Mental Health Services: Black and Minority Ethnic Communities
Lord Boateng
To ask Her Majesty’s Government what progress they have made in improving mental health services for people from black and ethnic minority communities.
Lord Boateng (Lab)
My Lords, in moving the Motion in my name on the Order Paper, I pay tribute at the outset to the very many black and minority ethnic patients who have suffered from what the Prime Minister rightly described as “a long-standing injustice” —discrimination in the mental health service of our NHS. I want also to pay tribute to their carers, their families and the clinicians who have stood behind and alongside them in what has often been a difficult and challenging fight to have recognised the injustice to which they have been subjected.
This injustice is rooted in the issue of race. There is no escape from that reality, however uncomfortable it may be. All the evidence—from the Mental Health Foundation and the Prime Minister’s own excellent race disparity audit—shows that, if you are from a black or minority ethnic community, you are more likely to be hospitalised, to be in receipt of pharmaceutical rather than talking therapeutic interventions, to be detained or to have less good outcomes than your white counterparts. You are also more likely to feel alienated and ill served by the mental health service. This is the sad reality of the conditions that black and minority ethnic patients face in the mental health system.
In earlier debates in this House, we have heard that it is the Secretary of State’s wish that safety should run like a golden thread through the NHS. This is a commendable wish but, sadly, for black and minority ethnic people NHS mental health services are not a safe place. Too many have died or been the subject of abuse for us to be able to say this with any degree of certainty.
In his ground-breaking report on the tragic circumstances surrounding the death in secure hospital accommodation of Rocky Bennett, Mr Justice Blofeld referred to institutional racism in NHS mental health services. He referred to the services received by black and minority ethnic communities as “a festering abscess” on the NHS. I fear that many people who have experienced what the black and minority ethnic communities go through in the NHS will concur with that verdict.
The Prime Minister has done the nation a great service by highlighting the injustices in the treatment of black and minority ethnic people within the NHS and by initiating an independent review of the Mental Health Act. I commend and welcome that, but it is important to remember that it is only one part of the picture. The wider picture is the context in which the Act is administered. So we look forward to the outcome of the independent review. We hope that the Government will legislate urgently on it and that it will have rights-based conclusions. These will enable patients to access services that are underwritten by capacity within the health service so that we can meet the norms that we look to achieve. We hope for all those things.
In the meantime, it is vital that we address the issue of patient care now. I hope that in the course of this short debate we will be able to come up with some practical recommendations and proposals in that regard which can be implemented—and implemented as a matter of urgency. Over the years, there have been many inquiries and studies in this area. They were initiated by successive Governments with good intentions but the reality is that, in the main, they have been only partially implemented and when they have, I fear that they were underresourced. I urge the Minister, as she takes forward the Prime Minister’s initiative on mental health, to ensure that along with the recommendations come resources, a timescale for those recommendations to be implemented and, importantly, a gathering of the data to enable us to judge the outcomes. Without the data, we will not be able to make the judgments or have the insights necessary to establish whether patients are getting the care that they need.
It is also important that we spread good practice. I have been a very junior Health Minister and I know that the holy grail in the NHS is to spread good practice. There is some great stuff going on out there, even in the field of BAME mental health, but there is also some terrible stuff. The challenge for Ministers, service providers and commissioners is in how we spread the good practice and ensure that inevitable pressures on budgets do not lead to neglect of this area because it is simply all too difficult. It is difficult and complex; we are dealing with not just an illness but racism and the encompassing social disadvantage and exclusion. No one pretends it is easy but we have to address it, and in ways that make a practical difference on the ground to hard-pressed clinicians, to hard-pressed community workers and, above all, to the patients and their carers.
I shall make a number of brief points on some positive ways forward. First, it is important to recognise the interface between local authorities, health authorities, hospitals and providers in this area. I believe—I championed this as Chief Secretary to the Treasury and I go on doing so—in having pooled budgets wherever you possibly can. I am also driven to the conclusion that although the Treasury does not like hypothecation or ring-fences, there is no alternative when it comes to mental health. If we do not ring-fence then I am afraid, for reasons that many Peers in this Room who have day-to-day experience of it will know, it simply will not happen. I urge the Minister, as she takes forward these proposals with her colleagues, to look at pooled budgets and ring-fencing.
Secondly, it is important that we find ways of ensuring that patients themselves have a voice and that patient advocacy is taken seriously. My early experience as a young community lawyer in this area showed that patients need advocates. They may need community advocates and sometimes they need professional advocates. We have to look at how they access help in that regard.
My third point is on early intervention. I fear that, when we look at what the evidence shows in relation to black and minority ethnic communities, all too often it is the police and the prison officers who have to deal with this issue, because there has been no earlier accessing of services. I have been Police Minister and Prisons Minister. I know just how hard it is for those professionals, without adequate training or support from the surrounding services, to deal with mental health patients in custodial settings and in circumstances in which the police are called to the scene on the streets or in private premises. We have to look at ways, whether community street triage or whatever, of ensuring that the police and prison services get the professional support, and the funding underpinning that, to enable them to respond and, even more importantly, that these communities have a sense that they can access services before they reach that acute and desperate level; that is, early intervention.
Finally, progress and best practice in this area have tended to come when the community and the voluntary sector in the community have been involved. There are some excellent examples in Brent, Lambeth, Birmingham and elsewhere of black and minority ethnic community-led voluntary organisations working with GPs and hospitals to deliver services. Very often, these organisations are the first to get cut at a time of pressure on local authority and health budgets. They are, in fact, the last organisations we should be cutting out of the picture, because they are a depository of good practice and understanding and a gateway into the service for the community.
I end on that, save to say: we know what needs to be done. I sense that across the Chamber, in both Houses and in the wider community there is a desire and a will that it should be done, so let us adopt what I learned in South Africa as a particular approach when there is a will and when there is an outcome. It is encapsulated in this one word “Vukuzenzele”, which simply means, “Let’s get on with it. Let’s do it”.
Baroness Hussein-Ece (LD)
My Lords, I thank the noble Lord, Lord Boateng, for securing such an important and timely debate on an issue of real interest to many people and communities across the country. Good mental health is essential for a healthy society, and it is positive that recently there has been a greater emphasis on mental health and calls for it to be afforded parity with physical health. I have worked with people with mental health difficulties. I worked in Tottenham in mental health services, I was a councillor in Hackney and in Islington, and I sat on one of the first mental health and social care trusts, the Camden and Islington trust, which was established about 15 years ago to bring mental health and social care together—so we have come a long way. However, the figures show that black and minority ethnic communities are still not getting access, quality services and, as the noble Lord, Lord Boateng, said, early intervention at the appropriate time.
