Persons, populations, parity of esteem . . . and the NHS Long Term Plan

John Coggon and Judy Laing

The NHS is a public service under considerable strain. It has experienced a significant decrease in funding over the last 10 years, which came at the same time as a huge rise in demand for services. Unsurprisingly, this has led to concerns about the standards and quality of care provided by the NHS. As the King’s Fund, an independent charity think tank, has recently reported, patients are still waiting too long for emergency and routine care, and NHS Trusts and Clinical Commissioning Groups (CCGs) remain under tremendous financial pressure.

In response to these concerns, the government pledged in 2018, through its funding offer, to increase the amount of funding available to NHS England. The NHS Long Term Plan (the plan) was published in January 2019, to sit alongside the funding and set out a long-term plan for the service.

The plan is ambitious in scope and aims to transform the delivery of care in the NHS over the next 10 years, to ensure that it meets the needs of the country’s changing population. The plan recognises that the landscape has changed dramatically since the NHS was created in 1948, and we are now facing huge challenges in terms of funding, staffing, increasing inequalities and pressures from a growing and ageing population. Significantly, the plan has identified several key clinical priorities which impact heavily on the health of the population, where health-care inequalities are particularly acute, and outcomes are much poorer than would be expected in a developed health-care system. These priorities include cancer, cardiovascular disease, maternal and neonatal health, as well as mental health. The plan recognises that there is an increasing need to reduce inequalities and focus on population health in order to improve outcomes in these key areas. Accordingly, it recommends a move towards integrated care systems, whereby primary and specialist, physical and mental health, and health and social care are fully integrated to provide comprehensive and consistent services. The plan sets out new commitments for action that the NHS itself will take to improve prevention. But it acknowledges that a comprehensive approach to preventing ill health depends on action by a range of other actors and sectors, including individuals, communities and national/local government.

Crucially, at a policy and practical level, the plan seeks to remedy the gaps and inequalities that have persisted for far too long between mental and physical health. Evidence suggests that mental health services have been underfunded for decades, and the plan makes a renewed commitment to grow investment in mental health services faster than the NHS budget overall for the next five years. This should mean that, in future, mental health will receive a long-overdue and increasing share of the overall NHS budget. The plan reaffirms the government’s commitment to improving mental health services (as set out in the Five Year Forward View of Mental Health), and shifting the focus to prevention, by redesigning core community mental health services and providing comprehensive support for children and young people.

The plan also commits to improve care for people with dementia, recognising that there will be over a million people living with dementia in the UK by 2025, and there are over 40,000 people in the UK under 65 living with dementia today. There will be significant investment in research, and improving professional and public awareness and understanding, as well as in developing comprehensive and integrated community support.

This renewed policy focus in the NHS plan on population health approaches to reduce health inequalities is much needed. Legal and regulatory mechanisms clearly have an important role to play in helping to direct and develop this policy and practice. We maintain that health law research and scholarship also has a key part to play in fuelling and shaping these policy initiatives and shifting the narrative to focus on prevention to tackle these long-standing health inequalities.

Our article in the recent Northern Ireland Legal Quarterly special issue highlights the contributions that may be brought from new and emerging discourses in academic health law to these developments, from the perspective of the related fields of public health law and human rights law. Whilst core definitions of public health speak to questions regarding mental health and well-being, recent reports from a range of professional and advocacy organisations urge the message that mental health remains a neglected area of concern. And this has, of course, also been brought into sharp focus recently by the plan. These narratives have led to an emphasis on the field of public mental health as a discrete area of study, policy and practice. In our article, we argue and explain how the related field of public mental health law should be conceptualised and operationalised.

This entails an examination of the fundamental requirement of law to support and promote good mental health, with a renewed focus on prevention and proactive intervention rather than reactive measures. We suggest that a framing made by reference to human rights models will support the combined ethical and practical commitments that must be met by public mental health law. We draw on dementia as a specific case study to highlight how this new approach could work. In line with the explicit commitment  to dementia in the plan, we explain in our article the need for investment in public-mental health measures and associated regulatory responses to help combat the challenges posed by the dementia ‘epidemic’.

We argue that the time is now ripe for a fresh approach, by looking through the lens of public mental health law. Health law scholars must work in tandem with policy-makers, health-care providers and practitioners to help tackle the current challenges relating to mental health, and to realise the potential of the NHS Long Term Plan.