Mental health and parity of esteem: A policy quandary for Labour?
| Author | Manthorpe, Jill |
| Position | THE NHS |
Mental health services have long been the 'Cinderella' of healthcare provision. (1) They are generally last in line for funding, low on any list of priorities and, until recently, not important enough to have to meet NHS performance standards. The effects of this underdevelopment are profound. People with mental ill health are more vulnerable to social exclusion, poverty, unemployment and multiple social and family difficulties. (2) They are often unemployed, and live in poor-quality housing, like communal establishments such as hostels. They report high rates of historic and current abuse. Their access to a healthy diet and leisure facilities may be limited by stigmatisation and because living with mental health problems leaves them with little energy to pursue healthy 'life-style choices'.
They are also at increased risk of developing long-lasting disorders like diabetes and heart disease. (3) Many also self-medicate, treating either the original mental health problem, or the side effects of prescribed medication, with alcohol, cannabis and nicotine. On top of that, their access to general primary and secondary NHS and social care services is restricted by stigmatisation, by self-neglect and (when they do reach services) by 'diagnostic overshadowing' (when symptoms of physical illness are attributed to mental illness). Mental illness, in other words, is a social phenomenon deserving of a social model of care. We will return later to what a social model of care might mean.
Physical illness can have consequences for mental health and psychological wellbeing, and such disorders can worsen physical problems. For example, we have long known that:
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One fifth of patients with breast cancer will develop depression in the first year after their diagnosis. (4) Much of this will go untreated, and will exacerbate functional impairment (the loss of ability to carry out everyday tasks), and undermine treatment adherence (the voluntary continuation of recommended treatment programmes). (5)
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In 2013 over 41 per cent of people over the age of 18 years using specialist mental health services in 2011/12 visited hospital accident and emergency (A&E) services at least once, compared to 20 per cent of the general population. (6)
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42 per cent of all of the tobacco smoked in England used to be smoked by people with mental illness, yet despite the dispropor tionate harm that this causes they are less likely than the gen eral public to be offered smoking cessation help. (7) More recently, researchers report that smoking may account for a substantial proportion of the reduced life expectancy of people with psychotic disorders. (8)
The damaging effects of racism on mental health are woven into inequalities in income, status and care. Compulsory detention in hospital in England has doubled under the Mental Health Act since its introduction in 1983. People from Black African backgrounds are four times more likely than white people to be detained in hospital, and ten times more likely to be the subject of a Community Treatment Order (a legal order requiring them to have supervised treatment outside hospital). (9)
A draft Mental Health Bill was published early in 2022 which would make compulsory detention more difficult to justify, and time limit Community Treatment Orders if enacted. If the Bill proceeds, patients' rights are likely to be strengthened by giving them more legal weight, such as a statutory right to have a culturally sensitive mental health advocate. (10) Labour activists will need to agree about what was good in these proposals, and what needs changing.
There can be little doubt that the pandemic is leading to rising demands for help with post-traumatic stress, delayed help-seeking, and the intense anxieties generated by isolation, unemployment and family pressures; the pandemic has also focused much attention on mental, as well as physical, health services. Labour needs a joined-up plan for mental health provision. This should focus on improving funding and ensure that funding is allocated to mental and physical health on the basis of parity of esteem and parity of need.
New Labour's investment (1999 to 2010)
In 1997 the New Labour government inherited mental health services in turmoil. There was a lack of sufficient in-patient capacity, and of community services to cope with 'Care in the Community' after closure of the asylums, which started in the 1970s. (11) New Labour also struggled with difficulties surrounding the coercive aspects of mental health practice. Mental health services are different from other parts of the NHS in that many patients are detained, or constrained to take treatment against their will, and many more know that detention is a possibility, a threat in the background. Mental health services are not necessarily popular with the people who use them, partly because they are perceived as being coercive or poor quality. These elements of coercion may be invisible to the general public, and services may sometimes be unpopular because they are perceived by the public as not being coercive enough.
The Blair and Brown governments made a serious attempt to change the Cinderella status of mental health services. In the ten years following the publication of the National Service Framework (NSF) for Mental Health in 1999, spending on mental health services rose by 6.6 per cent per year, or about 90 per cent in real terms over the decade. (12) Although these expenditure figures do not suggest any prioritisation of mental health services--the whole NHS grew at a similar rate--the mental health sector shared fully in the expansion of the NHS under New Labour. This extra funding enabled more staff to be recruited; the number of psychotherapists trebled, and the number of consultant psychiatrists increased by 50 per cent. (13) More than 700 teams were formed to provide specialist crisis resolution, assertive outreach and early intervention services. (14) More patients were treated; the number of adults using secondary mental health services rose by 3 per cent per year on average. (15)
However, at the end of the NSF for Mental Health several problems remained. (16) These included:
* The lack of adequate evidence to justify some services, like day care and counselling;
* The use of secure prisons as 'asylums', at huge cost;
* Poor services for children and young adults, older people, and people from ethnic minorities;
* A focus that was too medical and too 'downstream'--dealing with crises rather than 'upstream' - using early intervention techniques to minimise crises;
* A top-heavy workforce dominated by psychiatrists and insuf ciently organised into multi-disciplinary teams;
* The lack of a clear hierarchy of priorities, giving the impression that policy goals were undeliverable.
There had been gradual improvements in community support, a more gradual (and not yet complete) shift from a medical to a social model of care (the latter being less coercive than the former), and some progress in achieving parity with services for physical health. (17) But shortfalls in space for in-patient care had not been rectified.
Recession, austerity and the Coalition government (2010-2015)
The austerity policies of reductions to public expenditure introduced by the Coalition government, in the context of rising unemployment following the 2008 financial crash, led to increased precarity, growing debt and more housing repossessions, all of which had an adverse effect on mental health, yet growth in funding for mental health services was limited. Between 2012 and 2013, mental health services saw an increase in funding of around 5 per cent, whereas other services saw rises of up to 17 per cent. Under the subsequent Cameron administration, the 2015-16 budgets for mental health rose by only 2 per cent, compared with a 6 per cent increase for physical health services. (18) However...
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