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Monday, 7 February 2011

No Health Without Mental Health

Greetings all!

The Coalition Government has just published its initial plans on mental health - "No Health Without Mental Health": "No Health Without Mental Health"

I don't want to go into the content of the document at present or even raise the question of how mental health can be improved within a context of service cuts.

Instead, I want to draw your attention to and seek your thoughts on a key expressed assumption within the document highlighted by NHS Networks, namely that " THE GOVERNMENT [HAS THE] AIM OF ACHIEVING PARITY OF ESTEEM BETWEEN PHYSICAL AND MENTAL HEALTH". I’ve never come across such a strongly expressed statement of parity between physical and mental health in ANY government policy document before.

Now, of course, this may all be talk and that the reality may be quite different. However, my cynicism isn't quite so marked - not because of my belief in the intrinsic altruism of governments - but rather because of the financial issues currently being grappled with.

Firstly, there is the issue of the welfare budget. Forgive me if I'm teaching you to suck eggs here but for those unaware of the history of incapacity benefits let me give some brief background. Twenty years ago, Invalidity and Sickness Benefit (as it was then called) along with associated housing benefit was significantly short term in nature (six months or less) and primarily claimed by those with industrial injuries and pain problems. By 2010 this situation had radically changed whereby an increasing number of claimants were claiming for more than six months and over 50% of these were claiming for mental health problems. At estimated costs of £16 billion a year all political parties began to look seriously at the question of addressing this cost. IAPT (Increasing Access To Psychological Therapies), introduced by the last government and extended by this government by hundreds of millions of pounds, is the most visible example of how seriously central government now takes mental health. (CBT Training); (Managing Depression)

Secondly, the parity between mental health and physical health has also become apparent as a result of their interconnectedness - again from the perspective of the costs, this time associated with health costs associated with "long term conditions". The latter includes such illnesses as diabetes, cardiovascular problems, respiratory diseases and stroke. They are conditions that are often associated with repeated hospital admissions (which are costly) usually prompted by failure to maintain changes in health behaviour or because of the de-motivating effects of mental health problems such as depression. The thinking is that IF services can address depression or poor motivation in such groups, hospital re-admission rates will fall and costs reduced. (Motivational Interviewing Training); (Psychological Coping Post-Stroke)

Now this is all very understandable and laudable stuff - all industrialised countries at present are trying to contain healthcare costs, but a recognition that mental and physical health are intrinsically interconnected strikes me as a radical new framework in which to start debating this. However, it also raises difficult questions about the priorities that we we establish within this however.

• With limited money, do you agree that Depression and Degenerative Arthritis are of "parity of esteem".
• What about Panic Attacks and Palliative Care or Gall Bladder problems and Generalised Anxiety Disorder? Or do you think that we should recognise that such "parity of esteem" varies according to the type of problem.
• Should Botox continue to be funded on the NHS in certain circumstances when those with a diagnosis of borderline personality disorder still have problems finding ANY service wanting to work with them?
• Should Pancreatitis be seen as having a "parity of esteem" with PTSD or should the latter be seen as a more pressing issue.

These are difficult questions with no easy answers. However the government's express acceptance of "parity of esteem" between physical and mental health opens up this debate.



  1. Hi Paul

    Thanks for your e-mail and “No Health without Mental Health” attachment.

    As a charity that provides support for stroke survivors of working age our concern is that currently they don’t receive adequate psychological or counselling support to deal with their problems. In fact the recent CQC review highlights that only about 40% of stroke survivors receive any psychological support at all and what that consists of is anyone’s guess due to the shortage of Clinical Psychology positions within the NHS.

    In addition we also find that many GP’s really do not know what to do with stroke survivors as they only see a couple of younger stroke survivors in perhaps a year. I have received calls from carers and stroke survivors where GP’s are referring stroke survivors for CBT under the remit of IAPT when the individual has severe memory problems!! Obviously a more appropriate route would be to refer the individual for a cognitive assessment with a Clinical Psychologist and then that individual can then be given strategies to deal with the memory deficits before even trying to address the negative thoughts, emotional and identity change issues.

    If the government want to achieve parity with mental health and physical health then greater investment in psychological, psychiatric, counselling and psychotherapy services is required which will entail more financial investment than training nurses in CBT skills, which does not suit everyone and nor does it provide an individual with choice, or a model to deal with more complex issues for someone who has had a stroke, and as a result their marriage has broken down, and in addition they are suffering from memory loss, temperamental outbursts, coupled with a change in identity, self and all the emotions that go with that.



