The Older Adult Directorate of South Birmingham Mental Health NHS Trust has adopted an outreach and partnership approach in its attempt to engage effectively with elders from black and ethnic communities, explains TR Downes, B Allcock, A Symthe, JA Sutton, and J Wyatt. The development of partnerships with established local care services has been a key factor in the success of the community outreach team in ensuring accessibility of mental health services

This article describes the changes that South Birmingham Mental Health NHS Trust has made to improve its services for ethnic elders and focuses particularly on the development of culturally appropriate services for Irish, Black, African-Caribbean and South Asian communities. Papadopoulos et al³argued that culturally appropriate care should be at the heart of mental-health service provision, and this paper describes the approach taken by the Older Adult Directorate of South Birmingham Mental Health NHS Trust to meet this challenge.

Although there are a number of day care services for elders from ethnic minority communities in South Birmingham, there was no culturally specific mental health provision. It was identified that the mental health needs of these communities were not being met, for a number of reasons. The article will also outline the approach taken by the Community Outreach Team, set up to work with elders from Black and ethnic minority communities, and an Irish Working Group, established specifically to look at the needs of Irish elders with mental health problems. Finally, potential future developments of the mental health service will be discussed and considered.

The NHS Plan¹ and the National Service Framework for Older People² both identify the need for NHS and Social Services to work towards ensuring that their services are culturally sensitive to the needs of people from Black and ethnic communities. Translating this rhetoric into action, however, is one of the greatest challenges facing the statutory care services as they attempt to modernize their services and develop them in ways that combat inherent racism, and reflect the cultural diversity of the UK in the 21st century.

Through its ethnic monitoring of service users, the Older Adult Directorate recognized that the uptake of its services was not representative of the cultural diversity of the population of South Birmingham, where approximately 18 per cent of the total population aged over 65 years is made up of ethnic minorities . The number of elders from ethnic communities using the Directorate's services should have been greater and this raised concerns around accessibility of services.

The Irish are one of the largest ethnic groups in Birmingham⁴, yet the literature is limited by identification of ethnicity with skin colour⁵, and for this reason it has been thought that the Irish do not warrant special attention6. However, the Irish are grossly over-represented as users of the psychiatric services, and are more that twice as likely as native-born people to be hospitalized for some forms of psychological distress⁵. The Irish too experience racism; particularly in Birmingham, where events such as the 1974 pub bombings have intensified anti-Irish feelings⁷.

A number of areas were identified within the Older Adult Directorate that would address issues of cultural sensitivity, such as the interpreting services. Language is a major barrier for some communities when accessing health services and so a clear working protocol was devised for Directorate staff to help them access appropriate interpreting services, particularly for people from South Asian communities. As religion is an important part of culture, religious artifacts representing multi faiths were also made available in the Directorate inpatient settings. Food was provided that met the individual's cultural and religious dietary needs, and culturally specific reminiscence resources were developed. Recruitment was focused to attract staff representative of South Birmingham's Black and ethnic communities.

While these initiatives undoubtedly increased the cultural sensitivity of existing services, it did not increase or improve the accessibility of our services to older people from Black and ethnic communities with actual or potential mental health problems. Midgley8 described the linguistic and cultural barriers that prevent South Asian people in particular accessing health services and the challenge that this poses for the NHS. A literature search indicated that among older Irish people there can be a mistrust of health services, and a lack of cultural awareness among staff, that can act as a barrier to them accessing services. For example a lack of understanding of the Irish language and culture can lead to misinterpretation and misdiagnosis. Williams and Mac an Ghaill9 described a situation where an Irish woman told her social worker that she had been out 'getting messages' (running errands for neighbours), and the social worker took this as an indication of mental ill-health.

A Community Outreach Team was set up, with a remit to develop care partnerships with local Black, Irish, and ethnic community services.

The Community Outreach Team made contact with established Black, Irish and ethnic day services in local neighbourhoods, initially on an informal basis, and once a relationship was established offered the staff working in these centres training in mental-health awareness. The training packages focused on areas such as the psychological aspects of ageing, depression, and dementia, and the team also facilitated practical training for staff in the form of lifting and handling. The Community Outreach Team also took the opportunity to work alongside day-centre staff in African-Caribbean, South Asian, and Irish centres to understand the general work they carried out and also to learn and absorb from them the cultural components of their care delivery.

It became clear that while none of these ethnic day services were labelled 'mental health,' and in some cases the existence of mental-health problems in their client group were denied, there were clients attending these centres who were suffering from mental health problems. For example a number of clients were identified who were past users of South Birmingham Mental Health Services and who had been placed in an African-Carribean residential complex because it could meet their social and cultural needs, but not necessarily their mental health needs should they become unwell. The Community Outreach Team were able to advise and support the residential staff on strategies to engage with, and manage, these clients and importantly gave them a point of contact should the clients' mental health deteriorate to the point that they needed specialist input from mental health professionals.

