Parity of esteem?

Peter Martin and Marcus Longley argue that good health is both psychological and physical, and that despite good policy intentions, there is still much to do if mental and physical health are to achieve truly equal value

The economic and humanitarian case for giving proper priority to mental health services may be preached by Welsh politicians of all shades, but do mental health services have the same priority afforded to physical conditions? With unique mental health legislation in Wales and all-embracing NHS bodies serving all aspects of health need, are mental health services getting any better? What’s the problem?  And will we ever solve it?


Much has been written recently about the concept of ‘parity of esteem’ between mental health and physical health, particularly in England. It is described by the Royal College of Psychiatrists as meaning ‘valuing mental health equally with physical health’.  In other words, you would have equal access to the most effective and safest care and treatment, whether your diagnosis is ‘physical’ or ‘mental’, there would be equal status within healthcare education and practice, equal status in the measurement of health outcomes, and the allocation of time, effort and resources would be on a basis commensurate with need.


But does mental health have ‘parity of esteem’ with physical health in Wales? Perhaps a better way of posing this question is: are mental health services given the same priority as, say, cancer or stroke services? How do policy intent and expenditure compare? What about outcomes? And is future progress equally likely?


The policy intention is clear. We have unique and pioneering mental health legislation in place in Wales – The Mental Health (Wales) Measure 2010 – and we have a very good ‘all age inclusive, Cross Government Strategy’: ‘Together for Mental Health – A Strategy for Mental Health and Wellbeing in Wales’. Welsh Governments have consistently asserted that mental health is a priority, exemplified by ring-fencing mental health expenditure and ensuring that Health Board Vice-Chairs have a specific mental health remit.


On expenditure, mental health is the largest of all the programme budgets in NHS Wales (just over 11%), and is ‘ring fenced’.  Successive Welsh Governments have been committed to reducing inequalities amongst people experiencing mental illness and mental health problems’.


As far as outcomes are concerned, part of the problem when comparing mental health services with cancer or stroke services is that mental health problems or mental illnesses are not homogeneous. They can be any one of numerous conditions, ranging from emotional and behavioural disorders experienced by teenagers to dementia experienced by older people. It can mean having mild to moderate depression or it can mean being diagnosed with paranoid schizophrenia. It is not a single condition, and this makes establishing meaningful performance indicators for mental health, or setting standards for mental health services, problematic.


The extent of mental health problems is difficult to measure as information on the incidence and prevalence of psychiatric illness is limited. However, we do know that people with a diagnosed psychiatric condition such as schizophrenia or bipolar affective disorder die an estimated 15-25 years earlier on average, and that this is mainly due to preventable physical health problems, such as cardiovascular disease or diabetes.


From the limited research that has been undertaken, we know that people who have a mental illness are around three times more likely to be in debt and have financial problems, and are over five times more likely to cut down on the use of the telephone, gas, electricity and water than the general population. We know that personal finances are regularly cited as a major cause of difficulty and distress, and that people are far more likely to lose their job because of their condition.


The scale of inequality for people with a diagnosed psychiatric condition is huge. People with mental illness have the lowest employment rate for any main group of disabled people, endure greater poverty, have poorer housing, have fewer training and educational opportunities and experience greater social isolation. The list goes on. So there is much still to do.


The question of whether mental health services in Wales are getting any better is a difficult one to answer. One reason for this is the lack of any meaningful success indicators. We should be able to measure whether people’s needs are being met, whether successful outcomes are being achieved, and whether more people who use mental health services are getting back into education or training, volunteering or work.


But these types of success indicators are not published in Wales. We know how many people have a valid Care and Treatment Plan; we know how many people are accessing services and are being assessed; and we know how many people are receiving treatment within 28 days of referral. But we struggle to provide the data to show how many people are getting any better as a result of the care and treatment they receive.


People who have a severe and enduring mental illness often need support from a broad range of services such as health, social care, housing and employment, and so it is particularly important for these services to work together in a seamless and coordinated way. This is precisely what Part 2 of the Mental Health Measure – Wales’ own mental health legislation – is all about: delivering effective, coordinated care, treatment and support.  


But service providers don’t always work in a fully integrated way. Organisational interests and budget constraints can outweigh working together for the common good or in the best interest of the individual. Costs that may be saved by a local authority are often picked up later by the NHS, and vice versa. People with mental health problems routinely have their physical health ignored.


All too often, our default position is to think about our organisational silo first, and people’s outcomes second. Organisations can more easily measure progress by way of changes to structures, systems, processes and budgets, rather than by how many people are now enjoying better lives. There is still a long way to go in tackling people’s expectations and behaviours – including those of staff, of service users, and of us all.  


So there’s a lot still to do. We need to dissolve the silo mentality that pervades many of our health and social care services in Wales. We need to recognise that mental and physical health are intrinsically linked, and design services accordingly. We need to ensure that young people who have their education interrupted through poor mental health or mental illness return back into education as soon as possible. We need to ensure that people who experience poor mental health or mental illness receive care and treatment as soon as possible and return to employment, or training, or education, or volunteering. We need to improve the quality of life of those with dementia, and those who support them. We need to focus on the ultimate objective – our health and wellbeing.
In this way, hopefully, we will see that that having good health means both psychological and physical health. We will genuinely have ‘parity of esteem’.



Peter Martin is Senior Policy Advisor at Hafal, the Mental Health Charity. Professor Marcus Longley is Professor of Applied Health Policy at the University of South Wales and Director of the Welsh Institute for Health and Social Care. He is also Vice Chair of Cardiff and Vale University Health Board, but writes here in a personal capacity.

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