Acting on what is known and knowing what is needed: A European perspective on health policy-making
Further to a powerful session on ‘Mainstreaming mental health policies across sectors’, we sat down with John Bowis to hear about his views and experience on health policy-making at national and European levels. John Bowis is the President of the Health First Europe multi-stakeholder alliance, a former Member of the European Parliament for London and served as the UK Health Minister between 1993 and 1996.
During the session “Mainstreaming mental health policies across sectors”, you explained that unlike Member States, the EU had the opportunity to work beyond the election terms. As an MEP, how did you see the influence of the EU recommendations into country’s health systems/policy (working beyond the next election)?
JB: The first thing I want to highlight is that the influence the EU has on Member States in not only in the health competence areas or the health and safety at work area, but in a whole range of areas. As an MEP, I was involved with health, the environment and food safety. For example, the environment was not just about prettifying the countryside, but making sure that we had clean air and water, and safe soil for our food to grow in. Food safety was about not only human health but also animal and plant health. Coming from London, a city with major air pollution levels in certain areas, when working on transports scheme, I was strongly supporting stronger regulations on emissions.
Remember that there are three different levels of EU legislation: the regulations with which countries have to comply absolutely; the directives with which countries have to comply with the intentions; and the recommendations, which are just that, recommendations. Under the treaties, EU competencies on health started with health and safety at work and continued with public health, and then health emergencies (such as the flu pandemics, SARS, bio-terrorism) and, from the Treaty of Amsterdam, health promotion. However most of EU health legislation comes through recommendations. EU influence comes also by shaming. Part of the EU’s work in health is to identify and disseminate good practices. By giving that information to the citizens and associations of each country, they can then use this information to push for change, using the examples of their European neighbours. It’s quite a powerful tool: no country wants to be named and shamed!
In your career, what would you say was your biggest achievement/impact in the field of mental health?
JB: With regards to mental health, we brought in a policy called the Care Programme Approach. Even though one cannot say it was brought in perfectly or it works perfectly, it was a first step. The idea was that every individual should have a key worker who would negotiate that person’s needs, and would make sure that the initial assessment would be met, with the provision of services from whichever agency those come from. Another achievement is more effective discharge procedures [when people with mental health issues are discharged from hospital back into their family or community], which we brought in. And finally we “educated” GPs in order to improve the detection of mental health issues. One in three people presenting to a GP have some form of mental health problems, but only one in six is identified as such.
Finally, I would like to mention the creation of a “users and carers group”, which advised me during my term as a minister of health. They were free to put on the agenda whatever they wanted to discuss with me. This group particularly helped with the purchase of services, as patients, providers and purchasers were sitting together, making sure that the services provided were acceptable and fit for purpose.
You said earlier today that politicians and policy-makers “build policy based on what [they] know and understand”. Many of the solutions to promote health and well-being are known but are yet to be fully implemented in practice. What do you think are the main challenges and solutions to their implementation? What do you – as a policy-maker – need or would like to have to build policy or take action?
JB: Lack of money. The lack of priority causes a lack of money. I first became involved in health policy, working in a community health council where I took an interest in mental health in the health authority. Each year, we would have a budget dedicated to the improvement of health services. Within 6 months, the whole budget was gone because of a crisis in paediatric beds the public was more aware of. Mental health has not been a priority in terms of services, even less in terms of promotion. Convincing ‘finance people’ that this issue is important is difficult but you have to convince them. The way to do that is to show them what happens if we don’t act: more cost, more mental ill-health, more people unable to work because of illness (or to become carers), and eventually, more social cares and benefits to pay. It has been better understood now within the government, but not fully understood yet.
This has been exacerbated by the period of austerity we’ve been through – even though this is a time when the demand for mental health support is increasing as people are losing their jobs, their businesses, or had to migrate.
The focus of this year’s forum is Health in All politics. In your experience, which sector(s) is/are the least receptive to including health concerns into their agenda?
JB: It’s clearly the finance sector, unless a key decision-maker there is personally affected by the issue. But I doubt that any sector isn’t affected. We worked hard on the housing sector, because housing is crucially important to the well-being of somebody who perhaps came from a hospital into the community, and needs to have a non-threatening environment to live in. Another important sector is social security. The problem was the systems they had set up. If someone gets a job, their benefits stop, and don’t start again until after a few months if they lose their job. People with mental health problems may go through such periods where they work for five weeks and after that are unable to work for the next three. Waiting for benefits at that point makes the situation worse. Even the army has the role to play. In London, we realized that many of our homeless people were former armed forces who couldn’t cope with civilian life.
In your opinion, what will be the impact of Brexit on health systems or on health policy in Europe, especially in the EU?
JB: The honest answer is: I don’t know. However, there are certain things that are clear. First of all, if there were to be an exodus of the EU citizens working in health and social care services – 130 000 people – the services would collapse. We have to find a way to prevent that. They are looking for ways to prevent that. At the moment, they are looking at pay levels, which may not be enough to keep these people in.
Secondly, the European Medical Agency will be leaving the UK. For the UK to have its own medical agency looking at every drug would be ludicrous. There will have to be some ways to link it to the EMA. The same goes for the ECDC, to monitor health threats and pandemics. Additionally, both of these agencies have a lot of British expertise in – they extensively depend on British scientists. However, I don’t believe that science will be “closing the door” after Brexit. Science and research will go on across borders as before. Even the research funding issue the UK may have is no different than the one faced now when collaborating with non-EU countries.
In terms of the average citizen, the immediate question is whether British people will be able to keep their European health card and access local healthcare treatment when they travel, study or work in other EU countries and vice-versa, when the EU citizens come to the UK. Not only that but also on the cross-border healthcare legislation, which I supported and which allows European citizens to seek healthcare in other European countries.
I think that they are obstacles we don’t need. It’s a great pity, as they are creating a lot of the uncertainty at the moment. They need to be sorted out as soon as possible! There is no secret of my position as a remainer. I still hope that Brexit will not happen, but I think that this is more a wish than an expectation.
This interview was conducted by the Young Gasteiners Filip Lassahn Elodie Besnier.