Mental health: Achieving ‘parity of esteem’

It has long been acknowledged that a diagnosis of mental illness can have an adverse effect on life expectancy. Due to unmet health needs, people with serious mental illness die on average 20 years before the rest of the general population.

In the last decade there has been increased emphasis in England on regarding mental health with the same urgency as physical conditions and the term ‘parity of esteem’ has gained prominence.

Parity with physical health

The Centre for Mental Health estimated that in 2016/17 the costs to employers of mental health problems at work was £34.9 billion.

The Coalition Government’s 2011 cross-government mental health outcomes strategy, No health without mental health, set out the expectation there should be parity of esteem between mental and physical health services.

Section 1 of the subsequent Health and Social Care Act 2012 enshrined in law equivalent duties on the Secretary of State in relation to the improvement of physical and mental health services.

Since 2013, the NHS Constitution in England has contained a commitment “to improve, prevent, diagnose and treat both physical and mental health problems with equal regard”. Successive NHS mandates have set objectives for parity. For example, the NHS Mandate 2018-19 states there should be measurable progress, particularly for those in vulnerable situations. The 2014 NHS Five Year Forward View included a commitment to achieving parity by 2020.

Progress towards parity

Measuring progress on parity is difficult for a variety of reasons:

There is no universally accepted method for measuring parity, although there are three common concepts recognised as indicators of parity; see box below.

• In England, most mental health funding is not ring-fenced. Local Clinical Commissioning Groups (CCGs) must determine their own budgets for mental health from the overall funding allocation received from the government. CCGs are expected to meet the ‘mental health investment standard’. That is, their mental health budgets must grow each year by at least the same percentage as their overall funding allocation.

• Comprehensive waiting times for mental health services are not collected, and not all services are subject to maximum waiting times standards. Some services have waiting time targets, for example Improving Access to Psychological Therapies and Early Intervention in Psychosis, but these programmes do not cover all services. New standards have been proposed and are being tested by the NHS in England, but at present there is no comprehensive picture of how long people wait to access mental health services, and how this varies across the country.

Common concepts
indicating parity:

‘Excess mortality’ – the negative impact mental health has on life expectancy.

‘Burden of disease’ – measuring the impact of a disease. Mental health is one of the leading causes of ill health and disability in the world.

‘Treatment gap’ – the difference between the number of people thought to have a particular condition, and those receiving treatment for it.

What are the barriers to mental health parity?

Increasing investment and improving access to mental health treatments alone will not achieve parity. Significant medical, legal and educational obstacles remain.

Stigma and discrimination

Increased awareness and understanding of mental illness has reduced some of the stigma attached to many conditions. However, a public fear of those with mental illness and a fear of discrimination experienced by mental health sufferers can prevent many from seeking help.

The 2018 Independent Review of the Mental Health Act 1983, chaired by Professor Sir Simon Wessely of King’s College London, found a fear of being subjected to discriminatory practices from mental health services was strongest in those from ethnic minority backgrounds. The powers of coercion under the Act are more likely to be used against those of black African or Caribbean heritage.

Diagnosis and treatment

Mental illness is less likely to be diagnosed than physical health conditions for a number of reasons, including the intermittent nature of many mental health conditions and gaps in medical training. In addition, the relationship between physical and mental health is complex: research shows that those with poor mental health are also more likely to suffer from poor physical health but have the lowest chances of receiving treatment.

The vision in the NHS Five Year Forward View, published in 2014, acknowledges the inter-relationship between physical and mental health and directs that, “Patients with mental illness need their physical health addressed at the same time.”

Legal framework

Despite the equivalent duty towards mental and physical health in the Health and Social Care Act 2012, mental health law presents obstacles to parity. Provisions in the Mental Health Act 1983 allow people to be treated against their stated wishes, even if they are deemed to have sufficient capacity to refuse.

This has led commentators, such as King’s College’s Professor George Szmukler, to argue that involuntary treatment does not respect the autonomy of mental health patients and is discriminatory when contrasted with the treatment of physical conditions. Some stakeholders have called for a ‘fusion’ of mental health and mental capacity law, so that detention is determined on the basis of a person’s capacity to make their own decisions.

The Independent Review of the Mental Health Act 1983, accepted that there was “a strong argument in principle that maintaining separate mental health and mental capacity laws can lead to discrimination towards those with mental health problems”. It did not advocate a fusion of the two systems but proposed reform of the 1983 Act to include clear fundamental principles to protect patients’ rights.

Further reading

• Parity of Esteem for Mental Health, POST
• Mental Health Policy in England, House of Commons Library
• Are NHS mental health therapies working for everyone?, House of Commons Library
• Towards Mental Health Equality, Centre for Mental Health