the Motion I suggest that the Report stage begin again not before 8.36 p.m.

Moved accordingly, and, on Question, Motion agreed to.

Mental Health

7.36 p.m.

Lord Chan rose to ask Her Majesty's Government how they intend to implement the recommendations in the Department of Health report on mental health in ethnic communities, Inside, Outside.

The noble Lord said: My Lords, I am grateful for this opportunity to discuss the report on improving mental health services for black and ethnic minority communities in England, which was published in March this year. I also thank all noble Lords for participating tonight.

Your Lordships may consider me rather impatient as I asked a similar Starred Question of the Minister two months ago. In my defence, I was not expecting my request for this dinner-hour debate to be agreed to so soon after 28th April. But I must point out that Inside, Outside is the first report in 55 years of the NHS of a national approach taken to reduce and eliminate ethnic inequalities in mental health service experience and outcome for patients from black and ethnic minority groups in Britain.

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For 30 years before this important report, African-Caribbean people have been over-represented in our psychiatric hospitals. Although they make up less than 2 per cent of the British population, African-Caribbean people formed 25 to 40 per cent of the in-patient population. Their admission to hospital was two or three times more likely than white patients to be on a compulsory order and twice as likely to be under Section 136 of the Mental Health Act 1983. In addition, African-Caribbean people were twice as likely to have been admitted to hospital from prison and less likely to have been referred to psychiatric services by GPs. African-Caribbean young men were more likely to receive treatment in secure facilities. The admission rates for schizophrenia have been seven times the rate in men and 13 times for women in African-Caribbean communities.

The experience of Asian and Chinese communities in mental health services has been hindered by language and cultural barriers. Presentation of mental illness tends to be through physical symptoms such as loss of energy, poor appetite and dizziness. Whether these symptoms are determined by the stigma of mental illness among ethnic minority communities or by cultural factors has not been conclusively determined.

In that context, I am pleased to note that this report recommends that minority ethnic groups will not be excluded from any research unless there are very good reasons for such exclusion. There are financial implications of this recommendation, of course. Bilingual professionals who understand the culture and speak the same language as patients are needed to cross the cultural and linguistic divide. Suicide rates are also higher in young Asian women and among Irish-born people living in the United Kingdom compared with the majority population.

Against these experiences of black and minority ethnic people in Britain, mental health advocates have developed in these communities in order to argue for culturally appropriate services in mainstream mental health.

The Government's National Service Framework for Mental Health and the NHS Plan surprisingly have only limited references to black and minority ethnic patients. The NHS Plan identifies the need for crisis resolution services for acute mental illness among ethnic minority patients to be in place by this year—2003. It does not adequately address the particular needs of black and minority ethnic groups.

So how comprehensive is the new report, and will it fulfil its aim of improving mental health services for black and minority ethnic communities in England? First, the report acknowledges that problems experienced by minority ethnic groups within our mental health services may be worsening. It sets out to tackle ethnic inequalities within mental health services, including tackling racism and institutional discrimination within the services. That comprehensive approach is to be welcomed and fully supported.

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Secondly, extensive consultation has taken place among ethnic minority communities across England in the production of the report. That exemplar of best practice must be applauded and continued for other service issues. Thirdly, the document aims to set out proposals:


    "for reforming the service experience and service outcome of people from black and minority ethnic groups who experience mental ill health and who come into contact with mental health services as users and carers".

That emphasis on mainstream services is absolutely correct.

However, fourthly, I am surprised that no emphasis has been placed on encouraging leadership commitment of clinicians and support services—especially as mental health services operate in a range of settings such as primary care, hospitals, the community and prison. The document states:


    "it is essential to place progressive community based mental health at the centre of service development and delivery".

For that to become a reality, surely clinical leadership should be identified to implement that progressive objective. Therefore, would the Minister inform us of plans to develop clinical leadership in the care and support of black and minority ethnic patients in mental health services?

Fifthly, in primary care, the capacity of general practitioners to recognise psychiatric disorder in black and ethnic minority patients appears to be more limited than in others. That has not improved since 1996–97, when I conducted focus groups to listen to GPs in seven inner-city locations in England when I was director of the NHS Ethnic Health Unit.

