Health: Parity of Esteem

Baroness Hollins Excerpts

Monday 28th November 2016 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I, too, thank the noble Lord, Lord Alderdice, for introducing the concept of parity in such an interesting way. I admit to being delighted that my amendment to the Health and Social Care Act has contributed to moving mental health issues up the political agenda, with a commitment to parity of esteem. I declare an interest as a former president of the Royal College of Psychiatrists, a former consultant psychiatrist and emeritus professor of psychiatry at St George’s, University of London. I also steered the development of the British Medical Association report published in 2014, Recognising the Importance of Physical Health in Mental Health and Intellectual Disability: Achieving Parity of Outcomes, and I will return to that in a moment.

Parity also means that if a diagnosis of a mental health problem has been made, investigations and treatment should be provided on an equal basis, as they would for a physical health problem. But we know that this is not happening yet, and one reason for this is because evidence-based tests and treatments for mental disorders lag behind those for conditions seen as purely physical. There has been an unacceptable underresourcing of research into the understanding and treatment of mental illness, and this is really important.

Another aspect is the physical health of people with severe mental illness, who face earlier death than people without. As with people with learning disabilities who experience earlier mortality, discriminatory attitudes are probably partly responsible. In July this year, the United Nations Human Rights Council adopted a resolution on mental health and human rights, which highlighted that,

“persons with mental health conditions or psychosocial disabilities, in particular persons using mental health services, may be subject to … widespread discrimination, stigma, prejudice, violence, social exclusion and segregation, unlawful or arbitrary institutionalization, over-medicalization and treatment practices that fail to respect their autonomy, will and preferences”.

I think this is relevant to tonight’s debate.

I have long been an advocate of liaison psychiatry teams in acute hospitals. The announcement by Simon Stevens of a new standard for mental health care is to be welcomed. It says that,

“anyone who walks through the front door of A&E or is on a hospital ward in a mental health crisis should be seen by a specialist mental health professional within an hour of being referred”.

This includes mothers in maternity wards. We should not underestimate how hard this will be to achieve, because it will require not only a change of attitude among health professionals and a change in the culture of hospitals but a completely different way of commissioning and providing mental health services. The standard demands that patients should,

“within four hours … have been properly assessed in a skilled and compassionate way, with the correct next steps for their care planned in partnership with them”—

and, I hope, with their family or partner when relevant.

For me, two very important words in this announcement bear careful thinking about. One of these is “compassionate”. We have spoken about compassion many times in this House in connection with the report of the Francis inquiry but not in connection with parity of esteem. In the department of psychiatry at Harvard Medical School, the idea of Schwartz rounds developed—and these are now being used in some hospitals in the United Kingdom—to provide an opportunity for staff from all disciplines to reflect on the emotional aspects of their work. I suggest that this type of approach is fundamental to breaking down the barriers to the acceptance and understanding of mental distress in our hospitals. In part, their success is because they are looking after the very staff who are working in an environment where mental distress is perhaps not understood, whether it relates to the patient or to the staff themselves. Another initiative that the department at Harvard is researching is whether empathy can be taught to clinicians, with a particular focus on non-verbal aspects of communication.

The second key word in the announcement is “biopsychosocial”, and all three parts of that word must be addressed. A key point about parity, which has already been mentioned in this debate, is that we cannot and must not think about mental and physical illness separately any longer. My main concern about our failure to achieve parity is that we are still separating the mental and physical parts of ourselves in such an unhelpful and inaccurate way. It is almost as if our hearts and our minds are in different bodies, and that the social context in which we live our lives is of no importance.

In current discourse, physical illnesses are seen as biological in nature and in need of biomedical tests and interventions, while mental illnesses draw on neuroscience explanations as well as social and psychological ones. In reality, both mental and physical disorders need to draw on biopsychosocial formulations and responses. The problem arises when medical practitioners fail to make the connections. In many ways, this is not surprising given the current separation of services between different provider organisations and the too-early separation of clinical training into physical or mental. Yet we know that people with mental ill-health are three times more likely to end up in A&E than the general population, and five times more likely to be admitted to general hospital wards in an emergency. Is any more evidence needed for the provision of skilled mental health practitioners to be present in the acute hospital, on an equal footing with other specialists?

The NHS has published an aide-memoire on what every sustainability and transformation plan needs to consider in relation to mental health and dementia. The Royal College of Psychiatrists believes this aide-memoire to be a very important guide. Can the Minister say what the Department of Health has done to promote this document and to ensure that local areas take the advice,

“to think more holistically across mental and physical health, rather than just”,

in terms of a separate “mental health ‘section’”?

Does the Minister also agree that the Government have a duty to address the urgency of the fact that 46% of people with serious mental illness have a long-term physical health condition and are at risk of losing, on average, 10 to 20 years of their lifespan due to physical ill-health? Will the Minister explain how in practice the Government’s policy is expected to have an impact on reducing premature mortality? Will the Minister also tell the House what measures are being taken to increase the essential research funding which will underpin any chance of success in this policy initiative?

Will the Government commit not to sign off any sustainability and transformation plan that does not have a clear plan for improving services for children’s mental health? I have not spoken specifically about children or about people with learning disabilities or autism, who have a much higher prevalence of mental illness.

My final comment relates to the urgent need for more attention and money to be given to creating safe and supportive environments and providing skilled support at home for all people with mental health problems and to take seriously the psychosocial part of the word “biopsychosocial”.