Mental and Physical Health: Parity of Esteem

Baroness O'Neill of Bengarve Excerpts

Thursday 10th October 2013 Lords Chamber

[Baroness O'Neill of Bengarve (CB)]

My Lords, I think that we are all very grateful to the noble Lord, Lord Layard, for securing this debate. It is a theme of such enormous dimensions that it is almost tempting to avoid how centrally serious it is. He has concentrated on this area for many years, and I am sure that many of us have learnt from his work. I declare an interest as chair of the Equality and Human Rights Commission, which has among its responsibilities helping to reduce—of course, one hopes, to eliminate—unlawful discrimination on the basis of disability, including unlawful discrimination on the basis of mental health disability.

Speaking in June this year, the Minister with responsibility for care services, Norman Lamb, commented on the Royal College of Psychiatrists’ report, to which reference has been repeatedly been made, Whole-Person Care: From Rhetoric to Reality (Achieving Parity Between Mental and Physical Health). He said:

“What do we mean by parity of esteem? … I think the report—in its definition and vision for parity—has it right. It’s about equality in how we think about mental health and physical health care—it’s about how they’re valued. We need to ‘close the gap’ with physical health services—whether that’s a gap in access, in quality, in research, or even in the aspirations we have for people”.

As the Minister made very clear, this is an extremely large agenda ranging from the commissioning of services and the integration of services to interventions to reduce premature mortality among those suffering from mental health conditions. It is also an agenda that stretches far beyond the NHS. Indeed, it is an agenda to which anybody and everybody, particularly employers, communities and schools, can make a large contribution.

Parity of esteem is not just a matter of ensuring that different conditions are treated with the expertise appropriate to them, although that is, of course, central. It is not just a matter of concern within the health and care systems that the people who suffer these conditions are treated with dignity and respect. It extends far beyond medical treatment and care, and many non-medical approaches are also of great importance.

First, I shall give a brief reminder of how stark and bitter the absence of parity of esteem and all that goes with it can be for those who suffer mental health conditions and for their friends and family. I have been permitted by a colleague to quote from an account from a family with two sons who are both young adults. One is in an advanced stage of muscular dystrophy and the other is diagnosed as chronically mentally ill. The family said:

“The son who is physically disabled has many special needs. He gets emotional support everywhere he turns. His handicap is visible and obvious and the community, family and friends open their hearts to him and go out of their way to make his life better. My other son, on the other hand, is misunderstood and shunned by all. He is also terribly disabled … but his disability is not visible.”

At least, it is not visible in the same way. The extended family,

“all think that he’s lazy, stupid, weird and naughty. They suggest that somehow we have made some terrible mistake in his upbringing. When they call on the phone they ask how his brother is and talk to his brother but they never inquire about him. He upsets them. They … wish that he’d go away”.

That is poignant and sad, and shows how stark the absence of parity of esteem and all that goes with it can be for those who suffer mental health conditions. That probably is an extreme case, all the more poignant for being in one family, but it reminds us of a lot.

Of course, these conditions and their diagnoses are complex and highly varied. Many conditions have both mental and physical aspects. For example—I know that this also is a very large area of need—difficulties with communication are not easily classified as mental or physical, and there are many other conditions that combine both sorts of symptom. We have to agree that there are physical conditions—for example, disfigurement —where sufferers may encounter reactions from others that are as harsh as those sometimes faced by people with mental health conditions.

We also have to remember that there are many conditions which people do not want to disclose. We have very little idea how many of those we live among may be coping on a daily basis with physical and mental conditions that are invisible to us, that they manage more or less adequately and that they try to keep to themselves, be it diabetes or depression, digestive problems or severe phobias. Nor do we have much idea how much physical or mental pain, or both, others are often managing, whether day-in, day-out or episodically. Much of the burden of disease is invisible to others, and much of it is not solely mental or solely physical.

We also must not forget the cases where the conditions are all too visible. One of the difficulties is that the person who has the condition becomes invisible because people focus on the wrong thing. One only has to witness the many terrible stories of the condescension to which wheelchair users are subject, as though the use of a wheelchair somehow rendered one incapable of speaking.

For all those reasons, I believe that, while changes in the way in which we organise health and social care are essential for securing parity of esteem for persons with different sorts of health conditions, much also depends on the social and economic arrangements that we have, and in making sure that they recognise and include those with varying health conditions.

I shall make just a few illustrative comments on the way in which wider employment and community arrangements can make a difference. Let me start with something that perhaps is mainly a concern of schools; namely, speech and language difficulties. It has long been recognised that this is a major area in which complex interventions and social support matter greatly. The Bercow report, A Review of Services for Children and Young People (0-19) with Speech, Language and Communication Needs, was published a few years ago but its findings bear repetition. It states:

“Approximately 7% of five year olds entering school in England—nearly 40,000 children in 2007—have significant difficulties with speech and/or language. These children are likely to need specialist and/or targeted intervention at key points in their development. Approximately 1% of five year olds … more than 5,500 children in 2007—have … severe and complex”,

difficulties in this area.

“They may not understand much of what is said to them … may have very little spoken language”,

and are at risk of other mental health conditions.

Specialist intervention is, of course, what is important for such children and young people but again it is not all that is needed. For those with communication difficulties, the reaction of others can be one of the worst hurdles. The parents of such children,

“expressed concern that their children’s ability to communicate, to speak and to understand was taken for granted”.

They said that,

“their children often looked like any ‘normal’ child and yet behaved differently”.

One parent commented:

“They don’t think quickly and they can’t express themselves quickly, but they look as if they can manage. All my children stare at people because they are looking for cues, and that causes fights”.

Here we can see very clearly that a great deal of what matters for partly invisible conditions is inclusion; that is, including the child with communication difficulties in activities, in school, in play, in the community and, later, in the workplace.

A final example is one that employers can foster. I believe that the example of really energetic ways to develop flexible working can make a great difference to many people. The British Telecom report, Flexible Working: Can Your Company Compete Without It?, states:

“At BT, flexible working is business as usual. Already seven out of 10 people work flexibly and nearly 10% are home-based. It has saved the company millions in terms of increased productivity and cut costs. It has also motivated our people and released more potential … we are attempting nothing less than the complete transformation of the way in which the company runs, the way we communicate, and the way we work together”.

For BT, that saves costs and improves productivity. I think that we must all acknowledge that it is in an advantageous position because telecommunications allows for distant working more easily, but remote working, even if harder in other areas, can have many benefits—above all, the benefit of the possibility of including many people who either could not travel to work or could not work as many hours as some others. It has great benefits for carers, including the benefit of a working life of self-respect and money they have earned.

There are many other examples of businesses making creative and effective use of specific disabilities, including mental health disabilities. There are companies that have found ways to use the distinctive capacities of some people with high functioning autism spectrum disorders to carry out tasks that require focused accuracy and have given them preferential employment in these areas. For example, the Danish company—I may mispronounce it—Specialisterne, is almost entirely staffed by people with autism spectrum disorders. They specialise in the high precision task of quality checking software. Apparently, those of us who do not have those disorders would be less good at it.

The benefits of inclusion matter greatly for those with mental conditions as well as those with physical conditions. We should make efforts to secure as much inclusion in schools, at work and in community life for those with disabilities of all sorts as we possibly can.