Hári Sewell is founder and Director of HS Consultancy and a former executive director of health and social care in the NHS. Hári questions how much is known about the experience of out of area placements of black or other racialised people.
Balancing various clinical, professional and organisational risks is an immense challenge for mental health professionals in secondary care. The use of specialist placements away from the local area of the person being referred is usually an exemplar of this balancing act. As with all clinical and relational aspects in mental health, decisions have an uneven impact when scrutinised comparatively by ethnic or racial background.
Out of area placements introduce amongst others, another potential confounding factor in the plethora of metrics that indicate that racialised minorities (or ‘people from Black, Asian and Minority Ethnic Backgrounds’) have poorer experience within, and outcomes from mental health services in England. Given the awareness of the intersecting nature of inequalities there is surprisingly scant research evidence or data reported on this issue.
The Joint Commissioning Panel for Mental Health’s guidance for commissioners of services for people from black and minority ethnic communities published in 2014 cites earlier national guidance on out of area placement but there is little evidence of primary research.
There are some factors that can be extrapolated from what is known about some groups within the massive heterogenous umbrella of people from ‘Black, Asian and Minority Ethnic Backgrounds’ (BAME). Black groups are more likely to have diagnoses for psychosis and assessed as posing greater levels of risk. Use of forensic sections is used disproportionately for this group. Socioeconomic inequalities and poverty also affect this group disproportionately. Additionally, relationships between people from black backgrounds and mental health services are reported in many studies to be poorer, and have been widely known for since 2002 when the (formerly Sainsbury’s) Centre for Mental Health published the landmark report ‘Breaking the Circles of Fear’. It is reasonable to conclude that the relationship between out of area placements and these data hold some important pointers for further study.
The impacts of being placed out of area can be understood from the perspective of the person themselves, their loved ones and the mental health services (clinically and financially). When considering the impacts on people it is important to keep someone’s racialised identity central because the evidence is consistent; race is a critical dimension in experience and outcomes in mental health. Take the evidence that racialised minorities as a social group face economic hardship at higher levels. Being away from local social networks is likely to pose greater challenges to loved ones wishing to make visits. The consequences on people placed away from home of greater isolation and less access to things and relationships that support resilience and recovery are a potential detriment; one faced by racialised minorities disproportionately more frequently. Each individual clinical decision may stand up to scrutiny, but it is also important for systems to consider ways in which decisions operate to disadvantage particular social groups, however unintended these patterns are.
Given the evidence that relationships with black people are generally less therapeutically beneficial, mental health systems may do better by being attuned to the consequences of out of area placement on the relationships with the person themselves, and their loved ones. In a social context where disproportionately more black people: are excluded in schools, receive more custodial sentences, and taken into the mental health services via the criminal justice system, there is merit in mental health services paying attention to how its decisions repeat patterns of exclusion. The pattern is unlikely to be outside of the awareness of individuals, their loved ones and communities affected by this. When a mental health system leaves this unacknowledged and does not explicitly attempt to mitigate the effects, the argument that racial inequalities in mental health data are a result of inequalities further upstream loses validity.
There are two arguments raised here. The fact that decisions on individual care and treatment may appear legitimate does not negate the need to interrogate patterns of variation that appear as inequalities. Additionally, failure to give validity to the lived experience of people, their families and communities through explicit systemic responses to unintended consequences, is a form of discrimination, unintended though this may be. Perhaps the obvious question is how much is known about the experience of out of area placements of black or other racialised people, at the community level compared with the other groups. Having searched for such evidence and found little, it appears that the answer is that very little is known.
The publication of 'Close to Home' may serve as a call to action to researchers. It is well known that the first stage in problem-solving is understanding the problem. Right now, patterns of out of area placements in mental health may appear to be a result of passive or systemic forms of discrimination. In the absence of scrutiny of patterns, this appearance of discrimination remains unanswered. It is clearly time to establish a body of research that provides answers and informs the debate and subsequent actions.
Hári Sewell is founder and Director of HS Consultancy and is a former executive director of health and social care in the NHS. He is a writer and speaker in his specialist area of social justice, equalities and ethnicity, race and culture in mental health. Hári is honorary Senior Visiting Fellow at the University of Central Lancashire and was the co-founder of the national Social Care Strategic Network (Mental Health). Hári has had various books, articles and book chapters published, with new material emerging regularly, usually every year.
Hári Sewell is founder and Director of HS Consultancy and is a former executive director of health and social care in the NHS. He is a writer and speaker in his specialist area of social justice, equalities and ethnicity, race and culture in mental health. Hári is honorary Senior Visiting Fellow at the University of Central Lancashire and was the co-founder of the national Social Care Strategic Network (Mental Health). Hári has had various books, articles and book chapters published, with new material emerging regularly, usually ever year.
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