Why create new demand when you can’t manage old demand? Or healthcare as shopping.
Demand for what the NHS produces is increasing by 4% and funding or investment by 1%. Instead of stalling or winding back demand so that it meets the level of funding, a combination of very powerful vested interests, insider blindness, the continuing invention and stretching of pathology, and the dismantling of both individual and collective self-sufficiency and resilience have been allowed to expand demand. This is continuing to put fuel in a car which has run out of brake fluid. So, what or where is the source of this folly?
Organisational systems are analogous to human ones. Robert de Board, in The Psychoanalysis of Organisations (1978), persuasively bridges the two, though the decades since it was written have taken us from an era of playful abstraction and theory-making to one of concrete, mechanistic anti-thinking: while we ponder whether machines will ever be like humans, humans are being press-ganged into being like machines.
Humans, if they are to survive and mature, have to reconcile an essential contradiction. That is, the opposing forces of grandiose fantasies of immortality and invulnerability on the one hand, and of what Freud elliptically called the death instinct on the other. Clinically, a failure to rein in the former manifests itself as mania (the patient feels untouchable or unreachable in a world of laughably inadequate others); while suicide – and perhaps perversely self-destructive behaviours such as smoking or excessive drinking or eating – are the enactment of the latter.
The process of maturation, which is never fully achieved of course, requires a certain amount of adaptive introspection or self-observation. This must be combined with the formative, curbing influence of reality which applies the brake to teasing fantasies and ambitions that promise further expansion of the ego but lead eventually to its implosion. These corrective mechanisms, when they are intact and active, lead instead towards balance and health in the individual who must nevertheless continue to operate and learn from them since stasis is the enemy of maturity.
This dynamic applies precisely to organisations as well. The primary function of leadership or management is to sit on the boundary, ruthlessly overseeing expansionist impulses from within which threaten the effective functioning of the organisation, or even ultimately destroy it, and the inward flow of external pressures or stimuli which carry the same threat.
The NHS is particularly vulnerable to these powerful drives which take the form of vested interests and unfettered idealisation working in tandem on the inside, and the brakeless engine of demand coupled with a bottomless need for reassurance and consolation on the outside; this in a marketised culture where the limitless invention and elasticity of illness have created universal patienthood such that to be sick is to be normal and being normal is to be sick.
The chaos of these uncorrected, unmediated forces is mostly too pervasive to be noticed: as the saying goes, it’s only fish that don’t know it is water they swim in. But every pathology has its symptoms or markers which carry the potential for cure. Paradoxically, they can be found in the very place where you go to get better and stronger but are insidiously made to feel worse, a low-lying, vulnerable island hunkered down as the tsunami of disease and disorder inexorably approaches. That is to say, the NHS doctors’ surgery.
The mission of the market is to create states of mind or of being – namely, vulnerability, dissatisfaction, dependency, anxiety and need. It will do this covertly, using code or a kind of linguistic sleight of hand – as in “because you are worth it”; or indirectly through technology such as the mobile phone which has created vast reservoirs of anxiety where none existed before. The NHS unwittingly apes the former in the guise of education, health promotion and other shibboleths which are antithetical to self-reliance, resilience, autonomy and organic forms of mutual support. The following are all from actual notices in one average surgery on one random day:
“Muscle and joint pains? You may need to see a physiotherapist.”
“Do you look after or support a family member who depends on you? You are a carer…”
“Please tell your GP practice if you are a carer”
“Unwise, drunken sex on the beach [sic]? You should visit……”
“Tried stopping smoking? You should……”
“Anxious about a physical health condition, feeling unwell? You should think GP first.”
“Worried about your memory…….?”
“Toothache out of hours………?”
“Losing weight? Had a stroke…..?
“Meningitis – it could happen to anyone.”
“There is a large Ebola outbreak going on…..” [it was over months before]
“Please see the practice nurse for minor illness, minor injuries, cystitis……..”
“Pack medication in separate cases in case one is lost….”
“Plague in the US…..”
“West Nile virus in Italy”
“Feeling anxious? Exams stressing you out? “Struggling to get out of bed in the morning? Finding it hard to sleep? There’s a peer support group where you can talk about what’s on your mind or listen over a cup of tea in a friendly, non-judgemental environment”
“Even sunshine in the UK can cause melanoma”
“Sunburn = skin damage = melanoma”
“Vomiting? Ear pain? Stomach ache? Backache? Choose your GP”
The motives behind these posters are almost audible: that is, diverting demand away from A+E, the endorsement of some kind of right to well-being, dissemination of the image of the state as the benign protector of its citizens and so on. But the meta-communication is that the world is a dangerous place where disease or disaster could strike at any time, that suffering must be eliminated at every opportunity, and that individuals and their informal networks carry a kind of deficit which only formal agencies or experts acting as agents of the state can fill.
