Parity of esteem by David Smith

My thoughts on Mental Health Parity of Esteem and its opportunities for the Voluntary Sector

David SmithBefore I move on to Parity of Esteem I just want to quickly recap on mental healthcare in general and where we currently stand in terms of NHS provision.

We all know the general statistics – each year 1 in 4 of us will experience a mental health problem and 1 in 10 children will need support for a mental health condition.

Whilst figures like these are helpful for showing the scale of the problem what they fail to do is capture the complexity as mental ill-health covers a vast spectrum of conditions from short periods of anxiety through to chronic depression, trauma, schizophrenia and suicide.

  • Recent data published by the Health and Social Care Information Service shows that people with mental health problems have a significantly different level of contact with physical health services compared with other patients. In 2011/12:
  • 78% of mental health service users used hospital services compared with 48% of non-mental health service users.
  • A higher proportion of those with mental health problems were admitted to hospital and they also stayed there for around 30% longer.
  • 54% of mental health service users arriving at A&E came by ambulance or helicopter compared to 26% of non-mental health service users.
  • 71% of those admitted to hospital were classified as an emergency compared with 40% of non-mental health service users.
  • The report also tells us that people living with mental ill-health also have more outpatient appointments than those with physical health problems alone.

We know that mental health cannot be treated in isolation, that it is often a complex web of interactions that include ‘wider determinants of health’ such as Education, Employment and Housing and there is often an important link with physical health too. On average people living with schizophrenia will die 10-15 years earlier and there are strong associations with other risky behaviours such as smoking and drug and alcohol abuse.

Given the obvious nature of these interactions you might wonder why we still maintain separate ‘mental health services’. Organisations that focus solely on mental health and have little if any interaction with physical health or social care organisations. It’s a good question, and one whose answers are rooted in 19th century legislation, a flawed attempt at de-institutionalisation and the bureaucratic nature of the NHS that since its inception has been the Achilles heel of how we integrate mental and physical health.

Where the phrase comes from

So moving on to ‘Parity of Esteem’ – a phrase that seems to have come from nowhere to being all over every government media release and policy document for the last 18 months. It was first used by the care services minister Norman Lamb to describe the principle by which mental health must be given equal priority to physical health.

It was enshrined in law by the Health and Social Care Act 2012 and the government requires NHS England (the body which commissions primary care along with other key services) to work for Parity of Esteem to mental and physical health through the NHS Mandate.

All of this sounds great but despite all the rhetoric there has been surprisingly little progress on the ground. There are many, many areas in which mental illness is treated less favourably with waiting time targets, choice and availability being just three. In my own area, York, people with mental health problems are routinely having to wait over twelve months for access to what can be lifesaving talking therapies. Imagine if the same were true for those with broken legs, sepsis or cancer. There’d be a national outcry but the stigma and shame surrounding mental illness stops this happening and has allowed successive governments to shirk their responsibilities for far too long.

In terms of finance, mental health problems account for 28% of morbidity, but spending on mental health services is only 13% of total NHS expenditure.

Bizarrely, in this time of austerity, the financial case alone for Parity of Esteem should be all government needs to act: it’s estimated we lose 105 Billion pounds and 70 million working days every year due to mental illness. 2.6 million People – 43% of those on long-term health related benefits have a mental health problem listed as their primary condition.

On all scales, we simply cannot allow the current system to continue.

What is DH doing about it?

At the moment, without wanting to sound too critical, it’s hard to find anything that is practically changing on the ground. To give credit to the DH they are making some very powerful statements about Parity of Esteem and the need to change. They’ve recognised they have a decades old culture to change and I have no doubt that truly achieving parity will no doubt be a generational effort with these early years being about changing the rhetoric and expectation with more significant changes to funding and removing silo-working coming later.

So what do the DH say : well in their own words – “These deficiencies cannot be redressed solely – or even primarily – through greater investment, although it is crucial that mental health attracts greater priority in allocation decisions. Achieving parity between mental health and physical illness will require a fundamental change to the culture of healthcare, and in the way services are commissioned and provided.”

So, Parity of Esteem is now on the agenda and for those of you like me who have been around for a while maybe we need to hold our cynicism in check. Whilst there has been huge opposition to many of the coalition’s healthcare reforms, their mental health strategy, ‘No Health Without Mental Health’ has received near universal praise and though a long way to go – they have at least opened the door and publicly acknowledged the huge problems we have with mental health care in this country.