Yesterday, while preparing for this debate, I read that there are now 5,000 fewer mental health nurses than there were in 2010. Will the Minister say whether that is the case—and, if it is, what is being done to recruit more mental health nurses?
Figures show that in recent years people from the black community have had the highest rate of detention in hospitals under the Mental Health Act—56.9 per 100 people—and people from Asian groups have had the second-highest rate. These are shocking and very stark figures. We know that socio-economic factors contribute to these findings. We know that coming from a poorer background, living in an inner city and encountering poverty and discrimination contribute to poor mental health. Stigma is attached, and there is a lack of willingness to seek help when necessary because families and individuals worry that they may be stigmatised within their own community.
For a long time there has been a lot of research—it is not new research; it has been going on for many years—and many findings about the challenges facing BME communities. However, so far there has not been significant change to improve the outcomes and satisfaction consistently—this is the important point—across the country. There are pockets of excellence, and some very good services, but they are not always accessible to people across the country. Health services and local councils, as I have said in my previous roles, have a range of statutory duties and functions related to mental health and supporting mental health well-being. From housing to public health, social care and leisure services, councils lead local services that help prevent mental ill-health and which support early intervention and provide ongoing support.
The evidence, some of which was referred to by the noble Lord, is overwhelming. It always shocks me—it did when I first read it 15 years ago, and it still shocks me now—that people from black and minority ethnic groups living in the UK are more likely to be diagnosed with mental health problems, more likely to be diagnosed and admitted to hospital, more likely to experience a poor outcome from their treatments, and less likely to have talking and other therapies.
It is particularly shocking that African-Caribbean people are still more likely to enter mental health services via the courts or the police than from primary care, which is the gatekeeper for treatment for most people. They are more likely to be treated under the Mental Health Act and more likely to receive medication, and are often overrepresented in high and medium secure units and prisons. This was the finding of a report by the Mental Health Foundation in 2014. I would be very surprised if those figures have changed dramatically in the intervening years. It is very disappointing.
I will turn briefly to youth justice. The Taylor review in 2016 indicated that many children and young people who offend have mental health, behavioural or learning difficulties, and often these conditions have gone undiagnosed. These problems can often be the root cause of a child’s offending, and frequently are a barrier to progress in education and proper engagement at school. This is particularly concerning because as many as 60% to 70% of children and adolescents who experience mental health difficulties have not had appropriate interventions at an early age. Can the Minister say what is being done to address this appalling statistic?
In a recent review of child and adolescent mental health services by the CQC, waiting times were highlighted as a big concern. Young people themselves, when they were interviewed for the report, said that they felt that the waiting lists were the big problem and that when they reached crisis point they ended up in A&E. Staff in A&E are already at breaking point and are not trained sufficiently to deal with this. This is a real problem and creates a revolving door for many young people.
At school, mental health support is not always there. As we have already heard, early intervention support is not always available, so young people and children in schools who need it are often quickly labelled as “naughty”, “a troublemaker” or “difficult”, and find themselves excluded or facing time out of school, when in fact what they and their family need is proper support in dealing with these early signs. There is a great disparity in the way BME communities, children and young people are treated. There is a plethora of research and information which highlights this. We do not need to prove it; we know it exists. What we are doing is highlighting what we can do about it.
The commission called for a patients and carers race equality standard to be piloted in mental health, to ensure that there is no discrimination against particular groups of patients, alongside other efforts to improve the experience of care for people from BME communities, including staff training. Will the review of the Mental Health Act consider how we can prevent more people from BAME communities reaching mental health crisis in the first place?
What steps will the review of the Mental Health Act take to ensure that the views of a cross-section of society are being represented? It is really important that views are heard. If we want to reduce the inequalities in mental health for BAME communities, we need to make health services work for them. That means listening, particularly to those who are already in the system, their families and their carers, who are constantly trying to get the best services for family members. It also means supporting the voluntary and community organisations that are working to meet the needs of communities. Without this, it would be impossible for BAME people to have confidence in mental health care services.
Lord Ouseley (CB)
My Lords, I thank the noble Lord, Lord Boateng, for securing this debate and for his eloquent introduction to it. No one is better equipped to articulate this issue than the noble Lord, with his experience not only on the streets across London and other parts of the country but in occupying high office.
My own experience with mental health services goes back some four or five decades, running local authority adult care services at a time when mental health services were almost invisible. Predominantly white mental health patients were hidden away, left in corners or locked away. Very rarely were any specialised services prioritised for people with mental health conditions. That is the memory that I still hold of seeing how mentally ill people were treated. Thankfully, we have moved on and that era is now over. We are better aware of the needs of people with mental health disorders.
As the noble Lord, Lord Boateng, pointed out, what was important during that period was community-based responses to the needs of people within those communities who were being deprived of the right diagnosis and the right care. The extent and complexity of mental health issues require careful consideration to determine the appropriateness and adequacy of provision to meet the different and varied needs of patients and sufferers, as well as providing support for their dependants and carers. That was the situation then and it remains so now.
Another complexity within this debate is how we respond to an increasingly diverse population, with a wide range of ethnic minority groups experiencing some degree of adverse mental health conditions. Given language and cultural differences and the way that people interact with standardised perceptions of monocultural responses, there are likely to be wrong diagnoses and inappropriate prescriptions. That has been the case in responding to the mental health needs of black and minority ethnic sufferers over the years.
Incremental improvements in service provision have been driven by representations and campaigning by voluntary community groups. That has been backed up by community representation and research studies showing ethnic disproportionality and race disparities, with the evidence of discriminatory treatment. Data from surveys and studies consistently confirms variations in the prevalence of disorders affecting different ethnic groups and requiring appropriate responses to meet their particular needs.
Arguing about the particular and different needs of ethnic minorities is often seen as pleading for special treatment. However, we should understand that, by responding to the different needs of BAME patients and sufferers, the NHS is able to enhance its responses to all sufferers and patients by recognising the importance of dealing with each individual in an evidence-based and appropriate manner. It is the way in which we are able to deal with one particular problem that exposes the weaknesses of not treating people as individuals and diagnosing their needs in a proper and appropriate way. The ultimate benefit of ending discrimination and disproportionality in mental health services as they impact on black and minority ethnic communities will be the essential knock-on effect of making mental health services provision more appropriate for meeting the individual needs of every mental health patient and sufferer in the country.
