The need for change in UK mental health services: South Asian service users' views

Objectives. UK literature on mental health services for ethnic minority service users relies heavily on perceptions of professionals, carers and community representatives. This research investigates the views of South Asian service users themselves about experiences of mental health services and how they might be improved.

Design. Thematic analysis of material from focus groups and individual interviews with Asian mental health service users within one local area.

Results. South Asian service users clearly identify the impact of socio-economic exclusion upon their mental health. Cultural and institutional exclusion compound this, leading to continuing insensitivity towards their particular needs within hospital and community-based services. Asian service users feel unsafe to share their particular concerns within many service settings. They see advocacy that recognises their experience of exclusion as a significant resource for mental health improvement. They want sounder financing of culturally appropriate services for recovery; further development of the cultural competence of staff within mainstream services; and educational programmes about mental health directed at minority communities.

Conclusion. UK mental health services remain unresponsive to the consistently expressed views of South Asian service users. A major cultural change is required if the UK Government initiative Delivering Race Equality is to impact successfully at the local level. It will have a greater chance of success if the rhetoric of user involvement is matched by systematic consultation with South Asian service users.     

Tackling health inequalities and social exclusion through partnership and community engagement? A reality check for policy and practice aspirations from a Social Inclusion Partnership in Scotland

In the contemporary UK policy context, multisectoral partnership initiatives and community participation are increasingly viewed as appropriate mechanisms for tackling health and social disadvantage. Such initiatives are often put into practice in contexts of industrial and economic decline, fragmented neighbourhoods, hard-pressed public services, and sustained under-investment in voluntary and community sector organisations. This paper draws on ethnographic fieldwork in a Social Inclusion Partnership (SIP) in Scotland to suggest that policy-makers and public health practitioners need a better understanding of the difficulties involved in implementing partnership and participation initiatives in this kind of context. The East Kirkland SIP was set up to tackle social exclusion and health inequalities within the most deprived neighbourhoods of a Scottish town, yet community engagement remained elusive. Partnership proved to be risky territory for all involved, marked by rivalry and suspicion between SIP members, rather than co-operation, whilst health promotion and social inclusion priorities conflicted with those of community development and regeneration. In sum, this paper presents a reality check for some contemporary policy and practice aspirations.     

A partial solution: a local mental health authority for the UK

BACKGROUND: the structural problems of the mental health system in the UK have been analyzed by a number of authors over the past several years as the "reforms" of the health and social service systems have continued (Kavanagh and Knapp, 1995; Mechanic, 1995). In a recent article, Hadley and Goldman (1995) suggest that one possible solution to some of these issues may be the creation of a local mental health authority. Such an authority would consolidate the funding, authority and responsibility in a single entity. We believe this model, which is typical of many local public mental health systems in the US, is at least part of the solution to the current problem of financial and service fragmentation of the current system in the UK. The numerous "reforms" of the health and social service systems (which include the Community Care Act, the development of the Internal Market, GP fundholding and the purchaser-provider split) were not designed for the care of the mentally ill (Han, 1996). These policy changes in the design of health and social services have created a complicated and difficult context in which services must be delivered. Too many agencies play a significant role in the delivery and management of mental health services. Health authorities, social service agencies and GP fundholders are direct and indirect funders of the system while community care trusts, social service agencies and GPs are service providers (Hadley, 1996a). RESULTS AND A PROPOSAL: We believe that the development of local mental health authorities may be part of the solution to the structural and economic problems of the current system in the UK. It is not the answer to limited resources or limited skills, but can create a new structure, which will permit and encourage the cooperation and innovation that is now possible only with unusual effort. Local mental health authorities have a number of crucial characteristics, but, most importantly, they refocus the system on the provision of care to the seriously mentally ill. This is the expressed priority of government, advocates and providers, alike.These new entities could be created at either the purchaser or provider level or, as exists in a number of jurisdictions in the US, at both levels, where a single purchaser may be responsible for multiple consolidated providers. This combination is now the emerging model for innovative services in the US. In the UK, the development of a local mental health authority at the purchaser and/or provider level might be relatively simple. Although the creation of a statutory authority would require primary legislation and is therefore probably not a short-term solution, there appears to be a variety of administrative options that would have the same effect. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The creation of a local mental health authority may be a necessary first step towards the development of a coordinated and comprehensive system of care. It seems likely that there is currently more "political" support for the development of a purchaser model but the development of a sophisticated purchsaer is also likely to take considerable time and effort. Although all the structural and policy problems of the mental health system in the UK will not all be solved by local mental health authorities, they may be beneficial if responsibility for mental illness care is to be centralized and fragmentation is to be reduced. Without making structural changes, the best efforts by clinicians, policymakers and managers are most likely to be in vain. Without a clear point of ultimate purchasing and service responsibility, the fragmentation and inefficiency of the current system will remain (Hadley et al., 1996).     

