Turning a Blind Eye: the invisibility of race and ethnicity in Scottish Mental Health.

Authors: (originally written in July 2019) Professor S P Sashidharan; Hon. Consultant Psychiatrist; Hon. Professor, Institute of Health & Wellbeing, University of Glasgow. Mr Shabir Banday; Director, REACH Community Health Project (SCIO); Honorary Research Fellow, Institute of Health & Wellbeing, University of Glasgow. (At present, CEO Banday & Mackenzie Consultants) Dr Moira Connelly; Interim Medical Director Mental Welfare Commission for Scotland. Dr Arun Chopra; Consultant Psychiatrist, Royal Edinburgh Hospital Commission Consultant Psychiatrist, Mental Welfare Commission for Scotland.

Situation 1. Little is known about the mental health of ethnic minority groups in Scotland, the extent of mental health problems or service usage by these communities.1,2 Mental health of minority ethnic groups is under-researched in Scotland1 despite policy and legislation commitments3,4. In contrast to England, there are no national policies or strategies on ethnic minority mental health, despite increasing ethnic diversity and double the number of people from non-white backgrounds in Scotland.5 This suggests a lack of priority and attention to minority mental health needs in Scotland.

Background 2. Much of what is known about minority mental health in UK, including ethnic variations in mental health service use, is based on English data. However, there are significant differences in the minority populations between Scotland and England.6 Research from England is largely focused on the experience of people of African, African Caribbean and South Asian (mainly Indian) origin with some work on the Irish. The biggest minority ethnic group in Scotland is of Pakistani origin.

3. Four per cent of the Scottish population is identified as non-white. The Black and Minority Ethnic (BME) population in Scotland is mainly in the cities of Glasgow, Edinburgh, Dundee and Aberdeen, with 1 in 10 Glaswegians (12%) identifying themselves as Asian, African, Caribbean or black. There are also significant numbers of people of minority ethnic background in rural Scotland, including the Highlands and Islands.

4. There are no epidemiological studies of ethnic minority mental health and no Scotland-specific data on the prevalence of mental health disorders in minority ethnic communities.7 The only systematic study of mental health service use by ethnicity in Scotland was carried out 10 years ago. This was a retrospective record linkage study of psychiatric hospital admissions and detentions under the Mental Health Act.8 This study revealed substantial ethnic disparities in hospital admissions and use of the MHA, indicative of under utilisation and delayed access to specialist mental health care by people from BME backgrounds. All minority groups were found to have an increased risk of detention under the MHA. Despite these findings (published six years ago), there has been no further research in this area. Nor has there been any attempt to evaluate the extent to which local health services (Health Boards) are addressing mental health care needs of minority ethnic groups. This neglect of BME mental health in Scotland, despite evidence of ethnic disparities in service use, is of concern.

5. Apart from the work of Bansal et al,8 there is only one study of ethnicity and use of secondary care mental health services in Scotland. This was based on the Glasgow Psychosis Clinical Information System (PsyCIS),9 a secondary care case register of people diagnosed as having a psychotic illness in Glasgow. Over a period of 42 months (2002 – 2005) in a subset of those diagnosed with schizophrenia, over 7% were from BME groups. The period prevalence of psychosis in BME groups in Glasgow was estimated to be higher than in the white population but, unlike the white group, there was no significant gradient in the illness rate in relation to socio-economic status.

6. A literature search of published research yields no studies of minority ethnic mental health in primary care in Scotland. Similarly, there are no population-based studies of minority mental health.

Assessment

7. There have been three health surveys of black and minority ethnic populations in Scotland undertaken by Greater Glasgow and Clyde NHS. The first set of surveys was carried out twenty years ago.10,11 These were interlinked surveys (using different methodologies) of the Chinese community and Pakistani, Indian, African and Caribbean communities (PIAC surveys, as they were called). The findings were compared with a separate survey of the general population (again, using a different methodology). Although the surveys focused primarily on general health, they included questions about mental/psychological wellbeing (apart from the survey of the Chinese population). In very broad terms, these surveys found that minority ethnic groups’ perceptions about their general health tended to be more positive than the general population. The PIAC surveys used GHQ-12 and, based on this measure of psychological wellbeing, 12% of Indian origin people, 16% of Pakistani origin and 20% of people of African Caribbean backgrounds were thought to experience psychological distress.12 Elevated GHQ scores were associated with reports of racism. Comparison with the general population was not possible given the differences in methodology.

