Public Healthcare Rights and Mental Health: where does the market fit?

Public healthcare, as a right of citizens, was created in this country with the creation of the NHS, establishing the principles of universal, comprehensive, and free at the point of access healthcare. As the world continues to deal with Coronavirus, with the expectation this will not be the last global pandemic, it is more important than ever to know your public healthcare rights.

This crisis has created huge tension within the NHS, exposing the fragmented and disconnected nature of our public health service that has come as a consequence of years of counterproductive reforms. Therefore, it is important to discuss the context that brought the NHS to such a fragile position, if we are to deduce its core issues, and offer any potential solutions. 

The historical journey of our Public Healthcare Rights

While many at the time quibbled over the incomplete nature of the NHS, it was a breath-taking feat, as it materialised the concept of Public Healthcare Rights. This embodied the establishment of healthcare as a human right, articulated within the Universal Declaration of Human Rights (1948).

Healthcare as a right, and prerequisite for participation in society, has its theoretical roots in the Millite principle of ‘positive freedom’. This justified government intervention in society, in order to facilitate maximum life-satisfaction for individual citizens, by enabling them to take these opportunities.

Within the context of health, this means the provision of a good standard of public health, as well as access to healthcare when sick, so that one is able to participate in society and achieve their fullest potential.

Recent Public Health reforms

The NHS presently succeeds remarkably well in curative medicine, for example, in its ability to combat cancer. However, it has failed to keep pace with the potential preventative medicines we know of today, that it could be administering instead of medication.

In our advanced society old age, obesity, and mental illness continue to be the most pressing public health crises (bar Coronavirus), and the NHS needs better direction and organisation if it is to help keep us all fit and healthy for longer.

The NHS’s principles of universal, comprehensive, and free at the point of access, healthcare, have been undermined by forty years of reforms, while there has been scarce reflection on the effectiveness of these reforms. This was initiated by Prime Minister Margret Thatcher’s imposition of the ‘internal market’ within the NHS.

The undermining of public health rights has stemmed from this fragmentation, rather than integration, of our health-system, due to the ideological adoption of market mechanisms in place of efficient rational planning.  The market is beneficial, but not effective if there is not proper conditions for competition and consumer choice.

While this author agrees the NHS structure is, to an extent, over-centralised, hierarchical, and non-responsive, evidence shows that Thatcher’s introduction of the ‘internal market’ created “little, major measurable change”, due to a lack of real market competition and continued managerial inefficiencies.

Unfortunately, this new consensus has informed the continual ‘marketization’ of the service up to the present day. This is evidenced in the 2012 Health and Social Care Act, which justified further budget contractions and further removal of rational planning as competitive ‘efficiency’ gains, while the evidence conversely shows this has actually “driven up costs and produced worse results”

Concurrently, an assessment of the Act found “the fragmentation of the commissioning and delivery of public health is likely to lead to problems of co-ordination”. These reforms concealed and justified further cost cutting of the service, which has inevitably lead to adverse negative health outcomes, as quality of care becomes subordinate to cost-cutting.

The roll-back of our Public Healthcare Rights

Budget cuts have resulted in the practice of ‘off-rolling’ mental health patients. This refers to the discharging of still unwell mental health patients due to their lack of response to treatment.

This is due to the need to reach targets of discharged patients, which should reflect the services ‘efficiency’ and value for money. However, budget cuts are the reason ‘efficiency’ gains are made, which then results in a poorer and less comprehensive, but cheaper, service.

And sadly an unintended consequence is that some of the most mentally vulnerable are subject to “draconian levels of seclusion, physical restraint and ward restrictions”.  While this seems removed from most people’s experiences, this is a denial of all of our rights as citizens.

Concurrently, hernia repair surgery has been removed from the NHS list of approved operation in a drive for ‘efficiency gains’, forcing patients to “endure pain… or pay for private care”. This physically restricts individual movement, and is a drag on quality of life, while no one should be forced to pay for something that is theirs by right.

The expansion of private care homes is a clear example of how poor healthcare provision denies people their right to free healthcare. The underfunding of the State Social Care sector forces individuals to seek satisfactory care in the private sector, leaving the poorest with inadequate care. In this instance, no one’s healthcare rights are being upheld.

How do we redefine our c.21st Public Healthcare Rights?

How can we articulate opposition to what is a subtle and almost intangible change to our healthcare rights? Watts alludes to a change in “ideological frameworks”, which has enabled the practice of ‘off-rolling’ to become a norm, where cost-efficiency replaces the principle of comprehensive care, and the ethos of public healthcare fades.

At a time when increasing longevity and quality of life are available, healthcare rights should be expanding, not retracting! Our right to healthcare is being redefined before our eyes without sufficient political scrutiny, or a sufficient public understanding of what healthcare we should expect as citizens of an advanced country.

Hart argues “commercial patterns, no matter how modified, are inappropriate” in health, as this leads to the incursion of commercial ambitions in healthcare production, undermining the principles of universal, equitable, and free at the point of access, healthcare.

The market mechanisms of competition and the price mechanism are at odds with a public health system defined by universality and egalitarianism. However, we can protect our healthcare rights and benefit from private healthcare.

LetsReset, a compliment to Public Healthcare

But where can private healthcare help public healthcare, ethically and effectively? In conversation with Suki Thompson, CEO of LetsReset, we discussed how the private sector was addressing the mental health crisis, and its role in relation to public healthcare.