As a result, all minority ethnic groups are more likely than white patients to be, to cite the report,


    "misunderstood and misdiagnosed and more likely to be prescribed drugs and ECT (electro-convulsive therapy) rather than talking therapies such as psychotherapy and counselling".

Readmission rates are also higher among those diverse groups. I am pleased to note the report's suggested standards for all GPs to have training in cultural awareness, and for culture and mental health to become part of GP training. Can the Minister give details of the programme to train GPs and staff in the mainstream mental health services to provide a culturally competent service?

Sixthly, national service framework 7, on preventing suicide and reducing the national suicide rate by at least one fifth by 2010, makes the important observation that UK death certificates do not record ethnic data. That deficiency needs to be corrected. I therefore urge the Minister to encourage the Government to include the ethnic group of the deceased to replace place of birth in all UK death certificates to improve mortality data—particularly on suicides.

Seventhly, the report recommends the recognition and use of community development workers to improve the capacity of communities to support members with mental health needs. That is a long-awaited recognition of voluntary groups which have

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been developed over at least three decades among ethnic minority communities. But those workers need to be part of the mainstream mental health services if the scheme is not to be marginalised. Will the Minister therefore outline how community development workers will be integrated into mainstream mental health services?

My final question concerns plans to monitor and audit the implementation of the report. If that is to be through clinical governance, it would merit inclusion in the race equality schemes of NHS trusts and local authorities.

In conclusion, I commend the Government on publishing this highly significant report. It has the potential to fulfil the wishes of people, such as Geoff Thompson in Manchester, who work with young disaffected black men. He has identified high-quality mental healthcare as a means of helping those young men to rejoin society with a feeling of self-worth and well-being and to contribute positively to the local community. I look forward to hearing the Minister's response.

7.45 p.m.

Baroness Howells of St Davids: My Lords, it is often considered by some that any debate raising the concerns of minority groups is "political correctness". This topic concerns us all. That is why I am pleased to support the noble Lord, Lord Chan, by adding a few thoughts to this debate on the Department of Health's report on mental health in ethnic communities, Inside, Outside.

Let me begin by drawing attention to a report published by the Sainsbury Centre for Mental Health entitled, Breaking the Cycle of Fear. That report highlighted the client group as African and African-Caribbean. It explored circles of fear and identified impediments to change. The document referred to by the noble Lord, Lord Chan, Inside, Outside, addresses an identical list of findings and recommendations.

The report found that professional staff who worked in areas with significant populations of black people do not have opportunities to talk about their needs and concerns as professionals in working effectively with the client group. It also found that mental health services were re-enforcing the disadvantages of being black in this society.

The report found that the culturally sensitive organisations in the community were doing a much better job than the NHS, despite being poorly resourced. That lack of adequate funding prevented the groups from giving long-term care. That type of user community care has been a catalyst for promoting the best practice on offer, but voluntary groups need funding to provide the right structure for sustainability.

I could go on about the similarity between the recommendations, but that is not the point that I want to pursue. I want to draw the House's specific attention to the long-held belief in our community that we are the most researched group to date in the UK. Empirical data continue to be collected, with a

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significant lack of interest in implementing the findings and recommendations. I hope that the Minister can assure the House tonight that the recommendations in the report will be given due care and attention—with a view to implementation. Both reports contain recommendations for black mental health services.

The report recommends that that service should be delivered within a culturally appropriate environment. The agenda should be client-based to address the needs of parents, carers and other family. A strong partnership between statutory and voluntary agencies is needed. Services must be developed and rooted in the local community. Personal and professional staff development is a necessity. Patients must be treated as people with very defined needs. Those recommendations also form part of the National Health Service's own report. My question to the Minister is this: will anything be done to implement the recommendations, and if so, what?

I should like to turn to an area of deep concern to the black community, that of spirituality and mental health. Spirituality and mental health are more intertwined in the African-Caribbean community than in any other. There is now a growing body of evidence which suggests that the relationship between mental health patients and their religious and spiritual lives is very intertwined and that beneficial health outcomes can be derived from encouraging patients to share their beliefs. It can also bring about great benefit not only to the patient, but to those who listen to and care for them. Yet there seems to be a reluctance on the part of practitioners to engage with religion even though the patient may display a strong need for the solace of his or her religious beliefs.

