The Bristol Picture
Alex Raikes MBE, Strategic Director, SARI • Mental ill health - 23% of total burden of ill health in the UK!
• Largest single cause of disability! (1 in 4)
• Cost of treating mental health problems could double over the next 20 years. BMH’s Promise…
1. Work with patients to promote resilience and wellbeing and on service design and delivery 2. Be inclusive 3. Be locally accountable and Bristol focussed 4. Meet the diverse needs of Bristol’s population 5. Consider the wider context of the patient Bristol • Largest city in the South West and 7th largest in the UK (437,500). • A young City. (More under sixteen than pensioners • 22% BME • Approx. 15% of the population (60,000 people) are likely to have mental health issues in any one year Demographics – working in a changing climate
“Change does not roll in on the wheels of inevitability, but comes through continuous struggle.”. Population Increase…
2003 – 2013 due to: • increase in net-international migration • increase in births • decrease in the number of deaths. • Students increased by 10,000 to 35,638
Population Increase… Our CARDS
Our mental health and related experiences are connected to our: C class, socio-economic status A age R race, ethnicity, culture D disability, health S sex, gender, sexuality Our CARDS
• Population groups experiencing discrimination have an enhanced risk of developing mental health problems.
• In terms of access to services, these groups tend to be either under or over represented in mental health service system.
And other added risks for certain groups…
• Looked after children • Those who have experienced violence, abuse, neglect or discrimination • Disabled people, people with long term health conditions • Those in poor housing conditions • Those in poverty
Bristol
• 1,828 hate crimes reported to the police in 2014/15 and SARI opened 553 new cases.
• Law Centre – over 2000 new clients reporting discriminatory behaviour.
Class/ Socio-Economic Status…
• Across the UK both men and women in the poorest one fifth of the population are twice as likely to be at risk of developing a ‘mental illness’
• There are differences in diagnoses made that seemed linked to social class Class/ Socio-Economic Status…
• 32 Lower Layer Super Output Areas • 2 in the bottom 10% • 14 in the bottom 5% • Whitchurch Park the bottom 1% • 63,000 live in the most deprived areas of Bristol (15% of the population). • 28.4% of private housing non decent. • Free School Meals increasing (21.5% in 2008 to 24% in 2012, and ranges from 2% in Henleaze to nearly half of all schoolchildren in Lawrence Hill (47%).
State of the City Report 2013 and Private Sector House Condition Survey (2011)
Postcode Lottery?
Life expectancy difference between the most and least deprived areas:
10 years less for men
6 years less for women.
Postcode lottery?
• The wards in Bristol which emerge with the highest mental health risk score are Lawrence Hill, Lockleaze, Filwood, Southmead, Kingsweston, Hillfields, Avonmouth, Whitchurch Park and Hartcliffe Postcode lottery?
• Locations with higher levels of domestic violence are: Lawrence Hill, Avonmouth, Hartcliffe, Filwood and Cabot. Central Bristol
A third (31%) of the total increase in population in Bristol took place in Cabot and Lawrence Hill wards alone.
Inner City and East is the ‘youngest’ part of the City (JSNA 2014)
Southmead Development Trust view…
• High health inequalities • Wards very different well off and very poor • Changes in demographics last 5 years BME (Polish and Somali) 4%-16% very isolated • High number of single parents’ young parents’ domestic abuse • Large LA housing so large families rehoused there • North poorer than south with reduced infrastructure/ reduced services South Bristol
• Almost half the areas are more deprived than the national average and the health of South Bristol is generally worse than the Bristol average.
• For Filwood ward (Knowle West), there are poor health outcomes on most indicators.
• South Bristol has areas of persistent worklessness, high numbers of children with Special Educational Needs and high numbers of disabled people.
JSNA 2012 KWHP view:
• Access to services poor • Really Local services needed • Cultural issues often missed • Lack of trust of outsiders • Issues of Literacy • Low aspiration/ expectations • High Domestic Abuse and hate crime • High levels of Crisis • Mental health often hidden • Poor travel routes – won’t go out of area • Key areas of high deprivation Hartcliffe and Filwood
Age - CYP Age - CYP
• The growth in child population (particularly under 5s, which grew by 34% in the last decade) is one of the highest in the country and has significant implications for services within the health, care and education system…
• One in four children in the city live in poverty compared to one in five nationally. Many of these children are growing up in households unable to afford, or to have access to, food to make up a healthy diet.
