I am grateful for the opportunity to debate this important subject. I became involved in it due to the tragic death of a constituent who was a patient in the Norvic secure unit in Norwich. I should like to acknowledge the work of my hon. Friend Dr. Gibson in pursuing the case and the issues it raises.
David Bennett—"Rocky" as he was known to his friends and family—was certified dead in the early hours of
David's sister, Dr. Joanna Bennett—a lecturer in mental health—her legal representatives from the organisation Inquest, my hon. Friend and I have had a series of meetings with Ministers and officials at the Department of Health in the past three years, the most recent of which was held this September.
We have consistently stressed the need for a public inquiry as the most appropriate means to investigate all the circumstances of David's death in a way that will highlight the more general issues and the occurrence of similar cases in the mental health services.
The Minister was generous with her time and listened sympathetically. In her subsequent letter, she confirmed a number of the steps that the Department will take, offering Dr. Bennett considerable input into an inquiry, which will have a broad remit but will not be a full public inquiry. Only parts of the inquiry will be public, over which the chairman will have discretion.
Although grateful for such progress as has been made, David's family, through their representatives, have expressed a number of reservations about those proposals, especially about which issues will be heard in public. They naturally think, as I do, that racism should be one of them, as should be the use of control and restraint. There are other concerns about the membership of the inquiry panel; how the results of the inquiry will be made public; and how they will be fed into future policy and practice.
Dr. Bennett has also stated her concern that the black and minority ethnic mental health strategy lacks definition, especially in its use of terms such as "culturally appropriate non-drug therapy" or "culturally sensitive". Such terms are hard to put into practice and do not therefore lead to real changes for service users. The strategy group has not adequately consulted black service users, providers and families, and so may be unsupported by key stakeholders.
An inquest into David's death was finally held in May this year, and it returned a verdict of accidental death, aggravated by neglect. The coroner, William Armstrong—a specialist in mental health—took great pains to ensure that the circumstances surrounding David's death were explored in depth and made public a number of recommendations that he felt the whole NHS should take on board.
Of particular relevance to this debate is the fact that he stated that many NHS trusts do not take racism seriously and that all trusts should have a written and active policy on dealing with racial abuse, which the Norwich trust has now addressed.
It has been established that David was racially abused by other patients on several occasions before the incident that caused his death—there was no indication of that being addressed by staff—and that he wrote a letter to the ward manager suggesting that more black staff should be employed at the clinic, as there was a significant number of black patients. He complained to the family that he felt he was being treated unfairly because he was black, and he told staff that he felt white people were treated better.
The trust's internal inquiry identified a case in which a member of staff had racially abused another patient, and an incident of racial abuse against Rocky by another patient started the chain of events that resulted in his death.
William Armstrong said:
"There seemed to have been a feeling that here was a man who was big, black and dangerous, would always be big, black and dangerous and would not respond to medication."
As he also noted, David had the advantage of a family who were very caring and well informed about mental health issues.
The recommendations following the inquest reflect many of those following previous inquests and inquiries. For example, 10 years ago, following the inquiry into the deaths of three other black men at Broadmoor hospital, similar recommendations regarding medication, the use of restraint and racism were made.
The organisation Inquest has drawn national and international attention to the disproportionate number of deaths of black people in custody following the use of force or gross medical neglect. Following deaths in police and prison custody, there have been detailed coroners' recommendations on the use of restraint and the dangers of positional asphyxia, yet prone restraint continues to be used in other settings, including psychiatric settings, without regard to the potential dangers.
In February, the report of the ethnic issues project group in the Royal College of Psychiatrists, which it kindly sent to me, stated:
"African-Caribbean individuals are over-represented among admissions to psychiatric hospitals, especially as compulsorily detained patients. Various reports have shown that"— such patients—
"on the whole receive a more coercive spectrum of care. Among offender patients, African-Caribbean men were 26 times more likely than white men to be detained on criminal sections."
It also cites research that suggests that psychiatrists tend to overpredict dangerousness in black people, and that such bias leads to a more restrictive outcome.