8) More recently, there has been a further survey of BME health and wellbeing in Glasgow.13 This involved home interviews with 1,798 individuals over the age of 16 from the five largest ethnic minority groups in Glasgow (Polish, Indian, Pakistani, Chinese and African origin) and, like previous surveys, focused on general health and wellbeing. The only measure of mental wellbeing was based on the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS). The findings were compared with a previous health and wellbeing survey of Glasgow general population in 2014. Over 90% of the BME respondents reported positive views of their mental/emotional wellbeing and the mean WEMWBS score in BME groups was found to be slightly higher than the general population,14 consistent with the findings of the Scottish Health Survey 2008 – 2011.

9) In contrast to the paucity of research in relation to the mental health problems (and use of mental health services) in minority ethnic communities, there are several reports on community perception and attitudes towards mental health in ethnic minority communities in Scotland.15, These reports identify several community barriers to recognition of mental health problems and seeking help. Many of them used qualitative methods to explore these topics. The common themes emerging from these reports are: (i) stigma towards mental health problems is prevalent in BME communities, which may act as a barrier to help seeking16; (ii) BME communities are reluctant to seek help when experiencing psychological distress; (iii) BME communities have limited knowledge regrading mental health services; and (iv) they consider mental health services to be inappropriate or inaccessible. A preference for informal support in dealing with mental health problems amongst minority groups is also noted, along with strong reliance on self and family members in managing and alleviating mental illness. Based on these reports, community attitudes, low awareness of available services, cultural and educational barriers to accessing services, and lack of cultural sensitivity of available services may result in delays or barriers to accessing primary care and mental health services. This means that, as with other medical conditions, professional help is sought in relation to mental health problems only when informal methods prove ineffective or mental health problems worsen and result in crisis situations.17

10) Scotland is recognised as having “some of the best health service data in the world”.18 However, the range, completeness, and quality of ethnicity data available through various national data platforms is poor. This has been an ongoing problem although, recently, there has been some improvement. However, the lack of comprehensive and complete data on ethnicity is severely limiting research in relation to ethnicity and health in general in Scotland. It is a legal requirement to collect ethnicity data19 and, without good data on inequalities in health (including ethnicity), it is impossible to plan and prioritise effective action or monitor progress towards a more equal society. However, systematic, and comprehensive data on health service use by ethnicity is still not readily available.20

11) The Information Services Department (ISD) of NHS National Services Scotland hold more than 100 datasets. Healthcare data on individuals is collected as a series of Scottish Morbidity Records (SMR) and these record ethnic categorisation along with other demographic variables. The only mental health specific SMR is SMR04 (mental health inpatient and day case dataset). Currently, ethnicity data is recorded in 79% of SMR04 nationally. The data is not available by area, but it is likely that completeness of ethnicity data in SMR04 varies across health boards.21

12) Mental health information is, potentially, available in other national health datasets. These include Annual Inpatient Census, Unscheduled Care Datamart (USD) which includes data from NHS24, ambulance and out of hours GP contacts, Scottish Primary Care Information Resource (SPIRE), Community Health Activity Dataset (CHAD) for district nursing and community mental health activity, Prescribing Datamarts that include Prescribing Information System for Scotland (PRISMS) and Scottish Suicide Information Database (ScotSID) are also potential sources of national (and local) data on mental health. Currently, these data systems do not record ethnicity.

