Mental health commissioning, prevention and parity of esteem: Interview with Luciana Berger MP

Source: NHE Nov/Dec 15

NHE’s Luana Salles talks to Labour’s new shadow mental health minister.

In today’s NHS, mental health is the new physical health. If you open any newspaper on any given day, you are likely to see at least one story discussing mental health services, positively or otherwise. 

The welcome focal shift towards the historically undermined – or ignored – importance of mental health initiatives in the health service may have been a long time coming, but it is now arguably starting to achieve real results. Mental health is no longer just the dusty bookend holding up more significant NHS services: it has become a public fight, a commissioner’s nightmare and, importantly, a governmental debate. 

Just a few weeks ago, for example, former care minister Norman Lamb MP published an open letter to the chancellor pressing for greater mental health funding in the Spending Review, signed by hundreds of other high-profile figureheads. 

But perhaps one of the most significant political shifts was Labour’s recent creation of a ministerial position focused solely on mental health. Those who have been heavily involved in the mental health debate for as long as they can remember saw this as nothing short of a triumph, and a spectacular culmination of years’ worth of attempts to break the silence. 

Political pioneer 

The 34-year-old Luciana Berger, MP for Liverpool Wavertree and a former shadow public health minister, has now taken up her role as shadow mental health minister during one of the sector’s most defining moments in NHS history. She has been intent on pushing forward the argument on parity of esteem between mental and physical health during these first few months in the post, peppering her proactive visits to mental health trusts with anti-Conservative digs about what she has seen during them. 

This unusual blend of encouraging collaborations with the sector, offset by a politically-driven approach to the state of mental health services in the country, has given Berger’s rhetoric a depth often lacking in ministerial announcements or the debates inside the healthcare sector. 

Commissioning inconsistency 

On the quality of services themselves and how they are specified, she had countless praises to sing. “Some places are doing some really great stuff in terms of how they commission: they’re very creative, they’re very joined up, they’re very cutting-edge. I had the opportunity to engage with providers [involved with] the Positive Practice Collaborative, and they are really doing some fantastic things,” she said. 

When we spoke, Berger had just finished touring mental health services in her hometown of Liverpool, where she was set to speak at an ADHD Foundation conference the following day (ADHD Foundation chief executive Dr Tony Lloyd contributed to the last edition of NHE).

439 Luciana Berger with staff and services users from the ADHD Foundation  

But these achievements are not the norm when it comes to commissioning, Berger noted. “There’s no consistency. [Good commissioning] is not happening across the country – only for those at the top. And the government doesn’t apply the same focus when it comes to mental health. 

“There are various thresholds and targets that CCGs are expected to respond to and meet, and fewer when it comes to mental health – so it means they’ve got less of a focus and less tension because they’re not held to account in the same way for mental health as they are for physical health,” she continued. 

And the levels of expertise in the sector also fail to match up, she said, which in turn fuels major ambiguity about how services are commissioned. “CCGs are driven by GPs, and some GPs are really excellent when it comes to mental health and some coming through the system training are increasingly getting more mental health training – but it’s not the case of all GPs. Therefore, it’s no surprise that, if you [have] some GPs commissioning services who don’t have that focus or that expertise, it means they’re not going to do it as well,” Berger concluded. 

Talking therapies 

Yet even the more conventional services considered essential in any commissioner’s handbook are taking a hit – whether by poor contracting or by growing waiting lists resultant from high clinical thresholds. “That is a conversation we are having in Parliament at the moment, about those thresholds and what the availability of treatment is and for how long you can receive treatment for,” Berger said, citing talking therapies and the number of sessions people are entitled to receive as a subject of constant complaints due to existing thresholds. 

“What happens when you complete that number of sessions? You have to start over again if you want any more, and the challenges that that presents to a lot of people is something we should be aware of and concerned by,” the shadow minister said. 

Prevention in lieu of crisis 

But what about smaller steps being taken in primary care to address knowledge gaps, such as mental health first aid (MHFA) training?

The MHFA course, developed in Australia in 2000 and now recognised in 23 countries, teaches people how to recognise the signs and symptoms of common mental health issues. 

