Mental and Physical Health: Parity of Esteem

Lord Layard Excerpts

Thursday 10th October 2013 Lords Chamber

Moved by

[Lord Layard]

That this House takes note of the implications of parity of esteem for mental and physical health, as required by the Health and Social Care Act 2012.

[Lord Layard (Lab)]

My Lords, by an extraordinary coincidence, today is World Mental Health Day, so I wonder whether it is not due to ballot rigging that we are having this debate today. This is also the time when the Government are preparing the next mandate for the National Health Service, so the timing of this debate could not be better.

Of course, we would like to be in a situation where we did not need to debate parity of esteem, but I start from one simple fact. We have 6 million adults in England suffering from depression or crippling anxiety disorders, and of them only a quarter are in treatment. You can compare that with people with physical conditions where, in most cases, more than 90% are in treatment. The same is true of children: only a quarter of those who would be diagnosed as mentally ill are in treatment. That is not parity of esteem; it is a really deplorable situation. What is the reason? The reason is the lack of parity in the provision of care; that is the central reason.

Of course, medication is available for most people who come forward with those problems, but most of them would prefer, or would want in addition, psychological therapy. We have excellent psychological therapies with 50% recovery rates for anxiety and depression conditions, for children’s disorders and so on, and NICE has reviewed all of them and recommends that psychological therapies ought to be offered to all patients with mental health problems. However, that recommendation is largely disregarded in huge areas of the country where those therapies are not available. Let me give just one extra argument why they should be available—other than the obvious humanitarian argument that we should treat people who are ill; that is why we have a health service. In this case, there are also huge savings to be had if we treat them. Those savings in welfare benefits and extra taxes would pay for the cost of the psychological therapy. That is a complete, 100% offset. Another probable 100% offset is in the cost of additional physical care that mentally ill people demand.

So the argument for making those therapies available is overwhelming, but it is happening very slowly. As Sir Mike Rawlings, the former chairman of NICE says, this is the area in the whole of the NHS where NICE recommendations are the most flagrantly and casually disregarded. If the same thing happened with cancer or heart disease, there would be uproar. That is why what happened in this House two years ago was so important. It was the landmark moment for millions of people because the amendment that we passed in this House introduced the principle of parity between mental and physical health. The issue that we must discuss today is what that means. That was not said in the Bill. We need to discuss exactly what that means and how we would know if we got there.

I want to suggest two simple principles. First, NICE guidelines should be as faithfully implemented for mental illness as they are for physical illness. That is a very simple principle. Secondly, treatment should be provided speedily when it is needed, as it generally is in the case of mental illness. Those two basic principles should guide the way forward. How do we get from here to where we need to be? The mandate, which is now under discussion, is the key. I very much hope that the Minister can help us with some improvements in the draft of the mandate which has been circulated for comment.

Let me start with waiting times. It is shocking that there are waiting times for hospital treatments and no waiting times for psychological therapy. This is not acceptable. Depression and anxiety are pressing conditions; more pressing than some physical conditions, although obviously less pressing in most cases than cancer. With cancer we talk about two weeks. It seems clear that we should be aiming at a maximum wait for access to psychological therapy of 28 days. Many people have argued this. I very much hope that that can be included in the mandate.

Of course, that raises the question of what scale of service would be needed to achieve that objective. The main provider of psychological therapy in the NHS is Improving Access to Psychological Therapies—the programme known as IAPT, launched in 2008. It has been very energetically and faithfully supported by Ministers from all political parties, for which everyone is extremely grateful. The programme grew rapidly, but 80% of those treated still wait for more than 28 days. Some wait for more than 12 months. Waiting lists are rising as people become aware that there is some hope in their lives.

How large a service is needed to implement the NICE guidelines for all who need them? By 2011, in the third to fourth full year of the programme, the programme was seeing more than half a million people. But that of course is only 10% of the 6 million with the condition. Since 2011, the programme has stalled due mainly to poor priorities on the part of local commissioners, the dislocation of the messages coming down to them and the pressure on them from the higher levels of the NHS as it is being reorganised.

I think we can all agree that 10% is a completely unacceptable figure. The Government have already committed to 15% by 2015, but even that deals only with the tip of the iceberg. From our experience in the first three and four years of the programme, it would be feasible to reach a figure of 25% by 2020. I would urge the Government to be thinking in those terms.

The Government, rightly, will want to have people not only treated but recovering. That is the right way to be thinking and that is where the IAPT programme is so strong because we know how many people recover. Patients are monitored on a meeting-by-meeting basis and there is now a 45% recovery rate for the patients who have two or more sessions. The Government target is 50% and the right way to express a vision for 2020 would be the numbers of people who have recovered as a result of treatment.

So I hope that the Government will be giving some indication of that longer term perspective in the mandate. It is really important because we can get good people to train as therapists for the service only if they see that the number of jobs will go on expanding. We will get commissioners to commission this service at an expanding rate only if they see that they are expected to do that and block in increasing sums. Too many of these commissioners have concluded that they have done what they need to for IAPT, which is how it has stalled. It has to be restarted, so I urge the Minister to include at least some phrase in the mandate, if he can, such as “continuing expansion of access up to 2020, linked to 50% recovery rates”. Some phrase of that sort would show that the Government and the service are serious about this. We know that the good will is enormous towards IAPT on the part of the coalition Government, but can they please set this down in some concrete way that commissioners can read and see that they have to act on?