I am grateful to MIND for the information in a 1997 study called "The Black Experience of Detention under the Civil Sections of the Mental Health Act". It shows that more than 75 per cent. of professionals from all agencies interviewed felt that black clients were more likely than white clients to be perceived as dangerous, and black patients were twice as likely as white patients to be detained on a longer section 3 order. White patients were more likely to be on the shorter section 2 orders.
The research also showed that 85 per cent. of black people were being given medication, compared with 72 per cent. of the white group; 61 per cent. of the black group were being given at least two types of drug, compared with 39 per cent. of the white group; and 35 per cent. of the black group were in receipt of three types of drug, while that was true for 22 per cent. of the white group.
I understand that evidence of racial inequality in mental health services has been available for 20 or even 30 years. All this together shows that black people are more likely than whites to be removed by the police to a place of safety under section 136 of the Mental Health Act 1983; retained in hospital under sections 2,3 and 4 of the Act; diagnosed as suffering from schizophrenia or another form of psychotic illness; detained in locked wards of psychiatric hospitals; and given higher doses of medication.
The research also shows that black people are less likely than white people to receive appropriate and acceptable diagnosis of, or treatment for, possible mental illness at an early stage, and to receive treatments such as psychotherapy or counselling.
There is no legal requirement to report sudden deaths in custody to a central body, but I am told that in the past 10 years there have been at least 12 cases of black people with diagnosed mental health problems who have died in this tragic way—12 lives lost which, with more appropriate treatment in the widest sense, might have been saved.
Last year the Health Committee report on the provision of mental health services made the following recommendations. The Department of Health's requirement that all NHS trust boards should undertake training on management of diversity should be expanded, so that all front-line NHS staff receive training on race awareness. All educational bodies providing pre- qualification training to health professionals should be required to include training on cultural and racial issues as part of their curriculum. All NHS trusts should designate a board member to take the lead on issues of race and culture within their trust and to ensure that active policies are in place to champion the needs of the ethnic minority groups in their areas. The Department of Health should ensure that trusts have access to a comprehensive network of interpreting services, if necessary providing grants to the voluntary sector to enable the services to be developed. Priority should be given to early intervention services, such as providing easy access to counselling.
The Health Committee believes that it is crucial that users and carers are involved in all aspects of service delivery, and that user involvement in setting the outcomes that services aim to achieve should be central to service planning. As that would be a new way of working for many professionals, the Committee recommends that both pre-and post-qualification training of all health and social care professionals should include structured input from users as part of the national programme.
All mental health service providers need to acknowledge the importance of social factors, including race. They need to understand how what MIND calls "mental distress" is differently experienced and expressed in different cultures, and that prevailing white, western concepts are not always appropriate to understanding the behaviour of patients.
I was glad to read that the Royal College of Psychiatrists is undertaking an independent review of race equality issues, to identify and tackle institutional racism in its structures, policies and procedures. Indeed, I note that it is the first medical royal college to do so. The report to which I referred states that
"all patients have the right to equal access to services, that is, services must be equivalent not necessarily the same" since the needs of a diverse population are likely to be equally diverse.
A national expert on ethnicity and mental health, Professor Sashidharan of Birmingham university, has consistently demonstrated the need to tackle inequalities in mental health services. In his paper on institutional racism in British psychiatry, he says that
"despite efforts . . . to provide ethnically sensitive . . . services, the overall experiences . . . by black and south Asian people remain largely negative."
He suggests that the practical emphasis placed on improving services has distracted attention from the more fundamental task of addressing racism within mental health services. To achieve real change, we need to understand how the procedures and practices of those services affect black people's experiences of mental health care and the outcomes of treatment; therefore we must closely examine the experience of which David Bennett provides a tragic example.
I am aware that I am skating over many topics that require detailed consideration, but time is short, so today I have focused on the extent and the seriousness of the problems that policy makers and practitioners must resolve if they are to end the pernicious effects of racism in mental health policy and practice. It is because those problems are so pervasive and so serious that the Bennett family and those of us who have worked with them continue to say that a full public inquiry is the best way in which to collect and examine the evidence and arrive at proper evidence-based recommendations for future policy and practice, which can then be implemented nationwide.
