Lack of cultural competence in care contributes to poor experiences and outcomes from care for migrants and racial and ethnic minorities. As a result, health and social care organizations currently promote cultural competence of their workforce as a means of addressing persistent poor experiences and outcomes. At present, there are unsystematic and diverse ways of promoting cultural competence, and their impact on clinician skills and patient outcomes is unknown. We developed and implemented an innovative model, cultural consultation service (CCS), to promote cultural competence of clinicians and directly improve on patient experiences and outcomes from care. CCS model is an adaptation of the McGill model, which uses ethnographic methodology and medical anthropological knowledge. The method and approach not only contributes both to a broader conceptual and dynamic understanding of culture, but also to learning of cultural competence skills by healthcare professionals. The CCS model demonstrates that multidisciplinary workforce can acquire cultural competence skills better through the clinical encounter, as this promotes integration of learning into day-to-day practice. Results indicate that clinicians developed a broader and patient-centred understanding of culture, and gained skills in narrative-based assessment method, management of complexity of care, competing assumptions and expectations, and clinical cultural formulation. Cultural competence is defined as a set of skills, attitudes and practices that enable the healthcare professionals to deliver high-quality interventions to patients from diverse cultural backgrounds. Improving on the cultural competence skills of the workforce has been promoted as a way of reducing ethnic and racial inequalities in service outcomes. Currently, diverse models for training in cultural competence exist, mostly with no evidence of effect. We established an innovative narrative-based cultural consultation service in an inner-city area to work with community mental health services to improve on patients' outcomes and clinicians' cultural competence skills. We targeted 94 clinicians in four mental health service teams in the community. After initial training sessions, we used a cultural consultation model to facilitate 'in vivo' learning. During cultural consultation, we used an ethnographic interview method to assess patients in the presence of referring clinicians. Clinicians' self-reported measure of cultural competence using the Tool for Assessing Cultural Competence Training (n = 28, at follow-up) and evaluation forms (n = 16) filled at the end of each cultural consultation showed improvement in cultural competence skills. We conclude that cultural consultation model is an innovative way of training clinicians in cultural competence skills through a dynamic interactive process of learning within real clinical encounters.

Overall the evidence base to guide the development of mental health services for immigrant populations appears limited. Future research requires appropriate funding, should be of sufficient methodological quality and may benefit from collaboration across Europe.

SummaryExplanatory models of illness – the way people perceive, interpret and respond to it – are mediated not only by the illness itself, but also by cultural and social contexts. This article discusses recent evidence showing how the exploration of explanatory models can help to shape treatment and outcomes for some of the most common categories of mental illness, and presents case studies illustrating dilemmas clinicians face when their explanatory models differ from those of their patients. It concludes with recommendations on how a culturally sensitive clinical approach based on the exploration of explanatory models during assessment and treatment can be used as an effective way of dealing with the complexity of patients' and families' needs.Learning Objectives• Appreciate the use of explanatory models in clinical practice• Understand the relevance of explanatory models in relation to specific diagnostic categories of mental illness• Recognise that dilemmas may arise if the explanatory models of the clinician and the patient differ, and be able to manage this tension

This paper outlines the history of workforce strategies for providing mental health care to "black and ethnic minorities" in England. Universal mental health policies failed to deliver equity in care, and thus specific policies were launched to address ethnic inequalities in care experiences and outcomes. The emphasis on race equality rather than cultural complexity led to widespread acceptance of the need for change. The policy implementation was delivered in accord with multiple regional and national narratives of how to reduce inequalities. As changes in clinical practice and services were encouraged, resistance emerged in various forms from clinicians and policy leaders. In the absence of commitment and then dispute about forms of evidence, divergent policy and clinical narratives fuelled a shift of attention away from services to silence issues of race equality. The process itself represents a defence against the pain of acknowledging systemic inequities whilst rebutting perceived criticism. We draw on historical, psychoanalytic, and learning theory in order to understand these processes and the multiple narratives that compete for dominance. The place of race, ethnicity, and culture in history and their representation in unconscious and conscious thought are investigated to reveal why cultural competence training is not simply an educational intervention. Tackling inequities requires personal development and the emergence and containment of primitive anxieties, hostilities, and fears. In this paper we describe the experience in England of moving from narratives of cultural sensitivity and cultural competence, to race equality and cultural capability, and ultimately to cultural consultation as a process. Given the need to apprehend narratives in care practice, especially at times of disputed evidence, cultural consultation processes may be an appropriate paradigm to address intersectional inequalities.