Facing the cuts: a health authority's experience of rate-capping.

Health and social services in Britain are both publicly funded, but health care is provided centrally by the National Health Service while social services are provided by local government. Central government has sought to limit overall public spending by limiting the income of local authorities from rates (property taxes)--a policy known as rate-capping. In the face of this policy, one inner London local authority was forced to cut its social services budget in 1988/89 by 17%. We have compared the actual social service reductions with the perceptions, expressed in semi-structured interviews, of 69 health and social services staff. There was a perceived deterioration in social service provision, and indicators were suggested which would help health service staff to monitor these changes. There were also recent and more long-standing difficulties of communication between the two services, which limited joint working. The increasing emphasis on community care requires health authorities to cooperate more closely with social services at the local level.     

Working with families in Tower Hamlets: an evaluation of the Family Welfare Association's Family Support Services

This paper describes an evaluation carried out by South Bank University of the work of the Family Welfare Association's (FWA's) Family Support Services (FSSs) in Tower Hamlets, London. Tower Hamlets is a multi-racial area in east London that, according to the 1991 census, has high levels of poverty, overcrowding and unemployment. Increasing poverty and social exclusion, which further entrench inequalities in health, are reported by sources such as government, health and social services and research as requiring innovative local responses to meet pressing welfare needs. The evaluation reported here examined three projects: Family Support, Building Bridges and Quality Protects - these are referred to collectively as FSSs. The evaluation shows that FSSs are innovative services that demonstrate effective ways of working with vulnerable families affected by experiences of racism, bullying, mental health difficulties, domestic violence or child abuse. In common with other successful initiatives in the UK and abroad, FSSs are aimed to be non-stigmatising, non-intrusive and responsive to the ethnicity, views and specific needs of families. This paper focuses on the participatory work of FSSs with families to illustrate effective methods of quality support, detail outcomes, and draw lessons for policy and practice.     

Fear of crime, mobility and mental health in inner-city London, UK

This paper examines the relationship between fear of crime and mental health, and assesses the role interventions may have in helping overcome any negative impact arising from this fear. The data were gathered over a 2-year period in the Gospel Oak neighbourhood of North London using in-depth interviews, focus groups and participant observation. The data are analysed primarily by comparing the impact of fear of crime across sub-groups notably divided by gender, age and mental health status. It was found that fear of crime had a disproportionately negative impact on certain sub-groups, most notably low-income mothers, and to a lesser extent the mentally ill. They experienced what we term "time-space inequalities" as a consequence of fear of crime and other related factors. These inequalities describe variation in the ability to access and utilise different times and spaces within both the immediate and the wider environment. These have negative behavioural and affective consequences that appear to impact on overall mental health. They restrict spatial and temporal movement deterring protective social activity, health-promoting community involvement and use of services. Affective consequences include negative mood and low self-esteem. These inequalities were experienced less in other groups such as mentally healthy men or middle-income women. They appeared to be diminished by interventions that encourage spatial and temporal movement. These include comprehensive local transport, government-issued free travel passes for vulnerable populations and neighbourhood community safety measures such as the installation of CCTV. We suggest that experience of time-space inequalities may be damaging to mental health and that interventions which lessen them may help prevent, ameliorate or shorten episodes of mental illness.     

