Will more choice help us through the maze?

Patients will want to take the path that leads them to the healthcare that they want, at a time when

Choice is often touted as a panacea. If you give people the power to choose you make them responsible for their own destiny rather than treating them like commodities on a conveyor belt.

But what use is having an array of options if you don't understand the consequences of your selection? Healthcare, and the bureaucracy that shapes it, changes swiftly and it takes an astute, almost abnormally interested individual to keep track of the various bodies operating in one's local NHS, let alone at national level. There are primary care trusts, hospital trusts, community trusts, foundation trusts - and most recently, "super surgeries", or polyclinics, which are being built in certain areas to give patients far greater access to healthcare services.

Alongside all of these alternatives, pharmacies are being recommended as places for patients to go to seek medical help for what they perceive are minor problems. The press that surrounds the promotion of pharmacies is mixed: some say the advice given is inadequate, others concur that another avenue for people to obtain healthcare guidance can only be a good thing.

Of course, it's a no-brainer that greater access to healthcare is beneficial, especially in overcrowded or remote areas. But how are members of the public meant to know which source of medical advice is most appropriate for them? Joe and Jane Public may have an inkling as to what constitutes "primary" care, but as the boundaries change and services that used to be hospital-based are offered in new settings, confusion is likely to result in them resorting to visiting the most familiar setting: the GP surgery - if they can get an appointment - or, at the weekend and evenings, A&E. The NHS Direct helpline earns praise and criticism, with negative comments along the lines of, "They just told me to see my GP", to positive accounts of lives being saved thanks to timely advice being dispensed.

Seeing a door marked “consulting area” in a pharmacy helps to embed the idea that asking advice is expected, is welcome

There is no obvious consistency when it comes to the healthcare facilities in area A or B. Why should patients know that a pharmacy is linked to the local GP practice, which in turn falls under the aegis of the primary care trust (PCT)? They may view the pharmacy solely as somewhere to pick up some paracetamol and toiletries, failing to appreciate that the pharmacist can offer far more than a swift exchange of prescription docket for packets of pills and ointments.

Indeed, if patients have only ever used their pharmacist as a post-GP stop-off to collect new medication, they need to be made aware that the professionals behind the counter can provide a range of guidance. Some pharmacies - the major chains - have installed quiet booths within which consultations can take place away from the other shoppers. Seeing a door marked "consulting area" in a pharmacy helps to embed the idea that asking advice is expected, is welcome, and is not an added extra that interrupts the flow of pharmacy life.

However, while some patients will feel confident enough to seek advice from their pharmacist, either because they trust them or are aware that dispensing advice is the done thing, others prefer the continuity afforded them through their GP. The same principle applies when considering the move to polyclinics. People value the connections they cultivate with various health professionals. These relationships are intimate and are not to be underestimated, as they can drive individuals towards, or away from, particular sources of healthcare.

That said, the problem remains that, when someone approaches a pharmacist for advice, they are perhaps relying on diagnostic skills being better than the profession demands. This is not to denigrate the pharmacist in any way, but pharmacists lack the medical training and records that GPs have at their fingertips, so is it not imperative that the two professions work closely to deal with patients in a mutually accepted, consistent manner, referring to each other when necessary?

Where there are numerous healthcare options available, all parties must collaborate, not compete. This will help make it obvious to the layman or woman that these seemingly disparate parts of NHS healthcare fall under one umbrella, that they communicate, access common information (that is safely and accurately maintained) and are working together to drive up health standards by putting patients at the centre of all decisions. Only when all the potential participants in a person's quest to achieve good health are integrated can people be successfully guided through the maze of options available to them. Who does what, where, why, and how, will become obvious through good practice.

It doesn’t matter to patients that a procedure once carried out in a hospital outpatients department is now taken care of at their local GP practice

The NHS, an unquestionably mammoth, dynamic organisation, will seldom be transparent to the average patient but, if further entry points are introduced to the system that merely serve to compound confusion, this would be a missed opportunity to truly widen access. Yes, in the short term, seven-days-a-week health centres will benefit those who cannot take time off work to see their GP, or who cannot wait the best part of a day to have a routine blood test carried out. However, there will be gaps or duplications in commissioning and priorities that would be shamefully senseless in an environment where money is tight and the ultimate goal of high-quality patient care is common.

It doesn't matter to patients that a procedure once carried out in a hospital outpatients department is now taken care of at their local GP practice. No one bothers - and neither should they - that funding for a health check comes from primary, rather than secondary care coffers. As far as the taxpayer is concerned, they are paying for the lot.