Berger called that work “really interesting” and said: “I think it’s done some important work to raise awareness and challenge stigma. But it’s not a replacement for trained mental health professionals. It’s an important tool, but it’s not going to solve all the problems that they have.” 

No, it’s not – but what will? There is, of course, no panacea to an ailment caused by decades of systemic failures, but Berger is adamant that reconfiguring the way we approach mental health will do much to patch up existing service holes – not necessarily in terms of stigma, but in terms of prevention. 

“We’ve got a system which very much focuses on crisis, and some of the things that have been done in the last few years have focused on crisis,” she said, indicating a potential symptom of a wider problem as she echoed what most of us have also heard about other parts of the healthcare system. 

“I welcome the establishment of the [Mental Health] Crisis Concordat. However it’s about what happens when someone is in crisis and, actually, we should be doing everything to prevent people from getting into crisis,” she continued. 

“And the system does not do that. In fact, the system does that even less because of the extensive cuts to local government, which previously provided the services which stopped people getting into crisis.”

Four-way integration 

The shadow mental health minister cited reductions to other fundamental services as a significant contributor to the swelling mental health crisis – such as fewer educational psychologists and fewer youth services and children’s centres – “all of which are services that really, I believe, cost-contributed to preventing mental ill-health”. 

When I reminded her of the confirmed cuts to in-year public health budgets, set to be slashed by a 6.2% flat rate across all councils in 2015-16, she said this was a “sure sign of a government that doesn’t understand the value of prevention” – but refrained from saying anything else because, though once having been shadow public health minister, that is now under the purview of her colleague, Andrew Gwynne MP. 

But she did acknowledge that fatter public health purses could present a real pick-me-up to the quality of mental health services. 

Luciana Berger c. Stefan Rousseau, PA Images

In fact, an effective prevention scheme would integrate public health, mental health, physical health and social care services: “It saves money, because you’re not having to duplicate or triplicate the things that you’re saying and the people that you’re saying it to,” Berger said, as she started to list the benefits of integration. 

“And it also results in a much better experience for the patient and their families. It ensures that if you have a mental health condition, that’s arguably taken care of, because we know that if you have a mental health condition, you’re more likely to have poor physical health – and vice versa. So you can have better outcomes for your physical health if you are concerned about mental health at the same time.” 

Manchester warnings 

Her calls for service integration are not new or unique, which in turn only serves to strengthen her argument rather than devoiding it of power. 

These calls exist because services are beginning to fail entirely. In Manchester, for example, some mental health services are set to be shut down as a result of a shattering £7m funding black hole. 

But this can’t be wholly attributed to poor commissioning or clinical thresholds – material disasters are part of a broader ripple effect from the historical failure to adopt parity of esteem between physical and mental health. Evidently, physical health services are also under undeniable cost-saving pressure from growing deficits – but mental health services are usually sent to the firing line first. 

Parity of esteem 

So I asked Berger, out of genuine curiosity, if she believed we had achieved any progress at all on parity of esteem since the term was popularised during the Coalition government and especially by former minister Norman Lamb, from about 2013. 

“Mental health has seen so many cuts in the last five years. In the last financial year, Monitor applied cuts to mental health trusts that were 20% higher than the rest of the NHS. So that was the opposite of parity of esteem,” she said, before conclusively stating: “Other than the government introducing waiting time targets for mental health, there hasn’t. Our mental health trusts are receiving cuts that are disproportionately high compared to the rest of the NHS, like acute hospitals. That is not parity of esteem.” 

For example, she said, the NHS currently accounts for about £120bn of state spending a year, but of this, mental health services only receive £11bn: “It accounts for 22% of the burden of disease – the fact that there’s just less than 10% of NHS resources allocated to mental health highlights the starkness of the challenge.” 

But stepping up to the seemingly utopian parity of esteem vision is not as complex as it is made out to be. “Critically, funding is key,” she noted, adding: “But I’m yet to see the effects of the introduction of the term ‘parity of esteem’ in law actually translated into action.”


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