Blacks and psychiatry: a framework for understanding access to psychiatric services

In efforts to improve the acceptability of psychiatric services and their ease of access, the issue of how people get psychiatric help when they need it is one of growing concern. There is now increasing evidence that psychiatric services operate differently for black and white people in Britain, and much concern that services may differentially disadvantage blacks (Francis et al, 1989). A number of studies indicate that Afro-Caribbeans are over-represented among compulsory admissions (e.g. Ineichen et al, 1984). In addition, there is evidence of a higher level of police involvement and a lower level of GP involvement in admissions of Caribbean patients (e.g. Harrison et al, 1988). How ever evidence of differential service use is incomplete. To date there has been little consideration of any overall framework for understanding differential uptake of services. As a result efforts to improve ser vice provision are likely to be piecemeal and ignore the complex set of interactions between different parts of services and their users. A clear framework for understanding' service operation is therefore

In efforts to improve the acceptability of psychiatric accident and emergency provision or the various services and their ease of access, the issue of how liaison psychiatry services available. Such access may people get psychiatric help when they need it is one of be particularly common among those who construe growing concern. There is now increasing evidence their problems as physical rather than psychiatric or that psychiatric services operate differently for black those whose admission has been precipitated by a and white people in Britain, and much concern suicide attempt. These services are usually readily that services may differentially disadvantage blacks accessible and may be considered a more accept- (Francis et ai, 1989).
able source of help given the stigma attached to A number ofstudies indicate that Afro-Caribbeans mental illness. The quality ofliaison between medical are over-represented among compulsory admissions and psychiatric services is likely to determine the (e.g. Ineichen et ai, 1984). In addition, there is effectiveness of this route. evidence of a higher level of police involvement and Although not well documented, it is becoming a lower level of GP involvement in admissions of increasingly clear that some people present them-Caribbean patients (e.g. Harrison et ai, 1988). How-selves directly to psychiatric services, either by themever evidence ofdifferential service use is incomplete. selves or at the instigation oftheir relatives or friends.
To date there has been little consideration of any The use of this route may be increased by the availoverall framework for understanding differential ability of 'walk-in' psychiatric emergency services. uptake of services. As a result efforts to improve ser-The location of such services, together with their vice provision are likely to be piecemeal and ignore acceptability and the way in which they are perceived the complex set of interactions between different by the local community, may also be important. parts of services and their users. A clear framework With the development of community mental health for understanding-service operation is therefore centres and demise of remote psychiatric hospitals, essential.
use of this route is likely to increase. Probably the best articulated model now available The GP and primary care facilities continue to is the 'filter model' of Goldberg & Huxley (1980) provide an important point of access to psychiatric which describes the routes people take to psychiatric services as described by Goldberg & Huxley (1980). care. With its emphasis on the role of the GP, this As the number of statutory and voluntary commodel fails to encompass the evidence concerning munity support agencies increases, they are likely to routes taken to psychiatric care by black patients. It have a more important role both in the provision of also fails to incorporate those people who present care and in mediating access to psychiatric services, themselves directly to psychiatric services (emerg-in theory, such agencies should be more responsive ency clinical, wards, etc.); those who come by way to local needs and therefore have the potential for of general medical services (accident and emergency providing a more acceptable form of access to help. departments, liaison services, etc.); those who come Clearly, if services are to be delivered effectively the through the legal system (courts, police, etc.); or links between such agencies and psychiatric services those whose initial contact is with one of the increas-are of crucial importance. Similarly, the training of ing number of voluntary sector or social services. If psychiatric workers in liaison work with such the variety of ways in which people gain access to agencies, and the training ofsocial services/voluntary psychiatric services is to be understood and system-sector workers in detection of psychiatric problems atically investigated a more comprehensive model is and how to access resources is vital. required. Fig. 1 illustrates such a model.