Another point for consideration is that, because of society's perception of mentally ill people as dangerous, society's perception of black men as dangerous and the minority communities' fear of psychiatric services, the reaction between these competing attitudes is all-important in perpetuating the problems of service delivery. From the various reports, we are led to believe that those perceptions delay treatment and society suffers.

Could the Minister say what action, if any, has been taken to overcome the complex interactions between the perceptions of the patient and the service providers? These are areas of consistent concern and have been much researched, revealing a lack of non-pharmacological treatments, poor communication, low levels of involvement in treatment delivery, ignorance on the part of psychiatrists of any spiritual dimension to patients' problems and a general failure of services to acknowledge that racism is a factor in their illness.

I welcome the proposals in the NHS document. I urge the Government seriously to consider those proposals and to seek implementation.

7.52 p.m.

Baroness Finlay of Llandaff: My Lords, I am grateful to my noble friend Lord Chan for raising the

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issue of the mental health of those in minority communities. Both he and the noble Baroness, Lady Howells, have outlined the issues for black and ethnic minority groups and the importance of this report. My noble friend Lord Chan also mentioned the importance of further research to move forward the quality of care and to ensure that services meet needs.

I should like to widen the debate and go beyond the visible markers of race and the report itself, which addresses England. There are many important subtleties in the delivery of services to those whose first language is not English. The most stark examples come from members of the refugee population, many of whom have been deeply traumatised. Among them, the women are often culturally mistrustful of male professionals.

Language is for the communication of facts. It also communicates beliefs and expressions of value. But it is also for the communication of empathy and confidence. In the setting of a doctor's surgery or a hospital, patients feel anxious and therefore inhibited. That is a sad inevitability. Even the stammerer will have difficulty expressing himself and will communicate less fully than when relaxed. Anxiety makes people more tongue-tied, especially in their second language. So for all patients it is important that the setting is comfortable, quite apart from the language used.

Even when healthcare professionals have a few words of a patient's language, whatever that language may be, it can help to break down barriers. The patient feels that the doctor, nurse or other healthcare worker has some understanding of their culture and values and, therefore, of their needs. This topic is not about political correctness, as the noble Baroness, Lady Howells, emphasised. It is about the quality of care for all.

When my son came back from a placement in Hong Kong, as a keen cook he had learnt a few words of Cantonese to shop in the markets. As a medical student back on the hospital wards, he joined the morning ward rounds. One day a woman with no word of English had been admitted as an emergency. She looked frightened and so he stepped forward from behind the consultant and greeted her in Cantonese. She grabbed his hand and, with great relief, managed to communicate with him, and him with her. Her anxiety levels fell as she realised that, even with limited language, he had some understanding of her culture—he was communicating empathy and compassion, but I think probably remarkably little factual information.

In general medical illness, around 20 per cent of patients develop psychiatric illness. In women the rate is slightly higher than in men; in breast cancer patients it is probably because of all the body image and sexuality issues as well as the trauma of illness and treatment. Add to that issues of race and culture, along with the approach to sexuality within different racial groups, and one can see that quickly a problem can develop which demands great sensitivity.

In those with neurological or endocrine disease, the incidence of psychiatric illness is particularly high. Liaison psychiatry is crucial, but the service is

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currently woefully undermanned. Many ill patients feel most comfortable when communicating in their primary language. When delirium or dementia occur, the ability to communicate in a second language may be lost completely and patients retain only first-language skills learnt early in life. It is the language of their mothers, with which they were comforted, that they retain. There are case reports of patients who were severely depressed and became mute, unable to communicate in their second language. As their depression lifted, their communication skills in English returned.

I should like briefly to turn to the Welsh dimension. There are many living outside Wales whose first language was Welsh. Many spoke only Welsh until the age of five when brought up in bilingual families; a few were raised in monoglot families and did not use English until much later, in their education. In Wales it is often said: "English for intelligibility, Welsh for identity". Until the mid-1880s, around 90 per cent of those living in Wales spoke or understood Welsh—the history and culture is integrally linked to language. Today there are around 3,000 Welsh speakers but, interestingly, S4C, the Welsh language TV channel, has total viewing figures of 900,000, which shows that there are many in England who watch Welsh language television.

