Implementing PCREF – our progress one year on

It's been almost exactly a year since NHS England publicly launched its first anti-racism framework, the Patient and Carer Race Equality Framework (PCREF), aimed at improving care for racialised communities accessing mental health services.

As we all know, reviews and action plans on this topic have been around for decades.

So what makes this different? 

Our journey

Back in 2020, South London and Maudsley became one of four national pilot sites involved in developing the PCREF.

Inequity has long been a major concern for us. In our local boroughs, 40-60 per cent of residents identify as non-white, with our staff equally diverse.

Past failings were particularly visible, with the deaths of Sean Rigg in 2008 and Olaseni Lewis in 2010. Both men were black and died as a result of police restraint while under our care.

“Despite developing responses to these failings and a huge amount of positive intent, inequities persisted”

Despite developing responses to these failings and a huge amount of positive intent, inequities persisted. However, being an early implementer of PCREF has been key in helping us develop the approaches and governance needed to begin addressing these issues. 

From the very start, we developed our anti-racism PCREF approach in partnership with two local organisations: Lambeth Black Thrive and the Croydon BME Forum.

The initial stages focused on listening and learning. We grappled with data on inequalities in our services while creating space for meaningful engagement with service users, carers, the wider community and our staff – both separately and together.

Transparency and accountability

As our work progressed, our governance arrangements ensured transparency and accountability. We developed our group agreement early on, with collective accountability for a successful PCREF as key. We held public events where service user/carer representatives and community representatives joined staff in reporting on findings, plans and progress.

Together, we learned not to follow the usual pattern of engaging stakeholders and then the trust implementing change on its own terms. We understood that a significant cultural shift is required. So, we embraced co-learning, co-producing and working in partnership – three of the National Organisational Competencies in the PCREF.

Triple leadership model

Through this approach, we jointly developed what we call a triple leadership model. Here, decision-making is shared between our staff, representatives of black service users and their carers, and the wider black community. This model allows for better-informed service design while upskilling our teams, enhancing their cultural awareness, staff knowledge and accountability.

Getting this right is far from easy. We're applying it to nine different project areas, with progress reviewed quarterly through a co-created developmental evaluation process.

Our board routinely reviews key metrics on equality of access, experience, and outcomes. This board-level oversight maintains focus on eliminating inequity. One critical metric is the rate at which black service users are restrained compared to their white counterparts – a key indicator of how effectively we're embedding change.

“We envision anti-racism as continuous improvement in the most literal sense”

We know that to successfully eliminate inequity for racialised communities, our approach must be rigorous, systematic, transparent, iterative and participatory. Given the lack of progress in the past, this comprehensive approach is essential. We envision anti-racism as continuous improvement in the most literal sense, driven by both data and the experiences of the service users, carers and communities who are deeply affected by these issues.

None of this would have happened without the tenacity and intellect of Dr Jacqui Dyer, NHS England's mental health equalities adviser, who has led PCREF nationally and is the joint strategic lead with me locally at South London and Maudsley. But even with our head start, there's still much to do to make PCREF business as usual. I appreciate the scale of change required by trusts at different stages of this journey. As our trust has understood, for PCREF to succeed it must be embedded within a comprehensive trust anti-racism strategy.

“…equality of care isn't an optional add-on, it's a core principle of what the NHS is and must always be”

While every trust must tailor approaches to their circumstances, viewing this as a partnership of equals while acknowledging power differentials has allowed us to unlock a sustainable new force for quality improvement. Driven by service users, carers and local communities, this has been immensely valuable for us.

Some might view the framework as ‘one extra thing to worry about’  but equality of care isn't an optional add-on, it's a core principle of what the NHS is and must always be.

Zoë Reed is director of organisation and community at South London and Maudsley NHS Foundation Trust and joint local PCREF strategic lead with Dr Jacqui Dyer MBE. You can follow Zoe on LinkedIn.