Race and ethnic disproportionality is a fact, as the noble Lord, Lord Boateng, pointed out. It is a reality. With one in six adults in the UK and one in 10 children experiencing some form of mental health condition, the NHS is under pressure to respond with adequate resources—one issue already picked up—expert practitioners, clinicians, carers and the provision of advice and support to meet the medical and care needs of patients and sufferers and, to stress once again, their families and those who are supporting them.
The Government’s recent Race Disparity Audit reveals that, in the general adult population, black women were recently assessed as more likely to have experiences of common mental disorders such as anxiety and/or depression and black men were the most likely to have experienced psychotic disorders. There is nothing new in that. Most significant, and well known for years among the black and minority ethnic communities, is the fact that black adults were more likely than adults in any other ethnic minority group to have been sectioned under the Mental Health Act.
Assumptions made by some police officers when attending reported incidents, particularly involving black and ethnic minority men, often result in them being detained in police cells rather than receiving appropriate treatment for their mental health disorders. Many of the deaths in custody, which have indeed disproportionately involved black and minority ethnic men, appear avoidable in retrospect. Some have even received inquest verdicts of unlawful killing without any consequential prosecutions or justice for the families of the deceased. The use of unreasonable force in such scenarios has been highlighted by campaigning organisations, and the recently reported use of Tasers by police entering mental hospitals when called on is another issue that must be addressed, because it is of concern to the community.
With regard to the progress being made to improve mental health services for black and minority ethnic communities, it is important to get some response from the Minister about the guidance alluded to by the noble Lord, Lord Boateng, on good practice: how it is being disseminated and implemented, the action that should flow and who is involved in assessing the effectiveness of the implementation and the process. Are community organisations, families and, indeed, patients part of that process? There is also concern about the involvement of community groups in helping to reduce barriers and improve the uptake of and access to psychological therapies to all sections of the community.
In conclusion, my final point is one which probably deserves a lot more time. It is the increasing number of children and young people who are affected by mental health conditions. It would be useful if the Minister could tell us what systems are in place for the rapid and early identification of children in need of specialised services and for them to be referred to the Improving Access to Psychological Therapies programme, with access to evidence-based and appropriate interventions.
The Lord Bishop of Worcester
My Lords, I, too, am very grateful to the noble Lord, Lord Boateng, for securing this debate and, like the noble Lord, Lord Ouseley, pay tribute not only to his eloquent introduction but to all he has done in this area. We owe him a great debt of gratitude.
Some of the evidence which has already been cited—there is lots more— concerning black and minority-ethnic individuals and mental health is a dreadful indictment of our society. One of the most shocking statistics to me is that UK minority-ethnic individuals are 40% more likely than white Britons to come into contact with mental health services through the criminal justice system rather than through referral from GPs or talking therapies. There have been a number of explanations for these differences, including limited awareness of or reluctance to engage with statutory services at an early stage of illness, possibly due to previous poor experiences, the belief that services are not culturally appropriate, or the stigma around mental health in some communities. Cultural differences in how mental health is perceived may also decrease the likelihood of individuals seeking care before reaching crisis point.
However, it has been recognised that differences in treatment for individuals experiencing mental health issues also arise from what is politely described as cultural differences on the part of the onlooker—in particular in relation to a number of high-profile cases involving Afro-Caribbean men, to which the noble Lord, Lord Boateng, has already referred. The problem arises from racialised views of a black man being more aggressive or out of control. Such views are racist and a terrible indictment on our society.
It is good that organisations working with black and minority-ethnic communities around mental health have recognised and responded to many of these issues. Understanding them and highlighting best practice, as has been indicated, is crucial to tackling poor mental health outcomes in black and minority-ethnic communities. I fear that the Church’s record has not always been good in its attitude to mental health or indeed, in its attitude to black and minority-ethnic people. We are now working very hard on both, and I hope that we have something positive to offer.
Medical Ethics: A Christian Perspective, published by the Mission and Public Affairs Council as a position paper, articulates salient theological themes informing Christian approaches to healthcare in general and adumbrates four guiding ethical principles arising from them: affirming life; caring for the vulnerable; building community; and respecting the individual. I make reference here only to the imperative to affirm life. That is to say that every individual life has purpose, value and meaning, even if some individuals may doubt that for themselves. It also means that we wish to see everyone attain the highest quality of life possible in whatever circumstances they find themselves. A civilised society is one that fundamentally affirms life and ensures that this and other benefits and protection are fairly experienced by all its members.
In practice, of course, this means giving particular attention to vulnerable individuals and groups. History indicates that the powerful will often neglect or abuse the vulnerable unless strong and specific action is taken to protect them. Caring for the vulnerable, however, goes beyond issues of protection. It includes ensuring that vulnerable people are supported, cared for and enabled to live fulfilled lives, and being afforded the same respect as other members of society. That is what is at stake here. You do not have to be a Christian to sign up for all that.
As the noble Lord, Lord Boateng, suggested, most people agree on what needs to be done—on both sides of this House, in the other place, and in wider society. If we are to be a truly civilised society, we need to put resources into ensuring that these problems are properly addressed. The noble Lord, Lord Boateng, has suggested some sensible, practical ways forward while we await the outcome of the welcome inquiry into mental health legislation which the Prime Minister has announced.
What can the Church do? We have been looking at this as part of a black and minority-ethnic concerns mental health project. In Breaking the Circles of Fear, the Church of England Mission and Public Affairs Council published a report in which we make it clear that in addition to church leaders, church workers and chaplains becoming more fully aware of mental health issues among black and minority-ethnic individuals, we want to ensure that cultural competence is displayed by all those ministering to individuals with poor mental health.
That could have a large effect on wider society. The Church has a ready-made network of communities, buildings and pastoral contacts that we want to utilise in helping to design and deliver culturally appropriate and accessible services in collaboration with local communities. Being embedded in communities, the Church can play a leading role in helping to educate both communities and health professionals with regard to health issues. At all levels the Church can be a voice for the voiceless, helping to reduce the stigma often associated with early mental illness, and thereby helping to address the problem of the lack of early intervention among black and minority-ethnic individuals.