13) The Mental Welfare Commission for Scotland (MWC) has the statutory duty to monitor the use of Mental Health (Care & Treatment) (Scotland) Act 2013 and publishes monitoring reports every two years. Ethnicity data is provided by Health Boards but there have been longstanding problems in ensuring full compliance with this requirement. Currently, ethnicity information is available for only 80% of the cases,22 not dissimilar to SMR04 data. Using MWC data over a three-year period (April 2006 – March 2009), Bansal et al found a higher risk of compulsory admission among BME groups compared to the White Scottish group and the extent of ethnic inequalities increased with the duration of detention.8 There has been no attempt to monitor the MWC data and explore ethnic variation in involuntary admissions since this study.

14) The absence of reliable and comprehensive ethnic data in relation to mental health service use in Scotland is a major barrier to appropriate policy development, service planning and delivery. Although it has been a legal requirement to collect ethnic data in relation to service use since April 2011, concerns over the quality and completion of ethnicity data remain. It is unclear why there is no ethnicity data for 1 in 5 patients in SMR04 currently. The quality and reliability of ethnicity data in Scottish administrative health datasets is untested and the extent of missing/invalid ethnicity recording varies according to the NHS Health Board and dataset.20 There are no national data outputs in relation to ethnicity and mental health service use and, more worryingly, little sign that this is likely to change any time soon.

15) The paucity of data on service use/experience is matched by the absence of any specific policies or plans to improve minority ethnic mental health in Scotland. Although national mental health policies and other initiatives by the Scottish Government and the NHS invariably contain a commitment to address “any discrimination based on gender, sexual orientation, age, race and disability”, this is not reflected in any specific plan to actively monitor and tackle ethnic disparities in mental health care. For example, Scotland’s current Mental Health Strategy (2017 –2017) recognises that “inequality related to disabilities, age, sex, gender, sexual orientation, ethnicity and background can all affect mental wellbeing and incidence of mental illness” and accepts that ethnicity should not be a barrier to achieving high quality services23. However, the strategy offers no specific commitment or provision to address ethnic disparity in mental health services or understand and respond to mental health problems in minority communities. More broadly, this reflects a lack of attention to ethnic minority mental health. It is unsurprising that the current Quality Indicator Profile of mental health services (action 38 of the Mental Health Strategy) for improving service quality has no quality outcome measure related to ethnicity, despite one of the six domains of quality outcomes being the provision of an equitable service.24

16) A key recommendation by the Independent Race Equality Adviser to the Scottish Government was that the Government should commission research to identify the barriers to effective mental health care for minority ethnic groups and develop a plan to address “the unmet needs and persistent ethnic inequalities in mental health care” (Action 55).25 In the subsequent action plan,26 the Scottish Government promised to “take clear steps” to deliver their commitment to race equality. This included reducing race inequalities in mental health by ensuring that clinicians and care professionals had “access to information they need to identify risk factors and to assess performance in reducing inequalities” and “that the data collected routinely through health and care information systems is sufficient to achieve this objective for people from minority ethnic communities”. There is little evidence of any progress in relation to these plans. The BME communities in Scotland are still waiting for the Scottish government and the NHS to begin to deliver these commitments.

Recommendations a) The Scottish Government should commission research into BME mental health as outlined in Action 55 of ‘Addressing race equality in Scotland; the way forward’. This should include (i) extent and nature of mental health problems in BME communities (ii) barriers to accessing effective mental health care (iii) ethnic inequalities in mental health service experience and outcome and (iv) community wellbeing and resilience.

b) Scottish Government should carry out a national ethnicity audit of mental health services, including the use of the Mental Health (Care & Treatment) (Scotland) Act 2003.

c) Scottish Government should commission a full Race Impact Assessment of the Mental Health Strategy 2017 -2027.

d) Ethnicity should be included as a specific Quality Indicator measure under the Quality Outcome (Equitable) dimension and incorporate this into current plans for developing QI profile in mental health, as required by Action 38 of the Mental Health Strategy 2017 – 2017.

e) NHS Scotland should ensure BME status as a mandatory field in routine NHS reporting systems.

f) NHS Scotland should commission a scoping group to explore the means to improve the quality and completeness of ethnicity data across the NHS for all contacts.