Abstract
Introduction
‘Parity of esteem’ means ensuring that society provides equitably for mental and physical illness, but evidence indicates that parity is far from being achieved. Mental illness accounts for 23% of the total burden of disease, yet despite the existence of cost-effective treatments, it receives only 13% of National Health Service expenditure. 1 Mental illness has the same effect on life expectancy as smoking, and more than obesity. Improved mental health has many benefits, including fewer physical illness symptoms and less demand for physical healthcare, increased employment of adults of working age and greater independence for elderly frail people. Thus, as well as individual benefit, appropriate treatment can also reduce expenditure in various government departments.
According to the Chief Medical Officer, about three-quarters of people with mental disorders fall into the ‘treatment gap’, that is, they have a mental disorder, as defined by international diagnostic criteria, but they are ‘not currently referred for or receiving treatment from services (including primary care mental healthcare)’. 2 The Chief Medical Officer also commented that stigma and discrimination towards people with mental illness are common. The cycle of stigma means that personal stigmatisation links to institutional decisions which then affect the individual and so on. Stigma for the individual is associated with exclusion from education and employment, victimisation, poverty and homelessness. In the Chief Medical Officer's words, these are also ‘driving factors in maintaining the status quo of poor access to [mental] healthcare’, influencing National Health Service priorities and provision. This premise was apparent in measures introduced in March 2014 by National Health Service England, cutting spending on hospital services for physical illness by 1.5%, but reducing expenditure on community healthcare, which includes mental health, by 1.8% – a 20% difference. 3
Making Parity a Reality 4 was the Royal College of Psychiatrists’ manifesto for the 2015 General Election. It stated that treatment for people with mental disorders has ‘long been underfunded and undervalued … Fortunately, this is beginning to change.’ Unfortunately, that is what our psychiatric forbears thought a century ago. The need for parity has been reiterated intermittently since then. This paper explores parity from a historical perspective.
1914: Shell shock and parity
Shell shock was recognised in 1914, in the early months of World War I. 5 Although initially its aetiology was much debated, it gradually became apparent that it was a psychological disorder, not the result of physical injury. At that time, ‘degenerative’ theories explaining the causes, prognosis, inevitability and irreversibility of mental illness prevailed, reflected in the view: ‘Once a lunatic, always a lunatic’. 6 The War was associated with a shift to a more sympathetic approach to mental illness, acknowledging that it could occur in previously exemplary, healthy and respected citizens, like the soldiers. Psychiatrists were beginning to recognise the possibility of improving some psychiatric disorders and proposed outpatient clinics parallel to those for physical illnesses. 7 However, while soldiers with psychiatric problems were admitted to ‘hospitals’ for treatment, civilians were admitted to ‘asylums’ often with a less optimistic therapeutic outlook.
Plans to modernise the Lunacy Act (1890) commenced in 1918. 8 A Royal Commission in 1926 emphasised the similarities between mental and physical illness: ‘insanity is, after all, only a disease like other diseases, though with distinctive symptoms of its own’. 9 By renaming ‘asylums’ as ‘hospitals’, the ensuing Mental Treatment Act (1930) took an important step towards parity.
Parity from the 1940s to 1980s
In the early 1940s, initial plans to create a National Health Service did not include mental hospitals. In part, this was due to concerns of the Board of Control, the mental hospitals supervisory body, about whether new mental health legislation was needed prior to major administrative changes. The British Medical Association, however, was fiercely opposed to excluding mental hospitals, 10 and the Board acknowledged the need for closer links to general hospitals. Mental hospitals were eventually included in the government’s proposals, 11 on the basis of the Royal Commission’s parity statement in 1926.
The Mental Health Act 1959 improved parity by permitting the admission of mentally ill people to general hospitals, rather than just to mental hospitals. This went hand in hand with closing the mental hospitals, a government goal, encouraged by groups such as the ‘anti-psychiatry movement'. This had further potential to improve parity. However, recognition of inequity in service provision continued into the 1970s, illustrated by Sir Keith Joseph, Secretary of State for Social Services: ‘This is a very fine country to be acutely ill or injured in, but take my advice and do not be old or frail or mentally ill here – at least not for a few years'. 12 Government reforms at that time aimed to improve ‘non-acute’ services including mental health, recognising that they were poorly provided compared to acute hospital services which had previously been given ‘legitimate priority’. 13
Closure of the mental hospitals was not purely motivated by liberal care policies or aims to achieve parity. To a certain extent, it was the opposite: a cost-cutting exercise. The government worked on the premise that ‘community care’ would be cheaper than care in hospitals. 14 The Royal College of Psychiatrists warned: ‘money, staff and resources saved by closing an in-patient ward are not sufficient for running a similar-sized unit for equivalent patients in the community’. 15 This assertion was reiterated during the 1980s. 16 Policies still failed to effectively address the lack of parity.