People will take the path that gives them what they need when they need it. If that means going to A&E because their GP practice has unacceptably lengthy waiting times, so be it. It doesn't have to be that way but patients may not know any different and, until they do (which is the responsibility of NHS providers), change may be hard fought and "choice" may simply equate to confusion.

Joy Persaud is a freelance journalist and can be reached here.

This article first appeared in the 03 November 2008 issue of the New Statesman, Israel v Hamas

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“I felt so frantic I couldn’t see my screen”: why aren’t we taking mental health sick days?

Some employees with mental health problems fake reasons for taking days off, or struggle in regardless. What should companies be doing differently?

“I would go to the loo and just cry my eyes out. And sometimes colleagues could hear me. Then I would just go back to my desk as if nothing had happened. And, of course, no one would say anything because I would hide it as well as I could.”

How many times have you heard sobbing through a work toilet door – or been the person in the cubicle?

Jaabir Ramlugon is a 31-year-old living in north London. He worked in IT for four years, and began having to take time off for depressive episodes after starting at his company in 2012. He was eventually diagnosed with borderline personality disorder last January.

At first, he would not tell his employers or colleagues why he was taking time off.

“I was at the point where I was in tears going to work on the train, and in tears coming back,” he recalls. “Some days, I just felt such a feeling of dread about going into work that I just physically couldn’t get up ... I wouldn’t mention my mental health; I would just say that my asthma was flaring up initially.”

It wasn’t until Ramlugon was signed off for a couple of months after a suicide attempt that he told his company what he was going through. Before that, a “culture of presenteeism” at his work – and his feeling that he was “bunking off” because there was “nothing physically wrong” – made him reluctant to tell the truth about his condition.

“I already felt pretty low in my self-esteem; the way they treated me amplified that”

Eventually, he was dismissed by his company via a letter describing him as a “huge burden” and accusing him of “affecting” its business. He was given a dismissal package, but feels an alternative role or working hours – a plan for a gradual return to work – would have been more supportive.

“I already felt pretty low in my self-esteem. The way they treated me definitely amplified that, especially with the language that they used. The letter was quite nasty because it talked about me being a huge burden to the company.”

Ramlugon is not alone. Over three in ten employees say they have experienced mental health problems while in employment, according to the Chartered Institute of Personnel and Development. Under half (43 per cent) disclose their problem to their employer, and under half (46 per cent) say their organisation supports staff with mental health problems well.

I’ve spoken to a number of employees in different workplaces who have had varying experiences of suffering from mental ill health at work.

***

Taking mental health days off sick hit the headlines after an encouraging message from a CEO to his employee went viral. Madalyn Parker, a web developer, informed her colleagues in an out-of-office message that she would be taking “today and tomorrow to focus on my mental health – hopefully I’ll be back next week refreshed and back to 100 per cent”.

Her boss Ben Congleton’s reply, which was shared tens of thousands of times, personally thanked her – saying it’s “an example to us all” to “cut through the stigma so we can bring our whole selves to work”.

“Thank you for sending emails like this,” he wrote. “Every time you do, I use it as a reminder of the importance of using sick days for mental health – I can’t believe this is not standard practice at all organisations.”


Congleton went on to to write an article entitled “It’s 2017 and Mental Health is still an issue in the workplace”, arguing that organisations need to catch up:

“It’s 2017. We are in a knowledge economy. Our jobs require us to execute at peak mental performance. When an athlete is injured they sit on the bench and recover. Let’s get rid of the idea that somehow the brain is different.”

But not all companies are as understanding.

In an investigation published last week, Channel 5 News found that the number of police officers taking sick days for poor mental health has doubled in six years. “When I did disclose that I was unwell, I had some dreadful experiences,” one retired detective constable said in the report. “On one occasion, I was told, ‘When you’re feeling down, just think of your daughters’. My colleagues were brilliant; the force was not.”

“One day I felt so frantic I couldn’t see my screen”

One twenty-something who works at a newspaper echoes this frustration at the lack of support from the top. “There is absolutely no mental health provision here,” they tell me. “HR are worse than useless. It all depends on your personal relationships with colleagues.”

“I was friends with my boss so I felt I could tell him,” they add. “I took a day off because of anxiety and explained what it was to my boss afterwards. But that wouldn’t be my blanket approach to it – I don’t think I’d tell my new boss [at the same company], for instance. I have definitely been to work feeling awful because if I didn’t, it wouldn’t get done.”