I stand with the noble Lord, Lord Boateng, in commending the Prime Minister’s initiative on mental health and in pressing for the question of patient care to be addressed in the meantime, before the independent inquiry reports. I hope that the Minister will be able to give assurances on this.
Lord Brooke of Alverthorpe (Lab)
My Lords, I too thank my noble friend Lord Boateng for promoting this important debate and for the very masterly way in which he introduced it. I also welcome the return of the noble Baroness the Minister. I normally speak on alcohol and drugs issues but there is a very strong overlap here with mental health, and I hope to speak on mental health more in the future than I have in the past—particularly on this area, where I have some experience.
As we are aware, the Government’s recently published race audit highlighted differences in the rates of mental illness among different ethnic groups. For example, it is estimated that in the past year psychotic disorders were more than 10 times as prevalent among black men as among white men. With regard to access to treatment, the audit highlighted that white British adults were more likely to receive treatment for a mental or emotional problem compared with other ethnic groups.
The acute care commission report, led by the noble Lord, Lord Crisp, who is here today, helpfully summarised some of the evidence around access to general mental health services. For example, Indian, Bangladeshi and Chinese people had consistently low referral rates to crisis teams, but BME groups, particularly black Caribbean patients, were generally more likely to be admitted to hospital once they had been seen by a crisis team. There is also evidence that some BME groups have more complex pathways into care than white patients, with more involvement by the police and the criminal justice system, as my noble friend Lord Boateng and others have mentioned.
We also know that, compared to white patients, black patients are 53.8% more likely and Asian patients 42.4% more likely to be detained under the Mental Health Act. I therefore welcome the independent review into the Mental Health Act being led by Professor Sir Simon Wessely. I hope that it will provide an in-depth analysis of why this is happening. I hope that the review will also consider how we can prevent people reaching a crisis in the first place and how we can improve crisis services for those who need them most. Therefore, I would be grateful if the noble Baroness could say just what research will be coming out in this exercise and how we are going to establish the main causes behind these problems.
Moving back to services, we know that the literature suggests that there are multiple complex reasons for these differences between ethnic groups. BME groups have higher rates of mental illness, and there are also some psychosocial factors to take into consideration. For example, there is evidence that some BME groups are less likely to view themselves as having a mental illness. In some communities, there is still a large amount of stigma surrounding mental illness and there can also be a mistrust of the services on offer. These factors may lead to patients not seeking help early and thus presenting in crisis.
So why is this still happening? We have known about inequalities in our mental health care system for many years and a number of policies have tried to tackle these issues—for example, there was the Delivering Race Equality in Mental Health Care report as long ago as 2005. These policies have helped to raise awareness of the issues, but the inequalities still remain. What is the Minister’s analysis of why these policies have not had the desired effect and how can we implement policy which starts to improve the current situation?
Next, I would like to focus on the recommendation from the acute care commission, led by the noble Lord, Lord Crisp, which asked for a patients’ and carers’ race equality standard to be piloted to try to improve the experience of care for people from BME communities. What progress has been made on the report’s recommendation that it should:
“Identify a clear and measurable set of Race Equality Standards for acute mental health services by October 2016 and pilot them in a selection of Trusts from April 2017”?
We need to raise awareness of mental ill health and availability of services among BME groups. We need to ensure that there are strategies in place to reduce the stigma of mental illness and to ensure that services are more culturally aware. One recommendation from the guide published by the joint commissioning panel for mental health is that we need,
“targeted investment in public mental health interventions for BME communities”.
What it is being done to ensure that commissioners across the country are starting to take this recommendation on board and act on it?
How can the Government bring together different groups, such as healthcare services, social services, police, community groups, commissioners and, of course, drug and alcohol treatment services, so that patients and carers work together on this topic to develop culturally appropriate interventions and to make real improvements? One problem that I often see is that if someone has a drink and drug problem as well as a mental health one, no attention is paid to the latter. Vice versa, if someone goes into hospital with mental health as well as drink and drug problems, no help is offered to them. They fall between the two and we need to look for ways to bring the services together and avoid a repetition of the problems.
In summary, inequalities in mental health have, as we all know, persisted for many years. Past attempts have not had the impact we would like to see in improving the situation. We need to be united in our campaign efforts to ensure that people from BME groups get the access to mental health services they need. We need to improve public mental health and focus more on prevention than we have in the past. The Five Year Forward View for Mental Health says:
“People with mental health problems, regardless of their age, ethnicity, or any other characteristic will have swift access to holistic, integrated and evidence-based care for the biological, psychological and social issues related to their needs, in the least restrictive setting and as close to home as possible”.
How can we make this a reality now?
Baroness Watkins of Tavistock (CB)
My Lords, I thank the noble Lord, Lord Boateng, for bringing this crucial debate to this House and for exploring many of the key issues so eloquently. I declare my interest as a qualified mental health nurse of some 39 years’ standing, who has worked in south London and in rural communities. I am particularly pleased to welcome the return of the noble Baroness. She qualified as a nurse at about the same time as me. I also thank Kathleen McCurdy, a psychiatrist from Oxleas NHS Foundation Trust, who is working with me at the moment and who has helped me with this speech.
Other noble Lords have already highlighted the huge disadvantage faced by black and minority ethnic people in the area of mental health. They suffer higher incidences of mental illness, higher rates of admission, threefold excess of compulsory detention under the Mental Health Act, longer periods of hospitalisation, negative experiences of services and poorer overall outcomes than the majority of the population.
As the recent race disparity audit highlights, it is impossible to generalise about BME people and health in the UK. Given the multicultural nature of our country, the term encompasses any number of different societies and cultures, each with a heterogeneous population. We have to remember that each patient is a person with their own unique needs within this wider cultural context and with a right to equal and uncoerced treatment for their mental health problems. Co-design between patients, their significant others and health professionals is essential good practice.
As a signatory to the UN Convention on the Rights of Persons with Disabilities, the UK was scrutinised last year by a committee, which was highly critical of our treatment of people with a range of disabilities. Its subsequent report expressed significant concern about the use of physical and chemical restraint in healthcare settings on people with disabilities and expressly noted that this disproportionately affected persons belonging to ethnic minority communities. The committee criticised what it referred to as the,
“absence of a unified State party strategy to review these practices”.
