Dr Jacqui Dyer - Tackling race and mental health inequalities

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  • Posted:Friday 19 July 2019

In this session at the Improving health in urban communities event, Dr Jacqui Dyer MBE shared about the realities of centering the views and experiences of communities when addressing systemic challenges. 

I really don’t like speaking. I feel so shy, but I have to get over it. So, part of how I get over it, feel the anxiety in the stomach and everything, part of how I get over it is to say hello to everybody, so I can feel that you’re with me.

So, hello everybody.

Yes, okay, right, that’s really helpful. Thank you so much for your graciousness.

To introduce myself a little further and I think it’s the most important aspect of who I am, I’m actually somebody with lived experience of mental health challenges and I am carer of three siblings with severe mental illness, although my younger brother died in 2013 after twenty years on anti-psychotic medication. I still get a lump every time I think of it.

So, my driver around addressing mental health challenges within our communities and our services is very both personal and professional.

And I wanted to sort of set the context for tackling race and mental health inequalities; you can see I’m a black woman, I talk all different kinds of ways; I’ve got a Yorkshire accent. I’m not from London but I lived in London the longest part of my life and I wanted to sort of take, look at the sort of wider context of actually tackling race and mental health inequalities before going into my work within Lambeth.

So, I was involved in the Independent Mental Health Act Review and I lobbied within the context of the Mental Health Act Review for a particular focus on African and Caribbean mental health because two out of the terms of reference for the Mental Health Act Review, which was published at the end of last year; 6 December last year was, one, to tackle the rising rates of detentions under the Mental Health Act and the other was to look at the over-representation of people from black and minority ethnic communities in mental health services. And those two particular terms of reference out of the six, speak to the experience of African and Caribbean people within the UK.

So, profound inequalities exist in terms of accessing mental health treatment, our experience of care and our mental health outcomes. And often, what we know, is that there is an over-representation of these communities in crisis and secure mental health services. So, for example, people of African and Caribbean heritage are 40% more likely than their white counterparts to come into mental health services through the Criminal Justice System, rather than through primary care. Significant over-representation in locked wards, psychiatric intensive care and secure services and there are longer inpatient stays for people with this heritage. And under-representation in treatment as well as over-representation in crisis.

Research shows that Western approaches to mental health are not necessarily suitable or culturally appropriate to meet the needs of people from these communities. And people of African and Caribbean heritage are less likely to be offered psychological therapies either in the community or as NICE guidance says when they are inpatient and are experiencing severe mental illness.

Two of the recommendations that emerged that I want to pay particular attention to before I go into the presentation was to actually look at how might we tackle this in terms of recommendations from the Mental Health Act Review African and Caribbean Working Group, and two out of our many recommendations were, one, a development of a recommendation that was developed when I was on a commission for looking at inpatient mental health beds and the shortage of mental health beds. It was done by the Royal College of Psychiatrists and it was called the Crisp Commission, reporting in 2016.

And we recommended that there should be a patient and carer race equality standard, because what I was really conscious of is that feedback from service users to improve services and carers and communities, that voice seemed really, really absent from the system, in my view. And I felt that there needed to be much more recognition of that voice, basically.

And a parallel process for me that I experienced, which actually brought me into the world of politics as well as on the mental health sort of national and local agenda, was being involved in, I lived on a housing estate in Lambeth that was going through a £150 million regeneration process and I was horrified, and it was actually after an experience that I was at a very low ebb at that point with my own mental health, having just gone through an experience of my sister going through the worst mental health crisis that we’d ever experienced in our family, being really severely manic for about three years with services doing what? I don’t know. And the family really supporting her but with very little support from the services.

And I just kept getting sort of a bureaucratic sort of response to my challenges all the up to the Chief Exec of the mental health services, and I was just so disappointed. I was like if this is what it’s like for me, imagine what it’s like for so many other families and communities and service users in this kind of system that says that it does this, but actually when you need it, it’s like that. And I was just, I had, I was very ill.

But what I was experiencing in this regeneration is that when residents who didn’t know what was going on, that their houses were going through this significant process of change, that the commissioners of the local authority and the developers didn’t really want to speak with the residents. I was like what’s going on here? We need to be part of how you are implementing this multi-million-pound contract that you say is in our interest. And that’s not what was really taking place.  They were making every effort to exclude us.  And when I went to the councillor to help, the local councillor; “oh, we’ll speak to the developers for you” and then he’d send back the very developers that are sort of resisting our involvement to come and amend the thing. I was like well, if that’s what you’re doing, I might as well become a councillor, that’s how I became politicised. Because I know that I want to help the local people.

What I’m saying it to say, is that without the voices of those people that we say we’re serving being involved at every step of the way, we will not get the outcomes that we say that we’re trying to drive forward, and that is part of the agenda as regards why I set up Black Thrive basically.

Black Thrive, a Partnership for Wellbeing, came about through an independent, well an inquest into the death of Sean Rigg who died in Lambeth in the hands of the police. And he was known to services. He’d been experiencing a psychotic episode for some time. The services didn’t seem to be listening to the carers and his requests for help and the inquest found that actually the system failed him. The inquest found that all the partners; the police, the mental health services, primary care, the local authority all failed this man and he slipped through the net.

