Transcript Document

Delivering Race Equality:
DIVERSE APPROACHES TO DIVERSE
COMMUNITIES
The Central and North West London (CNWL) NHS
Foundation Trust’s Focused Implementation Site
(FIS) was one of the 18 FIS Projects that were the
vanguard of the UK’s Department of Health’s
Delivering Race Equality Action Plan launched in
2005.
CNWL provides adult mental health services and a
range of older peoples, child and adolescent mental
health and addictions services across a number of
London boroughs, including, Brent, Harrow, Hillingdon,
Kensington & Chelsea and Westminster.
This presentation is a brief account of the project’s
outcomes. The full evaluation report can be found on the
Trust’s website:
http://www.cnwl.nhs.uk/equality_diversity_news.html
The CNWL FIS Project was one of the few national FIS
sites to be based solely within a mental health Trust. The
Project is also significant in that CNWL mental health
services cover some of the most ethnically diverse
boroughs in the UK, Brent is the most ethnically diverse
Borough in London, Harrow the most religiously diverse.
Populations of Borough’s served by CNWL mental health services
Borough
White
British
Harrow
Population %
49.90
4.38
4.49
Brent
Population %
29.19
6.95
Westminster
Population %
48.51
K&C
Population %
White White Mixed Indian
Irish Other
Pakistani
Bangladeshi
Other
Asian
Black
Caribbean
Black
African
Other
Black
Chinese
Other
ethnic
group
2.82
21.91
2.09
0.46
5.19
2.96
2.74
0.45
1.24
1.38
9.14
3.72
18.46
4.03
0.45
4.79
10.47
7.83
1.56
1.07
2.34
3.63
21.07
4.13
3.12
1.01
2.76
1.99
3.10
3.68
0.66
2.25
4.10
50.08
3.26
25.26
4.09
2.03
0.76
0.72
1.36
2.58
3.78
0.61
1.63
3.82
Hillingdon
Population %
72.53
2.84
3.69
2.30
9.56
1.57
0.60
1.87
1.35
1.74
0.21
0.77
0.97
Overall
Population (%)
42.89
4.83
13.78
3.66
12.69
2.22
1.02
3.59
5.36
4.81
0.89
1.49
2.78
Admissions 2007/8 by ethnicity to CNWL adult mental
health in-patient services
Admissions
2007/8 (%)
White
British
White
Irish
White
Other
Mixed
Indian
Pakistani
Bangla
-deshi
Other
Asian
Black
Caribbean
Black
African
Other
Black
Chinese
Other
ethnic
group
Not
Known
Refused
to
Answer
Brent
19.13
4.81
5.50
3.67
5.38
3.55
0.46
4.70
20.39
11.68
6.99
6.99
5.50
1.26
0.00
Harrow
41.20
5.42
4.26
2.71
10.06
2.32
0.58
7.54
5.03
9.48
0.58
0.58
3.68
3.87
2.71
Hillingdon
42.52
0.52
6.82
3.15
8.14
1.31
0.26
6.04
4.46
6.82
2.36
1.84
9.71
4.72
1.31
Kensington
& Chelsea
32.91
5.32
16.11
5.32
1.54
0.28
0.70
2.38
7.00
8.96
6.02
6.02
7.28
0.14
0.00
Westminster
34.50
3.61
18.18
2.96
1.75
0.66
1.20
2.85
4.05
7.23
7.23
7.23
8.00
0.55
0.00
THE FIS Plan, Do, Study, Act cycle
The CNWL FIS Project from the outset was conceived
as an approach to system-wide change through testing
small scale projects and interventions.
These were to be regarded as stepping stones to
introducing improved practice on a mainstream scale
by promoting the learning from these small scale
projects both across the organisation, and nationally.
The FIS Project was not an academic research project
but service development initiative
What were we looking at?
1. A reduction in the disproportionate rate of admission of people
from BME communities to psychiatric inpatient units &
A reduction in the disproportionate rates of compulsory
detention of BME users in inpatient units
2. A reduction in the proportion of prisoners from BME
communities
3. A more active role for BME communities and BME service users
in the training of professionals, in the development of mental
health policy, and in the planning and provision of services
4. A workforce and organisation capable of delivering appropriate