‘Getting involved means making a difference?’ Insider views on the impact of a ‘healthy living’ community intervention

Addressing inequalities in health has featured strongly in UK health care policy over recent years, and efforts to consider inequalities at ‘ground level’ are increasingly evident. This includes enhancing primary care and other community-based services and emphasising consultation at community levels. The Healthy Living Approach to community development in Pembrokeshire, West Wales, was initiated and evaluated as part of the Welsh Assembly Government's Sustainable Health Action Research Programme (SHARP). As part of that programme an action research project was organised to respond to a context of funding and service delivery coloured by rural isolation, social exclusion and poor health. The project was adopted in three marginal communities and was evaluated using multiple methods to understand the effects of the initiative and how well it was seen to have worked. This paper reports on one aspect of that evaluation: focus groups with Project Steering Group members that examined the impact of the intervention from the perspective of those involved in the study's implementation. The paper highlights the perceived impact on community members and study organisers, the process of liaison between community and statutory body advisers and the appropriateness of the methodology. There was overwhelming support for the project and agreement that action research was the only feasible working methodology. The results offer insider views on the potential for ‘healthy living’ community interventions to enable communities to engage with locally defined health issues, but sets a note of caution about being able to achieve real and sustainable change.     

The helping network approach: Community promotion of mental health

The Galt Helping Network Project was a two-year program to augment mental health and community services in a rural California community through the use of natural or informal resources. The experiment made use of a preventive intervention model which identified important needs of local youth and families, board and care residents, the entire community for recreation and for mental health services, and the Mexican American Community for recognition and participation. It brought a number of volunteers into the provision of direct services and created a number of institutional forms by which continued services and enlarged voluntary participation in community affairs are continuing beyond the official end of the project. This article concludes that the Galt Helping Network Model can provide a major contribution to mental health maintenance and community involvement through the recognition of natural helpers and the involvement of the community in an active form of problem solving. Through these methods a community with limited fiscal resources can take a major step toward providing a caring and helping environment for its members.     

Building an inter-disciplinary science of health inequalities: the example of lifecourse research

Across the post-industrial world, new public health strategies are being developed with the goal of reducing the socio-economic gradient in health. These new strategies are distinguished by a commitment to tackling the macro determinants of health inequalities through policies informed by scientific evidence. The engagement with macro determinants and with scientific evidence presents a major challenge to the health inequality research community. This is not only because of the complexity of the links between distal causes, proximal risk factors and health outcomes. It is also and more importantly because of the narrow disciplinary base of health inequality research. Grounded in social epidemiology, health inequality research has illuminated the pathways which run from individual socio-economic position to health-but has left in shadow the factors which influence socio-economic position. Broadening the evidence base to include these structural processes requires a new science of health inequalities, resourced both by epidemiological research and by research on social inequality and social exclusion. The paper demonstrates how such an inter-disciplinary science can be constructed. Taking lifecourse research as its example and the UK as its case study, it nests epidemiological research within social policy research: setting evidence on the health consequences of cumulative exposures within research on lifecourse dynamics, and locating both within analyses of how state policies can amplify or moderate inequalities in socio-economic position.     

The space of access to primary mental health care: a qualitative case study

Guided by theoretical perspectives of relational social science, this paper draws on reanalyses of multiple qualitative datasets related to a multi-ethnic, economically disadvantaged area in Liverpool, UK, with the aim to advance general understanding of access to primary mental health care while using local Somali minority as an instrumental focus. The findings generate a novel concept: the space of access. The shape and dynamics of the space of access are determined by at least four fields of tensions: understandings of area and community; cognitive mapping of mental well-being, illness and care; positioning of primary care services; and dynamics of resources beyond the 'medical zone' of care. The conclusions indicate a need for de-centring and re-connecting the role of medical professionals within primary care which itself needs to be transformed by endorsement of multiple avenues of access to diverse support and intrepid communication among all involved actors.     

The importance of economic,social and cultural capital in understanding health inequalities: using a Bourdieu‐based approach in research on physical and mental health perceptions

In this article we adopt a Bourdieu‐based approach to study social inequalities in perceptions of mental and physical health. Most research takes into account the impact of economic or social capital on health inequalities. Bourdieu, however, distinguishes between three forms of capital that can determine peoples' social position: economic, social and cultural capital. Health research examining the effects of cultural capital is scarce. By simultaneously considering and modelling indicators of each of Bourdieu's forms of capital, we further the understanding of the dynamics of health inequalities. Using data from a large‐scale representative survey (N = 1825) in Flanders, Belgium, we find that each of the forms of capital has a net effect on perceptions of physical and mental health, which persists after controlling for the other forms of capital and for the effects of other correlates of perceived health. The only exception is that the cultural capital indicators are not related to mental health. These results confirm the value of a Bourdieu‐based approach and indicate the need to consider economic, social and cultural capital to obtain a better understanding of social inequality in health.     