So, I co-chaired a commission; Black Health and Wellbeing Commission, that was working with community members, service users, carers, interested community organisations and the system’s stakeholders; the police, the same ones that have failed the man basically, to work together to set up a series of recommendations about how we could improve the system so that these kinds of terrible deaths didn’t happen again. And a series of recommendations around improving access, improving prevention, improving the patient experience emerged from that.

In terms of now and by that, when I started that commission, I wasn’t a councillor, when I finished that commission I was elected as a councillor. And then I was like “oh right, now we’re going to be really busy implementing these recommendations” – da, da, da. It didn’t happen like that.

And I think that’s partly to do with not having the same sense of urgency as the communities have in relation to these experiences. Not that totally resistant, but just didn’t have the sense of urgency, and I had that sense of urgency. So, I went and found interested parties to help the community to work with some of the system leaders to develop a mechanism that the community could trust, that could hold the services to account and that’s where the Black Thrive, Partnership for Wellbeing came from.

So, this is one of our community workshops and you will know that there’s been a whole series of deaths of black men, it’s actually a very extreme situation the African and Caribbean experience of mental health services. And in 2005 the Government did deliver race equality, there’s been several inquests for deaths in custody, deaths in mental healthcare and so forth and so forth. But the bureaucratic responses have never really worked in terms of delivering improved outcomes for our community here.

In Lambeth, this is our population. We’ve got great features, landmarks, the London Eye, for example, the Headquarters of MI6, the Black Cultural Archives and so forth, and these are some of the sort of public health stats that are really pertinent to this particular agenda.

So, for example, over a third of black Caribbean pupils that are eligible for free school meals. Black boys are just under three times more likely to be arrested than white boys. I want to sort of like just mention the Race Disparity Audit which also highlights the whole system kind of experience of people by ethnicity throughout the public sector. So, we’re talking about the whole range of public services beyond health services, employment, housing, education, criminal justice, where this experience is replicated, and in a sense mental health picks up the experience of what peoples’ lives are throughout the rest of the system.

And there was a recent report, the Timpson Review, is anybody aware of that? The Timpson Review into School Exclusions, yes, and in that report, they said that ethnicity, although a feature is not significant in exclusions and we have to pay attention to other things. Now, if we don’t look through that racialised lens actually we miss the experience. One size does not fit all. So, if you look at school exclusions people who are from African and Caribbean, a black boy who has a special educational need, who is on school meals is 168 times more likely to be excluded than his white counterpart.

Now, if we just block it all up and tackling exclusions you won’t get to the degree of work that you need to do with particular communities that are experiencing the intersectionality of issues. Do you get what I’m saying?

So, the vision for Lambeth, black communities in Lambeth thrive, experience good mental health and wellbeing are supported by relevant accessible services which provide the same excellent quality of support for all people regardless of their race.

And I’m just going to focus on acute few elements of how the Black Thrive model operates with the support of its partners which you can see.

So, we have strategic leadership which is made up of some of the system leaders alongside the community working together in a collaborative way, that provides strategic leadership. We have a whole range of working groups and we have a facilitating team which provides the backbone of doing the sort of work to facilitate the working groups and the steering committee, and doing the work of engaging with the communities. And we have a shared measurement system. So, education, the police, the mental health services etc. contribute the data that the community has identified, these are the measures that we want to look at and explore over a period of time, whether or not they are actually changing as a whole, these will help us know whether or not we are realising the vision.

So, you’re going to get these slides, so I’m not going to go into them in any kind of like more depth because I’m sure my time is nearly gone.

Children and young people is one of our working groups and before we had working groups around prevention, access to appropriate services and experience and we’ve moved that to a live course approach, so that where children and young people, adults of working age and older people, because that’s what the community demanded that we paid more attention to. And that this is the prevention etc. is led into that live course approach.

Some of our working group priorities, so one, for example, is around, okay so going back, what underpins all of that is the Collective Impact Approach. And the elements of the collective impact are around sharing a common agenda, which is the vision. Another is around a mutually reinforcing activity.

So, what we’ve chosen as our mutually reinforcing activity is tackling school exclusions. So, what that means is that everybody across the stakeholders has agreed that their going to align in contributing to attending to that issue. And so that has enabled me as a cabinet member within the local authority to hold all the departments of the local authority, for example, to account as how are you tackling school exclusions? So, it’s built into our political manifesto and into our political strategies for the local authority.

And the same is with the police and the mental health trust etc. etc. So, everywhere has to pay that contribution to that, because we know that children who are excluded are more likely to suffer from mental health challenges.

And one of the other things that we wanted to address, another framework that helps us to think about this strategically, because we’re talking about structural inequalities and we’re talking about system, taking a systemic approach to systemic, deeply systemic issues, is to address perceptions. The mental models, the perceptions that hold these systems, these structural inequalities in place. Relationships and connections and the power dynamics, all things that you’ve talked about today, that we’re wanting to name and have those difficult conversations and we are having those difficult conversations about these elements.

I’m not going any further because I know I’ve gone out of time, over time.

But what we’ve learned at Black Thrive is that we have to address a symmetry of power in this social movement that we have embarked on, and that we use dialogue to identify our shared goals. And the focus is on top down, bottom up, diagonal, horizontal, every which way but loose, we are attending to this issue and that we want to and are delivering and embedding change. And that we aim to ensure accountability through transparency and build the trusting relationships that are required in order to address some of the most challenging issues that we face as a local borough.

Thank you.