A long way from equality − an HSJ special report

In many ways, the debate over parity of esteem for mental and physical healthcare is not a new one. There have long been questions over perceived gaps between the care the NHS offers for bodies and the care it offers for minds. Do those with mental health needs receive equal access to treatment? Can they be certain that they will always receive the best, most effective, most evidence based treatment for them? Will the mental health services they encounter receive funding that correlates with need?

The realisation that the answer to these questions is often “no” is also not new. In one way, however, the debate has significantly changed. For the first time, health organisations and workers are being explicitly asked to change the situation. The 2012 Health and Social Care Act states that the health secretary has a responsibility to secure improvement “in the physical and mental health of the people of England”.

‘There is insufficient understanding of mental health services demonstrated by commissioners, and this results in insufficient priority being given to them’

More notably still, the November 2012 NHS Mandate to NHS England states that mental health should be “on a par” with physical health. “By March 2015,” it states, “we expect measurable progress towards achieving true parity of esteem, where everyone who needs it has timely access to evidence-based services.”

The results of an HSJ survey − run in association with King’s Health Partners academic health science centre − suggest there is still significant progress to be made.

When asked if they believed patients in their local area had equal access to mental and physical health services, 73 per cent of our 167 respondents − drawn from acute, community, mental health and ambulance providers as well as from primary care, commissioning, local authorities and the third sector − gave the same answer: no.

“It’s not even close,” said a mental health doctor working in the London region, expressing a common view. Multiple respondents pointed to the long waiting times for psychological therapy as evidence of the inequalities. “It is much easier to get help and referrals for physical health problems,” reported one respondent, a drug worker employed within the third sector.

Funding gap

The next natural question: why? Our survey explored several possible reasons. One was funding, and it was a popular explanation for the continuing gap between mental and physical healthcare. Almost 80 per cent of the people who completed our survey said that they did not believe mental health services in their area received sufficient funding. One respondent put it very simply: “Funding is disproportionately in favour of physical health problems.”

It was an oft-repeated opinion. A clinical director and practising clinician working in London suggested that “mental health is very poorly funded compared to the significant morbidity and need that is around, and is a poor relation to physical healthcare funding”.

Another respondent said: “Mental healthcare has not seemed like a priority in the local area, with low levels of funding compared to the national picture.”

A mental health doctor working in Manchester reported that the area’s very high levels of physical and mental health morbidity meant that demands on health services were high. “Yet the relative spend on mental health services has fallen and the mental health service is not commissioned to provide an adequate or modern liaison service to the three general hospitals.”

That was an answer which touched upon another issue raised by many of those who responded to our survey: the lack of cooperation and coordination between health organisations. The essential conclusion? Partnerships between providers of physical and mental healthcare services frequently remain weak or non-existent.

‘On our psychiatric ward we cannot even provide IV fluids and the physical health of our patients is a low priority’

One respondent questioned why services were often so geographically separate. “Psychiatric hospitals are often distant, on other sites, or in the community.” Interestingly, however, an executive board director at one mental health trust suggested that proximity does not necessarily makes a difference. “The two trusts are very separate, although they often share the same site. There is no commissioned liaison service: for example, the crash teams will not attend our mental health wards.”

With anecdotal data such as this, it is perhaps little surprise that just four people among the 167 who responded to our survey felt mental and physical healthcare services in their local area were “very well integrated”. Meanwhile 47 per cent described services as “not integrated at all”. The same percentage described services as “somewhat integrated”.

It is a state of affairs with which those who answered our survey are clearly not happy. A striking 90 per cent said they felt physical and mental health services should be more closely integrated.

To merge or not to merge?

How such a change should be achieved, however, was open to debate.

On one side were those who argued for the sort of total integration which was once present. “Fragmentation of the health service has led to less cooperation between health bodies,” argued one senior manager working within an acute organisation.

“The separation of acute and mental health trusts was folly,” agreed another respondent, a mental health executive director. The board member continued: “We are reaping the rewards, with increasing ghetto-isation.” It was a view echoed by one of the mental health doctors who responded to the survey: “There is no reason for separate acute and mental health trusts. There is no reason in the post-asylum era for psychiatric hospitals to be separate. I have seen excellent examples of good practice in Europe.”

On the other side were those who feared organisational mergers would be a backward step. “Older people’s services and A&E would benefit from [closer integration]. However, I do not support full integration or the return to district general hospital acute mental health units,” said one respondent.

A manager at an acute provider said: “Integration of care doesn’t start with organisational mergers, but with design of care for patients with shared use of information and integrated care plans and management of clinical risk.”

“Integration should be patient-focused, as opposed to organisational, to enable patients to access the services that they need,” agreed an executive board director at a mental health trust. “Many mental health patients require specialist management and risk assessment.”

Setting aside debates on what the precise nature of greater integration should be, we asked respondents about the barriers to it. What is it that stops the successful integration of services? The most highly ranked answers were cultural differences between acute and mental health care and the idea that existing ways of working are too entrenched.

Commissioning worries

Arguably the most noteworthy response, however, was the third most highly ranked: poor commissioning structures. Several of those completing our survey raised concerns about the quality of commissioning around mental health − and said their concerns had been become more serious since the April 2013 NHS reforms. Could this now be one of the main reasons for the inequalities in provision?

One mental health trust board-level director who answered our survey thought so: “There is insufficient understanding of mental health services demonstrated by commissioners, and this results in insufficient priority [being given to them].” Said an allied health professional working in mental health: “Lack of understanding of commissioners often results in services that don’t meet the needs of patients locally.” Meanwhile, a doctor described as “scandalous” the loss of “many senior mental health commissioning colleagues in the north west”.

