NHS: The muddle at the middle: a business without a brake
Organisations are organisms too. The NHS, being an organism with a human face, has a capacity, as humans do, for projection. This is the mechanism by which negative aspects of the self are exported outwards onto others. So, as I was walking up the Charing Cross Road I caught sight of a sombre warning on the side of a phone-box, itself a clunky vestige of pre-digital times, in familiar NHS sky-blue livery. The booth-length poster read: “Over 60 with wheezes, coughs or sneezes? A minor illness can get worse quickly: early advice is the best advice”.
In its flaky portrayal of anyone over 60 as delicate and vulnerable, this faintly offensive ageism can be fairly easily dismissed, as can its conclusion – as bad advice, since no advice is often the best advice. But sadly it is more than a dodgy advert which you can pass and forget. It is, first, the image in the mirror, the unsayable message from the subject, an organisation in its 67th year which ostensibly soldiers on, fit and prospering in some areas but sclerotic and in decline in others, its immunity from entropy long since compromised.
Secondly, and more important, it is a symptom, like a telling tracing on the ECG, of systemic misalignment and fundamental un-health. At the heart of the institution there is what will eventually become a fatal fixation on creating new patients, on carving out new territories (markets, actually) for intervention by inventing illness, on the covert promotion of dependency and need, while subverting resilience and self-sufficiency, and on transforming whole groups (children, the old, the pregnant and the dying) into suitable cases for treatment.
A number of different routes lead to an inevitable endgame in which the tectonic plates of the untrammelled commercialisation of healthcare and unfettered demand will no longer slide across each other. First, the lexicon of mental health disorders, by their nature more elastic than those of physical health because they are less amenable to objective, observable diagnostic confirmation, is gradually expanding, driven mainly by market forces and behaviours in the US. Thus, constructs such as Attention Deficit Hyperactivity Disorder (ADHD), once a rare condition of childhood but now applied to numerous adults who find the rigours of academic or working life a challenge, Bipolar II Disorder (BPADII), Asperger’s Syndrome (AS), Autism Spectrum Disorder (ASD), Social Anxiety Disorder (SAD) and an expanding nexus of disorders of personality, once coined and validated, develop a compelling currency. And spectrum disorders, by their nature, are highly elastic, partly because the decision about where a line should be drawn between the actionable or treatable and the everyday or normal is socially, culturally and, most significant, economically determined.
This dynamic is backed by powerful vested interests, namely drug companies and health professionals – and their professional bodies – and sustained by individuals understandably searching for a name for their distress and suffering, and a kind of absolution from their seeming failure to be in step with the majority and to make material progress in their lives. Subscribers see this trend, not as the cult of illness gathering momentum, but as the product of enlightened medicine, bringing hidden suffering into the light of day, dispelling isolation and blame and providing pharmacological and psychotherapeutic relief, if not cure.
Pressure and support groups gather around the brand which gradually becomes an established and unarguable feature of the clinical canon, such that to question it is seen as a reactionary and retrograde attack on sufferers. And the fact that, say, hyperactivity was a definite but rare phenomenon among children in the 1970s and 1980s, but is now treated with over 650,000 prescriptions of methylphenidate in the UK a year, having increased by 11% just between 2011 and 2012, is interpreted by some as the NHS finally getting to grips with a troubling and disabling illness.
One explanation for an apparent increase in the incidence of this particular constellation of behaviours is that if you have a construct, in some circumstances behaviour will change and expand to fill it out. Multiple personality disorder, renamed dissociative identity disorder to make it more diffuse and elusive, is a compelling example of this. A popular and established construct in the US (again), it is far more prevalent there than it is in the UK which has resisted granting it a diagnostic import licence and thereby according it mainstream recognition. To put it differently,
construct + promotion + expertise + currency → prevalence.
Even with unarguable and distressing behaviours such as bulimia, this equation is at work, the very well-respected psychiatrist who was involved in its development as a formal mental disorder once saying that he regretted his role because it seemed to have created many more cases. The mimetic dimension, well-known in the tendency for suicide to cluster at times of increased reporting or publicity, is responsible for what might be called nosogenic morbidity or disorder-creating disorders. And the suggestibility which is necessary to catalyse this dynamic is, of course, more generally ruthlessly exploited and fostered by the market in its obligation to create demand in order to survive..
The second pressure which pushes the NHS towards the endgame is the reframing of unusual, exceptional or problematic traits and behaviours as disease, combined with the secondary benefits, both intrapsychically for the individual as a person and externally in the form of material gains, of being co-opted as a patient or case. This is perhaps clearest in the expanding construct of personality disorder, in particular the borderline or emotionally unstable subtype, which once would be subsumed into the all-purpose construct of neurosis, now largely discredited because of its overtones of Freudian sexism.
