Parity of esteem and its role in achieving good outcomes
Talking as a guest on BBC Radio4’s today programme this morning (15th August 2014) was Dr Martin McShane, NHS England Director of the care for Long Term Conditions. Recently there has been lots of discussion on the importance of reducing the stigma associated with mental illness. It can be claimed that stigma is not only present in everyday life, but also in the healthcare system itself. Dr McShane provides a succinct example of the disparity in care:
“If you fall down and break your hip, an ambulance will be with you in eight minutes to give emergency care at the scene before taking you to A&E. If, however, you suffer an acute psychotic episode in the street, you are just as likely to be attended by a police car and taken to a cell.”
Dr McShane purports that parity of esteem is essential in reducing this disparity.
At a base level, parity of esteem means valuing mental health equally with physical health, but Dr McShane wants to take it further to mean that mental health issues should be tackled with the same energy and priority as physical illness (McShane 2014 available here). If parity of esteem is to be adopted, it means to change the experience of having a mental illness by tackling and putting an end to stigma, and so reduce barriers to healthcare.
People with severe mental illnesses such as schizophrenia die on average 25 years earlier than the general population. Premature mortality in people with severe mental illness is largely due to comorbidities such as diabetes, respiratory disease, cardiovascular disease and infectious diseases like HIV/AIDS (Parks et al 2006). It is clear from these facts that there is a lot of work to be done in improving healthcare for people with mental illnesses.
Medical anthropology fights for the dissolution of ‘Cartesian Dualism’ which is a notion, first put forward by Descartes in the 17th century, and has since permeated into the fabric of Western culture, that the human mind is an active subject which is separate from and has control over the passive body. Medical anthropology instead supports the philosophy that the mind and body are intricately linked and can have mutual influence on each other in many ways. My background in anthropology has given me an implicit belief in moving beyond Cartesian Dualism, and I was excited to find that McShane and his ideas on parity of esteem seem to support this.
Cartesian Dualism is implicit to current mental health services, which primarily focuses the diagnoses and treatment on psychological problems, often neglecting physical factors. The current system has fragmented IT systems for different health care providers. A person with mental illness may be treated by psychological services in isolation from and without knowledge of concurrent treatment for comorbidities by a GP or hospital care. Treating psychological and physical symptoms in isolation from each other in this way chimes with Descartes’ ancient ideas that the mind performs independently of the human body. This system isn’t working. Statistics on reduced life expectancy for people with severe mental illnesses paint a clear picture. One in four people will experience mental illness throughout their lifetimes. It is crucial that care is improved and integrated.
A transformation of this kind requires a redefinition of the system, whereby a patient’s records for all contact with healthcare are in one record that is accessible to all health care professionals with which the patient comes into contact. An Integrated Practice Unit (IPU) (read more here), underpinned by an enabling IT platform will facilitate this kind of care. IPUs are central to a Value-based approach, and allow for specialised care tailored to the needs of a specific cohort. Creating an IPU for people with severe mental illness would host diagnosis and treatment of all of a person’s mental and physical problems associated with their illness.
Reducing stigma and synchronising treatment of psychological and physical problems of people with mental illness are both important factors for improving their quality of life. In fact these two factors could be related. By giving greater emphasis to the physical aspects of mental illness, the public perception of mental illness may become one that is less exoticised. Mental illness may come to be thought of as closer to other chronic diseases. It is widely known that people with long term conditions such as diabetes and cardiovascular disease also develop depression as a part of the ongoing strain of living with their disease. Recognising that many diseases cross the boundary between body and mind may help towards more integrated healthcare design and reducing the stigma associated with mental illness.
McShane, M. (May 2014) Parity of Esteem: What are we trying to achieve?
Parks, et al., (2006) Morbidity and Mortality in People with Serious Mental Illness, 13th technical report, Alexandria, Virginia: National Association of state Mental Health Program Directors.