In the minds of some respondents, competition was closely linked to all of the obstacles to integration.

“Competition between different service providers is a barrier to integration of services generally,” argued one allied health professional working in an acute organisation.

A director at a community provider said that “things [integration] appear to have gone backwards over the past couple of years, in part as a response to competition and a preoccupation of becoming foundation trusts at all costs. Instability of the whole system and the key leaders within it does not provide the basis for trust and dialogue on providing good services no matter which organisation provides them.”

Another individual who completed our survey spoke of fighting over limited funds - and suggested that physical healthcare providers tend to get priority in such situations.

“The acute trust will always be − and frequently is − bailed out if they overspend. The money has to come from somewhere, and is usually followed by a drop in the budget for the mental health trust,” said the respondent, a manager in a mental health organisation. “The acute trust appears to suck up any spare money there is.”

“Unmet need is accepted by providers and commissioners in a way which would be intolerable in physical healthcare,” agreed another respondent, a doctor working in mental health.

“Providers ration services routinely, and commissioning decisions are to cut, cut and cut again, with no apparent reference to the impact such cuts would have on patient and family wellbeing. Mental health services are generally seen as being unnecessary and a sign that the system is not working. The stigma shown in commissioning decisions is extreme.”

Stigma: it is a word which crops up frequently in conversations about mental wellbeing, and so the frequency with which it crept up in the answers to our survey is perhaps unsurprising.

Its impact was spoken of in multiple contexts. Almost 20 per cent suggested that it explained why patients with a serious mental illness can expect to live up to 18 years fewer than the national average. It was also frequently cited as a reason that the majority of those with mental health problems are not in treatment while the majority of those suffering from physical ill health are.

Most suggested that removing this stigma and ignorance was a matter of education - not merely of patients or of commissioners but of clinicians as well.

Three quarters of those who responded to our survey disagreed that current education and training gives healthcare students and staff the skills to assess, care for and manage both physical and mental health care needs. Of those, 44 per cent disagreed strongly.

“Mental health clinicians don’t know about physical health and aren’t confident to manage those type of problems, while acute trust and primary care clinicians just can’t cope with patients who can’t give good histories and lack compliance,” suggested one mental health doctor.

Lack of training

A respondent working within an independent provider of NHS services argued: “Healthcare students are not given adequate training on mental health. It is often brief, outdated and inaccurate, perpetuating stigmatising attitudes.”

Meanwhile a manager working in mental health in the Midlands pointed out that “doctors leave medical school with four weeks of experience in psychiatry, and locally that is usually experience of [only] one part of psychiatry. ‘Mental health’ is viewed as a diagnosis without recognition of the complexity and the different skills required to assess and treat different mental health conditions.”

‘Our survey implies that the attitudes within the NHS are in keeping with the aim of parity of esteem, even if the practice is not yet’

Arguably, one of the most striking responses was from a mental health doctor. “We are on the same site as the hospital yet they won’t pick up our blood samples for the lab. They summon us for hideously inappropriate referrals because they have almost no mental health education.

“On our psychiatric ward we cannot even provide IV fluids and the physical health of our patients is a low priority.

“Smoking rates among psychiatric patients are sky high and they receive less attention [from] national efforts in this area.”

A consensus, then, that mental health experts do not know enough about physical wellbeing, and that those focused on treating the body do not know enough about treating the mind.

Some of our respondents did detail signs of improvements in this respect, however.

One executive level director in mental health reported: “The trust has invested in physical health expertise on mental health wards. Patients have increasingly complex needs which can only be met effectively with the right range of staff skills readily available.” Another explained: “My job is designed to help pull together the two streams of care for people living with serious mental ill health and affected by HIV/hepatitis/STIs and other physical health problems. We have had great success.”

Our survey implies that the attitudes within the NHS are in keeping with the aim of parity of esteem, even if the practice is not yet. Almost 90 per cent of respondents strongly agreed that the provision of good mental healthcare was just as important in their local health economy as the provision of good physical healthcare.

In addition, the vast majority of those who completed our survey regarded their duties as crossing the physical and mental health divide. When asked to what extent they felt their organisation had a responsibility for both the physical and mental health of those it cares for, 64 per cent replied “to a large extent” and 26 per cent “to some extent”.

When the question was moved to the personal level, the percentage was higher still: asked to what extent they thought they had a responsibility for the mental and physical wellbeing of those they cared for, 68 per cent of those to whom the question was applicable said “to a large extent”.

“Completely,” said one. “I am a doctor who looks after patients.” A GP echoed this: “I have the cradle to grave responsibility for the holistic care of my patients.” Another respondent stated that: “As a senior manager, it is my responsibility to bring these [physical and mental healthcare] together.”

Will the national commitment to parity of esteem make that mission easier? Will the now frequent headlines and soundbites on establishing equality of mental and physical health become reality? Our sample was unsure. Just over 20 per cent described the NHS Mandate commitment to parity of esteem as merely political rhetoric. Around 17 per cent described the concept as important but extremely difficult to achieve.

More than half, however, characterised the commitment as something that is long overdue and needs sustained attention. “I think this is one of the most important problems faced in the NHS today,” said one respondent.

The pressing question now: how to solve it. If parity of esteem really is to become reality rather than rhetoric by 2015, the answers need to be found quickly.