There are many ethnic minorities living in the UK who are not identified by racial or other groups. I used the Welsh as a specific example whose needs must not be overlooked, but the same applies to those from eastern European backgrounds and so forth. Only today I heard from a psychiatrist of a patient whose language is French. He was looking for a psychiatrist sufficiently fluent in French to speak to the patient. Despite not being a psychiatrist, I volunteered to help out as my knowledge of the French language is not too bad.

So whenever there is a consideration of communication with those with psychiatric needs who are traumatised by life events or otherwise disturbed secondary to systemic illness, care must be culturally sensitive. It is as if a louvred window can open when empathy is expressed in the patient's own language, recognising the culture with which they are familiar. Thus communication can come through to those in need.

The report makes some important recommendations which could potentially improve the care of all patients and raise the quality of care right across the board. I hope that the Department of Health will take them very seriously because we could see improvements in care for all, not only for those in the black and ethnic minority communities specifically identified in the report.

8 p.m.

Lord Alderdice: My Lords, I am grateful to the noble Lord, Lord Chan, for introducing the debate. He does not need to apologise for his remarkable success in achieving it.

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I might be thought to have a particular interest in this subject, both as a psychiatrist and as an Irishman, because on a number of occasions in the report my ethnic minority is mentioned as having difficulties in this area, particularly in regard to suicide and the diagnosis of alcoholism.

In my part of the world, the whole notion of people being discriminated against is more often regarded as sectarianism, whereas both here and in the United States it is regarded more often as racism. It is an issue that has been of substantial interest to me for a long time. It is not easy to deal with. Whether in terms of mental health or outside of it, this is an extremely difficult issue.

The report is valuable because, for the first time, it sets out the enormity of the problem in a particular way, although other reports through the 1990s and at the start of 2000 identified some quite striking matters. For example, they identified that African-Caribbean citizens were six times more likely to be diagnosed with a schizophrenic illness; that they were more likely to have ECT and physical treatments, as the noble Lord, Lord Chan, said; and that they were much more likely, as the Royal College stated in its submission to the Health Select Committee, to be admitted and detained against their will.

These are striking matters and cannot be ignored. But when one becomes convinced that there is a problem—as any reading of the report and its predecessors would demonstrate—what precisely does one do about it? The first thing to do is to consider the problem. So the first question I would ask the Minister is what arrangements have been made for this report to be distributed to enable wide consultation? Reports such as this benefit a great deal from being circulated to all health and social service trusts and to a wide range of responsible individuals and groups, who can then respond to it. So what has happened so far with the report? One would expect something of this kind to have happened.

Dealing with the problem will be difficult. In the United States and my own part of the world—where we have tried to deal with these matters over quite a long period of time—we have set down many of the kinds of procedures identified in the report. For example, the compiling of figures requires the identification of those involved. As the noble Lord, Lord Chan, said, the fact that there is no identification of ethnic background on death certificates makes it difficult for anyone to carry out research on suicide figures. There are many other ways in which it would be possible to carry out research work if there was an identification of ethnic background.

People are very often wary of doing this. In my own part of the world it was very worrying when it was suggested that one's religious background should be noted down. People thought that that would only emphasise differences. We have to strike a balance and, on balance, I and my colleagues have felt over the years that it is important to have such identification. It is not without its dangers but it is very difficult to get figures if it is not done. The idea is put forward in the

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report that it should be on death certificates and, by analogy, in many other areas, for instance, on admission forms and so on. It would be extremely valuable if ethnic background were noted down— not only for research into the size of the problem but for ongoing monitoring to ascertain whether there have been any better or worse developments.

However, I cannot respond to the report as though it is the answer to all the problems. I know that the authors of the report do not suggest that it is, but I should like to point out one or two matters that need to be considered along with the report. It is stated that most of the reforms have rarely been implemented and that not much research has been carried out previously. That is only partly true. Some of the recommendations have been implemented, particularly on the wider issues not only of mental health but of racism and sectarianism.

One of the worries is that after 30 or 40 years we still have in the United States of America and in my part of the world many of the same underlying difficulties. Even when you have improved the figures, you have not necessarily changed the feelings people have inside. That is a real problem. In the United States it has now reached the point where approximately half the population believe that the problem of racism has been sorted out when of course it is manifestly clear that it has not been. Even among those who believe that it has not been resolved there is something of an impasse. There are those who one might describe as anti-racists, who take the view expressed in the document that anti-discriminatory practice will follow from ensuring the eradication of discriminatory attitudes. However, there are others, who one might describe as pragmatists, who believe that the way to deal with the problem is to ensure that there are anti-discriminatory practices and that changes in attitude will then flow from that.