Age - CYP
• For half of those with mental distress, symptoms are already present by the age of 14.
• Therefore the early years provide a critical opportunity
• In economic terms, it has been suggested that investing in early intervention services for children and young people could prevent 25 – 50% of adult mental illness with economic returns of intervention programmes exceeding cost by 1:6. Age - CYP
A study by the NSPCC in children's’ experience of DV found that of those interviewed:
• 12.5% of under 11s • 17.5% of 11–17s • 23.7% of 18–24s had been exposed to domestic violence between adults in their homes during childhood.
Age - CYP
• Bristol’s student population: 35,638 (39%)
• Suicide accounts for 20% of young people’s deaths
• There are more victims of crime amongst younger age group
Age – Older People
• There are estimated to be between 4,400 and 4,700 people in Bristol with a form of dementia in 2013. Approx. 1,500 men and 2,900 women.
• Of this number, only half (2,300 in 2012/13) have a Dementia diagnosis on their GP registers.
Age – Older People
• Research suggests that there is discrimination against older people within health services
• Rate of ECT prescribed is double for the older adult age group
• Suicide rate is higher amongst older people particularly men, increases throughout old age
Disability
Number of people registering with ‘Limiting Long Term Illness’
National average: c 18% 2001 18%
2011 17% Minor Limitations Significant Limitations
37,154 34,570
Carers 2001 2011 Providing between 1 to 19 hours care: 23,643/ 6.2% 25,709/ 6%
Providing between 20 and 49 hours care: 3,859/ 1% 5,253/ 1.2%
Providing 50 hours plus care: 7,842/ 2.1% 9,176/ 2.1%
Non paid carers: 9.4% in 2011 Disability
• 35,000 people in Bristol with a hearing impairment and almost
• 11,000 people living with sight loss.
• Approx 8,300 adults and 1,750 children in Bristol are estimated to have a learning difficulty.
• Approx. 4,300 people (adults and children) are estimated to have Autistic Spectrum Disorders of some level in Bristol.
Disability
• National research linked to Bristol highlights the average age of death for people with learning disabilities (65 years for men; 63 years for women) was significantly less than for the UK population.
• Men with learning disabilities die, on average, 13 years sooner
• Women with learning disabilities die 20 years sooner” Mental health and physical health…
People with mental illness are significantly more likely to experience some serious physical illnesses (diabetes, heart disease, stroke, hypertension and epilepsy) than other people.
The health of deaf people: communication breakdown
2012 article in Lancet about Mental health of deaf people outlines the social adversity associated with deafness, the high prevalence of depression and anxiety among deaf people, and the barriers they face in accessing mental health services.
They say it is deeply worrying that the 201 people evidence suggests communication who’s between deaf patients and health language is professionals is so poor. BSL in Bristol! Disability
The Disability Rights Commission (2005) confirmed that the health of people with learning disabilities is likely to be worse than that of other people, (even before taking into account specific health needs or disability related barriers to accessing health care), as they are likely to live in poverty. and are exceptionally socially excluded. Serious Case Review – Disability Steven Hoskin (1967- 2006)
‘He was generous…he knew he had a learning disability…he tried to do as others do…he wanted friendships…he’s at peace at last…now he can’t be hurt any more” Serious Case Review – Disability Steven Hoskin
What is striking about the responses of services to Steven’s circumstances is that each agency focused on single issues within their own sectional remits and did not make the connections deemed necessary for the protection of vulnerable adults. High Profile Cases Disablist
Keith Philpott (1969 – 2005) David Atherton (1966 – 2006) Kevin Davies (1977 – 2006) Barrie-John Horrell (1975 – 2006) Steven Hoskin (1967 – 2006) Sean Miles (1969 – 2006) Christine Lakinski (1957 – 2007) Brent Martin (1984 – 2007) Gemma Hayter (1983 – 2010) Winterbourne View May 2011 SANE report on homicides…
• Investigated summaries and recommendations of 23 homicide inquiries involving mentally ill people in which 35 lives were lost.
• One in three of the homicides were judged to be either predictable or preventable.
Gender & Mental Health Gender
• Women are more likely to have been treated for a mental health problem than men (29% compared to 17%).
• Women are twice as likely to experience anxiety as men. Of people with phobias or OCD about 60% are female.
• Domestic violence and abuse is the most common cause of depression and other mental health difficulties in women and 1 in 4 women experience domestic abuse at some point in their lives.
