Wrapping future mental health services around patients

Following publication of NHS England’s Planning Guidance, four CCG leaders have agreed to give their perspectives on the planning process in their local health economies, providing insight with a series of blogs on the process of developing, and delivering, the two year and five plans in their area. In his latest blog Dr Nadim Fazlani, Chair of Liverpool CCG and chair of the NHS Commissioning Assembly CCG Development Working Group, explores Parity of Esteem and what it means in reality:

At the Liverpool Health and Wellbeing Board, committee members have signed a pledge to work towards ‘parity of esteem’ so that mental and physical health are seen as being of equal importance.

We are all committed to making sure mental health gets treated the same way physical health does, but I do have some difficulty with the language. In political philosophy ‘parity of esteem’ explains a theory to overcome inter-communal conflict. Promoters of the theory argue that ‘parity of esteem’ offers a language for negotiation of a post-conflict equilibrium. Surely this cannot apply to how we deal with physical and mental health?

The Health and Social Care Act 2012 secured explicit recognition of the Secretary of State for Health’s duty towards both physical and mental health. Together with a clear legislative requirement to reduce inequalities in benefits from the health service, these place an obligation on the government to address the current disparity between physical and mental health.

However, the concept of parity of esteem, a principle which underpins all six objectives of the English mental health strategy – No Health Without Mental Health – is less clear in practice.

Words and concepts change and now I think we are using the term parity of esteem to mean “treat mental health issues and those with mental health problems equitably with physical illness“.

To move forwards one has to look back in time. In 1926 the Royal Commission on Lunacy and Mental Disorder stated that “mental and physical illness should now be seen as overlapping and not as distinct”.

Deinstitutionalisation since the 1960s has been one of the primary drivers behind the development of modern care. It has been defined as “the process of moving patients from large-scale psychiatric institutions towards the community, where alternative psychiatric services strive to provide care and support in the client’s community, together with more modern and appropriate treatment with better outcomes. Its main goal is to empower and emancipate people with psychiatric and social problems, enabling them to be fully participating members of society”.

Deinstitutionalisation and community care are at the heart of health policy development. Asylums were places of refuge and provided care, including health care, housing, food, occupation and leisure. This has to be unpacked and rearranged on an individual basis with assessments by many different agencies in community settings, while dealing with the risk – and often perception of risk – to society.

Mental health policy from the 1970s onwards has wrestled with this and we have had a number of policy changes, some of which are helpful and some of which have just created an industry of risk management.

So what do we do to tackle this?

The commissioning system is described by its critics as complex and fragmented, however in many respects it has always been so. One current initiative to address the situation is the designation of mental health as one of the national Programmes of Care (PoC).

This is designed to organise individual service areas into five functional groupings. This relates to both specialised and highly specialised prescribed services. There are 11 Clinical Reference Groups (CRGs) under the Mental Health PoC Board. I attended the Specialised Services PoC strategy event for mental health which brought all the CRGs together.

It was clear that in practice this distinction of specialised and other mental health services is unhelpful, as to work differently we would commission the whole pathway across health and social care. We are not seeking to have asylums by a different name to contain people, but to have units where the whole pathway is effective, so that patients need to be in that pathway less often and only for the period of time which their needs dictate.

In Liverpool we are exploring alliance commissioning and we have tested the water with an initiative to provide direct referrals to Citizens Advice Bureau advisors direct from GP practices. We are looking forward to the first meeting of the Mental Health Transformation Board, which will bring together all commissioners and providers, including NHS England as the commissioner of specialised mental health services, to do just that – commission across the whole pathway.

We will share risk across all parties but also take collective ownership of opportunities and responsibilities for improving health outcomes for the citizens of Liverpool. We need a collaborative environment, not new organisational forms.

I passionately believe that we need to move away from mental health/ physical health duality. I think the greater understanding of neurobiology, the genetics and therapeutic basis of mental health care, all support moving away from mind/body duality.

So given what we know of the negative synergy between mental health and physical health, ‘total’ separate systems have little logic. Therefore, should we not be saying that the solution is an integrated model that wraps services around the patient?

We need to pay closer attention to individual needs rather than the service. I think this debate about an artificial distinction between physical and mental health is unhelpful. I wonder if future generations will look at this separation and our standalone mental health units as we look at remnants of asylums – with shock and profound puzzlement.

Dr Nadim Fazlani

Dr Nadim Fazlani is Chair of Liverpool CCG and has been a GP in Kensington Liverpool for the past 22 years, having worked in the NHS since 1983.

A Fellow of the Royal College of General Practitioners, he was Chair of Liverpool Health Care Practice Based Consortium from 2006 – 2011 and Chair of Liverpool Central Clinical Consortium from 2011 to 2012, before being elected as Chair of Liverpool CCG.

He has also been a long standing GP trainer and an examiner for MRCGP conducted by Royal College of General Practitioners since 2004.

In addition, he is also a performance assessor for General Medical Council, a role he has undertaken since 2005.


  1. Colette Whelan says:

    I most certainly do agree that mental health is no where near on the same par as physical health. Neither am I fully convinced that those who make the decisions to improve mental health services understand what is bing achieved at ground level.
    Decisions are being made to extinguish art psychotherapy in some uk hospitals without the knowledge of art therapists when informed decisions are being made. The real value of it’s services are clearly under valued and do not receive the recognition it deserves. The result is to cut such services then refer people into specific clusters that may or may not b e relevant. By doing this no one is accountable for what happens to such vulnerable groups of people.

    Therefore I am having to campaign to insist that art psychotherapy should be accessible to all those who have complex mental illnesses and trauma to remain throughout NHS hospitals in the UK. Please support by signing and sharing my petition below so I can continue with my treatment plan. Thank you!

    Kind regards Colette

  2. Shaibal Roy says:

    I enjoyed reading your blog posting. I have some questions:

    1) Re: “…to have units where the whole pathway is effective, so that patients need to be in that pathway less often and only for the period of time which their needs dictate.”

    If there were no restrictions and you could design/build something from scratch, i.e., to enable effectiveness across the whole pathway, what would your guiding principles be? Instead of being in the pathway less often, why not flip the idea of the pathway and have something they are in all of the time, proactively supporting health and holistic well being?

    2) Alliance commissioning – sounds interesting, searching for the term gives this: Is this the place to find out more?

    3) Re: “…negative synergy between mental health and physical health, ‘total’ separate systems have little logic. Therefore, should we not be saying that the solution is an integrated model that wraps services around the patient?”

    Can you elaborate on recent-ish experiences whereby the illogical system is championed? Or perhaps a better question – can you elaborate on your view of the challenges to move from the illogical to logical, and in your experiences of the NHS can you make a comparison to a change/improvement to the system that has previously occurred?

    Shaibal Roy, @SR_Disrupt