The difficulty in the United States is that these two groups of people, who are both concerned to deal with the racism that manifestly still exists, have got into a stand-off with each other. It would be a serious mistake if we started arguing about which of these attitudes should come first. On its own, simply trying to change people's attitudes may not bring the results we want.

There is a suggestion that board members and so on should go on courses. That is all very well, but we have an old saying at home that "a man convinced against his will is of the same opinion still". People can go through all kinds of educative training methods, but they will still feel the same inside.

So what might change people's attitudes? It is quite clear from a practical point of view that people from ethnic backgrounds, particularly African-Caribbean backgrounds, are six times more likely to be diagnosed as suffering from schizophrenic illness. In the past, some people said, "That is because we know that when people are taken out of their normal culture there is a much greater likelihood that they will break down in psychotic illness". That was all very well 15, 20 or 30 years ago, but the vast majority of these people are

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second and third generation—they are not out of their cultural environment, they are in it. This is their home. That explanation clearly does not work.

So what is the reason? Is it the expression of religious faith, as the noble Baroness suggested, of culture or background or ways of relating? Or is it simply a misunderstanding of language? Are these the reasons for people being misdiagnosed? Or is it the case that the diagnosis is correct—in which case one would expect to see appropriate treatment leading to rapid remissions? But have we done the research to know that? Are we following these matters up? The truth is that we do not know for sure. Before we assume that a sixfold increase in diagnosis is only about racism it might be worthwhile for my psychiatric colleagues and others to look at the issue more closely and to recognise that it is not good psychiatric practice to get it wrong in terms of diagnosis and treatment.

It is fortunate that within the psychiatric community there is a substantial body of people from different ethnic minorities. Indeed, the Royal College of Psychiatrists is not restricted to England, England and Wales or even these islands, but has many members throughout the world who could be collaborating in these kinds of studies. But research takes money, resource and encouragement from government. I should like to feel that even today we might have an indication from the Government that they regard the issue as so important and they regard mental health as so important that they not only give encouragement, as asked for in the report, but provide resources for the research, which, as is pointed out in the report, is at the moment inadequate.

All of us could say much more about this subject, but for the moment it is perhaps enough to say that it is important that the debate is pursued by this report going around the country. Perhaps in another few months the noble Lord, Lord Chan, might feel free to come back so that we might see something of the reporting back from those consultations.

8.9 p.m.

Earl Howe: My Lords, I understand why the noble Lord, Lord Chan, should wish to table this Question before the summer recess, since it provides us with a timely opportunity to debate these complex and important issues. I say "timely", not only because we now have a new cohort of Ministers in place in the Department of Health who are, doubtless, eager to hang upon our every word, but because the implementation framework for Inside, Outside is something that will be uppermost in all their minds very soon.

It is excellent to be able to welcome back to our debates the noble Lord, Lord Alderdice, who has such first-hand knowledge and experience of mental health matters. The noble Baroness, Lady Howells is also an indispensable participant in any debate that touches on ethnic minorities. I listened to both, as I did to Lord Chan, with great attention, and agree very much with what they said.

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A charge of institutional racism against clinicians and mental health workers is an extremely serious one. If there is one thing that I hope Inside, Outside is able to do before any implementation framework is even discussed, it is to make people sit up and question their own behaviour. Of course, the racism we are dealing with is usually not an arrestable offence of a kind that overtly infringes the Race Relations Act. But if there is discrimination in the delivery of care, whether conscious or not, against patients of particular ethnic backgrounds, the charge of racism unfortunately sticks. I find this disturbing enough to ask the Minister whether the Government have considered a public inquiry. We are into that territory. The report suggests that the problems experienced by minority ethnic groups, in terms of both patient experience and health outcomes, may actually be getting worse. But even if that is an overly pessimistic perception, that kind of racism, as MIND has pointed out, is difficult to eradicate. That is why the remedial measures proposed in the report focus on what have to be seen as longer term strategies. Cultural awareness training, entrenching quality standards and involvement of consumers in the delivery of services—all are sensible ideas but require sustained commitment and resources.

