Ethnic Monitoring

A Practical Guide for Mental Health Services

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Ethnic Monitoring in Mental Health

This Guide to Ethnic Monitoring in Mental Health
aims to support front-line mental health staff and
their managers to accurately record the ethnicity
of the people using mental health services. It
provides information and advice on:

What is Ethnic Monitoring?

The Duty to Promote Race Equality
What is Ethnicity?
The 16 Standard Ethnic Group codes
How to Record Ethnicity
Common Concerns

This guide is compiled from the following

documents:
Department of Health (2005) A Practical
Guide to Ethnic Monitoring in the NHS and
Social Care
Commission for Racial Equality (2005) Ethnic
Monitoring: a guide for public authorities
National Institute for Mental Health in England
(2002) Inside Outside
Department of Health (2005) Delivering race
equality in mental health care, an Action Plan
for reform inside and outside services
Race Relations (Amended) Act (2000)

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What is Ethnic Monitoring?

Ethnic monitoring is the process we use to collect,
store, and analyse data about peoples ethnic
backgrounds. We can use ethnic monitoring to:
highlight possible inequalities;
investigate their underlying causes; and
remove any unfairness or disadvantage.
We can then consider ways of reaching underrepresented groups and making sure that services
are relevant to their needs, and provided fairly.

Ethnic monitoring can tell us

which groups are using our
services, and how satisfied they
are with them.
Ethnic monitoring is only one part of an overall
assessment of an individuals cultural, ethnic and
religious needs.

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The Duty to Promote Race Equality

The Race Relations (Amendment) Act 2000
gives all public authorities a duty to promote
race equality and good race relations. The duty
means that, in carrying out their functions, public
authorities should aim to:
eliminate unlawful racial discrimination;
promote equal opportunities; and
promote good relations between people of
different racial groups.
Mental health services, along with all public
bodies, must be able to demonstrate compliance
with the duty to promote race equality.
Where evidence from monitoring shows unequal
outcomes between different ethnic groups,
services are required to take action to promote
greater equality and to prevent direct and indirect
discrimination.
Without ethnic monitoring, we will never know
whether the race equality scheme is working.
There is a risk that people will just see the scheme
as paying lip service to race equality.
If this happens, services could lose credibility
amongst staff, service users and the wider
community. Through the use of good and robust

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ethnic group data on patients and service

users, we will be in a better position to address
health inequalities, difficulties in access and
discrimination experienced by some black and
minority ethnic individuals and communities.

To have a race equality scheme

without ethnic monitoring is
like aiming for good financial
management without keeping
financial records.
Information on a service users ethnicity can
contribute to the assessments of their needs.
This ensures that service delivery can be as
personalised and appropriate as possible.
For example, insights into a persons ethnic
background or the ethnic background of their
family may assist with diagnosis and planning.
In addition, ethnic monitoring is essential in
order to compare the uptake of services between
different groups. This ensures that services
are delivered fairly and according to individual
needs.

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What is Ethnicity?
Ethnicity is complex to define. Importantly,
ethnicity is subjective: a person should self-assign
his or her own ethnic group. While other people
may view an individual as having a distinct ethnic
identity, the individuals own view takes priority.
Features that help to define an ethnic group are:

a shared history or cultural tradition;

a common geographical origin;
descent from common ancestors;
a common language or religion; and
forming a distinct group within a larger
community.

While an ethnic group is sometimes perceived

as a minority within a larger community, ethnic
groups cover people from all communities not
just those of African, Caribbean, Asian or Chinese
backgrounds.
For example, White British people are an ethnic
group. Because they outnumber all other ethnic
groups in England, comprising 87% of the
population, they are the majority ethnic group at
the national level. White Irish people are a minority
ethnic group because they only comprise 1.3% of
the national population.

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What is BME?
The term Black and minority ethnic (BME) is used
to refer to all people of minority ethnic status in
England.
It does not only refer to skin colour but to
people of all ethnic groups who may experience
discrimination and disadvantage, such as those
of Irish origin, those of Mediterranean origin and
East European migrants.

Good Practice Points

Ethnic monitoring policies should
include a clear statement from
Board level about the importance
and significance of this exercise
Policies should include
commitment to analysing
collected data, disseminating
findings and taking positive action
Joint data collection should be
undertaken with local partners

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The 16 Standard Ethnic Codes

From April 2001, the Department of Health and
Local Authorities have used, as a National Standard, a set of 16 codes to record the ethnic group
of services users (see below).
The codes are identical to those used in the
2001 ONS census and are grouped under five
headings : White; Mixed; Asian or Asian British;
Black or Black British; and Chinese or other ethnic group.