I congratulate my hon. Friend Mrs. Clark on securing a debate on this important subject. The Government have made public their commitment to delivering a health service that is truly inclusive, available to everyone on the basis of need and without prejudice, and delivered in a way that is not only accessible to everyone but is appropriate to the communities that it serves.
To provide such a service, the NHS has to understand the obstacles facing ethnic groups in Britain today. As well as racism and racial harassment, those obstacles include institutional discrimination that arises not necessarily from malice, but from ignorance and a lack of understanding between people from different backgrounds and cultures. To deliver the service that we all want and that our communities deserve, we need both to tackle racism and to ensure that the NHS develops services that recognise cultural differences and are of a high standard for all people.
My hon. Friend raises the specific issue of the untimely death of David Bennett, which has rightly focused attention on the wider issue of the experience of people from black and ethnic minorities who have mental health problems. First, I take the opportunity to express in public my sincere sympathies to the family of David Bennett, as I have already done in private. I have met David Bennett's sister, Dr. Joanna Bennett, and have been impressed by her commitment to ensuring that lessons are learned from this tragic event and that they are translated into real change in mental health services.
My hon. Friend has called for a public inquiry into the death of David Bennett. I hope that the action that I shall outline in relation to this case and in the wider development of our mental health policies will persuade her that I share her and the Bennett family's commitment to improving mental health services for black people. As I have already explained, I am not convinced that holding a public inquiry is the best way to achieve changes and improvements.
I have already proposed a range of actions that will lead to a full investigation of the circumstances surrounding David Bennett's death; address the issues raised in the coroner's inquest; tackle wider issues of concern regarding the care and treatment of people from black and minority ethnic backgrounds in mental health services; and provide an appropriate platform and gravitas for this important issue.
These measures include the health authority undertaking a local independent inquiry, with Department of Health officials working with the authority to ensure that the inquiry's remit addresses concerns that the family has raised, that there is full access to the inquiry by family members and others, including decisions as to the membership of the inquiry panel, and that the findings are made public.
Furthermore, I have given a commitment to write to ministerial colleagues in other Departments to ask them for their support in considering the specific issues raised by my hon. Friend again today concerning restraint of people with mental ill health. I am commissioning research to address issues of supporting and informing families through traumatic events such as those experienced by the Bennett family, and ensuring that the lessons learned from this inquiry, and other similar inquiries, are taken fully into account in the developing of a mental health strategy for black and minority ethnic groups.
As my hon. Friend has ably outlined, there have been specific concerns for some time about the care and treatment of people from black and minority ethnic groups with mental health problems. I accept that there is still much to be done. However, there is much that we have already done to start tackling these serious issues.
The report of the Select Committee on Health on mental health services raised important issues involving challenging institutional discrimination in the area of mental health. In the Government's response, we acknowledged that challenging institutional discrimination is the responsibility of those who lead and deliver mental health services, as in all other areas of public service. In its report earlier this year, the mental health work force action team highlighted the need for the work force to represent the ethnic diversity of the community that it serves. We are committed to supporting the NHS locally to deliver this diverse work force, and to address some of the important training and education issues that my hon. Friend raised.
Through NHS Direct, we have begun taking action to overcome some of the language barriers to which my hon. Friend referred. NHS Direct sites are now engaging with their local black and minority ethnic communities to scope out their needs, promote NHS Direct and raise awareness of the service to the local community. Sites have systems in place to ensure access to advice and information in languages other than English. Currently, help is available in more than 30 languages.
As my hon. Friend rightly said, professional bodies need to be active in tackling racism and discrimination. I welcome the fact that the Royal College of Psychiatrists, for example, has set up a committee to examine ethnic minority issues and stated that it will make training in cultural competence, including racial sensitivity, mandatory for psychiatrists. It has initiated an internal audit to examine its policy and practice on ethnicity. However, as my hon. Friend also rightly said, more needs to be done.