Whenever we debate mental illness, we refer to the stigma that accompanies it. I think that gradually it is becoming less stigmatised. Indeed, a survey published by the Department of Health only last Friday contained, for me, some encouraging statistics about public attitudes. The vast majority of people, nearly 90 per cent, have a caring and sympathetic view of mental illness; and about three-quarters of respondents thought it should be treated as an illness like any other. Those results send out a rather different flavoured message than the one of institutional racism contained in Inside, Outside. The two messages do not contradict or nullify one another. They simply point up valid but contrasting truths from different perspectives. What really matter are the perceptions of service users, and here the data are more worrying.

The noble Baroness, Lady Howells, referred to the recent work by the Sainsbury Centre which focused on what it terms "the circles of fear" surrounding service users. That is not so much referring to fear about this or that kind of treatment. It is the fear that by merely engaging with mental health services it will ultimately cost the patients their lives. They see before them a system that appears coercive and inhumane. They associate it automatically with that other system characterised by compulsion and control, namely, the criminal justice system. Black people are therefore deterred from accessing services. They have little confidence in the care pathways that are on offer and there is therefore no incentive for the relevant communities to become actively engaged with the design or delivery of those services. It is truly a vicious circle, which is why I say again that none of us should underestimate the difficulty of the problems that have been identified.

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Those difficulties are compounded by the perceptions surrounding the Government's Mental Health Bill, published last year. The debate on the Bill—rightly or wrongly—concentrated on the potential dangers that psychiatric patients posed, rather than on the far more important issue of appropriate treatment for all patients. We need to shift the debate away from the rare incidents of violence that all too easily tend to stigmatise anyone with a mental health problem.

Even if those problems can be tackled effectively and we begin to move away from those perceptions—I am sure that it is possible to try—there are other hurdles that stand in the way of timely and effective interventions for ethnic minorities. Many have been mentioned, not least by the noble Lord, Lord Chan. Many GPs lack the training to identify psychiatric disorders. There is often a language barrier. The significance of a patient's ethnic and social background is sometimes overlooked. There are shortages of trained staff, especially in London, as identified by the King's Fund in its report last year.

It is the resource issue that many of us regard as central to the forthcoming implementation strategy. If I were being critical of the Government's performance in this area of healthcare, I would say that it is now six years since they promised as a manifesto commitment to treat mental health as a priority. Yet, in many crucial respects, they have not delivered. The experience and opinions of 27 mental health trusts, recently garnered by my party, reflect real concerns about the Government's engagement in the area and about the future.

To be sure, some new funding is flowing in, but many trusts feel constrained by national service frameworks to spend money on developing new services while baseline services are pared back. In some trusts, there are large inherited deficits, and the books can be balanced only by maintaining vacancies deliberately. That is not a healthy climate for progress in service delivery, either for patients or for those looking after them. A good number of trusts depend heavily on agency staff—again, not exactly a marker of stability—while many others have not yet employed any primary care mental health workers, which is a key requirement under the NHS Plan.

It is good to see that assertive outreach teams are gradually becoming established, although that is not by any means universal, and the majority do not have 24-hour cover. Early intervention teams—another key target in the NHS Plan—are still a rarity, largely, it seems, because of funding constraints. The same applies to crisis resolution teams. If we are in that situation today, what hope is there for making a reality of the kinds of resource-intensive initiatives recommended in Inside, Outside? With that in mind, it would be helpful if the Minister could say why there is no indicator in the mental health trust performance indicators to measure a trust's ability to deal with the needs and health outcomes of patients from ethnic minority communities.

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A year ago the Department of Health published a survey of ethnic minority psychiatric illness rates carried out by the National Centre for Social Research and University College, London. It was, I think, the first time that any sort of detailed analysis had been done of the mental health of ethnic minority groups and how it compared with that of the white population. The key finding—I found it surprising—was that, contrary to what is commonly perceived and despite their over-representation in the mental health system, black Caribbeans do not have significantly higher rates of psychotic illness, including schizophrenia, than other population groups.