Ethnic group 16 codes

What is your ethnic group? Choose ONE section
from A to E, then tick the appropriate box to indicate your ethnic group.
A : White
British
Irish
Any other White background (please write in)
B : Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background (please write in)

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C : Asian or Asian British

Indian
Pakistani
Bangladeshi
Any other Asian background (please write in)
D : Black or Black British
Caribbean
African
Any other Black background (please write in)
E : Chinese or other ethnic group
Chinese
Any other (please write in)

Good Practice Points

Ethnic monitoring applies to
everyone.
Because everyone belongs to an
ethnic group, everyone should be
asked to select their ethnic group
from the 16 codes.

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Recording Ethnicity
Assumptions should not be made about
someones ethnicity based on their appearance,
name or religion. For example, not all Muslims are
of Asian origin and some people may appear to
be white British, but may be of European, African
or mixed background.
Ethnic monitoring applies to all areas and is not
the sole preserve of services who have relatively
large black and minority ethnic communities.

Who Decides a Persons Ethnicity?

As mentioned previously, a fundamental principle
is self-classification; that is, service users select
their own ethnic group from the codes on offer.
In doing so, they should be aware of the different
codes they may choose from. Occasions where
third parties identify the ethnic group of service
users will be exceptional and should be handled
with care.
Self-classification is not a courtesy but a
recognition of the fact that a persons ethnic
group is an integral part of their identity. How an
individual sees her or himself may be different
from how that persons parents, other family
members or third parties see them. Individuals

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should not be assigned by a member of staff and

certainly not without explanation or discussion.

How Complete Should the Data Be?

Many analyses of monitoring data have been put
in serious doubt because of the large number
of people recorded as being of unknown ethnic
background. Often, this number is more than the
total number of people recorded as being from
ethnic minorities.

Good Practice Points

All staff involved in recording,
analysing and monitoring ethnic
data should be trained to do so.
Training should give frontline staff
the confidence to collect data
accurately and sensitively.

You should aim to get nearly 100% information

about the ethnic backgrounds of your service
users.

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Recording Ethnicity
Ethnic monitoring still arouses suspicion for some
people. Rather than see it as a force for good,
they see it as a means of further discriminating
against them. The reasons and benefits for
ethnic monitoring should, therefore, be carefully
explained.
When providing information about themselves, it is
not advisable to give service users the opportunity
to record Not stated on the forms they might be
asked to complete. Likewise, we recommend that
you do not say anything in your explanation to the
ethnic background question that might discourage
people from answering it. For example, do not say
This question is entirely voluntary.
An example of such an explanation could be
something like:
We want to make sure that everyone has a care
package that is tailored around their needs. We
recognise that ethnicity is an important part of
how people see themselves. If you can have a
look at the different groups on this form and put
a tick next to the one that most closely reflects
yourself, that will be a great help.

Theres a lot of research that people from

different ethnic groups have different experiences
of mental health services. Its important for us to
make sure that everyone receives the best quality
of care and we can only do that if we know who is
coming to us and using our services.

Good Practice Points

Information should be held at
both service and Trust level.
It should be used to inform
individual patients care plans
If asked, staff should make it clear that the question,
as with all of the questions asked in assessment,
is not compulsory. Ultimately, if someone refuses
to answer, then this can be documented in their
notes and revisited at a later date.
Consent and confidentiality should be respected
at all times. No-one should be forced into giving
their ethnic group against their will.

If someone wants to know more, then a more

detailed explanation may include:

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Common Concerns
There are a number of concerns, issues and
barriers that may be encountered in recording
ethnicity. This section provides some advice to
help staff to overcome these concerns.

I dont like to ask in case I offend

Most people are proud of their ethnicity and see
it as an essential part of their identity. People are
only going to be suspicious or offended if they think
that the information is going to be used against
them, or if it is just a meaningless paper exercise.
Explaining the reasons why we collect information
on ethnicity can help to overcome these concerns.
See the previous section on Recording Ethnicity
for an example of the kind of explanation that
could be offered.

