Health: Parity of Esteem

Baroness Tyler of Enfield Excerpts

Monday 28th November 2016 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I congratulate my noble friend Lord Alderdice on securing tonight’s debate, which provides a timely opportunity to consider one of the most fundamental issues in healthcare today. Efforts to achieve equal value of physical and mental health span many decades. The Royal Commission of 1957, the year of my birth, noted, not quite in today’s language, that:

“Most people are coming to regard mental illness and disability in much the same way as physical illness and disability”.

That was almost 60 years ago.

In recent times there has been a welcome shift in public attitudes towards mental health and a growing commitment among communities, workplaces and schools, and within government, to change the way we think about this issue. As we know, there have been a raft of commissions and taskforces as well as Future in Mind, looking at young people’s mental health, and of course the recent Five-Year Forward View for Mental Health. They have provided many important recommendations on how we can achieve genuine parity of esteem. They have all stressed, as has been stressed tonight, the inextricable link between mental and physical health. What does that actually mean? To help define this, I looked back at the All-Party Parliamentary Group’s very good report last year on parity of esteem. It said:

“What this would mean in practice is that taking a holistic view of an individual’s health (seeing the interdependencies between both their physical and mental health needs) would be the norm”.

Having listened carefully to my noble friend Lord Alderdice, I would add “health and well-being”.

The fundamental question for us is why it has been so difficult to achieve real and sustained progress. I did a quick survey of the scene, and many aspects I did not find very reassuring. As Michael Marmot so powerfully reminded us in his recent book The Health Gap: The Challenge of an Unequal World, people with mental ill health have a life expectancy between 10 and 20 years shorter than people with no mental illness. I am sure we all find that shocking.

Only a quarter of those with mental illness such as depression are receiving treatment, a figure that contrasts with 78% of those with heart disease and 91% of those with high blood pressure. A recent CQC report noted that, when facing a crisis, a shocking 32% of people do not know who to contact out of hours. Indeed, 24% of those who did know said they did not receive the care they needed.

It is not all doom and gloom—there has been some progress. Thanks to the persistence particularly of Liberal Democrats in the coalition Government, the first ever mental health waiting time standards were introduced. This was a real achievement and helped to bring mental health services into line with other NHS services, such as cancer and A&E waiting times. It was a tangible step on the journey towards parity of esteem. However, as the Mental Health Taskforce report earlier this year noted, for first appointments and for the right follow-on support, waiting times are still “unacceptably long”. Only a couple weeks ago, the Education Policy Institute’s report Time to Deliver found that only 18% of areas were meeting the four-week waiting times for routine cases and only 14% were meeting one-week waiting times for urgent cases. The noble Lord, Lord Lansley, drew attention to this lack of progress, and I very much look forward to hearing what the Minister has to say.

A number of factors underpin that lack of progress, and I want to focus first on the problems of funding, both disparity and historical underfunding. To their credit, the Government committed £1.25 billion to children and young people’s mental health over the next five years, which is £250 million a year. Despite that commendable promise, only £143 million was released in the first year and of that, only £75 million was actually distributed to clinical commissioning groups. Even less got to the front line.

As we have already heard, last year, across the board, 40% of NHS mental health providers had their funding reduced, despite NHS England instructing commissioners to increase it. This raises serious questions as to whether funding is reaching the areas where it is most needed, and it highlights the damaging impact of the Government’s refusal to ring-fence mental health funding. I know Jeremy Hunt said that he does not have the power to do that, but frankly, Governments, if they are so minded, can do something about it if they do not have the powers.

It is the same story with the £1 billion announced last year for mental health, much of which does not come on stream until the end of this Parliament. One could be forgiven for assuming that in last week’s Autumn Statement, the Chancellor would have offered a lifeline to mental health services, as well as other areas of health and social care. Instead, the Government found £240 million for the expansion of grammar schools, but not a penny for the NHS.

On a more positive note, the introduction of the five-year forward view included dashboards, an initiative welcomed by the Royal College of Psychiatrists. I, too, welcome them as representing a viable solution to ensuring better accountability and transparency from clinical commissioning groups. Obliging CCGs to publish facts and figures on their spend on mental health and the services they deliver will go some way to addressing the funding disparity, and stop money intended for mental health being siphoned off elsewhere. What is being done to publicise and promote the CCG dashboards, and how will people be able to compare the performance of their local CCG with others in other parts of the country?

Funding impacts on other factors which are also preventing parity of esteem. The mental health sector, in particular, is suffering from recruitment and staff morale problems. As noted in the report of the noble Lord, Lord Crisp, on acute adult psychiatric care, Old Problems, New Solutions, these problems are in part due to disproportionate financial cuts. The same report found an 8% decrease in the number of mental health nurses between 2010 and 2014, while there was a 1% increase in physical healthcare nurses over that period. Given that NHS England estimates that implementing access and waiting time standards will require a 7% increase in the number of mental health nurses by 2020, how do the Government expect to achieve that standard without staffing levels rising?

It is not for lack of ideas, recommendations or reports that progress on parity has been unsatisfactory—nor is it, as many other noble Lords have said, solely about money. There are other, non-financial issues, including cultural issues, and that provides the starting point for the Values-Based Child and Adolescent Mental Health System Commission, which I had the privilege of chairing. Its report, published on 7 November, explores how different values drive deep-seated culture, attitudes, decision-making, practice and behaviour—the invisible drivers, if you like—which can either inhibit or promote a truly system-wide approach to redesigning and transforming services. The report’s 10 recommendations were all about how a more explicitly values-based approach with a shared language could really improve the mental health and well-being of children by focusing single-mindedly on what really matters to them. That report, and the recent report Time to Deliver, by the Education Policy Institute, chaired by my right honourable friend Norman Lamb, had a number of important recommendations. In particular, it proposed that the Prime Minister should announce a national challenge on children’s mental health. Can the Minister indicate how the Prime Minister intends to respond to that recommendation?

In conclusion, we should aim to achieve a healthcare system in which parity of esteem means that mental healthcare is not only as good as physical healthcare but is delivered, as the recent King’s Fund report recommends, as part of an integrated approach to health and well-being, as my noble friend Lord Alderdice so powerfully reminded us this evening.