    Group Development Manager
    Different Strokes

  2. Dear Paul,
    Thank you for the mail and as always, I agree with your comments with an enormous YES on all counts, however, I can imagine my
    comment is not as useful as it could be and will endeavour to answer each of your questions fully in due course.

    Yours most sincerely,


  3. How about parity of funding! Depression according to WHO is going to be the world's second biggest killer by 2020. Is the government taking this statistic seriously?

    Sent using BlackBerry® from Orange

  4. Justifying marginal medical interventions by mental arguments...

    Dear Paul

    Thanks for this.

    My first thought is somewhat tangential to the "parity of esteem" argument. But I notice that in many cases, where one might argue that the State should not pick up the tab - for example much plastic surgery - a mental argument is produced to support the phyical surgical expenditure (like 'psychosocial wellbeing').

    On your main theme, I think the NHS tries to do more than the economy can 'afford'. The preservation of life and the quality of life cannot sensibly be goals: with modern techniques and medicines this is virtually a bottomless pit. The nation should address itself to the difficult decision of "What do we want to pay for?" . Should we include, for example, a cataract operation for a 92-year-old? Or bilateral hip replacement for a semi-retired 63-year-old? (both recent examples in my immediate family)

    Instead of engaging in "parity of esteem", would it not be a better use of our argumentative resources to look at every illness and draw up criteria for what we will pay for - and why? I think the bottom line for such a conversation in a National Health Service should be: "Is it in the Nation's interests to pay for this?"

    Counsellor, psychology trainee

  5. Hello Paul, thank you for your email. Very interesting questions, my brief thoughts are:

    I do agree that these conditions should have parity of esteem. Our mental health is linked to our physical health, clients of mine are not motivated to exercise or eat healthily because of depression, a feeling of 'whats the use', and that nobody cares about them so why should they. Pain that may just be ignored is dwelt on compulsively. GP's are visited regularly with common colds, etc.

    On another note, can i say that I attended your training of Brief Solution Focused Therapy in London last week, and was really impressed with it. I felt compelled to use the Miracle question with two clients I was seeing on thursday, and the effect was actually astonishing. They both looked completely confused momentarily, then proceeded to tell me how they would feel, who would notice. One actually said, ' I can see the error of my ways'. She had been bombarding her partner with questions about who he has slept with, were they better looking than her etc, compulsively, to the extent that he was going to leave.

    I await eagerly their next sessions, but even so, the change in their attitude, animation and level of involvement in the session changed dramatically. So thank you very much.

    Best wishes


  6. Dear Paul,
    Thank you for sharing your thoughts on the government's talking about parity between physical & mental health.
    I would love there to be more funding for mental health as I know there is not enough funding for talking therapies in the NHS & too many people are given anti-depressant drugs before/instead of being offered a talking therapy.
    I have more experience of Education than the NHS in my working life and if I contrast what is happening in Education I must come to the conclusion that the present government's tactic is "Robbing Peter to Pay Paul." This can be seen with
    1. The Building Schools for the Future programme where funding was stopped BUT money was being offered to people who wanted to set up "free schools." These could be set up by people without a background in Education & staffed by unqualified teachers! Funding for
    them would take funding away from state schools.
    2.All schools can choose to take academy status. Academies were set up by the previous government so that failing inner-city schools could acquire more funding matched by business to enhance their chance of success.
    Now schools already doing well will attract more government funding, taking funding from poorer schools in poorer areas.
    3.Local Authorities are being forced to make massive cuts in their budgets. The government says that it is transferring budget control to
    individual schools, away from LAs. LAs give standard support to all schools. If schools get their support from private companies it will cost more, not be checked by the LA & individual schools may choose not to call on services normally used for children with special needs-EPs, support services for emotional & behavioural difficulties, hearing & visual impairments, etc. Some children will not get the funding they need & will suffer.
    You probably see now why I am cynical about the proposals you discuss. At present I supervise 2 counsellors who work in GP practices. Last year
    their service was taken over by the Priory. On March 31st they are being made redundant. As I understand it, the PCT cannot now take on the
    counsellors because funding is going directly to GPs who haven't yet got the money so can't yet employ the counsellors!
    Not a happy time in my opinion!
    Best wishes,

  7. Paul,

    You raised some excellent points- having just completed a CBT course myself and working closely with the IAPT team here, I’ve seen the benefits, in terms of cost to the govt. and self esteem, directly. Any move towards boosting this parity between mental and physical should be encouraged as strongly as possible.

    Let me know if there is anything we can do here



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