Into the 21st century
In 1999 Our Healthier Nation stated ‘mental health is as important to an individual as good physical health’. National Service Frameworks followed, including for mental health, which was underpinned by additional funding. Five years later, a review of this Framework noted benefits, including reductions in the suicide rate, 17 a proxy indicator for the mental health status of a population. Better funding could improve outcomes.
During the early 2000s, NHS trusts were reformulated into ‘acute’ and ‘mental health’ trusts. Although dedicated mental health trusts had the potential to advocate more forcibly for mental health services and improve parity, the two types of trust perpetuated separation of psychiatry from other secondary care services. When ‘mental health’ trusts morphed into ‘foundation’ trusts they often adopted additional community health responsibilities which further distanced psychiatry from secondary care and diminished their specialist advocacy role. The community approach links to a greater emphasis on ‘social’ management, neglecting that some people require an intensive medical component to treat their disorders.
The Department of Health’s No Health without Mental Health initiative in 2011 confirmed intentions to achieve parity. Nevertheless, despite the parity rhetoric and ongoing evidence of inequity, the government emphasised that mental health services would have to make austerity savings like other parts of the NHS. Their vague, laissez-faire approach was written into the Health and Social Care Act (2012), stating that the Secretary of State ‘must have regard to the need to reduce inequalities’, a broad statement, open to interpretation, and with questionable meaning for mental illness. The equality statement did not seem to be followed after the Francis Report 18 in 2013 which obliged all National Health Service services to comply with recommendations to improve care and safety for patients: National Health Service England funded the additional costs of implementing them, but withheld this funding from mental health services. 19
The Chief Medical Officer noted an ‘evidence-based and ethical case for parity of esteem’ and her report referred to the Royal College of Psychiatrists’ Whole-Person Care: From Rhetoric to Reality (2013). This highlighted the treatment gap and that provision ‘falls short of government commitments to international human rights conventions which recognise the right of people with mental health problems to expect the highest attainable standard of health.’ Whole-Person Care outlined a vision for multi-agency collaboration to achieve parity, but recognised that ‘lack of parity between mental healthcare and physical healthcare is so embedded in society that it is tolerated and hardly remarked upon'. Both the Chief Medical Officer and the Royal College of Psychiatrists acknowledge the importance of positive attitudes to mental illness to help achieve parity. Without public and professional understanding and commitment from National Health Service leaders it seems unlikely that any political party will achieve it. It does not win votes.
Discussion
When high-tech and low-tech specialties compete for the same pot of money, the latter are disadvantaged. Western society demands state-of-the-art high-tech clinical practices for physical illnesses, and these are readily adopted and funded. It places less value on low-tech innovations, the mainstay of treatment in psychiatry. Changing this balance requires a mind-shift of professionals and public, but achieving a change in expectations and behaviours can take years. The slow rate of change for psycho-social behaviours compared to available evidence is illustrated by Richard Doll and Austin Bradford Hill identifying the link between smoking and lung cancer in 1950, yet people still smoke.
Although this paper focuses on England, the mental health treatment gap is a global problem. 20 England, and the devolved nations of the UK, previously took a progressive and innovative stand on many aspects of psychiatry and provided international leadership, such as for creating liberal mental health legislation and developing older people’s mental health services. They have not taken a similar enlightened and effective approach to parity.
The ongoing gap between governmental rhetoric and remedy is unlikely to dispel stigma and discrimination, or encourage commissioners to ensure equitable mental health services. However, perhaps some factors reinforcing lack of parity are linked to the organisation of psychiatric services. Formerly separated in the mental hospitals, today psychiatry is neither part of primary care nor embedded in hospital services. It is often located separately in community facilities, sometimes shamefully under-funded and run down. Entering such a building marks you out as different, in contrast to going to a hospital clinic which indicates you are unwell. Virtuous aims to reduce mental illness stigma by creating community services might paradoxically have reinforced it. Reinstating psychiatry in general hospitals alongside physical illness might redress the balance. Ongoing education for public and professionals could also help. The Royal College of Psychiatrists recently proposed to reinstate ‘patient’ in its official documentation, 21 a term which does not discriminate between mental and physical illness, replacing ‘user' and ‘client' terminology which has also marked psychiatry as different from the rest of medicine which treats ‘patients'.
The lessons learned in World War One began the process to achieve parity. Of the repeated cycles of good intention and under-implementation to achieve it, some are remembered but most have slipped from institutional and professional memory. Hence the need for a historical analysis which might help understanding and future implementation. Rhetoric has consistently favoured parity, but commitment by governments has been less obvious, despite evidence of benefit for individuals and society. The President of the Royal College of Psychiatrists, Professor Sir Simon Wessely commented recently: it is necessary for ‘good words to now be translated into good deeds’. 22 Doctors, and other concerned citizens, need to facilitate the transition from words to deeds. Inaction and failure to break patterns linking stigma, negative expectations and inequity of provision risk further letting down people with mental illness, or at best, putting their needs ‘on hold’ and maintaining the status quo.