BJPsych Bulletin

The debate on the causes of disparities in mental healthcare and outcome in different ethnic groups is complex. The consensus is that there are many reasons for the disparities, including ethnic variations in illness models, the perceived attractiveness of services and access to services. Attention to choice, workforce development and service redesign can improve access to and take up of care by under-served groups, improve cultural capability and so decrease disparities. To believe that disparities in care and outcome are not at least in part a reflection of our institutions would defy reason.

There are many examples of institutions making choices which affect quality of care (for example, the underfunding of interpreting services which mean that some Black and minority ethnic groups do not get equitable care). Some choices are more obscurely related to poor outcomes (for example, services not recruiting community development workers; McKenzie & Bhui, 2007). In all other public services, choices or service configurations which inadvertently lead to disparities for Black or minority ethnic groups are called institutional or structural racism.

It is not scientific to pretend racism does not exist in its individual or structural forms, or to suggest that racism is something health professionals should not consider and manage. A well-informed research programme on this topic could benefit public mental health (McKenzie, 2003).

Racism and institutional racism are key variables that are as relevant as other socioeconomic factors. In particular, there is an accumulation of evidence that perceived discrimination and racism are linked to poorer mental health outcomes (Karlsen & Nazroo, 2002; Nazroo, 2003; Bhui et al, 2005; Harris et al, 2006; Paradies, 2006; Veling et al, 2007). Nowhere in such debates has anyone proffered racism as the only cause of disparities and ignored all other sociocultural variables.

It is clear that this subject is challenging and such problems need to be constructively and honestly negotiated by clinicians, service providers, healthcare regulators and policy makers – not least because these concepts are enshrined in law, and services have a duty to deliver race equality and promote good race relations. However, it is another matter to deny that institutional/structural racism is a problem in public services, or perhaps to favour a more convenient form of language that obscures the objective and makes moving forward more difficult. With the weight of evidence that there is on this subject (for a review see Sashidharan, 2003) and the consensus of experts, service users, communities and the voluntary sector, ignoring individual and structural racism as a daily social reality and as a factor in human suffering and poor mental health would be neither scientific, constructive or humane.

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