and responsive mental health services to BME communities
The above are identified characteristics of a reformed mental health service,
as envisioned by the UK Department of Health’s Delivering Race Equality
agenda. Please note: BME stands for Black or Minority Ethnic
How did we do it?
An example – a process map for improving the Black African
and Black Caribbean In-patient Journey
Position at Outset
2005 ‘Count Me In’ Census Data shows
higher admission and detention rates for
Black patients than would be expected
from 2001 National Census for all
boroughs where CNWL has adult inpatient services
Analyse year on year ‘Count
Me In’ Census Data on
admission rates and detention
rates within CNWL
Examine trends and
identify any areas where
there is a reduction in BME
detention rates
+-
Formulate strategy to further
investigate areas showing persistent
reductions in admissions/detentions
and identify causes
(Westminster and Brent)
Initiate Trailblazer Project ‘Improving
the Black African and AfricanCaribbean Patients Experience’ in
Brent & Westminster
Analyse care pathway to In-patient
services & develop local Working
Groups for Trailblazer Projects in
Brent and Westminster
Gather baseline data on care pathway
Westminster Project
Ethnicity and Pathways into Inpatient treatment – How can we
modify routes into in-patient
services?
Exit Route to Mainstream
Clinical Governance Group
Westminster Adult Mental Health Services
Brent Adult Mental Health Services
Brent Project
Ethnicity and the In-patient
Experience – How can we
improve quality of the in-patient
experience?
Brent Project
Pine Ward ‘Moving
Out’ Project
Planned Outcomes
Produce Trust-wide guidance and good
practice examples as Trust-wide/national
models
1. Responding to disproportionate admissions
In some areas of the Trust
there was evidence of
reducing admission/
detention rates of Black
service users.
80.00%
70.00%
60.00%
Percentages
‘Count Me In’ Census
figures for 2005 and 2007
showed that Trustwide
Black in-patient overrepresentation was falling.
The rise in Harrow was
based on very small
numbers of detained
patients in this group,
making the very small rise
in the number of detentions
over the period produce a
large proportional change.
Changes in the proportion of admitted patients who are detained
between 2005 and 2007
White UK and White
Other
Detained as % of
Total Admissions for
this group
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
2005
2007
Brent
2005
2007
Harrow
2005
2007
Kensington &
Chelsea
2005
2007
Westminster
CNWL Adult Mental Health Services
Black African, Black
Caribbean, Other
Black
Detained as % of
Total Admissions for
this group
1. (cont) Responding to disproportionate
admissions
CNWL was already developing assertive outreach, early intervention and
crisis resolution teams and evidence is that these are treating significant
numbers of Black service users.
Community Mental Health Teams were not a significant cause of overrepresentation of Black service users on in-patient wards.
It was realised that perhaps the Trust could make a more significant
impact by addressing re-admission by ensuring appropriate and culturally
competent support and care planning within wards with supportive links
being established to the community ahead of discharge.
1. (cont) Responding to disproportionate
admissions
Brent Mental Health Service launched a series of initiatives on one of its inpatient wards in October 2009 to improve the Black patient experience.
This, coupled with more culturally appropriate discharge planning, we
hypothesise will lead to reductions in re-admission. These initiatives
include:

