Mental and Physical Health: Parity of Esteem

Lord Adebowale Excerpts

Thursday 10th October 2013 Lords Chamber

[Lord Adebowale (CB)]

I start by thanking the noble Lord, Lord Layard, and the noble Earl, Lord Howe, for bringing forward this debate on what is a vital issue not only for our health and social care systems but for society more widely. I should declare my interest as the chief executive of a health and social organisation called Turning Point, and I will draw on some cases that Turning Point has come across to illustrate why parity of esteem is so important. I should also declare my interest as a non-executive director of NHS England. Many of the points made by other speakers, including the noble Lords, Lord Layard, Lord Alderdice and Lord Stone, and the noble Baroness, Lady Murphy, I take to heart, and they can be assured that I will be making those points around the table of NHS England.

The strategy, No Health Without Mental Health, and the subsequent implementation framework make it clear that mental health is everyone’s business: one in four adults and one in 10 children in the UK are experiencing mental health issues at any given time; 30% of the 15 million people with a long-term health condition also have mental health problems; and, as has been pointed out by the noble Baroness, Lady Murphy, within a prison environment up to 90% of the population experience one or more mental health conditions, often alongside substance misuse and/or a learning disability. Given this and the costs of mental health, calculated by the Centre for Mental Health to be £105 billion, it is frankly shocking that huge disparity still exists between those with a diagnosable mental health issue and those without. As has already been mentioned in the debate, this results in there being an unacceptable difference in the life expectancy of those with a severe mental health condition and those without of between 16 and 25 years.

I want to illustrate my contribution to this debate from the perspective of people who have mental health issues, and perhaps I may do so by presenting to the House three very short vignettes. The first is a case that has come to the attention of Turning Point. It illustrates a lack of consideration of an individual’s whole needs. It concerns a chap called Fred, although I have changed his name. He has a learning disability and a history of poor eyesight, which staff assessed as contributing towards his high levels of anxiety. Staff working closely with Fred arranged for him to access specialist optical services. It was found that he had a detached retina and cataracts were diagnosed, leading to surgery. Following this surgery, a decrease in what had been perceived as “challenging behaviour” was clearly evidenced. This is someone who, because of a physical illness, had been classed as severely problematic.

The second case concerns professionals failing to work together. Alan had enduring mental health issues when he experienced a stroke and was admitted to the local hospital from one of our residential services. While in hospital undergoing rehabilitation, Alan had all medication reviewed by a ward doctor. The doctor, knowing that Alan had a mental health condition, decided without any discussion with him, the care manager or psychiatrist to stop his medication, even though it had a multiple purpose. It could be used to reduce mood swings and also to treat epilepsy. The hospital doctor stated that, as Alan did not have epilepsy, the medication could be stopped with immediate effect. This had a detrimental effect on his mental health—something that the doctor appeared to be ambivalent about, having not once discussed anything other than Alan’s physical needs with any member of his care team.

The final case is, I think, the most shocking example and most immediate in case we have any doubt that these issues are taking place right now. It involves a support worker who just happened to be at the bedside of one of our clients. They noticed that the file was open and that there was a “Do Not Resuscitate” note in it. Luckily, the care worker knew that no such thing had been discussed with the individual’s next of kin. The support worker challenged hospital staff and was told that because the individual was a mental health patient and under a Home Office order, he had “no priority of life”. Because our member of staff challenged this, the DNR note was removed, but the fact that it was there in the first place highlights the discriminatory treatment that people with a mental health condition can face, which is compounded when other complex needs are applicable, such as offending behaviours or a learning disability.

The implications of introducing parity of esteem are wide-ranging and they highlight the vast amount of work still required to make it real. Rhetoric, commitments and case studies have highlighted the need for parity but there are certain things that have to happen if this is to be embedded throughout the health and care system.

We will simply not achieve parity of esteem without first addressing equality of access and experience. This means breaking down the cultural barriers that still prohibit people from black and minority ethnic communities receiving the support that they need. As the Mental Health Foundation has found, people from BME groups are more likely to be diagnosed with mental health problems, more likely to be diagnosed and admitted to hospital, more likely to experience a poor outcome from treatment—this has been repeated in annual surveys of people in mental health institutions —and more likely to disengage from mainstream mental health services, leading to social exclusion and a deterioration in their mental health.

Staff at all levels of the health system, including GPs and A&E staff, must receive adequate training in mental health. So, too, should the police—something that was brought very much into my experience when I chaired the Commission on Mental Health and Policing. The police are too often the first point of contact for people experiencing a mental health crisis.

The commission reported that one of the clearest examples of disparity between physical and mental health was in regard to how the police and ambulance service respond to a crisis. If I or one of your Lordships had a heart attack—heaven forfend—I can guarantee that an ambulance would arrive within eight minutes. If I had a mental health crisis, it is more likely that I would be carted away by the police and it is highly likely that I would be put in the back of a police van. Such disparity has led to the deaths of too many people, particularly from BME groups. Responding to crisis is a whole other debate but, for me, it is the very start of any definition of parity of esteem. If you cannot have parity of esteem when you are in crisis, when can you have it?

Finally, I turn to something that I spoke about a lot when the Health and Social Care Bill was going through the House: the issue of integration. Until we have a health and care system that looks at the whole person and designs, commissions and delivers services in conjunction with the community to ensure that they are fit for purpose, fragmentation will persist. People will continue to receive disjointed care where their mental health issue is not considered alongside their physical health condition because it is not a priority or is not understood well enough.

The implications of embedding parity certainly will be challenging and require people to work differently, but if we do what we have always done, we will get what we have always got, and the experiences of the people that I have highlighted show why this is no longer acceptable.