A recent half-page advert in national newspapers is a graphic encapsulation of this dynamic. Under the trademarked banner “Expect the Unexpected”, the copy runs:
“Pneumonia can strike anyone at any time: up to 1 in 100 adults are affected every year. Don’t let it be you.”
Tucked away, bottom left, under a photograph of an ordinary healthy-looking woman in her thirties, is a little footnote: “Sponsored by Pfizer”.
While it is no surprise that one of the world’s largest pharmaceutical companies is drumming up custom for one of its products, it is the state, via its agent the NHS, which is complicit along withits citizensin the perpetuation of the powerful superstition, also exploited by the market, that vague, ubiquitous threats may be magically staved off by contact with the shaman, the guru, the witch-doctor or doctor. The inexorable insistence by patients that they are given anti-bacterial drugs for a viral disorder is a contemporary demonstration of this primitive process. And telling them that these drugs won’t have any benefit is irrelevant and ineffective because they are symbols before they are chemicals – for safety and reassurance dispensed by the doctor-as-parent. To that extent they do actually work, but not in the concrete way that the formulary describes.
The fear of imperfection now ranks higher than the fear of death. Every deficit, imagined or otherwise, every scintilla of suffering, every slight slide down the ladder of well-being or the league of comfort and health, every threatened interference with a full capacity to consume, every moment of misery is deemed to justify contact with the designated expert which is collusively, if sometimes unwittingly, promoted by the state. Visits to its agents and agencies are now seen not as a failure of self-healing, self-protection and self-sufficiency but as the mere exercise of a right or the calling in of a debt owed by the state.
Our duty to protect the NHS from our excesses, weakness, dependency, fears and neurosis has been inverted as part of the wider process of the migration of duty from the individual to the state. Demand and the appetite which flows naturally from this inversion now no longer encounter the old brakes of guilt, shame and moderation, nor run up against the market’s essential regulator, namely price.
Just as the market will only survive by stoking supply-led demand through the continuous creation of new brands so the faux-market of healthcare expands through the invention and elasticity of illness. In mental health, new low-stigma constructs such as attention-deficit hyperactivity, Asperger’s Syndrome and type 2 bipolar affective disorder find their way into the clinic and, being spectrum conditions, are stretched for economic, moral and other reasons to give room for an increasing number of cases, not least because diagnosis brings absolution from responsibility along with many other benefits.
Increasing state infiltration into the health of citizens has led to a marked lowering of thresholds for clinical intervention, for example in deeming the number of so-called units of alcohol which it is reasonable to consume per day or week and identifying the often self-limiting problems of living and maturation which must be converted into cases for the thousands of psychologists who now operate in primary care. A similar process, with its origins in the USA, is at work in the stretching of the parameters of diabetes, raised blood pressure and many other conditions.
The NHS is brilliant at creating patients but hopeless at creating un-patients. It has forward but no reverse. It behaves like a good capitalist or retailer, researching and inventing new products, and working on the psyche and appetite of consumers or potential consumers in order to achieve the diversification necessary for survival. In practice, it is a lumbering monopoly with an open door, the key of price having been stashed away by its paymasters for fear of protest and dismissal by the mob, inundation being preferred to remonstration. Instead of addressing its basic, primary flaw, vast amounts of expenditure both of cash and time are applied to its incidental, secondary consequences, the spectacular and inevitable failure of this approach leading to more resources and more people being co-opted into the right solution to the wrong problem.
When the deterrent pain of price (in the form of taxation) is remote from the exchange, overconsumption of a good is inevitable. In fact, in the case of state healthcare, those who pay the least (in taxes) are likely, for a complex variety of reasons, to consume the most while those who pay the most generally consume the least – partly, of course, because they are healthier, fitter and have the cash to buy it elsewhere but primarily, in fact, because they are attuned to the economics of the transaction. Thus the rate of consumption is in inverse proportion to the degree of awareness of cost.
In advanced capitalism the primary business of the market is to stimulate wants where there used only to be needs, a dynamic which has spilled over into healthcare. In the UK wants are increasingly considered to be coterminous, if not yet synonymous, with needs (if I want x, I need x). Designating patients as service users and therefore all-but-consumers is part of the process of co-opting them into the bustle of the market-place, thereby moving definition and decision-making from the objective to the subjective sphere. Counter-moves, for example CCGs (clinical commissioning groups) considering individual funding requests for expensive cancer drugs, remain confined to the perimeter.
So it is that the confluence of anxiety and entitlement meets in A+E, teeming mega-hospitals and the doctor’s surgery where it is welcomed and feared at the same time.