Mental and Physical Health: Parity of Esteem

Baroness Tyler of Enfield Excerpts

Thursday 10th October 2013 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I want to start by saying why this is such an important debate and thank the noble Lord, Lord Layard, for securing it. Some of the biggest inequalities in health today are faced by people with mental health problems. Nothing illustrates that more starkly than the fact that we know that people affected by serious mental illness die on average 20 years earlier than the rest of the population from preventable physical health conditions—something I am sure we all regard as a scandal. Thus I strongly welcome the Government’s very clear commitment to achieve parity of esteem for mental health. The 2011 strategy document, No Health Without Mental Health, made an unambiguous commitment to parity of esteem and set a clear objective that more people with mental health problems will have good physical health, fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health. In addition, of course, as we have heard, the NHS mandate commits to achieving this and will carry out a progress report in 2015.

I think, however, that in this Chamber we would all accept that there is still a long way to go. To make a reality of these very good intentions I contend that three things need to happen. First, people with mental health problems must have the same access to treatment and services as those with physical health problems; secondly, they must have the same rights within the NHS constitution; and thirdly, they must have equal patient voice as those with physical health problems. What more, then, can be done in practice?

I will start with something that I regard as very positive indeed, which we have heard spoken about so eloquently by the noble Lord, Lord Layard. I refer to the Improving Access to Psychological Therapies programme. We all know that in many places this programme has provided an invaluable service. It has achieved high recovery rates and has helped people both get back to work and stay well. Indeed, an IAPT service user recently told the mental health charity Mind that:

“Receiving psychological therapy turned out to be the best thing that could possibly happen for me, it was exactly what I needed … a place for me to finally look at my past and put the pieces together and come to understand why I felt the way I did”.

I shall now talk about how this affects people with complex needs. It was, of course, hoped that focusing additional resources on the more common mental health problems, such as anxiety and depression, would free up waiting lists and resources for other forms of therapy for those with more complex needs, such as people with substance misuse problems and those with more severe mental health problems. As ever, there have been unintended consequences. It is worth emphasising that IAPT was never intended to act as a comprehensive service delivering all forms of psychological therapy. Indeed, Department of Health guidance made it clear that IAPT money should not be used to replace funding for other psychological therapies. Despite that, in 2010 the We need to talk report showed that this was happening in a number of areas, where non-IAPT services were either having their funding cut or being entirely decommissioned, so that IAPT was replacing, not improving, the provision of psychological therapies.

If this were a physical health problem we would not tolerate the lack of choice and treatment options given to people with mental health problems. In some places we are in danger of reaching the point where if you do not get better after a course of CBT there is simply nowhere else for you to go—and we all recognise that for some people, CBT is not the right choice of therapy in the first place. There are other NICE-approved therapeutic interventions that should also be available.

I shall ask the Minister two questions. First, do the Government recognise the need to provide a full choice of evidence-based psychological therapies on a sufficient scale to meet the requirements of people with more complex mental health problems? Secondly—this echoes something that the noble Lord, Lord Layard, said—what plans do the Government have to introduce standards for waiting times for mental health equivalent to those for physical health, and, in particular, to amend the NHS constitution to ensure the availability of psychological therapies within 28 days of a referral?

I now turn to preventive approaches, and in particular to intervening early in a child’s or a young person’s life. There is now clear evidence of the importance of intervening early to promote resilience in young people, to prevent mental illness and to promote well-being. The children with the poorest life chances of all are those who have early-starting behavioural problems. They are 19 times more likely than their peers to be in prison by their mid-20s, and have high rates of school exclusion, unemployment, gang membership—especially among girls—suicide, and a range of physical health problems during their lifetime.

Cost-effective parenting programmes are now available for families whose children have behavioural problems, to help them manage them from an early age. These include family nurse partnerships for the most vulnerable families and parent training programmes. Of course, availability of these programmes is patchy and they are not always delivered as intended for maximum effectiveness.

For parity to extend to children with behavioural problems, two things are necessary. First, maternity services, health visitors, GPs and schools should regularly look out for families at risk and routinely assess healthy child development to identify children with early signs of behavioural problems. Secondly, parenting programmes should be made available to families who really need them, targeted towards those in greatest need but with easy referral routes to prevent them from becoming stigmatised.

I now turn to how primary care and mental health services are configured. I do not think that it will be a surprise if I say that they often do not work well together. How could primary care services be designed so as to encourage better integration with mental health services? There are three potential big improvements. The first would be mental health support for the 4.6 million people in England with major physical conditions, such as diabetes, heart disease and cancer, and a concurrent mental health problem—most likely to be depression—by offering psychological therapies, as I described earlier, and help with self-management. The second would be physical health support for people with severe mental illness—for example, those who may need help with weight management, particularly those on anti-psychotic medication, and with smoking cessation. Finally, there is care for people with medically unexplained symptoms. At least one-quarter of hospital outpatients who have physical symptoms with no explained physical cause may very well benefit from psychological support.

Breaking down the barriers between primary care and mental health is vital to achieve the changes that we want to see. I contend that GPs need clear incentives to address the overlaps between physical and mental health—for example, through the Quality and Outcomes Framework for general practice—and that payment systems for mental and physical healthcare need to be better aligned to prevent mental health budgets being raided when there is pressure on acute hospital spending. On that issue, we hear almost daily of the pressure on A&E departments. There are growing concerns about the quality of care and support that people with mental health problems receive when in crisis. Recently published research showed that people using mental health services were twice as likely as others to present in A&E, causing all the problems that we have heard so much about.

In the comprehensive spending review of June 2013, the Chancellor committed to every A&E department having constant access to mental health professionals to ensure that people with mental health problems got the best possible care. That is something that I very much support. It is vital that all hospitals put in place comprehensive liaison psychiatry services, available 24/7 to all hospital wards for people of all ages, from children with emergency admissions for self-harm to older people with dementia. Can the Minister update us on progress in this area?

I stress the very important and key role that family, friends and the wider community can play in mental health and well-being. In many areas, we have seen good projects and approaches. There is support and care for the families and carers of those with mental health problems, as well as, in some cases, carers having their own recovery plan, which is a very interesting idea. Finally, I emphasise the important role that health and well-being boards should be playing to embrace mental health, seeing it as a key aspect of public health. I know that in local government its profile is being raised, and some local authorities are now having a local authority mental health champion. That is very positive—to have a member who can champion mental health issues in every single area of council business—and I hope that we hear of more such examples today.