I dont see why its important

People from minority ethnic communities are
among the most disadvantaged groups in
our society, and are also among those least
satisfied with the services they receive. There is
overwhelming evidence to show that:

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Young Asian women are more than twice as

likely to commit suicide as young white women.
Cultural conflict has been suggested as a
precipitating factor in suicide.
Young black men are more likely than their
white contemporaries to be sectioned under the
Mental Health Act for compulsory treatment.
Older women of Indian, Pakistani and
Bangladeshi origin are more likely to visit a GP
for a nervous or mental health condition.
Re-admission rates are higher in black and
minority ethnic groups. They spend, on average,
longer periods of time within hospitals.
People from BME communities are less likely
to have their cultural, social and psychological
needs addressed within care planning and in
the treatment that they receive.
Minority ethnic groups report greater levels of
satisfaction in relation to Home Treatment/
Crisis Resolution services.
We need to ensure that personalised and effective
services are delivered to service users from these
communities. The only way we can do this is if we
know who is accessing and using our services.

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Common Concerns
I treat everyone the same, their
ethnicity is irrelevant.

What if someone is unable to state

their ethnicity?

Ethnic monitoring is not just about an individual

practitioner and the people on their caseload. The
duty to record ethnicity applies to everyone working
in services.

Close relatives or advocates may speak on

behalf of individuals who are unable to speak for
themselves or are not able to understand what is
being asked of them or give an accurate reply. This
could be because of physical illness or disability,
learning disability, cognitive impairment or mental
ill-health.

That said, ensuring equality is not always about

providing the same services to everyone. It is about
providing unique services to everyone, based on
their own individual needs.
It can be just as discriminatory to treat people the
same when, in many respects, they are different
as it would be to treat people differently when they
are, in many respects, similar.

However, such information should be treated with

caution. An individual may have a very different
perception of their ethnicity to their carers or
advocates. They should therefore be given the
opportunity to verify such information as soon as
they are able.

Whilst a persons ethnicity may not be a key factor

to a practitioner, we can be confident that it is
important to the individual service user. Ethnicity,
culture and religion are essential components of
a persons identity and have an important role in
how they perceive their own health and in their
recovery and wellbeing.

Past records, reflecting a time when the individual

could respond for themselves, which include a
previous self-assessment of ethnic group, may be
as good a source as any in these circumstances.
However, a persons perception of their ethnicity
may change over time and so information should
be routinely revisited.

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Common Concerns
What if I feel that asking about
ethnicity would be inappropriate in
certain circumstances?
Of course, in some situations, such as in an
emergency, the individual may be in no fit state
at the time to talk lucidly about themselves let
alone give their ethnic group.
Likewise, you may deem that asking about
ethnicity may, in a particular case, cause
additional tension and suspicion and be counterproductive. In these instances, staff should look
to completing the information at a later date.

What if someones ethnicity doesnt

fit with one of the 16 codes?
Some people have complex ethnic backgrounds,
resulting from migration, mixed parentage and
multiple nationality. The other groups give
service users the opportunity to define exactly
what they perceive their ethnicity to be.

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Staff should alert managers to genuine coding

difficulties, as Trusts and councils should keep
their coding lists under review to ensure that
they remain comprehensive and representative
of local demographics and issues.

What about confidentiality?

When it comes to seeking, collecting, storing
and using personal information about service
users, we all need to pay attention to the Data
Protection Act 1998 and the Human Rights Act
1998. Service users should expect their personal
information to be held securely and access to it
only given to people on a need-to-know basis.
As with all patient details, individuals should be
asked to give their consent for their personal
data, including ethnic group, to be recorded on
computer and other systems.
They should also be told who might have access
to this information and be given the chance to say
whether or not they are content for the named
agencies and individuals to have access to their
personal information.

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Further Information
More detailed information about ethnic monitoring
can be found in the following documents:
Department of Health (2005) A Practical
Guide to Ethnic Monitoring in the NHS and
Social Care

Mental Health Race Equality Team

Oxford Annex, Foundations
Oxford Street
Avenham,
Preston
PR1 3SG

Commission for Racial Equality (2005) Ethnic

Monitoring: a guide for public authorities

01772 558925

National Institute for Mental Health in England

(2002) Inside Outside

www.colourmind.co.uk

Department of Health (2005) Delivering race

equality in mental health care, an Action Plan
for reform inside and outside services
National Institute for Mental Health in England
(2003) Engaging and Changing

Document Information

Race Relations (Amended) Act (2000)

Title: Ethnic Monitoring, A Practical Guide for

Mental Health Services

All of these documents can be downloaded from

the Publications section of the Colour mind
website.

Date: July 2007

Additionally, you can contact the Central

Lancashire Mental Health and Race Equality
Team for advice and training.

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Authors: Tony Roberts, Zainab Dhukai, Pearly

Gupta, Tyrone King, Hajra Sardar
Audience: Staff and Managers in Mental Health
Services

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www.colourmind.co.uk

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