One can take that result in isolation and, perhaps, question it, but if one then looks at that finding in tandem with the results of a recent study by King's College, London, one sees an even more interesting picture. King's found that, although rates of schizophrenia were up to twice as high among British Afro-Caribbeans as in the rest of the population, they were also markedly higher than the rates among blacks living in Trinidad and Barbados. What that suggests, as the study points out, is that the reasons for the high incidence of illness among British black people are social, not genetic. Unemployment and separation from both parents are frequent common markers. If the roots of much mental illness lie in social disadvantage, rather than elsewhere, there are obvious major implications for other areas of government policy-making.

Modern society is often alienating and fragmented, which is why we all agree that governments have a duty to shape health services to support those who are most vulnerable. The way they do that is, in many respects, a measure of how civilised society is or aspires to be. Tonight's debate has shown that we still have a considerable hill to climb.

8.20 p.m.

Lord Warner: My Lords, I thank the noble Lord, Lord Chan, for his support on the issue and on maintaining its high profile. He need not apologise, certainly to me, for any sense of impatience he may feel he is exuding. We welcome continuing attention to this area and his concerns are totally justified by the history in this area.

I am also grateful for the thoughtful contributions from all noble Lords. I assure the noble Earl, Lord Howe, that I am hanging on everyone's words. I want to spend most of my time outlining how we shall be taking forward the ideas in Inside, Outside. Where I do not have time adequately to cover all the detailed points raised I promise to write to noble Lords.

I share my noble friend Lady Howells's concerns that we want implementation, not just more fact finding—as do the communities affected. The ministerial foreword recognises that we have to tackle racism in institutional discrimination in this area. The points made by the noble Earl, Lord Howe, and the noble Lord, Lord Alderdice, are well taken. I am not sure that a public inquiry, which the noble Earl,

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Lord Howe, mentioned, would be the right approach as it could delay pushing on with the changes we want to make, which I will outline.

I do not have time to go into the wider mental health issues raised by the noble Earl, Lord Howe. It is fair to say that we tried to give some information about progress in answer to a Question in this area last week and I am happy to write further to him and other participants with details of progress in the area. I do not think money is the issue in making progress in many of the areas. The noble Earl acknowledged that the assertive outreach teams were progressing well. There is also a human resource issue. It is not just about money, but finding the right people with the right skills and attitudes in the right places to work in the area.

The content of Inside, Outside is not new, but for the first time the inequalities faced by these groups in mental health services have been put across in a powerful manner. It is worth quoting briefly from the report:


    "There does not appear to be a single area of mental health care in this country in which black and minority ethnic groups fare as well, or better than, the majority white community"—

That is a damning statement. The report continues:


    "Both in terms of service experience and the outcome of service interventions, they fare much worse than people from the ethnic majority do".

That state of affairs cannot continue. The Government acknowledge that inequality and we are committed to taking action to improve the situation.

The noble Lord, Lord Alderdice, asked about dissemination. There was a ministerial launch of the report in March. Considerable media coverage was attracted, and the report is freely available on the Internet and from the department in hard copy.

Inside, Outside only sets out on paper the harsh reality faced by many black and minority ethnic people today: unacceptable numbers of young black men being detained under the Mental Health Act; higher rates of suicide by women of South Asian and Irish origin; and delays in accessing services and higher readmission rates by most groups. Inside, Outside only gives additional weight to the testimony given by the families, carers and friends of service users of their needs.

I turn to what the department is going to do. Inside, Outside advocates a way forward by reducing and eliminating ethnic inequalities in mental health service experience and outcome, by developing cultural capability within the workforce and by capacity-building within communities.

The Department of Health and the Modernisation Agency, with the National Institute of Mental Health in England, will be carrying out a wide range of activities to ensure that those recommendations take place. First, we will reduce the current ethnic inequalities in mental health services and outcome by a variety of methods. The story of people from minority ethnic groups contacting mental health services reported in Inside, Outside is unsatisfactory. To rectify this, the national institute will develop what we are

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calling a pathways to recovery model to identify critical paths in mental healthcare. The model will seek to construct a more positive pathway for people in distress by offering an earlier and wider choice of treatment and helping to reduce distress. The national institute will be working with partners with the objective of creating a better pathway into and out of mental health services. This is an initiative long asked for by the communities themselves.

We will also promulgate examples of effective practice, such as the innovative work of Antenna Outreach in Tottenham. Antenna provides a range of innovative services—home tuition, developing work placements, developing sports programmes and community involvement. These initiatives help with early intervention and improve outcomes.