• Self-harm and suicide rates among victims are at least four times higher than the general female population
Gender
• Rates of suicide in Asian women aged 15 to 24 increase to more than double the national average, among those 25 to 34 it is 60% higher.
• Disabled women are twice as likely to experience domestic violence as their non-disabled counterparts.
• People with learning difficulties are also more likely to experience domestic violence and abuse, to experience barriers to disclosure, and be more vulnerable to repeat victimisation.
Gender
• 1 in 5 women (aged 16 - 59) have experienced some form of sexual violence
• Between 430,000 and 517,000 adults were victims of sexual offences in the last year (366,000-442,000 female victims and 54,000-90,000 male victims)
• Approximately 85,000 women are raped and over 400,000 women are sexually assaulted on average in England and Wales every year.
Women’s Mental Health: Into the Mainstream DoH 2003
• Women’s experience of sexual assault within mental health services continues. Fewer then 4 in 10 victims of sexually harassment or abuse reported incidents to staff (Mind Ward Watch 2004)
• Studies suggest that women are 3 x more likely to have been abused then men
• Growing recognition that women need gender sensitive or specific mental health services
Gender
Gender • Men are more than three times more likely to be diagnosed with antisocial personality disorder than women.
• Men are more likely to have an earlier onset of schizophrenia
• Men are still spending more time in hospital than women, with the average number of bed days per year, per inpatient, 78 days for men compared to 68 for women
Gender and Bristol • 6,718 Domestic Abuse incidents reported to police – Home Office estimates 17,000 happened – 18% of all violent incidents
• 29% of women/ 17% of men have suffered DV
• 40 % of victims using Next Link come from BME communities
• 4,758 women and girls aged 16-59 have been a victim of sexual assault in the past year.
• Compared to other core cities in England, Bristol is ranked the third highest reported sexual offences per thousand population
Gender Orientation Gender Orientation
Transgender people have specific health care concerns:
1. Bias and discrimination in medical community 2. Delayed medical care 3. Lack of cohort studies and lack of research on long term effects of hormone therapy 4. Few MH providers experienced with TG patients 5. Reluctance to seek care 6. Negative exposure to insensitive providers 7. Negative reaction from peers Gender Orientation
One study in Brighton found that 64% of transgender respondents had experienced domestic violence and abuse.
Another study by LGBT Youth Scotland found that 80% of transgender respondents had experienced some form of abusive behaviour from a partner or ex- partner, although only 60% of respondents recognised the behaviour as domestic abuse. BHCS Transphobic Case History, 2013
Referred following severe assault by gang of youths in local park.
Client identifies as female having started transitioning 5 years ago but had stopped presenting as a women following a previous incident where she was attacked and stabbed.
Client walking through park when attacked. Incident was filmed by attackers who verbally abused and physically assaulted client who was eventually rescued by another women in the park. She was left needing stitches to face and hand and was very shaken and too scared to leave the house after attack.
Client called initially regularly in state of distress, very depressed and informing us of overdoses taken the night or day before on several occasions.
Race
2001 2011
BME population* 12%* 22%* 84%
All BME populations increasing other then White Irish
African 2310 12085 423%
White Other 10124 21950 116%
15438 Dual Heritage 7834 97%
New community information captured
Gypsy & Traveller 359
Arab 1272
National High Profile Cases
Race Hate
Stephen Lawrence (1974 – 1993) Anthony Walker (1987 – 2005) Rocky Bennett (1960 – 1998) Zahid Mubarek (1980 – 2000) Kriss Donald (1988 – 2004)
High Profile Cases
Race Hate
Marlon Thomas (1976 – ) Bijan Ebrahimi (1969 – 2013) Mohammed Sharif (1976 - )
96 Lives…lost to racism… Since Stephen Lawrence…