I am optimistic that the current review of the Mental Health Act will offer recommendations on that, but that will of course take time. Indeed, there is plentiful evidence to suggest higher rates of coercive practices when it comes to the groups we are talking about. Not only are the rates of compulsory detention under the Mental Health Act significantly higher for ethnic minorities, in particular Afro-Caribbean men, but research by McKenzie and Bhui suggests that people of BME backgrounds are more likely to be placed in seclusion during their admission and much less likely to be offered psychotherapy or other talking therapies. Even following release from hospital, the use of restrictive practices persists for some ethnic groups. Black men are five times more likely to be placed on a community treatment order than their white counterparts, meaning that they may be recalled to hospital if they do not comply with a set of conditions.
Another aspect I wish to highlight is the interface with the criminal justice system, as many BME patients come into contact with mental health systems not via GPs but via the police, the courts or in prison. Black people are 50% more likely to be referred to the mental health system by the police. Additionally, black people disproportionately make up 25% of prisoners and some 40% of young offenders. Other groups are also over- represented in prison populations, particularly Traveller communities, but none is as highly represented as the BME group.
The Angiolini report, published in January this year, acknowledges the disproportionate number of BME people who die after the use of force in custody. We know from a report by the Equality and Human Rights Commission that 50% of people who die in custody have mental health problems and 20% are black, which is hugely in excess of the 3% black people in the population as a whole. This is perhaps an unsurprising statistic given the number of high-profile cases of deaths in psychiatric hospitals and police custody secondary to restraint, including Seni Lewis, who was only 22 when he died while being restrained by police on a psychiatric ward. He is one of 46 mental health patients who died following restraint between 2000 and 2014. I am optimistic that the Mental Health Units (Use of Force) Bill making its way through the Houses of Parliament will begin to improve the situation by standardising and allowing scrutiny of practice, but it will be a drop in the ocean compared with the cultural and systemic changes required to improve this complex issue.
However, it is important to acknowledge the positive steps being taken and improvements in good practice that already exist—for example, the street triage schemes, in which a mental health professional, usually a psychiatric nurse, accompanies police to incidents where a subject may need mental health support. Initiated in 2013, these schemes have been effective at reducing Section 136 emergency admissions to hospital and may benefit ethnic minority patients who may otherwise be detained unnecessarily in a police cell or at a place of safety.
I was impressed to hear about the Black Thrive scheme, an initiative led by the Afro-Caribbean community in Lambeth to create a positive dialogue around mental health. It is linked to Healthwatch and the local health and well-being board, and aims to help in prevention, access to support and experience.
On workforce and staffing, it is vital to have a workforce that reflects the diversity of the community it serves. The NHS is the largest employer of BME people in the UK, and since its formation has prided itself on employing BME staff from both the UK and around the world. In 2008, 25% of successful applicants to nursing courses identified as BAME, and this number increased to 30% in mental health nursing. Since the scrapping of bursaries for student nurses, the number of applicants to nursing has fallen. Work needs to be done to make nursing an attractive option to minority ethnic students from the UK, particularly in the context of the drop in overseas nurses coming to work here. I have talked before about the importance of continued professional development, and a key part of this is cultural competence. The European Psychiatric Association recommends mandatory training on cultural competence and sensitivity in areas where it is needed.
There is a well-established link between staff satisfaction and subsequent patient experience—when people understand each other. However, BME staff consistently report higher levels of discrimination and bullying in the workplace and are afforded less opportunity to advance their careers. For example, over two-fifths of London’s population and its NHS staff are from BME backgrounds, but only 8% of trust boards and 12% of senior management are from the same background. Will the Minister give due consideration to investing in a diverse and culturally competent NHS workforce that, at all levels of seniority, reflects the multicultural society in which we live and is trained to be culturally sensitive and able to empower patients?
Viscount Younger of Leckie (Con)
My Lords, timing remains particularly tight for this debate. I know that we have only three more speakers but I respectfully ask that they stick to eight minutes and conclude their remarks at eight minutes.
Lord Crisp (CB)
My Lords, it is a pleasure to follow my noble friend Lady Watkins of Tavistock, who is a mental health nurse—an extraordinarily important profession in the whole world of mental health. I also congratulate the noble Lord on raising this important debate. As he said, there has been some improvement but there is much further to go, and it needs to be used and tackled systematically and practically. I note that this is not a simple issue, bringing together as it does issues of race, culture, societal attitudes and epidemiology. However, there should no longer be any excuses for the slow progress that is being made. It has been discussed and thought about for years, and expert guidance is now available from the Joint Commissioning Panel for Mental Health, set up by the Royal College. I declare an interest as an honorary fellow of the Royal College of Psychiatrists.
First, can the Minister say how effectively this guidance on commissioning is being applied, and with what impact? As other noble Lords have said, it is also good to see that the review of mental health has been asked by the Prime Minister to look particularly at the disproportionate numbers of people from black and minority ethnic groups who have been detained under the Act. I ask the question that other noble Lords have asked as well: will this review consider what can be done to prevent people from black and minority ethnic communities reaching mental health crisis point in the first place? We need to stop the flow into the system, not just treat people better when they are in the system.
On my own recent experience and observation, as the noble Lord, Lord Brooke of Alverthorpe, already mentioned, I had the honour to chair on behalf of the Royal College an independent commission on adult acute in-patient psychiatric care, which was made up of a whole group of patients, carers and many people from black and minority ethnic communities. We published a report in February last year—almost two years ago— and as the Minister knows, we are still waiting for the Government’s response. I thank her colleague, the noble Lord, Lord O’Shaughnessy, for his recent reply to my Written Question, which assured me that the response will be published soon—indeed, I think he said “shortly”.
We made headline recommendations about treating mental and physical health with parity of esteem. The two big issues were: why do we not have a four-hour standard for mental health as we do for physical health; and why are so many people still being admitted for general psychiatric issues out of their own area, sometimes over long distances?
Those were the headline issues, but we also addressed issues relating to people from black and minority ethnic communities. We found clear evidence of the problems that people have talked about here. We saw and heard from people about their experiences. We also saw and heard about good experiences and good practice—both exist within the health service, as the noble Lord, Lord Boateng, said.
We made two specifically relevant recommendations. The first one was about carers. We found that all too often carers were excluded from the initial assessment of patients when they were brought into the service—sometimes with good cause, of course, but in general not; in general it was a routine exclusion of carers. This is related to the points made by the noble Lords, Lord Boateng and Lord Ouseley, about the importance of community-led engagement and voluntary organisations. Carers are a vital source. They provide continuity of experience and advocacy and some level of stability. Their exclusion is probably particularly damaging in cases of people from black and minority ethnic communities who may be feeling disadvantaged within that environment in the first place. We recommended that patients and carers are enabled to play an even greater role in their own care, as well as in service design, provision, monitoring and governance.