Bianca in the neighborhood: moving beyond the ‘reach paradigm’ in public mental health

This article offers a critical analysis of how to address social inequalities in mental health. In public mental health, inequalities are commonly construed as a problem of reach, implying that existing mental health expertise often fails to reach low-income groups. We discuss two critiques on the ‘reach-paradigm’ in mental health promotion: the impoverishment of idioms of distress and the tendency to transform complex political issues into clinical ones that are assumed to be backed by evidence. Furthermore, we present the findings of our ethnographic research of an alternative approach to mental health promotion that used media storytelling focused on local knowledge and social context. Our analysis is guided by anthropological research on idioms of distress and sociological literature on health promotion and social inequalities.     

Exploration of joint working practices on anti‐social behaviour between criminal justice,mental health and social care agencies: A qualitative study

Although the police play an important role for people with mental health problems in the community, little is known about joint working practices between mental health, social care and police services. There is potential for tensions and negative outcomes for people with mental health problems, in particular when the focus is on behaviours that could be interpreted as anti‐social. This study explores perceptions about joint working between mental health, social care and police services with regard to anti‐social behaviour. We conducted a multi‐method sequential qualitative study in the UK collecting data between April 2014 and August 2016. Data were collected from two study sites: 60 narrative police logs of routinely gathered information, and semi‐structured interviews and focus groups with professionals from a range of statutory and third sector organisations (N = 55). Data sets were analysed individually, using thematic iterative coding before integrating the findings. We also looked at sequencing and turning points in the police logs. Findings mapped on a continuum of joint working practices, with examples more likely to be away from the policy ideal of partnership working as being central to mainstream activities. Joint working was driven by legal obligations and concerns about risk rather than a focus on the needs of a person with mental health problems. This was complicated by different perceptions of the police role in mental health. Adding anti‐social behaviour to this mix intensified challenges as conceptualisation of the nature of the problem and agreeing on best practice and care is open to interpretations and judgements. Of concern is an evident lack of awareness of these issues. There is a need to reflect on joint working practices, including processes and goals, keeping in mind the health and welfare needs of people with mental health problems.     

The impact of community mental health reform on service users: a cohort study

British mental health services have undergone considerable reform in recent years. This paper reports a study designed to assess the impact of these changes on service users. The functioning of 100 randomly selected users of community mental health services in a North Wales town was assessed before the advent of two significant service changes – the establishment of a local Community Mental Health Team (CMHT) and the introduction of the main community care reforms in April 1993. Repeat assessments of sample members were made on three further occasions over the following 27 months, with a 9-month interval between each. Comparison of baseline and follow-up data suggested that services were appropriately targeted on users with a severe and enduring mental illness and that the functioning of this client group was successfully maintained over the study period. However, the establishment of a CMHT was associated with a temporary fall in social functioning, quality of life and satisfaction with services and there was no evidence to conclude that organizational reforms had led to an improvement in user outcomes in the medium term. Future mental health reorganization should be based on the evidence of research which includes an assessment of the impact of reforms on service users.     

The health service needs of small rural communities

ABSTRACT: In recent years econometric models used in health service planning have tended to encourage the downgrading or closure of small rural hospitals with the effect of reducing access to services and transferring costs from health authorities to consumers. These changes have occurred despite mounting evidence that people in rural communities have specific health service needs which require special attention. This study aimed to identify the perceptions of community members, health professionals and administrators regarding the health service needs in their small rural communities as a basis for developing a more comprehensive model of rural health service planning. Focus groups were held in three selected towns in Gippsland, exploring participants' perceptions of the meaning of health, health service needs, impact of health services, and the best set-up for health services. Consistent with previous research, key findings include: a broad conceptualisation of health; the perceived overwhelming importance of doctors, hospitals and chemists; the economic and social importance of a rural hospital; and a preference for all health services being provided under the one roof, funding and program flexibility, and local involvement in health service planning and implementation.     

Beliefs about treatment of mental health problems among Cambodian American children and parents

Beliefs about treatment of mental health problems are a critical area for examination among immigrant and refugee populations. Data on treatment of child problems have been conspicuously absent from the literature. This study examines explanatory models of treatment among 40 second-generation Cambodian children aged 8-18 and their parents in the US. Comparisons of perceptions of intervention for an externalizing problem (gang-related behavior) and an internalizing problem (depression) are made in a group of children who have received mental health services, their parents, and a matched community sample. A significant interaction between respondent and group membership was present in the perception that these problems could be helped, and contrary to past findings among Asian Americans, both children and parents generally endorsed the use of mental health services. Data about actual experiences with mental health services are used to help explain the findings and suggest implications for treatment of Cambodian-American youth.     