Within inner city areas access to services by way In this model it is proposed that there are five of the police and legal system is an unfortunately major routes of access to psychiatric services. Medi-common occurrence (Rogers & Faulkner, 1987), and cal services form one such gateway by way of either one that is excessively used by black clients (see above). Because of its aversive nature for the clients concerned, it is clearly desirable to minimise this form of access to services. The availability and acceptability of alternative services would appear to be a critical factor.
Continuing psychiatric care may be offered within hospital-based and community psychiatric services themselves, but it may also involve social services, voluntary sector, GP input and family or friends. The relative balance between these will, at a service level, be determined by local availability and co-ordination ofservices. However, this may be another area where services operate differently for blacks and whites. Perkins & Rowland (1986) found that 500/0 of white patients as compared with only 23 % of black patients referred to a psychiatric rehabilitation and continuing care service were successfully engaged with that service. This may be a reflection of black patients' experience of services prior to their referral for continuing care. Compulsory admission and detention, and police involvement in the initial stages of contact are likely to lead to a negative view of psychiatric care that persists throughout the persons contact, and a higher chance ofdenial of the need for help.
Thus it is proposed that the relative importance and use of different means of accessing psychiatric care will vary depending upon a series of individual and service parameters. On the individual side, the way in which people perceive or understand the problems they experience, their knowledge and understanding of available services (psychiatric and non-psychiatric) and the perceived 'user-friendliness' ofservices will all be important. In addition, the range of services available, their geographical location, the psychiatric expertise of non-psychiatric services and the relationship between both psychiatric and nonpsychiatric services and the community at large will be important.
There is no blueprint for the provision of effective psychiatric services: a different balance between agencies might be appropriate in different areas. However, with current efforts to change services it is important that providers investigate the patterns that exist and the impact ofchanges upon these. With the devolution of services it is not sufficient to look at the operation of articular aspects (e.g. a general practice, a community mental health centre) without consideration of the overall picture.
The evidence ofdifferential service usage by blacks serves as a stimulus for the development ofa broader perspective of service usage. The framework presented here is one of relevance to all service users. It offers a structure for investigating local patterns of provision and usage, and offers some relevant variables to consider in changing and developing services. Medical care in general hospitals is a collective activity and liaison psychiatrists may become part of this process. Cornerstones ofsuccessful management are co-operation with colleagues and 'teamwork', although these elusive goals are not always achieved. A shared uniform is one possible solution to improve this teamwork, the white coat being the livery of the hospital doctor. Furthermore, patients may appreciate a uniform. One survey of 200 North American general hospital in-patients showed the white coat to be surprisingly popular (Dunn et ai, 1987); 650/0 of those replying wanted to see their doctor in a white coat. But the white coat is often unpopular with doctors and perhaps a more relevant question is whether it makes any difference to patient behaviour. In psychiatric wards this has been studied in relation to nursing uniform. One study (Klein et ai, 1972) could detect no difference in patient behaviour under a variety ofdress conditions, but another study did find an effect (Rinn, 1976). In a series of six week periods, when the staffwore street clothes, there was a reduction in aggressive behaviour, medication refusals and self-punitive responses as compared to similar periods of study with staff wearing either uniform or a mixture ofuniform and street clothes. It was concluded that street clothes create a therapeutic milieu. No parallel studies have been undertaken in general hospitals, so the psychiatrist can choose.
Does he join the company and wear the uniform or are there other ways ofworking with general hospital patients and colleagues?
To find out what happens in practice, a small survey was undertaken. A short questionnaire was sent to consultants in adult mental illness in the Oxford region and to selected senior registrars working with the Liaison Service in Oxford (n = 66). A short letter of explanation was included.

Findings
Of 66 questionnaires sent, 50 were returned giving a response rate of 75%. The questions and responses are set out below: Do you ever wear a white coat in the course of your clinical practice? Eighty-eight per cent of respondents never wore a white coat at any time. The frequency with which this group worked in the general hospital varied from daily to less than one visit per month, with a modal value ofweekly. Comparison with the 12% ofrespondents who did use a white coat is difficult because of the sevenfold difference in size of the two groups. However, among white coat wearers, the modal frequency for general hospital work was daily with a range from daily to less than once per month. This