1993: Saied Ahmed and Ali Ibrahim. 1994: Shamsuddin Mahmood, Donna O’Dwyer and Mohan Singh Kullar. 1995: Mushtaq Hussain. 1996: Daniel Blake and John Reid, 1997: Michael Menson and Lahkvinder ‘Ricky’ Reel. 1998: James Tossell, Akofa Hodasi, Remi Surage, Surjit Singh Chhokar and Farhan Mire. 1999: Jay Abatan, Stelios Economou, Harold (aka Errol) McGowan, Liaquat (aka Bobby) Ali, Joseph Alcendor, Ben Kamanalagi, Hassan Musa, Zardasht Draey and Jason McGowan. 2000: Zahid Mubarek, Santokh ‘Peter’ Singh Sandhu, Komra Divakaren, Jan Marthin Pasalbessi, Glynne Agard, Mohammed Asghar, Abdi Dorre, Tariq Javed, Khaliur Rahman and Sarfraz Khan. 2001: Gian Singh Nagra, Fetah Marku, Shiblu Rahman, Sharon Bubb, Firsat Dag and Ross Parker. 2002: Frankie Kyriacou, Peiman Bahmani, Shah Wahab, Derrick Shaw and Israr Hussain. 2003: Mohammed Isa Hasan Ali, Unnamed Asian man, Paul Rosenberg, Johnny Delaney, Awais Alam and Quadir Ahmed. 2004: Kriss Donald, Shahid Aziz, Akberali Tayabali Mohamedally, Brij Brushan Sharma, Bapishankar Kathirgamanathan and Kalan Kawa Karim. 2005: Deraye Lewis, Mi Gao Huang Chen, Mugilan Sutherman, Kamal Raza Butt, Anthony Walker, Rushi Kamdar and Isiah Young-Sam. 2006: Lee Phipps, Christopher Alaneme, Khizar Hyat, Hamidullah Hamidi, Mohammed Pervaiz, Changez Arif, Shezan Umarji, Wei Wang, Syed Sorafot Ali and Meshack Brown. 2007: Enayit Khalili, Tarsen Nahar, Marion Moran, Adam Michalski, Gregory Fernandes, Ahmed Hassan and Asaf Mahmood Ahmed. 2008: Hamida Begum, Alana Mian, Nilanthan Moorthy and Mohammed al-Majed. 2009: Syden Pearson, Kunal Mohanty, Marek Muszynski and Ekram Haque. 2010: Papa Mbaye Mody (aka Alioune Cisse), Mohammed Idris Mirza, Marcin Bilaszewski, Nachhattar Singh Bola and Simon San. 2011: Mahesh Wickramasingha and Anuj Bidve Faeces thrown over a families door Chinese Take Away Window Smashed… Swastika graffiti on a car belonging to a Pakistani man
Local Offices Sikh Shop Keeper South Bristol Young black single mum’s home vandalised with racist graffiti Bristol Bus Stop…
Bangladeshi run Indian Take Away German Contract Worker, North Bristol Sikh young man attacked in City Centre Race & Mental Health • Referral from criminal justice system 30–83 % higher for Black African, Black Caribbean and mixed race
• A&E admissions - White British (5.0%) and mixed White and Black Caribbean heritage (5.0%) = highest and Pakistani (2.0%) and Bangladeshi (2.0%) = lowest
• Rates of detention in Black and White/Black groups were between 19% and 38% higher especially Court detention
• Black Caribbean and White/Black Caribbean Mixed groups have longest stays and Chinese, South Asian, Black African, White British and Other groups shortest. Race & Mental Health
Detention rate under section 37/41 of the Mental Health Act: • White British = 16% lower than average • White/Black Caribbean group = 77% higher than average • Black Caribbean group = 100% higher • Black African group = 27% higher • Black Other group = 52% higher
Race & Mental Health
• African-Caribbean men 4 to 10 times more likely diagnosed with schizophrenia and paranoid psychosis.
• Irish people living in Britain highest rate of psychiatric hospital admission
• People who do not speak English are more likely to be diagnosed as having dementia
Being Mixed Race…
“Yeah. I think there’s a stereotype around white women with black children. And we are perceived to be a bit rough, a bit common, a bit like we don’t care who we sleep with, even if they are black! […] I think that people always expect your child to be behaving badly when you have a white parent with a black child because you’re a bit loose and feckless.” (Chloe) Being Mixed Race…
• Fastest growing ethnic group in Britain (2.2% of the population of England and Wales). • Higher prevalence of mental health issues amongst Mixed Race children • Due to “unrealistic" expectations from teachers and other adults who did not understand their backgrounds • Because of their struggle to develop an identity. Morley said the strongest common experience was the
"too white to be black, too black to be white". Race & Mental Health The “snowy white peaks” of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England.
