Parity and Public Mental Health: the paradox of policy and commissioning for populations and particular groups with complex needs
The Royal College of Psychiatrists has just published a landmark report seeking parity between physical and mental disorders. The report carries the title: WHOLE-PERSON CARE: FROM RHETORIC TO REALITY (ACHIEVING PARITY BETWEEN MENTAL AND PHYSICAL HEALTH). The report recommends better leadership at local and national levels, policies that promote parity rather than undermine it, tackling stigma and discrimination and respect between health specialisms and disciplines to promote whole person care over the life-course; parity in terms of preventing premature mortality through public health and care service interventions, integrated systems of care that yield better outcomes where physical and mental health is actively managed together, and of course funding that matches the burden of mental illness and co-morbidity of physical and mental illness which is the norm rather than the exception.
Building on the public health position statement there is a specific call for a cross-government approach to address welfare reform, unemployment, criminal justice, and schools and educational interventions, all to promote public health. A remarkable feature of the report is that it spans the biological interventions needed to prevent premature mortality (amongst those with mental illness and cardiac problems) right through to social and public health interventions, taking account of bio-psycho-social analyses of healthy society and healthy people. The report goes on to emphasise the role of wellbeing in both the population at large and in those with established illnesses. We know that public health interventions can benefit the entire population, not just those with diagnosed physical or mental disorders. For example, a study of health visitors trained in identification of depression and psychological interventions for it can prevent future episodes of depression 6-18 months postnatally even in women who were not depressed at the first contact. In fact there is so much evidence that this presents policy makers and commissioners enormous challenges if commissioning decisions are to be based on the best evidence to achieve the best outcomes for the public involved in public mental health, local government, NHS commissioners, care services and NGO sectors. Intelligence based commissioning requires that joint strategic needs assessment drives local decisions; this requires engagement with national and local evidence, and capacity to consider the evidence in public argument and reasoning if decision-making is to be truly transparent and in the interests of the populations, rather than serving the purpose of organisational efficiency and survival. There is an immediate need for better understanding of illness and wellness and the interaction and benefits of a linked approach.
Equity principles and values must be at the heart of public mental health and the parity agenda. A public health system and care system that does not actively tackle inequalities will continue to foster social exclusion, poor care practices for specific and isolated and marginalized groups as well as for populations as a whole. Equity is especially vulnerable at times of transition, for solutions only to be sought later once it is too late. We need a safe, equitable, parity based public mental health system. Systems of care that are not humane and equitable foster a workforce that overlooks poor care and inequalities. Public health and training bodies are coming together to develop the workforce, and promote more connected commissioning, and inequalities should be actively addressed.
 Brugha, TS. Et al. Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care. Psychological Medicine, 2011, 41, 739-748.