Another example concerned an Asian elder with dementia who had been in receipt of the Directorate's mainstream day services and who had had failed to settle in any of them. The Community Outreach Team requested a placement at a day service for South Asian Elders, with the proviso that they would support the gentleman during his attendance there. It was the success of this placement that led to the development of a more formal service development.

In partnership with the South Asian day centre and the Alzheimer's Society, a facility was developed for Asian elders with dementia at the day centre. The Community Outreach Team provided the experienced mental health staff, along with a support worker from Alzheimer's, herself a member of the South Asian Community with extensive language skills. A 6-place one day a week service was established, with the Alzheimer's Society paying for the room rental and travel costs. Figure 3 illustrates the monthly attendance figures over a 6-month period.

Although a separate room for the mental health service has been identified within the Asian day centre, this is essentially for specific work with the clients, and integration with mainstream clients attending the day centre is both encouraged and welcomed. A Carers Support Group has now also been established.

Links have been established with Irish day centres, the Irish Welfare Centre, and local Catholic churches. It is hoped to establish a regular outreach service, in order to provide older Irish people and their carers with access to a mental health professional's expertise in their own community.

The Community Outreach Team is also working alongside two African-Caribbean Centres for older people, essentially with the same agenda; to raise awareness of mental health in Black and ethnic elders, to assist in the timely detection, care, and treatment of Black and ethnic elders with mental health problems and to improve accessibility to the Directorate's services.

The work being carried out by the Community Outreach Team has been recognized as an NHS Beacon for Older People with mental health problems and a dissemination programme is underway to inform other interested NHS and Social Services departments of the work being undertaken in South Birmingham.

Ideally the aim is to extend this service further, if and when resources come along, but opportunity and creativity also have a part to play in service development. For example, a vacant community nurse post in a geographical area of South Birmingham with a very high South Asian population has been converted to a South Asian Community Development Worker post and filled with an Asian speaking mental health worker. This post will further strengthen the Community Outreach Team and the South Asian Community Development Worker will also liaise with GPs and primary-care staff around mental health issues within the older adult population of South Asian elders.

The work being carried out with ethnic elders is only a small start and there is a great deal more to be done if the Directorate is to fully meet the challenges of ensuring accessibility and developing culturally sensitive services. The Community Outreach Team is also looking at how it can engage with the large Chinese community in South Birmingham. The Team has also developed a cultural awareness training package that will be delivered to staff within the Older Adult Directorate and this will also include placements in Black and ethnic community centres in order to close the practice and theory gap. Reciprocal placements in our services for staff working in Black and ethnic community services will also form part of the cultural awareness training approach.

From the experience of the Community Outreach Team the starting point has to be partnership working with established neighbourhood ethnic community services. We have found that these established services have a good reputation and standing in the community, therefore making access to potential clients easier. It is also important to recognize a degree of 'taboo' around mental illness in Black and ethnic communities. By working alongside staff from the Black and ethnic community services, and by providing mental health training to them, this will hopefully reduce this 'taboo' and lead to a clearer understanding of the causes of mental health problems in older people from Black and ethnic minority communities.

Ultimately the goal and the challenge for NHS services is to ensure accessibility to mental health provisions for all people from ethnic communities and this will require culturally sensitive services to be at the heart of the NHS.

TR Downes is Community Services Manager, B Allcock RMN is Day Hospital Manager, A Smythe is Staff Nurse, JA Sutton is Assistant Psychologist, J Wyatt is Home Support Manager, South Birmingham Mental Health NHS Trust Correspondence to: TR Downes, Hollyhill Nursing Home, Rubery Lane, Rubery, Birmingham

References

1. Department of Health. The NHS Plan. 2000; HMSO, London

2. Department of Health. The National Service Framework for Older People. 2001; Department of Health, London

3. Papadopoulos I, Tiki M, Lees S. Cultural competence in care. Open Mind 2001; 110: 20-21

4. Williams I. Research Findings of the Birmingham Irish Elders Project. 1999; Irish Welfare and Information Centre, Birmingham

5. Bracken PJ, Greenslade L, Griffith B, Smyth M. Mental health and ethnicity: an Irish dimensio. Br J Psychiatry 1998; 172: 103-5

6. Norman A. Triple Jeopardy: Growing Old in a Second Homeland. Policy Studies in Ageing No 3, Centre for Policy on Ageing, London

7. Hickman MJ. Religion, Class and Identity: State, the Caholic Church and the Education of the Irish in Britain. Avebury Press, Aldershot

8. Midgley S. 2001. Speaking the same language. Public Finance 2001; 34-5

9. Williams I, Mac an Ghaill M. Health, Accommodation, & Social Care Needs of Older Irish Men in Birmingham. 1998; Birmingham Irish Community Forum, Birmingham

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