Parity of esteem is usually described in the abstract: mental health given equal priority to physical health. But the clearest place to see that principle actually operating is a single, concrete intervention delivered in GP surgeries across London every year – the physical health check for people with severe mental illness (SMI). It is one of the few parity-of-esteem commitments that has a name, a national target, and a measurable mortality problem behind it.
The London Health Commission’s 2014 review, Better Health for London, argued that prevention and primary care needed to reach people the system too often lost track of. People living with SMI – conditions such as schizophrenia, bipolar disorder and other psychoses – are exactly that group. This piece looks at what the check actually involves, why it was built the way it was, and what the evidence says about the gap it is trying to close.
Why a physical health check for severe mental illness exists
The starting point is a stark mortality gap. People living with severe mental illness die, on average, 15 to 20 years earlier than the general population. In England, people with SMI are estimated to be around 4.5 to 5 times more likely to die prematurely – before age 75 – than people without SMI, and that excess premature mortality has been reported as widening rather than narrowing in recent years.
Crucially, the evidence points away from the assumption many people make. The bulk of that gap is not driven by suicide. It is driven by preventable and treatable physical conditions – cardiovascular disease, diabetes, and respiratory disease – the same conditions any GP practice already screens for in the general population. The policy response, in other words, was not a mental-health intervention at all. It was a decision to make sure people with SMI actually receive the ordinary physical screening that non-SMI patients already get as a matter of course.
That is what parity of esteem means when it stops being a phrase and becomes a service: not creating something new for people with mental illness, but making sure they are not quietly excluded from something that already exists for everyone else.
What the check legally rests on
The duty traces back to the Health and Social Care Act 2012, which required NHS England to work towards giving mental health equal priority with physical health. On its own, that duty is a legal principle. The physical health check is one of the mechanisms that turns it into something delivered at a consulting-room level, with a defined set of tests, a defined population, and a funding stream attached.
What the check actually covers
In practice there are two tiers of provision, depending on how comprehensively a local area has commissioned the service. The table below sets out the difference.
| Tier | What it includes | Typical commissioner |
|---|---|---|
| Core annual check (QOF-incentivised) | Alcohol consumption, blood glucose or HbA1c, blood pressure, BMI, lipid profile, smoking status | General practice, incentivised nationally since 2006 |
| Comprehensive check | All core items, plus medical and family history, blood-borne virus and liver function screening, cardiovascular risk assessment (including QRisk), relevant immunisations, and support to access national screening programmes | Integrated Care Systems, where locally commissioned |
Anyone prescribed antipsychotics or mood stabilisers is expected to have physical health monitoring from the point those medicines are started, in line with British National Formulary guidance – regardless of which tier of check their area commissions. Checks can be delivered by GPs, practice nurses, pharmacists or occupational therapists, and can sit in either primary or secondary care, which is part of why coverage has historically varied so much between boroughs.
The national targets behind it
Three separate policy levers sit behind the check, and it is worth naming them individually because each one arrived at a different point and pulls in the same direction:
- QOF (Quality and Outcomes Framework). Since 2006, GP practices have been financially incentivised through QOF to carry out annual physical health checks – BMI, cholesterol, alcohol, blood pressure and blood glucose – for patients on their SMI register. Evidence associated with QOF suggests the incentive genuinely improves uptake, which is part of why it has stayed in place for nearly two decades.
- NICE guidance. NICE has published guidance on physical health monitoring for SMI since 2002, with formal NHS commitment to implement it following in 2017. The relevant guidelines direct primary care to keep an up-to-date register of patients with bipolar disorder, schizophrenia and other psychoses who need monitoring, and to start that monitoring at the point of diagnosis rather than waiting for problems to surface.
- The NHS Long Term Plan. The Plan set a specific national commitment: 390,000 people living with SMI receiving an annual physical health check by 2023/24, alongside supported follow-up once results come back. The check now also sits inside Core20PLUS5, NHS England’s wider framework for tackling health inequalities.
What this means for London specifically
A national target is delivered locally, and London’s 32 boroughs commission care through different Integrated Care Boards with different histories of investment – which is exactly the kind of borough-level variation Better Health for London flagged as a systemic weakness a decade ago. Whether a Londoner with SMI receives the six-item core check or the fuller comprehensive version, and how quickly an abnormal result triggers follow-up care, still depends heavily on where they happen to be registered with a GP. That is not a criticism unique to any one part of the system; it is the practical reality of a targets-and-incentives model layered onto a devolved commissioning structure.
Conclusion
Parity of esteem can sound like a slogan until it is traced down to something as specific as a blood pressure cuff and a lipid profile request form. The SMI physical health check is that trace-down: a legal duty from 2012, a set of NICE guidelines, a QOF incentive running since 2006, and a Long Term Plan target of 390,000 checks a year, all pointed at closing a mortality gap measured in decades, not percentage points. Understanding what the check actually contains – and which tier your local system has commissioned – is the most concrete way to understand what parity of esteem is supposed to deliver.