The African & Caribbean Community Network Services working with staff
and service users on the acute admission wards to ensure that on
discharge service users are supported in accessing the social inclusion
programme’s six life domains (faith, cultural communities, education &
training, employment & volunteering, art & culture and sports and leisure).
1. (cont) Responding to disproportionate
admissions

A Monthly Recovery Group (“Hope Project”) for Black British, Black
African, Black Caribbean and other black service users in the inpatient
units where motivational speakers are invited to attend.

New Roots (a substance misuse service for Black service users)
information sessions.

A Survey of clients to ascertain how the move-on care package can be
improved.

Primary Care Liaison Team working in liaison with Safer Neighbourhood
Police Officers re referrals for home treatment.

Increasing the uptake of Self Directed Support and Direct Payments by
this client group.
2. Responding to reducing BME prison admission
through improving court diversion
•
From auditing equality and outcomes from our existing Court Diversion
services in Harrow and Brent, we found that Black African and Black
African Caribbean defendants referred to us had a slightly improved
chance of being diverted compared with all other ethnic groups.
•
Combining this work with a parallel project, CNWL became a national
pilot for developing a Service Level Agreement for Psychiatric Court
Reports,
•
CNWL is currently working on a service redesign to produce a single
Court Diversion service that covers Brent, Harrow and Hillingdon.
•
CNWL developed a partnership with a local community organisation in
Brent - PLIAS (Prison Liaison Information and Advice Service) - who work
with Black-ex-offenders. We have supported them with organizational
development and jointly produced a report on the experience of BME
service users with an offending history and mental health problems who
have poor contact with the statutory services. This highlighted their fear of
mental health stigma and fear of racism.
3. Responding to developing a more active role for
BME communities
In Brent, the FIS Project held an event organised in partnership with
Brent Multi-Faith Forum that included representatives from a variety of
local faith communities and resulted in a report containing 5 key
recommendations from the faith communities. Subsequently these
recommendations included in the Brent Mental Health Service Business
Plan for 2008/09, were to:
– Work with users of mental health day service to develop support from
faith communities.
– Monitor the assessment of faith needs
– Identify & develop 5 faith groups to work in partnership with the
mental health services.
– Provide Mental Health Awareness Training for these 5 faith groups.
– Train at least 80 mental health staff on Faith Competency in the next
12 months.
3. (Cont) Responding to developing a more active role
for BME communities
In Harrow, the FIS Project developed the Asian Mental Health Reference
Group (form of Community members and CNWL managers) to identify
issues of concern for the Asian community. The group designed a local
conference on mental health in the Asian Community and subsequently
embarked on a work plan with Harrow Mental Health Services to take
forward the recommendations from the conference. This and other
community work in Harrow was recognised by a Community Cohesion
award at a recent national ceremony (Feb. 2010).
In Westminster and Kensington & Chelsea working with the BME
Health Forum’s BME Community Group Leadership Development
Project on a project aimed at changing GP/Primary Care practice across
Westminster and Kensington & Chelsea in response to recommendations
from ‘Primary Concern’, a research report by the BME Health Forum on
access to GP/Primary Care services by BME patients.
4. Responding to developing a workforce capable of
delivering a more appropriate and responsive service
The FIS Project was involved in the assessment of an e-learning
approach to training in basic Diversity Competence in the workplace
across the Trust. To date over 800 staff have completed the module. The
intention is for all CNWL staff to complete the module and for it to be
mandatory for all new staff.
The FIS Project and the CNWL Head of Equality and Diversity have
designed and developed a Cultural Competency Training Programme
for Managers and a supporting handbook. This uses ‘live’ case studies to
ensure relevance, and the training is inclusive of race/ethnicity, disability,
gender (including trans), religion or belief, sexual orientation and age. To
date over 100 Trust managers have attended this training.
4. (Cont) Responding to developing a workforce
capable of delivering a more appropriate and
responsive service
A further 2 pilots have been conducted of an adapted programme on
‘Cultural Competence for Doctors’. Guidance for doctors has been
produced on how to ask about cultural needs, based on feedback from
the first pilot session with doctors. We are now exploring how we engage
this programme with the local academic training of doctors as well as
continuing with the corporate level training sessions.
In addition, a presentation addressing the stigma of mental health within a
culturally diverse context was produced, and has been used to raise
awareness amongst CNWL staff.
Learning from the community (1)
The strong message from our community group partners in their
contributions to the FIS Evaluation Report was that the mental health
services need to invest in partnerships with local community groups to
create visible change in services.
Community groups have been substantially involved as a resource to the
FIS Project providing invaluable knowledge, expertise, enthusiasm and
ideas and they have welcomed and appreciated the Project’s support.
The cliché of ‘hard to- reach’ communities has been radically challenged
by the CNWL FIS Project’s experience to illuminate how much mental
health services can appear to be ‘hard-to-access’ organisations who
seem indifferent to local communities’ concerns.
Learning from the community (2)
During the course of its three years, the CNWL FIS Project made links to
33 community groups that had not previous had links with their local
mental health service. As a result CNWL has made substantial gains in
understanding and communicating with Black and Minority Ethnic
communities and experiencing the benefits that can be gained from
working with community groups as partners.
It can require persistence and openness to encourage trust. Communities
need to be encouraged by tangible evidence that their involvement leads
to changes and developments. Communities rightly need to feel that
something is being given back to them through their involvement.
This improvement in communication is an essential first step in improving
and delivering better and more appropriate services.
National / International
Recommendations
Recommendations (1)
Recommendations (2)
Routes into admission and
compulsory detention should be
compared with detailed local
ethnicity data and work developed
in partnership with local BME
groups in designing service
changes
Local mental health services
should explore options for more
direct alliance and partnership
work with Black 3rd Sector
providers, including faith
communities
Place a focus on supporting
‘moving out’ processes, including
robust culturally competent Care
Programme Approach (CPA) to
improve chances of sustaining
recovery by ensuring connections
are made with culturally
appropriate community networks,
including faith communities, and
appropriate housing, education and
employment opportunities
Develop effective Court Diversion
services in all regions.
Develop Court Diversion capacity
to reduce use of remand in
custody for the purpose of
assessment for psychiatric
reports
National / International
Recommendations
National Recommendations (3)
National recommendations (4)
Mental Health Trusts should take
a fuller direct role in raising local
awareness about mental health
as a way of breaking down fear of
local services and creating a
dialogue with local communities.
Cultural Competency Training should be
attended by all mental health managers and
senior clinicians from executive to ward level,
and learning cascaded through line
management and supervision processes,
team meetings and case discussion.
Corporate and local links with
BME umbrella groups/networks
need to be complemented by
developing direct links with
individual BME community
groups that are not previously
known to have links with the
organisation.
‘Culturally Competent Practice’ Support
Networks be established to support managers
Cultural Competence training should be
relevant to the experiences of services, based
around ‘live’ situations that are arising in
service provision and should be inclusive of
all the diversity strands (race, disability,
gender, religion or belief, age and sexual
orientation) as a more accurate reflection of
individual’s experience.
for further information contact:
[email protected]
or
[email protected]
You can access the Full Evaluation Report at
http://www.cnwl.nhs.uk/equality_diversity_news.html