And there are a few developments that might prove interesting. Recent announcements during the conference season have told us that government aims to introduce:

  • A drive to implement Closing the Gap – the 2013 strategy that reinforces the importance of access to talking therapies and the new Crisis Care Concordat.
  • The establishment of a new Children and Young Peoples Mental Health and Wellbeing Taskforce charged with using
  • A new £40Million fund to build capacity and kickstart change by:
  • Addressing the dreadful situation where young people are admitted to hosptial outside of their local area and all the resulting difficulty that brings. We know that 50% of all people suffering with mental health issues experienced their first episode before the age of 14 and additional inpatient CAMHS beds along with improved case management to reduce out of area placements and keep families closer together during really difficult times.
  • Early intervention services that reduce hospital admissions along with additional investment in crisis services including psychiatric liaison and crisis resolution home treatment teams
  • Beginning some of the ground work for equalising access and waiting time standards between mental and physical healthcare
  • By end of 15/16 95% of people referred to IAPT will be treated within 6 weeks
  • By end of 15/16 95% of people experience first episode psychosis will be treated within 2 weeks
  • By end of 15/16 All acute trusts will have an ‘appropriate’ psychiatric liaison service. This is particularly welcome as the Centre for Mental Health recently estimated that a comprehensive roll out of hospital-based liaison psychiatry services could save £5 million per year in an average 500 bed general hospital or £1.2 billion per year nationally.

That all sounds great but still feels to me like fixes to specific problems we already know about rather than the wholescale culture change we need to make parity of esteem a day-to-day reality in our daily lives.

Wider issues for the VCS

So there we are for Parity of Esteem. For those of you not from a mental health background you might have been getting a little bored and wondering what difference this might make to your work in the voluntary sector. The answer to that lies in some of the language that government are using – increasingly mental health is becoming less about mental illness and more about mental health and wellbeing. If we think about the wellbeing aspect of Parity of Esteem then the opportunities for the voluntary and community sector start to become much clearer.

I mentioned the ‘wider determinants’ of mental health earlier. Things like housing, employment, healthcare, education, community and social networks. These are all areas in which we as a sector excel and for most of us, improving people’s wellbeing is a core, fundamental part of our work.

Of course, there is the danger that we focus our scarce resources into an area of public policy that fail to materialize. We are seeing some of this with the current developments around personalisation. I know some parts of the country have seen this succeed but in many we are simply rehashing the same meetings, discussing the same problems and debating possible solutions with no decision makers sitting around the table. As a sector we can no longer afford wasting time sitting in talking shops – if this is to happen we need a real commitment from statutory partners to changing the established way services are funded and including us in that process from the very outset.

There is an opportunity for us to engage with this agenda on our own terms though, in a way we are usually pretty good at through our regular campaigning work. The relentless, repeated reminders that mental health and wellbeing are critical to a healthy, inclusive society are core VCS messages and even without focussing specifically on Parity of Esteem we can reinforce the message that the balance between resources going into mental and physical wellbeing needs to be evened out.

When I spoke earlier about the plans Government have for making parity a reality the area where they want to invest the most in is early intervention. Those things that can be delivered in the community that will have a measurable impact on visits to GP surgeries and admission into hospital. I know how difficult it can be to capture the outcomes in these areas – how do you prove you stopped somebody becoming ill – but there are tools we can use and with those we can frame our work in a way that will make it appealing to both local authority and CCG commissioners.

At the end of the day – if Government want community based activities that keep people well – the VCS are already there; we’re established, we’re trusted and we have the ability to scale our work to meet the state as it moves closer and closer into early intervention and our core areas of work.

The Reality

So what can we do now? What action should we take to not only make Parity of Esteem a reality but also ensure that reality has the voluntary and community sector at its very heart?

Firstly we need to make sure we have our voice heard at the right tables. From Whitehall down through the regional structures and into Health and Wellbeing Boards we need to give a clear and consistent message:

We’re glad you have finally caught up. We’re here already. We’re doing the work. We can give you solutions. Come and talk to us.

We have to make sure it’s on the agenda. Make sure our commissioners know it’s important to us and that it won’t simply go away if ignored.

We need to be prepared for difficult questions. Achieving Parity of Esteem isn’t about printing new money – we only seem to do that for the banks. It’s about reallocating resources and in doing so some organisations will inevitably object. When the local hospital says it cannot afford to lose funding to a new mental health project we need to acknowledge that loss and help the hospital see the benefits of early intervention and good mental wellbeing. The transitional period is going to be difficult and if we as a sector are to remain credible – we cannot simply call for more money for all services – we have to support some of the difficult decisions commissioners will have to make to make this new reality happen.

If we succeed, the rewards for our sector could be huge.

Not only could it bring NHS funding in to support some of our core activity, not only could it help us form stronger alliances with other providers – in both voluntary and public sector – to work collaboratively on redesigning services, the most important change will be that the people we support, the ones who are often marginalized, excluded and ignored get a better service. They get the help they need, they’ll be able to recover and they’ll be able to play full and inclusive lives in the world most of us are able to simply take for granted.

You can read more of David’s work at:


One thought on “Parity of esteem by David Smith

  1. Hi David,

    Thanks for sharing this with CareToShareMag. You’re a guy who really does know his stuff.


    Stuart (Ed)

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