We are pleased to be making progress, but we are not by any means complacent. The mental health taskforce, set up to drive forward the NHS plan and the national service framework for mental health, has been given a specific remit to consider the mental health needs of black and ethnic minority service users. Taskforce member Professor Sashidharan, rightly referred to by my hon. Friend as a leading expert on ethnicity and mental health, who is also the medical director of North Birmingham mental health trust, is leading the development of a strategy that will address head on many issues of concern surrounding the provision of mental health services to people from black and minority ethnic groups.
I take very seriously the points made by Dr. Joanna Bennett and by my hon. Friend. Both the timing and the way in which we engage users in the development of our strategy will be absolutely crucial in ensuring that it makes the difference in practice that we intend. A strategy is no good on its own unless it affects service and the treatment that people from black and minority ethnic groups receive in the mental health system.
Many of the services that Professor Sashidharan pioneered are now part of the improvements that we have set out in the NHS plan and the national service framework for mental health services. It is very important that, as we improve our mental health services—which is clearly very necessary—we bear in mind the range of services available. Among other initiatives, early intervention, crisis resolution and assertive outreach services are to be made readily available in all parts of the country.
My hon. Friend rightly said that a range of high-quality services must be in place to respond to the different needs of different individuals, and black and minority ethnic communities in particular. I agree with her analysis that the provision of a uniform service is not necessarily the best way of responding to the varying needs of people from different communities. We need to ensure that the views and needs of minority ethnic users are at the centre of our service development.
To take one example, Professor Sashidharan has shown that black people are far more likely to seek help if they can have access 24 hours a day, seven days a week, to crisis resolution teams. The teams respond immediately and whenever possible treat people at home. Such a service is much preferred by many service users, but is particularly welcomed by black people, whose experience of hospital care has often been negative.
I have also asked the new National Institute for Mental Health to examine the issues of ethnicity and mental health as one of its first priorities. It will be developing a specific work programme on black and ethnic minority mental health, with a remit to include communications with black and ethnic minority groups and interests; the development of targeted programmes such as those on cultural competencies, outcomes and research; and the involvement of black and ethnic minority groups in the development of the institute. I am aware that words are not enough to improve the services for users, and that we need a vehicle to implement change and ensure that that becomes a reality in the services offered by the NHS. The National Institute for Mental Health will ensure that the recommendations from the strategy will be given substance and taken forward.
The consultation document for the black and minority ethnic strategy will be issued next spring, and the final strategy will be published later next year. I am confident that the strategy will be a major step forward. It will provide a coherent and clear direction for mental health services and highlight the key issues that mental health services must address to tackle inequality and injustice. The problems experienced by black and minority service users in mental health cannot be put right overnight, but I believe that our actions already speak louder than words. The actions we have already taken, and those that we plan to take, show the priority that we have rightly given to tackling racial discrimination.
The Race Relations (Amendment) Act 2000 will help to ensure that public services, including the NHS, promote racial equality across the board. It will demand that all public sector bodies implement and audit race equality strategies, and that any major proposal to change service provision is assessed for its impact on black and ethnic minority service users. We have already taken action from the centre to ensure that all parts of the NHS recognise the significance of the racial equality agenda that is at the centre of the NHS plan. The plan sets out our vision for health services and our commitment to ensuring that, both as an employer and as a provider of services, the NHS works to eliminate discrimination and promotes equality across all parts of society.
We have moved from years of neglect by giving mental health a firm footing in the NHS plan and the national service framework. For the first time ever, we have a broad vision that is acceptable to and supported by service users. Now we must target areas of concern, which is why we have instigated the first ever national black and minority ethnic mental health strategy.
We have a particular duty in mental health to ensure that when people are ill and at their most vulnerable, they receive services that are respectful and address the diversity of their needs. To achieve that, we must acknowledge and understand those needs. Racism cannot be tolerated, and neither can ignorance. I will do my utmost, as will the Government, to ensure that these changes transform the experience of all those who use mental health services, across every community in the country. Everyone deserves the best that the NHS has to offer, and we are committed to ensuring the widest possible access to the best possible services for all our communities.
Question put and agreed to.
Adjourned accordingly at two minutes to Three o'clock.