Secondly, we will develop the capabilities of the mental health workforce in providing appropriate and effective services for a multicultural population. The National Institute of Mental Health in England will be developing a cultural capability framework for services, and this will involve developing a set of indicators for cultural competence, a curriculum on cultural competence for NHS staff, and developing and nurturing leadership in the field of cultural competence. The noble Lord, Lord Chan, is quite right to emphasise the importance of leadership in this area. This will enable services to deliver a more person-centred approach that fits people's cultural and linguistic background, to which many noble Lords referred.

We will also help local services. Albert Persaud of the national institute, in collaboration with local communities, has been leading on development of How are you feeling booklets aimed at the early detection of emotional distress in mothers. The booklets were developed in collaboration with local women in Sheffield and local minority ethnic organisations, and have already been greatly welcomed.

We are also seeking international collaboration on development of multicultural values in mental health. The national institute is supporting a meeting of the Values in Psychiatric Diagnosis Research Methods Working Group later this month. Eminent researchers from the UK, USA, Spain, Israel and Italy will be looking at how to include culture in models of interdisciplinary team working.

Thirdly, Inside, Outside identifies the important role of the voluntary sector in this field. We recognise that to ensure any significant change in mental health services, we will have to work better with communities and voluntary organisations. These are the areas my noble friend Lady Howells outlined so eloquently. We will actively work across government departments to ensure greater collaboration in ensuring local communities and voluntary organisations are involved with local mental health services. This is an area where, if we are honest, government departments have not always hit the highest spot in terms of performance.

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The national institute will also be hiring a fellow to work with the black and minority ethnic voluntary sector to help ensure that effective action takes place. We have already ensured that one of the key recommendations of Inside, Outside, the community development worker, will be introduced. The requirement of having 500 workers by 2006 was made a target in the current NHS priorities and planning framework. These are a new cadre of worker designed to improve access to mental health services and provide greater linkages between the statutory and community sectors.

Turning briefly to the department, these changes will take place and we will seek to modernise the services. The action plan will be in the shape of actions needed to be taken by health and social care services to combat the inequalities faced by service users.

We have consulted with the black, south Asian, Chinese and Irish communities across England over the past few months about what communities want and what they thought of the recommendations of Inside, Outside. In total, 12 community consultations were carried out, using community languages. They provided evidence of people's experience, their advice and the proposed impact of the recommendations of Inside, Outside. We will make public the findings from these consultations and they will be fed into the action plan work we are doing.

The National Institute of Mental Health for England, which is part of the Modernisation Agency in its role as the implementation arm of the department's mental health policy, will help trusts to implement the action plan being developed. But we are not waiting for the action plan to be issued.

Changes have already begun. Apart from the initiatives already outlined, the national institute will have a specific work programme on ethnicity and mental health. The chief executive will personally co-chair a national steering group with the noble Lord, Lord Adebowale, to help ensure close working with mental health services and effective change. The steering group will oversee the action plan implementation.

I can announce today that the national institute has appointed Professor Kamlesh Patel as the national strategic director of its black and minority ethnic programme. Professor Patel will provide overall leadership of the programme. Professor Patel is with the national institute in an acting capacity. In due course the post will be advertised nationally. Professor Patel is currently chairman of the Mental Health Act Commission and head of the Centre for Ethnicity and Health at the University of Central Lancashire. He has an established track record as both a practitioner and an academic in the fields of mental health and substance misuse. He is well qualified to undertake this important task.

The national institute's programme will push forward work on research and development, training, workforce development and service development. It will be done in a culturally sensitive way, as the noble

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Lord, Lord Chan, seeks. It will also promote black and minority ethnic leadership in conjunction with the leadership centre in the Modernisation Agency.

The institute will continue to work with community groups, professional organisations and voluntary organisations to bring about change on how black and minority ethnic mental health services are delivered.

The Inside, Outside report recognises that mental health services are going through a period of significant change. We need to harness this change to ensure the best outcome for black and minority ethnic service users. To deliver the principal objectives of Inside, Outside, immediate work is now starting. There are no quick fixes, but I hope that I have communicated to noble Lords that we are trying to give some impetus for this.

In conclusion, I pay tribute to and thank Professor Sashidharan and his colleagues for their work in producing Inside, Outside.


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