Editorial

Citation

Greenfields, M. and Sewell, H. (2011), "Editorial", Ethnicity and Inequalities in Health and Social Care, Vol. 4 No. 2. https://doi.org/10.1108/eihsc.2011.54504baa.001

Editorial

Article Type: Editorial From: Ethnicity and Inequalities in Health and Social Care, Volume 4, Issue 2

The Health and Social Care Bill continues to make its passage through parliament prompting many conflicting arguments about the merits or otherwise of the most radical changes to the NHS since its inception.

This issue of the journal is timely with the inclusion of two papers that bring international perspectives. They both raise questions about not just the organisation of health services but more importantly the values and epistemological standpoint that shape the kinds of services that are provided. The two papers “Building capacity of local governments, service users and carers to scale up provision for community mental health services in Africa: a case study of Kenya and Uganda” and “Moving traditional Caribbean medicine practices into healthcare in Canada” illustrate two different points, both of which are worth pondering on as we go through turbulent times in the English health service.

The first of these two papers describes a model of working with a larger number of people in Kenya and Uganda with mental health problems. This is achieved through using a pool of trained community individuals who provide valuable services. The positive contributions of these individuals stem from an ability to engage effectively rather than from expertise in the technologies of modern psychiatry. Alongside these community roles in Kenya is investment in supporting users of services to understand their experiences and shape their future treatment and support. Driven by a lack of resources, this model also maximises the role of general nursing staff, resulting in an approach to mental health that sees “patients” as individuals or citizens in a social and familial context. They are provided with support for self-actualisation, to make their journey of recovery. These themes have resonance with the kinds of rhetoric about service user led services and localisation that feature in much of current policy and political discourse in the UK. Alongside this, the current cash strapped nature of the NHS forces the hand of service leaders to find ingenious and efficient ways to meet needs. Perhaps, in this climate the direction of the gaze of the NHS on greater technological solutions is not the right one. The experiences in Kenya and Uganda outlined by Kingori and Ntulo may well have lessons for the NHS. Mental health problems do not exist outside of a social context and solutions which depart too far from this understanding may be more costly in funding more highly skilled staff than the number that is essential for connecting with people rather than “patients”. An alternative approach of re-connecting peoples presentations with their context is articulated clearly by Bracken and Thomas (2005). This makes for an interesting debate at a time when the NHS is being geared up, through the Health and Social Care Bill to being placed in the hands of medics.

The paper by McKenzie and colleagues “Moving traditional Caribbean medicine practices into healthcare in Canada” illustrates how a belief about what constitutes reliable evidence dictates the privilege given to one type of intervention over another. The experience of Caribbean people, who determine that they derive benefit from traditional practices may have only a partial impact on the services that are available routinely through health services in Canada.

It remains a challenge both in Canada and in England to determine the right service approach and design, based on the perfect balance between service user perspectives and the orthodoxy of the evidence-base that is derived from modern privileged research. Given these unresolved tensions it is perhaps not surprising that the UK-based papers in this issue point to challenges in establishing a significant voice or market presence for BME individuals or organisations. The architecture of the NHS, the culture, policies and practices contain in-built biases that are present for any system designed by the majority and experienced by a minority. The biases in the English health system do, however, exist within a wider socio-political context that glosses over linking back to the glossing of the historical presence of black and minority ethnic (BME) people in England back to Roman times and also the muted acknowledgement of the reasons for initial waves of mass migration in the middle of the last century.

The paper “Impacting on diversity in practice in an outer London Borough” illustrates how existing inequalities perpetuate further inequalities for people of BME groups over time. In discussing the policy and delivery of personalisation the authors note that “many of the Harrow BME community organisations are not yet ready to adapt to being service providers or advocates working within the personalisation agenda” and further, they add, “[…] To date it has been the larger voluntary organisations within Harrow that have been able to benefit from the personalisation policy”. Personalisation offers the opportunity of service user designed treatment and care, and purchased social support. The obstacles for BME people are well articulated.

Lauren Holland’s paper “Inclusion or exclusion – recruiting BME community individuals as simulated patients” leads us into equally murky territory. This paper again illustrates the how historical and current social and political structures create exclusions to engaging in health service development.

So as the Health and Social Care Bill makes it passage through parliament and the political classes exercise one of their greatest powers – which is to legislate – this issue of the journal might generate an alternative set of arguments to the well rehearsed ones about the role of the private sector of the ascendancy of clinicians in controlling the NHS. Perhaps, a new line of debate can be introduced about the epistemological standpoint that dominates health and social care which gives credence to the articulation of an aspiration of equality but which continues to struggle to deliver it.

Margaret Greenfields, Hári Sewell