I am delighted to say that the noble Lord, Lord Brooke of Alverthorpe, has already mentioned the second recommendation—it is always good when one’s own recommendations are recommended by someone else—but let me spell it out a little more. I suspect people know that in the NHS there is a workforce race equality standard. This is a standard introduced by Yvonne Coghill and colleagues from NHS England which looks at the way in which the workforce within the NHS is treated with regard to a few key indicators about how people from black and minority ethnic communities may be treated differently from others. That was published earlier this year and is starting to have an impact and effect because trusts are able to see the actual experience of their staff. We said as part of our review, “Why is there not a patient and carers race equality standard? Why is there not a standard that looks at the experience of patients and carers?” This could potentially have the same impact of drawing to the attention of trust management and trust boards—who sometimes do not know about these things because they are not close enough to the ground—the experience of their patients and carers. It is interesting that one was introduced in the NHS for staff before one for patients and carers, but I will not go down that route. We recommended that a patient and carers race equality standard should be introduced and piloted in mental health because it was evident that there was a problem in that area.
I conclude—satisfactorily within my time, I hope—by asking a final question: when will we receive our response; and, when the Government respond, will they accept these two recommendations on carers and, importantly, on the patients and carers race equality standard?
Baroness Tyler of Enfield (LD)
My Lords, I, too, congratulate the noble Lord, Lord Boateng, on the incredibly powerful and vivid way in which he introduced this debate. I will remember for a long time the words about this being a festering abscess.
The fact that we are having this debate shows not only how complex and critical the subject is but, frankly, how little progress has been made in improving mental health services for people from the BAME communities, despite repeated reports over the years highlighting the issues, debates in this Chamber and elsewhere. We pride ourselves on being a nation of diversity and equality, and yet the Government’s recently published Race Disparity Audit demonstrates that this is an issue in which we have patently not managed to provide anything like an adequate solution. Indeed, the NHS adult psychiatric survey published only last year showed that black adults were the least likely to receive treatment for mental illness.
The NHS’s The Five Year Forward View for Mental Health states:
“There has been a transformation in mental health over the last 50 years”,
due to “advances in care” and,
“the growth of community based mental health services”.
Obviously, such advances are welcome. However, research over that time period has shown repeatedly that people from BME communities have more adverse experiences and negative outcomes from mental health care, in terms of access to care and experience and type of care—things we have already heard about today.
Despite earlier targeted programmes, such as the Department of Health’s Delivering Race Equality programme—back in 2005, for those with a long memory —these inequalities have not improved. There are still significant ethnic disparities in rates of admission to hospital, detention under the Mental Health Act and practices such as the use of seclusion, as we heard from the noble Baroness, Lady Watkins. Indeed, one of the main concerns driving the independent review of the Mental Health Act is the disproportionate number of people from black and ethnic minorities detained under the Act. Like other noble Lords, I welcome the review and the sharp focus that the Prime Minister has placed on mental health as part of a wider social justice agenda.
I want to say at this point—I think it has come across strongly this evening—that it is so important that the review does not look purely at the point at which someone is being detained, but considers how we can prevent people from reaching a crisis in the first place and what we can do to improve crisis services for people who need emergency help. That has been one of the key points in the debate.
It is a statement of the obvious, but still worth saying, that focusing primarily on mental ill-health, rather than on how we can keep our communities healthy in the first place, is like trying to fix a leak by putting a bucket under the hole. Preventing mental health issues from arising, and intervening early if problems surface, can happen at a local level. Local government has a vital role to play. Clearly, local authorities need adequate funding to commission personalised services and to promote good mental health and well-being in their communities. I know from LGA figures how the core money that local authorities receive from central government has been going down year on year, which makes it difficult for them to fulfil their public health duties. Against this backdrop, can the Minister say what plans the Government have to encourage local commissioners to implement the Joint Commissioning Panel for Mental Health guidance on services for black and minority ethnic patients, specifically to identify and implement concrete measures to reduce the inequalities we have heard about?
As other noble Lords have highlighted in the debate, it is also important to acknowledge the socioeconomic factors that play a large part in psychiatric illness, with people from poorer backgrounds, people living in deprived communities and people encountering adversity and, yes, discrimination being particularly at risk. There are other critical issues: repeated studies have shown that cultural understanding is key to providing an effective mental health service that works for everyone. Other noble Lords have talked about that; I do not want to repeat what they have said.
It is a matter of real concern that there has been no real specific, targeted and strong national framework for improving mental health care for black and ethnic minority communities since 2010. Campaigning groups have expressed concern that mental health services lack a sense of strategic direction for reducing the inequalities in black and ethnic minority mental health that we have heard about.
However, there is positive news to report. There is good practice on the ground. Previous reports have highlighted many suggestions for solutions, and I have heard heartwarming stories from different local communities about the projects that have been set up to tackle the issue. Like the noble Baroness, Lady Watkins, I was encouraged to hear about the Black Thrive project in Lambeth, particularly the way in which it encouraged local people to understand their mental health needs and what services are available, and supported them to use their voices to shape and influence the commissioning of local services.
I applaud the new Synergi Collaborative Centre that has just been launched. This five-year collaboration between Queen Mary University of London, the University of Manchester and Words of Colour Productions is concerned with addressing the links between ethnic inequalities, multiple disadvantage and severe mental illness, with funding from the Lankelly Chase Foundation. This begs the question: what are the Government going to do to support and encourage excellent initiatives such as these? To be truly effective we need a clear national framework championed by government to improve mental health services for people from black and minority ethnic communities, with clear lines of accountability. It cannot all be left to the voluntary sector and local responses, however praiseworthy they may be.
Last year, the Government committed to invest an additional £1 billion in front-line mental health services by 2021 to deliver the five-year forward view for mental health—a welcome road map for reform of mental health services. I noticed that there was no mention of this in the Budget; indeed, there was no mention of mental health at all. I conclude by asking the Minister what proportion of money announced for the NHS in last week’s Budget will be earmarked for mental health care, whether it will be ring-fenced and whether specific money will be earmarked for tackling the quite shocking inequalities in access and outcomes for black and minority ethnic communities that we have been talking about.
