The cost of equal outcomes

Anti-racism, the secular religion of the modern British state, has been the focus of much attention in recent weeks, as its role in Henry Nowak’s death has become evident. Police policy documents have been found which instruct that arrest and charge rates should be made equal between groups — even though levels of criminality are different. The effect of such a policy can only be entirely perverse, ensuring that the police under-arrest high criminality groups and over-arrest lower-criminality groups as anti-racism twists the original purpose of an organisation to the pursuit of equality of outcome. 

Such perversity is not limited to policing. Last week it was reported that NHS psychiatrists are “under pressure not to section psychotic Black patients to avoid appearing racist”. As with the police, this isn’t an informal, or hidden directive. Rather, it’s made explicit in the NHS’s own policy documents, such as the ‘Patient and carer race equality framework’ (PCREF). The policy was written by NHS England’s Mental Health Equalities Adviser and Chair of the Advancing Mental Health Equalities Taskforce, Dr Jacqui Dyer, who according to the NHS’s website, does not appear to be a medical doctor but “an experienced counsellor, trainer, personal and professional development coach and group facilitator”. Dyer has also been a mental service user and carer, member of the Ministerial Advisory Group for Mental Health, is an elected Lambeth Labour Councillor, and advisory panel member of the Mental Health Act Review. 

It is unclear why someone with no clinical experience in mental health is trusted to write policy in this area, and in truth PCREF is a strange document, Dyer, explaining that:

The struggle to address racial inequalities and inequity in mental health services is a very personal journey for me. I am driven to fight for a fairer system where people from racialised communities no longer have significantly worse experiences and outcomes. I have lost two brothers, who throughout their lifetime grappled with long term mental health challenges, and sadly died young, Barry at age 53 and Carlton at 41. In 2023, I also lost my aunt, who died whilst in the care of mental health services. It has been extremely difficult for me to see how my loved ones were failed by mental health services where they endured racialised experiences. I live every day with the excruciating thought that if culturally appropriate care had been available for them, they would be alive today.

Unsurprisingly given the author’s evident bias, PCREF is full of this concern for those in mental health detention, but has not a word for the terrible harm which can and has been done by psychotic people. Cases such as the awful killings committed by Valdo Calocane in Nottingham, the fatal stabbing spree committed by paranoid schizophrenic Zephaniah McLeod, and Joshua Jacques’ murder of his partner, her mother and her grandmother all show the very great danger which can be posed by people suffering psychosis, and why it is sometimes necessary to keep them in secure hospitals. 

Instead of a balanced examination of risk, PCREF is focused on the fact that “despite numerous cross-governmental efforts over the past 18 years…people from black and black British groups are still four to five times more likely to be detained under the Mental Health Act”, and that “NHS England’s data has consistently shown that people from racialised and ethnically and culturally diverse communities (especially black/black British communities) are more likely to be detained under the Mental Health Act and are more likely to be detained in hospital for longer when compared to other ethnicities.”

In fact, this misrepresents the NHS’s own data, which shows that Irish, Indian and Chinese people actually have a lower rate of sectioning (or standardised detention rate) compared to white British (64.9 per 100,000). The significantly over-represented groups are those with black heritage — African at just under 200 per 100,000, caribbean at 250.4 per 100,000 and any other black background at 780.3 per 100,000. PCREF is clear, stating that “we must proactively address these inequalities, or we risk even deeper disparities and worse outcomes”. The framework states that it is ‘an anti-racism approach’, which requires mental health trusts and mental health professionals to introduce ‘mechanisms for advancing mental health equalities’. 

NHS Trusts are being judged on their compliance with PCREF. Under the NHS England Equality Delivery System 2022 (EDS 2022), Trusts we be required to ‘provide evidence of the PCREF, which will determine the grading and scoring within the EDS 2022’. The goal is clear – differences in the rate at which different ethnic groups are sectioned should be eliminated. NHS Trusts and staff which don’t do this will be marked down. 

The problem, of course, is that psychosis, like many other diseases, is not evenly distributed across ethnic groups. In particular, in the UK, black people have a substantially higher risk of experiencing psychosis. According to NHS data, between 2007 and 2014, for over-16s, while 0.5% of white people, and 0.9% of asians were diagnosed with psychosis in the past year, 1.4% of black people were. When this data is adjusted for sex the differences are even starker — 1.3% of asian men and 3.2% of black men diagnosed with psychosis, compared with just 0.3% of white men. This means that, in the UK, black men are almost 11 times more likely to be diagnosed with psychosis than white men. 

The existence of this difference isn’t controversial. Indeed, many researchers have tried to explain it. In 2024 the NHS Health Authority approved a study seeking to explain why “people from African-Caribbean backgrounds have a seven times higher risk of being diagnosed with psychosis, while people from Black African and Asian backgrounds have four and three times higher risks, respectively, compared to people from white British backgrounds”. That study, like many others, seeks to show a link “between discrimination and psychosis among ethnic minorities in the UK” via qualitative interviews which “explore whether the content of ethnic minority individuals’ psychotic thoughts is related to discrimination”. Previous studies have blamed sociocultural exclusion, or ‘cultural distance, and noted that these large differences in psychosis rates exist across Western countries. 

While there has been less systematic research conducted in Africa, some of it suggests that European “discrimination” against black people may not be the actual reason for their elevated psychosis risk. For example a 2023 study noted that while non-African populations have a 1.7% rate of Clinical High Risk of Psychosis (CHR-P), versus 3.19% of younger Rwandans. The authors suggest that this may be an overestimation due to the diagnostic tool being originally intended for Western populations. Meanwhile, scientists considering the extent to which genetics play a role in major psychiatric disorders have noted that the bulk of the research has been conducted on Asian and European populations. 

In truth, these debates over the reasons why black people are particularly likely to develop psychosis, while interesting, are not relevant to how we set policy around sectioning. The difference exists, as do many such differences in disease susceptibility between ethnic groups. More black men develop prostate cancer, more black people suffer from sickle cell anemia, and more Irish people have cystic fibrosis. In neither case do we choose to consider this a problem to be solved by providing less treatment to the ethnic group in question. 

And yet, in the case of psychosis, the sufferers of which often pose a very great risk to themselves and others, our entire healthcare system has set a policy which will minimise the sectioning of black men despite them being almost 11 times more likely to be diagnosed with psychosis than White men. The result is utterly predictable. Dangerous, psychotic people are being left free. More awful killings like those committed by Calocane, Macleod and Jacques are made inevitable by such a policy. Not for the first time it is abundantly clear that anti-racism is a wicked doctrine which kills.