Primary Care Trusts involving the community: is community development the way forward?

Patient and user involvement is central to current government thinking on the NHS. More comprehensive approaches to organised community participation and community development have received less support and examples of effective and genuine participation in key areas such as primary care decision-making are rare. The initiative described in this paper was established in Newcastle upon Tyne in 1995 to promote community participation in decision-making about local health services. It has particular relevance to current concerns about addressing social exclusion and tackling health inequalities since it operates in an area of social disadvantage with a significant black and ethnic minority population (6 percent). This case study is based on an independent evaluation which used multiple research methods, including interviews, questionnaire surveys and direct observation, to assess the project's practice and impact. Describes a community development approach to public participation. An emphasis on inclusive practices has facilitated meaningful involvement of minority groups such as ethnic minority residents and those with disabilities who tend to be marginalised in public debate. Argues that the project has made a significant impact on the ways in which local health services are planned and delivered     

Social networks, social support, health and HIV-positive gay men

The present pilot study explored the experiences of social support on the part of a number of HIV-positive gay men. It drew upon the growing body of literature that highlights links between social support, and the health and well-being of people with chronic illnesses. In particular, it drew upon the way in which social network analysis can be used to illustrate patterns of both emotional support and instrumental support. The study informants were 30 HIV-positive gay men who were recruited through community support organisations which they accessed at the time of the study. The findings highlighted patterns of support among members of this marginalised community. At a time when access to treatment is extending the life expectancy of people infected with HIV and when, in the UK at least, there are major changes in the funding of HIV services, this paper raises pertinent questions about the impact of social support on people suffering from this illness and about the development of appropriate services.     

Mental health care roles of non-medical primary health and social care services

Changes in patterns of delivery of mental health care over several decades are putting pressure on primary health and social care services to increase their involvement. Mental health policy in countries like the UK, Australia and New Zealand recognises the need for these services to make a greater contribution and calls for increased intersectoral collaboration. In Australia, most investment to date has focused on the development and integration of specialist mental health services and primary medical care, and evaluation research suggests some progress. Substantial inadequacies remain, however, in the comprehensiveness and continuity of care received by people affected by mental health problems, particularly in relation to social and psychosocial interventions. Very little research has examined the nature of the roles that non-medical primary health and social care services actually or potentially play in mental health care. Lack of information about these roles could have inhibited development of service improvement initiatives targeting these services. The present paper reports the results of an exploratory study that examined the mental health care roles of 41 diverse non-medical primary health and social care services in the state of Victoria, Australia. Data were collected in 2004 using a purposive sampling strategy. A novel method of surveying providers was employed whereby respondents within each agency worked as a group to complete a structured survey that collected quantitative and qualitative data simultaneously. This paper reports results of quantitative analyses including a tentative principal components analysis that examined the structure of roles. Non-medical primary health and social care services are currently performing a wide variety of mental health care roles and they aspire to increase their involvement in this work. However, these providers do not favour approaches involving selective targeting of clients with mental disorders.     

A partnership approach to health promotion: a case study from Northern Ireland

In recent years there has been a renewal of interest in community development and partnership approaches in the delivery of health and social services in Northern Ireland. The general thrust of these approaches is that local communities can be organized to address health and social needs and to work with government agencies, voluntary bodies and local authorities in delivering services and local solutions to problems. Since the Ottawa Charter was launched in 1986, government in Northern Ireland has stressed that community development should no longer simply be added on to key aspects of Health and Social Services, but should instead be at the core of their work. There is increasing consensus that traditional approaches to improving health and well-being, which have focused on the individual, are paternalistic and have failed to tackle inequalities effectively. Partnerships within a community development setting have been heralded as a means to facilitate participation and empowerment. This paper outlines the policy background to community development approaches in health promotion and delivery in Northern Ireland. Drawing on evidence from a case study of a community health project it highlights the benefits and difficulties with this approach. The findings suggest that partnerships can positively influence a community's health status, but in order to be effective they require effective planning and long-term commitment from both the state and the local community.