Lord Hunt of Kings Heath (Lab)
My Lords, this has been a very moving and powerful debate. I pay tribute to my noble friend Lord Boateng for leading it. I well remember when, as a Health Minister, I met him at the Home Office to discuss health in prisons. I learned then very clearly his passion and determination. I am glad he has brought that to our discussions tonight. He talked about the issue being injustice rooted in race. I do not think we can describe the problem more explicitly.
We have had an amazing amount of briefing from many organisations, and I thank them. I am certainly not going to repeat them; the case is absolutely made and convincing. However, I looked at the briefing from the University of Essex’s Institute for Economic and Social Research, which showed the clear link between racial and ethnic harassment and mental health. Around one in 10 people from an ethnic minority background living in England has experienced some form of racial harassment in the past year and the briefing showed the connection between that harassment and stress, anxiety, depression and poor mental health. This is a fundamental issue that we have to tackle in society and in the National Health Service, because there are real issues about the way people from black and minority ethnic communities are treated by our National Health Service.
We know that there is forthcoming mental health legislation and we have the Prime Minister’s promise of action, which are both welcome, but the overwhelming message to the Minister is that we cannot wait for this before some determined action needs to take place. I was struck, as my noble friend Lord Boateng said, that we have had so many reports. We know what to do. The report from the noble Lord, Lord Crisp, waited two years for a response from the Government. We have the Five Year Forward View for Mental Health, published in February 2016, with 57 recommendations. I put it to the noble Baroness that we constantly hear from Ministers that this is a priority, but we do not see any real hard-edged action to put these recommendations into practice.
I want to revisit some of the points raised by my noble friend. He set out some issues to be tackled, such as the need for hard recommendations, with timescales for implementation and resources. I agree with him about hypothecation. I know that we are beginning to see extra spending on mental health, but how long has it taken the NHS to do this? I am afraid I do not believe the NHS, left to itself, will ever prioritise funding for mental health services. That is why I firmly believe there will have to be a hypothecated budget.
I also think we have to look at the way in which financial incentives are put in place in the health service, because the Five Year Forward View for Mental Health fundamentally attacked the present funding system. The use of block contracts is rewarding low-cost interventions, regardless of outcomes, and penalising those that increase access or deliver more costly interventions, even though they may improve outcomes. We cannot go on like this. Why do we still have block contracts in mental health? It is because it is regarded as less important within the Government and the Department of Health. We have different, more sophisticated systems for other parts of the health services; why is mental health being left till last? It has produced a horrendous situation where we disincentivise the most effective outcomes.
My noble friend talked about data outcomes. We have to have reliable data so that we can judge outcomes. Spreading good practice, local authority/NHS collaboration, pooled budgets: none of this is rocket science. We know that it can be done—the question is whether there is a will to do it. On the Patient Voice and using community action groups and the voluntary sector, the health service seems to have done its best to cut out many of these groups because of its funding decisions in the last few years. That is a very great pity.
The noble Lord, Lord Ouseley, talked about discrimination and the right reverend Prelate the Bishop of Worcester talked about cultural competence. I fear that the NHS has a long way to go before we can say that it has really tackled those issues. We are focusing on mental health services but I hope that Ministers will reflect on a more general cultural problem within the NHS, which is as much about the workforce, as the noble Baroness, Lady Watkins, said, as it is about service provision. My noble friend Lord Brooke anticipated the report of the noble Lord, Lord Crisp. I totally agree with him about carers being excluded from initial assessment. It is difficult to fathom how that can be justified as a general principle. What he had to say about the workforce race equality standard and patient and carers’ equality standards was very profound and would be very helpful to the boards of organisations, which are probably not aware of some of these issues at the moment.
My noble friend ended by asking how we are going to make it happen. He said, “Let us get on with it”. I agree with him, but my final point for the Minister is this: if the Government stick to the mantra that this can be left to clinical commissioning groups, albeit with some national commissioning advice, we might as well give up and go home now. It simply is not going to happen. CCGs do not have the capacity or the will to do it. At the end of the day, Ministers have to take responsibility; they have to take a grip and there has to be national direction and national hypothecation. We know what needs to be done but at the moment I simply do not see the tools at central government level to enable it to happen. I hope that the noble Baroness will correct me if I am wrong.
Baroness Chisholm of Owlpen (Con)
My Lords, I thank the noble Lord, Lord Boateng, for securing this short debate and other noble Lords for their contributions on this important issue, which is close to my heart as well. I will try to address as many points as possible after my opening remarks. I apologise if I speak rather fast, but I always seem to be beaten by the clock when there is so much that I want to say. As the noble Baronesses, Lady Hussein-Ece and Lady Watkins, and the noble Lord, Lord Brooke, all mentioned, we know that people from black and minority-ethnic backgrounds experience significant inequalities in access to, and experience of, mental health care, with particular overrepresentation in acute and secure mental health services.
In the past, as noble Lords have mentioned, matters have gone terribly, tragically wrong, so in July 2016, as the noble Lord, Lord Boateng, mentioned, the Prime Minister launched the race disparity audit, an audit of public services to help end the burning injustices that many people from ethnic minorities experience. Last month, the Cabinet Office published the audit, which showed a complex picture. In some measures it reported significant disparities between and within ethnic groups, and in others it showed that there had been a narrowing of the gaps between ethnicities.
As the noble Lords, Lord Brooke and Lord Ouseley, mentioned, we know that black women are more likely than any other ethnic gender group to experience a common mental health disorder such as anxiety or depression. Similarly, black men are the most likely to have experienced a psychotic disorder in the past year. However, as the noble Lord, Lord Brooke, mentioned, white British adults are more likely to be receiving treatment for a mental or emotional problem than other ethnicities.
As the noble Baroness, Lady Watkins, mentioned, we also know that a disproportionate number of people from black and minority ethnicities are detained under the Mental Health Act. As the noble Baronesses, Lady Hussein-Ece and Lady Watkins, the noble Lords, Lord Ouseley and Lord Brooke, and the right reverend Prelate all mentioned, the Mental Health Foundation reported that Afro-Caribbean men were more likely to enter mental health services via the criminal justice system. The report also suggested, as did the noble Lord, Lord Ouseley, that there was a potential for mental illness to be overdiagnosed in people whose first language was not English. As the noble Lord, Lord Brooke, mentioned, we also know that the stigma of mental illness prevents many people from a variety of cultural backgrounds seeking early help.