Presenteeism is a rising problem in the UK. Last year, British workers took an average of 4.3 days off work due to illness – the lowest number since records began. I hear from many interviewees that they feel guilty taking a day off for a physical illness, which makes it much harder to take a mental health day off.

“I felt a definite pressure to be always keen as a young high-flyer and there were a lot of big personalities and a lot of bitchiness about colleagues,” one woman in her twenties who works in media tells me. “We were only a small team and my colleague was always being reprimanded for being workshy and late, so I didn’t want to drag the side down.”

Diagnosed with borderline personality disorder, which was then changed to anxiety and depression, she didn’t tell her work about her illness. “Sometimes I struggled to go to work when I was really sick. And my performance was fine. I remember constantly sitting there sort of eyeballing everyone in mild amusement that I was hiding in plain sight. This was, at the time, vaguely funny for me. Not much else was.

“One day I just felt so frantic I couldn’t see my screen so I locked myself in the bathroom for a bit then went home, telling everyone I had a stomach bug so had to miss half the day,” she tells me. “I didn’t go in the next day either and concocted some elaborate story when I came back.”

Although she has had treatment and moved jobs successfully since, she has never told her work the real reason for her time off.

“In a small company you don’t have a confidential person to turn to; everyone knows everyone.”

“We want employers to treat physical and mental health problems as equally valid reasons for time off sick,” says Emma Mamo, head of workplace wellbeing at the mental health charity Mind. “Staff who need to take time off work because of stress and depression should be treated the same as those who take days off for physical health problems, such as back or neck pain.”

She says that categorising a day off as a “mental health sick day” is unhelpful, because it could “undermine the severity and impact a mental health problem can have on someone’s day-to-day activities, and creates an artificial separation between mental and physical health.”

Instead, employers should take advice from charities like Mind on how to make the mental health of their employees an organisational priority. They can offer workplace initiatives like Employee Assistance Programmes (which help staff with personal and work-related problems affecting their wellbeing), flexible working hours, and clear and supportive line management.

“I returned to work gradually, under the guidance of my head of department, doctors and HR,” one journalist from Hertfordshire, who had to take three months off for her second anorexia inpatient admission, tells me. “I was immensely lucky in that my line manager, head of department and HR department were extremely understanding and told me to take as much time as I needed.”

“They didnt make me feel embarrassed or ashamed – such feelings came from myself”

“They knew that mental health – along with my anorexia I had severe depression – was the real reason I was off work ... I felt that my workplace handled my case in an exemplary manner. It was organised and professional and I wasn’t made to feel embarrassed or ashamed from them – such feelings came from myself.”

But she still at times felt “flaky”, “pathetic” and “inefficient”, despite her organisation’s good attitude. Indeed, many I speak to say general attitudes have to change in order for people to feel comfortable about disclosing conditions to even the closest friends and family, let alone a boss.

“There are levels of pride,” says one man in his thirties who hid his addiction while at work. “You know you’re a mess, but society dictates you should be functioning.” He says this makes it hard to have “the mental courage” to broach this with your employer. “Especially in a small company – you don’t have a confidential person to turn to. Everyone knows everyone.”

“But you can’t expect companies to deal with it properly when it’s dealt with so poorly in society as it is,” he adds. “It’s massively stigmatised, so of course it’s going to be within companies as well. I think there has to be a lot more done generally to make it not seem like it’s such a big personal failing to become mentally ill. Companies need direction; it’s not an easy thing to deal with.”

Until we live in a society where it feels as natural taking a day off for feeling mentally unwell as it does for the flu, companies will have to step up. It is, after all, in their interest to have their staff performing well. When around one in four people in Britain experience mental ill health each year, it’s not a problem they can afford to ignore.

If your manager doesn’t create the space for you to be able to talk about wellbeing, it can be more difficult to start this dialogue. It depends on the relationship you have with your manager, but if you have a good relationship and trust them, then you could meet them one-to-one to discuss what’s going on.

Having someone from HR present will make the meeting more formal, and normally wouldn’t be necessary in the first instance. But if you didn’t get anywhere with the first meeting then it might be a sensible next step.

If you still feel as though you’re not getting the support you need, contact Acas or Mind's legal line on 0300 466 6463.

Anoosh Chakelian is senior writer at the New Statesman.

This article first appeared in the 03 November 2008 issue of the New Statesman, Israel v Hamas