The NHS recruitment processes has been shown to disproportionately favour white applicants (Kline 2013). Previous research (Esmail 2007, NHS Institute for Innovation and Improvement 2009) has highlighted concerns about the absence of black and minority ethnic staff from senior NHS roles including Trust Boards. Refugees and Asylum Seekers 2009 Mind report on mental health provision for refugees and asylum seekers said:
• Limited use of interpreters in mainstream MH services and commonplace use of family and friends • Limited provision of therapeutic services in other languages • Lack of cultural awareness of refugee issues • Limited provision of culturally appropriate services • Many individuals with severe and enduring MH problems are being detained • Problems registering with GPs • Limited specialist services for those who have experienced torture Gypsy Traveller People Gypsy Traveller People… Report by Bristol MIND Do Gypsies, Travellers and Show People get the support they need with stress, depression and nerves?
• Struggle to talk about serious mental health issues or to allow support in.
• Do not engage with the terminology health services use e.g. the term ‘mental’ is seen as taboo and describes people who have completely ‘lost it’.
• Have experienced prejudice from GPs and Psychiatrists and insulting language from staff.
Religion Religion
2001 2011
Christianity 236,239/ 62% 200,254/ 47%
Not stated 35,304/ 9% 37,782/ 8%
No Religion 93,322/ 25% 160,218/ 37%
Muslim 7,664/ 2% 22,016/ 5%
7th ranked in England and Wales stating no religion 45 different religions
2011 - No other religion over 1%
2,310 Jedi Knights Religion/ Faith SARI Statistics 2013-2014 (1262 individuals)
• Christian 38% • Muslim 32% • No religion 22% • Sikh 3% • Buddhist 2% • Mixed faith 0.8% • Hindu 1% • Other 1.7%
Islamophobia
Tell MAMA (Measuring Anti-Muslim Attacks) – recent report in 2013: “Maybe We Are Hated” The Experience and Impact of Anti-Muslim Hate on British Muslim Women”: • 548 incidents reported to Tell Mama 2014 – 15 • 55% of off line incidents reported to them were Muslim Women of which 80% were visually identifiable e.g. wearing Hijab or Niqab. • Mostly low level but 8% were extreme violence and 24% assaults; 33% threats. Sexual Orientation The government estimates that 5-7% of the population are LGB, which would mean that of the 432,500 people estimated to be living in Bristol by the 2011 Census, 30,275 may be LGB.
A 2010 performance report from the Bristol register Office shows that 140 Civil Partnership notices were taken 1st April 2009- 31st March 2010 Sexual Orientation The government estimates that 5-7% of the population are LGB, which would mean that of the 432,500 people estimated to be living in Bristol by the 2011 Census, 30,275 may be LGB.
A 2010 performance report from the Bristol register Office shows that 140 Civil Partnership notices were taken 1st April 2009- 31st March 2010
Gay British Crime Survey 2013
1 in 6 LGB people – 630,000 people – have been the victim of a homophobic hate crime or incident in the last three years.
LGB people suffer abuse in all areas of their life – from strangers, neighbours, workmates and family.
Gay and bisexual men were almost twice as likely as lesbian and bisexual women to have been threatened with violence due to their sexual orientation, 23% compared with 12%. Gay British Crime Survey
• One in ten experiencing a homophobic hate crime or incident were physically assaulted. • Almost one in five victims were threatened with violence or the use of force. • One in eight victims experienced unwanted sexual contact. • One in eight victims have had their home, vehicle or property vandalised.
Sexual Orientation Sexual Orientation • Only 68% of LGBT people are satisfied with health services compared to the city average (80%).
• LGB people are almost 10% less likely to feel a • part of their neighbourhood than the general population
• According to the Quality of Life survey, 20% of LGB people had been discriminated against because of their sexual orientation in 2009 Sexual Orientation “When you assume that I’m straight you make it clear to me that your services aren’t relevant to me or my life, which pushes me closer to letting go of life.
I am already working as hard as I can to stay alive moment by moment. I don’t have the energy to constantly come out to you, and then have to deal with your homophobia or ignorance or confusion”. Social Isolation…
• This is a growing issue which impacts on people’s health & wellbeing. It is estimated there could be 20,000 people (18-64) experiencing social isolation in the city as well as between 6,300 and 11,400 over 65. What is BMH trying to achieve? BMH’s overarching approach to equality & diversity aims to:
• Treat everyone as an individual, valuing difference and promoting wellbeing and recovery recognising the impact of multiple discrimination
How are we going to achieve this?
“Attitudes to mental health are changing fast.
2 million people have developed a more positive attitude towards mental illness since 2011.
But long way to go until a mental health crisis receives same response as someone with a physical health emergency”.
CQC 2015, ‘Right Here, Right Now’