Personality disorder, a diagnosis which tends to be attached to those who, for many different reasons, can be more easily turned into a case, is essentially behaviour in the wrong place. Strengths, attributes and tendencies which might well be positive and productive in one sphere become inverted in other spheres into symptoms which are felt to cut across the grain of normality or acceptability. Once a construct has been legitimised, first medically and later politically, there is an early tipping point after which support and pressure groups coalesce around it. In this way, constructs gather momentum which even governments, highly susceptible as they are to campaigning believers, are powerless to resist.
Thirdly, there is now no ought in illness. Until healthcare became a form of shopping, a service industry like any other, where availability, accessibility and quality are driven by desires, ought had a decisive role – as in: “you ought to be able to manage this at home”, “you ought not to burden a service under extreme pressure”, “you ought to be able to cope with x or y”, “you ought not to let x or y have a disproportionate effect on your life”, and so on. Without this brake on behaviour, the NHS has become a mythic mother, a Shangri-La where excesses can be mitigated, anxieties assuaged, the fact and consequences of isolation and dislocation palliated, and the human diaspora briefly rooted and soothed, underpinned by a culturally induced sense of entitlement and expectation, a fantasy so powerful that the misery and anomie of Accident and Emergency Departments are miraculously tolerated. Indeed, the managed chaos of A+E is the friction of a wish or fantasy coming into contact with an ineluctable law of human nature and the cold, hard facts of economic life: that, where there is no brake on demand, supply will always be overwhelmed.
Stigma was another significant brake on demand for services in that an easy dependence on others for reassurance or remedy was disapproved of and resilience, self-sufficiency or self-solution highly prized. It also used to act as a retardant on the elasticity of constructs, as it still does with stigma-heavy conditions such as paranoid schizophrenia; whereas relatively stigma-lite disorders such as Asperger’s Syndrome and bipolar II, a distant descendant of what used to be called manic depression, a diagnosis which sufferers would generally implacably resist, are sometimes actually coveted by would-be patients, their incidence increasing in proportion to the number of specialist experts who choose to view human behaviour through these particular lenses. This is not an argument for more stigma but an acknowledgement that stigma puts a brake on certain behaviours (the stigma attached to teenage pregnancy in the Netherlands being a good example of this).
Fourthly, more services create more demand. Improving Access for Psychological Therapies (IAPT), New Labour’s mass psychotherapy service in primary care, had just under a million referrals in 2013/2014. For the record, it is unclear whether this venture has produced any lasting benefits for its patients. The Annual Report on the use of IAPT Services, produced by HSCIC, tells us that 40% of patients referred (364,000) finished a course of treatment (at least two treatment appointments) and 60% of them (i.e. 24%) showed “reliable improvement”, defined as “a reliable decrease in anxiety or depression scores between first and last measurement”. What the authors don’t address is the important question of whether this massive investment by the State has actually reduced pressure elsewhere in the system, for example on GPs or secondary mental health services. In fact, there is plenty of anecdotal evidence that in a subtle way more services actually create more work for other services, partly because thresholds for intervention drift downwards and the everyday sadnesses and difficulties of life become pathologised.
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My walk through central London took me past the steep rake of steps leading up to the spacious foyer of University College Hospital, easily mistaken for the grand entrance to a city bank. Hanging from girders were banners which read: “One in three of us carry bacteria that can kill” and “Every 7 minutes someone gets infected”. The marriage between medicine and the market, their copy and techniques for using fear and disproportion to lever demand now being indistinguishable, seemed complete.
Now worried that I might be that one in three, though unsure whether I or some innocent passer-by would be the victim of the homicidal germs that I was harbouring, I made my way home – which took just enough time for two people to be infected. On the mat was a leaflet with the reassuring white-on-blue logo of NHS Plc. “Anxious, stressed, depressed?” it enquired. It continued in the familiar tone of leaflets for no-win/no-fee solicitors, dodgy damp-proofing techniques and retirement villages which make the short journey from mat to bin: “How can we help? We can help with low mood, fears, social anxiety and shyness, worry and anxiety”. The help in question was “on-line therapy wherever you are”, “at any time of day, including evenings and weekends”. Vignettes from satisfied customers spoke of the pleasures of treatment “[while] not looking at anybody”, “when all the children are asleep in the evening”, and from the “supremely comfortable and safe” sanctuary of the sofa.
Thus the forward-thinking sales consultants of the NHS carve out new territories for intervention, imaginatively harnessing new media and tapping old dependencies and disappointments. It remorselessly creates patients but is incapable of creating un-patients. We must all have treatment and to deny this is itself evidence of the need for treatment. Indeed, life itself is an illness waiting for a name.