The current situation is clearly unacceptable. Therefore, what are we doing? As the noble Lords, Lord Boateng and Lord Ouseley, mentioned, we are reforming mental health legislation. We have commissioned an independent review of the Mental Health Act, which will report next year, aiming to improve the lives of tens of thousands of people detained under the Act each year. Professor Sir Simon Wessely will chair the review and work is under way with stakeholders to identify priorities, as the noble Lord, Lord Brooke, mentioned, with an interim report expected in early 2018. The noble Lord, Lord Boateng, will recall from his time in government the previous revision of the Mental Health Act, which he commenced in the late 1990s. Earlier this year, the Government accepted the recommendations of the independent Mental Health Taskforce report, the Five Year Forward View for Mental Health, which made it clear that inequalities must be tackled at local and national level.
However, this is not just about reports. As the noble Lords, Lord Boateng, Lord Ouseley and Lord Hunt, mentioned, it is about what is happening now. We are committed to real service improvement. NHS England set an expectation for local services to improve representation and recovery rates for black and minority-ethnic groups in improving access to psychological therapies services, leading to consistent improvement over the past five months. These therapies, as the noble Lord, Lord Boateng, and the noble Baroness, Lady Watkins, mentioned, are vital.
In secure care, NHS England’s project to address the overrepresentation of black individuals in mental health secure settings has resulted in a new mental health community forensic model to be piloted from next year. A “black voices” network has also been established to encourage co-produced approaches to wider initiatives.
NHS England has also commissioned the National Collaborating Centre for Mental Health to develop guidance to support commissioners and providers in addressing health inequalities. In due course NHS England will publish new pathways for crisis and acute care, building on input from experts-by-experience from ethnic-minority backgrounds. As the noble Lord, Lord Boateng, said, patients who have a voice need to be part of the solution. This will be followed by a community mental health pathway in 2018-19 and a patient and carers race equality standard.
However, we know that successfully improving mental health care for black and minority-ethnic groups needs specific local community as well as national action. The noble Baroness, Lady Tyler, and the noble Lord, Lord Brooke, talked about a joined-up approach. That is why initiatives such as Birmingham’s 300 Voices project, led by the government-funded Time to Change campaign, are essential. Young African and Caribbean men, health professionals, the police and community representatives shared their experience of mental health support, including issues of stigma and discrimination, and produced a practical toolkit which can be rolled out to communities across the country.
The Care Quality Commission is developing a publication to highlight providers’ good practice in reducing the need for restrictive interventions. This will be published by December 2018. We know that restrictive physical interventions are risky for all individuals involved and have a negative impact on patients’ dignity and trust in services. The CQC also has an important role in improving equality as part of the mental health trust inspections. As the noble Lord, Lord Boateng, mentioned, good practice is vital. The CQC recognises the good practice of those providing services with a focus on improving black and minority-ethnic mental health.
The noble Baroness, Lady Hussein-Ece, talked about recognising that mentally ill people need access to dedicated care at all times of the day. That is why, in January 2016, we announced that crisis resolution and home treatment teams would receive £400 million in additional funding by 2021 and that we would invest £247 million to 2021 in hospital emergency departments to support people with immediate mental health needs. Just last month, we launched a new £15 million scheme—Beyond Places of Safety. This will provide capital grants to help develop and enhance facilities for urgent and emergency mental healthcare in 2018-20, including places of calm—crisis cafés that offer support to people who are at risk of mental health crisis.
The noble Lord, Lord Ouseley, and the noble Baroness, Lady Hussein-Ece, talked about children and mental health. The soon-to-be-published joint education and health committees’ Children and Young People’s Mental Health Green Paper will set out improvements for the mental health of children. To further help equip our children and young people with the life skills they need, we have committed to providing mental health first aid training to a teacher in every secondary school by 2019, and to reach 1,000 schools by the end of the year. In their manifesto, the Government expanded this commitment to every primary school, and we are exploring options to deliver this.
During a debate yesterday on education and skills, there was an interesting comment about pharmacies as a tool for gathering information on people who are prescribed anti-depressants. This could give a local view of problems in an area and enable people to move in to help.
The noble Lord, Lord Boateng, and the noble Baroness, Lady Hussein-Ece, talked about recruitment and training. The Mental Health Workforce Plan, published in July, underpins the start of one of the biggest expansions of mental health services in Europe, creating 21,000 new posts by 2021. The recommendations of the independent review of the Mental Health Act, alongside ongoing work in response to the Five Year Forward View for Mental Health, will be instrumental in addressing the perennial injustice of racial disparities on display within mental health services. We will sustain efforts at national and local level to do so.
Many noble Lords mentioned the importance of data. NHS England is requesting from NHS Digital and other partners that all relevant data reports are broken down by protected characteristics. Breakdowns of access and outcomes across ethnic groups are now available within the mental health services dataset. This will allow the systematic identification of areas for improvement and monitoring of progress.
The noble Baroness, Lady Hussein-Ece, mentioned the workforce, as did the noble Baroness, Lady Watkins. I mentioned the extra 21,000 but it is interesting that in looking at the present workforce, there were 15,512 community psychiatric nurses in May 2010 and in July 2017 there were 16,583. The figure has gone up but obviously not by enough and we need to really concentrate on that.
The noble Baroness, Lady Watkins, talked about overseas staff and staff speaking the necessary languages. We have to concentrate more on making sure that we try to bring people into mental health nursing and the other professions who speak a range of languages. But as far as Brexit is concerned, it is important that these staff are not unnecessarily concerned about their future. The Prime Minister has been clear that she wants to protect the status of EU nationals living here.
I am looking at the time but I want to answer the point made by the noble Lord, Lord Crisp. He mentioned carers being excluded from an initial assessment. This seems absolutely extraordinary and I am going to take it back to the department. It seems to me completely obvious that they should be included in first-time assessments and, if it is not happening, I shall certainly find out why. As to when the response is coming out, I say soon.
The noble Lord, Lord Boateng, mentioned ring-fencing and I say quickly that it is for local areas to decide where to invest, based on local needs, in line with national priorities set out by the Government and NHS England.
As always, if there are points that I have not covered, which I am sure is true, I will make sure that we write to noble Lords. We must all work together to make sure that the vulnerable, their families and carers can feel confident that they are getting the right treatment in the right place and at the right time. As the noble Baroness, Lady Watkins, said, the treatment must also be equal for all. I thank noble Lords for all their contributions.