There are of course financial constraints and commissioners are always tempted to dumb down in areas which look like soft targets. Incredibly, one commissioner will not pay for any patient receiving more than two sessions unless they can be shown to have recovered. This is an outrage but there are many who will pay only up to a maximum of six sessions for any one patient, as if they would cut an operation short if it happened to need more than the standard time. This is absolutely unacceptable discrimination and it is rife throughout the commissioning system. How can we deal with it? It would be by pressure of all kinds from above and, of course, with a constant emphasis on outcomes. I place great hope on the measurement of outcomes as the ultimate source of pressure on commissioners. When we get to outcomes-based payments, which we may in a few years’ time, we must again resist the pressure to dumb down by leaving the tariff price free for the local commissioner. There has to be the national reference cost, otherwise this will again be the soft area which gets dumbed down.

I have one final comment on the IAPT programme. It is currently in the list of 10 services suitable for “any qualified provider” treatment, together with incontinency services, wheelchairs and a few other things. Is the treatment of depression and anxiety really worthy of being treated like that? A recent study from the World Health Organisation compared the disabling effect of depression with that of angina, asthma, arthritis and diabetes. I hope it is not surprising to Members of this House that depression was 50% more disabling than each of those four conditions. One wonders why those four were not included in the list, together with incontinency and wheelchair services. If there is confusion about parity of esteem at the centre, no wonder there is even more confusion at the local level.

I have concentrated on depression and anxiety disorders. There are many other mental health problems for adults, and of course for children as well, which I am sure other noble Lords will talk about. But I want to mention just one general point: research. According to the WHO, mental illness accounts for 38% of all illness when weighted by severity in this country and 23% of the total burden of disease, including premature mortality. But what percentage of health research goes on mental health? It is 5%. We need much more mental health research. We need more trials on therapies other than CBT and many more on therapies for children. For adults we do not even know about effective group treatment, which could be very economical and effective compared with individual treatment, and so on. Most trials in mental health are very short follow-ups compared with the decade-long trials for treatment of physical illness. All this should be changed and there should be some statement about it at this point, although it cannot be changed overnight.

I hope that the Minister will reassure us on the four points I have raised—the 28-day maximum wait; the commitment to continued expansion; taking psychological therapy out of the degrading position of coming under AQP, which leads to many of these terrible commissioning decisions; and more research for mental health, especially psychological therapy. We know that the political pressures coming for psychological therapy are trivial compared to the pressures on politicians from those who suffer from most physical illnesses—especially, of course, those which are helped by the pharmaceutical industry—but one third of all families include someone with a mental health problem. Many are silent because of shame, but I think that they will privately thank any politician who shows that they understand their problems.

It is an amazing fact that mental illness, as the surveys show, causes more misery in our society than physical illness does, causes much more than unemployment or poverty do and costs the Exchequer £60 billion. It is extraordinary that it still has such a low priority on the ground. I think that we still live in the materialistic shadow of William Beveridge. As noble Lords know, he identified five great giants—poverty; unemployment; undereducation; poor housing; and physical illness—but he omitted the problems of the human spirit within. This has caused us decades of unnecessary misery. It is time to name the sixth giant, the great, hidden problem in our society, and that is mental illness. If it had parity of esteem, it would have its own Cabinet Minister, like the other subjects I just mentioned. Perhaps the best test of when we eventually have parity of esteem is when we have a Cabinet Minister for mental health. I beg to move.

--- Later in debate ---

[Lord Layard]

My Lords, I thank everyone who has spoken in this substantial debate. We have had 15 excellent contributions and somehow, miraculously, they have been almost entirely complementary to each other, so in some way we have written a pretty good textbook on the subject in these three hours. As everyone has said, this issue is a massive problem, which is why we are all extremely grateful to the Minister for taking this problem seriously today, and indeed I know that he takes it seriously on all occasions.

I am grateful for what people have said and I agreed with almost everything, including most of what the noble Baroness, Lady Murphy, said, on which I, too, would like to comment. It is quite misleading to suppose that there is something called the mental health budget, which is then allocated between psychotic illness and common mental health problems. We have never argued for more expenditure on anxiety and depression at the expense of severe mental illness. What we have pointed out is the remarkable fact that a mentally ill person with a physical illness of given severity costs the NHS 50% more in physical healthcare than someone without mental illness in the same physical condition. If we can cure the mental illness or alleviate it, there is an awful lot to be saved on unnecessary physical healthcare.

Most commissioners should be able to fund the extra psychological therapy out of the savings that they can expect from their physical healthcare bills, particularly their references to the secondary sector. One could document how those are affected immediately when someone’s mental health improves. There is a huge amount of evidence on all that. On top of that, of course, taking the Government as a whole, there are the savings on benefits and lost taxes. When we can say that it certainly costs the Government—and probably costs local commissioners—nothing to expand treatment for people with depression and anxiety disorders, which are extremely serious problems, it makes no sense to say that we should be concentrating only on people with even more serious problems. Both groups must be helped.

As I said, there have been many wonderful speeches. I thought that the letter read out by the noble Baroness, Lady O’Neill, really says it all; it caught the basic point that everyone is making. I was also delighted when the noble Lord, Lord Alderdice, raised the issue of the comparative suffering from mental and physical pain. I have been trying to look into that topic and have found quite a lot of research on it. Many studies show that when people are asked how happy they are with their lives and then record the different dimensions of their health situation, it is found that mental pain reduces happiness more on average than physical illness. In a way, we have to justify our argument for parity of esteem, and I think that that is the justification: these are extremely serious conditions affecting the well-being of the people affected. Many people have made that point, and it is a central argument for parity.

I think that if in decades hence we look back on where we are today, we shall be able to see a lot of progress. I think that people will be amazed when they look at how mentally ill people were treated, even now, and they will find it quite difficult, just like we find it difficult to believe how slaves and so on were treated, to believe that we treated mentally ill people with as much blindness and cruelty as we have been up till recently.

Motion agreed.