Suki’s company is an example of the private sector responding to a public mental health crisis, which is costing the UK economy £34.9 billion per year. Having worked in the private sector, Suki spotted how businesses “don’t like feeling vulnerable”, as this is perceived as getting in the way of making a profit. However, the “macho side of business” has actually been shown to be a drag on business performance in the long run. 

LetsReset promotes a “culture of kindness” as a counter to this draining culture, and leads by asking employees and bosses, “are you having the work life you want to live?”. The overall aim being to build mental resilience, and “to get people performing at a good level”, improving business performance, and individual well-being.

This approach reflects the preventative style of public health care sorely needed for our mental health crisis. The idea is to maintain a well and resilient mental health, so that employees do not miss workdays, or have to seek further help, ultimately saving productivity.

Conversely, some people need professional help, which should be provided by the State at a minimum. LetsReset acknowledges this and is focused on improving the welfare of all staff, even if it is at the margins. 

Why do businesses need a Reset?

Suki describes bluntly how “culture eats strategy for breakfast”. Meaning, the ability of a company to fulfil its business plan relies upon the capability of its team to enact it, which is inhibited by a bad working environment or culture.

A reset in culture requires change at both “leadership level and organisational level”. Suki describes the companies ambassador programme, as well as coaching courses for leaders, as the mechanisms for impressing lasting change.

By training permanent employees to maintain and further the change in culture to a more “people centric” organisation, LetsReset aims to implement lasting change. While this is all very welcome progress, Suki argues that the biggest change will be getting “well-being on the balance sheet” of business, as many companies still view mental health as a box-ticking exercise.

LetsReset’s response to Coronavirus

In the current crisis, LetsReset have provided seminars online, as well as offline content, for their various clients. This included free training for all ‘key-workers’, such as those working for factories involved in producing PPE.

Thus far, LetsReset have trained 2,500 people in wellbeing, resilience, and anxiety during the public health crisis. Concurrently, they are taking up the advantages of digital connectivity to do lots of training remotely.

As LetsReset has pivoted in response to this public health crisis, Suki also sees a “fantastic opportunity to reset business”. Businesses have been forced to reassess their work environments and profitability drastically, due to the unprecedented shock to society, and our globally-integrated, urban-centric economies.

As a young business, launched 1st January 2020, following a book launch in December 2019, LetsReset is being forced to adapt to the challenges of Coronavirus. But Suki also sees this as an opportunity to “go beyond purpose” and find new ways to help businesses address mental health problems. 

Suki’s view to a Post-Covid future

When discussing the balance between the ethics and business motives behind this project, Suki says that she is “passionate that this is important”. She wants people to think “positively” about mental health, since “everyone has a mental health”.

To put things into perspective, she highlights that we “don’t treat [mental health] like cancer”, in the sense that donations to cancer charities dwarf mental health donations. Suki outlines how cancer charities receive vastly more donations and attention than mental health charities, while the latter is equally devastating to society in its own way.

There is a failure in business and Government to fully understand or acknowledge the extent of this problem, it seems, and Suki agrees that business are way behind. Suki also raises the comparison with cancer also illustrate how her own experience with cancer inspires her.

She describes her own recovery from cancer (on four different occasions) as a process of “post-traumatic growth”, something I relate to as someone who has overcome multiple spells of depression. It is the idea that following the most stressful and scary moments of our lives, we find our most strength and hopefully grow as people into whatever we put our minds to.

Suki argues that we have the “same opportunity now” for growth, as a society. The “nation has gone through trauma” and trauma requires self-reflection, honesty, and willpower to overcome.

LetsReset and future partnership with the Public Sector

This journal is focused on celebrating the way Civil Society has mobilized to fight Coronavirus, as well as how it has been a safety net for those failed by the Welfare State. However, LetsReset is separate to the State and Civil Society, as it occupies a place in the Market (private sector).

LetsReset is relevant because it compliments public mental health services, as it aims to maintain a good level of wellbeing for employees, so that they do not have to access stretched public services if it is not necessary. This saves the private and state sector resources and lost days of work, and contributes to better individual mental health.

In the future, Suki is hoping to build programmes, which could then given “free to schools”, for example. Concurrently, offering their service to a university could include the training of students for free, alongside the paid training of staff.

Can Suki’s service be a substitution for publicly provided counselling? No. And she does not market LetsReset as such. But clearly her service could make a significant improvement to public service work environments (for free) and does provide workplace wellbeing support that alleviates pressure on public healthcare.

So the private sector can certainly complement public health systems, if provided in an altruistic and socially sustainable manner. Unfortunately, it still takes at least six months to see a public sector counsellor, which is often too long for someone to wait.

How can you help?

The mental health crisis is not new, but it is only just being recognised and can only be dealt with properly if we all accept we have a mental health, just as we all have a physical health.

While I cannot ask you to donate to Suki’s private company, I can direct you to Mind, the student mental heath charity, where your donation will go directly towards providing young people mental health services. This money filters into a local system of 125 Local Minds, with 396,000 people being treated by the service in England and Wales.

Talking about your own mental health is a powerful first step also. The “macho” business environment is a consequence of a society that is not open about its emotions, and can be challenged immediately through independent conversations.

Hopefully this also leads to the acknowledgement we all have a right to a good mental health, and while that is not always possible, public healthcare should uphold this right to the best of its ability. Concurrently, the private sector has a role to play in public healthcare as a complimentary, rather than replacement, service.

It is unhelpful to denounce all forms of private healthcare, but it is important to recognise how private healthcare can undermine your healthcare rights. And when one is aware of one’s own rights, it is easier to articulate opposition to what is a current roll-back of of our public health system.

By Oliver Storey

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