Who is the NHS for? Not me!

On radio 4 early on Sunday morning I heard reported that 40% of the British population think people with disablities are ‘work-shy’. The figure comes from a recent survey of public attitudes to disablity called Access all areas. It doesn’t use the phrase ‘work-shy’ on the report, it says, “40% felt disabled people turned down job offers even when they were physically capable of doing them.” I was shocked. Obviously people turn down work they’re capable of for all sorts of reasons, but the figure shocked me because I think our attitudes to disability are symbolic of our attitudes to ourselves. I’m a GP in an inner-city practice with exceptionally high levels of deprivation looking after a lot of people with disabilities. Work-shy isn’t something that comes to mind when they struggle down the corridor on their crutches or sit at home all night after a stroke waiting to call me rather than bother the ambulance, or when they come in to see me for a review of their depression and apologise for their dishevellment – a consequence of being too depressed to eat, sleep or wash properly for the last month.

The answer to the question, “Who is the NHS for?” seems obvious, but most people reading this will have had little contact with the NHS and little experience of serious illness or disability. Illness doesn’t affect everyone equally. By far the unhealthiest years of our lives are at the end, and we’re pretty vulnerable at the beginning. In between, during our most productive years we are on the whole, pretty ignorant of illness and disability.

Conditions that affect us in our prime such as depression, learning disabilities, drug and alcoholism, epilepsy and so on are under-represented in our media saturated world of idealised conceptions of healthy people. The vicious cycle of illness, disability and poverty further alienates them, ‘the unhealthy poor’ from us, ‘the healthy’.

Combined with a historically unparalleled rise in prosperity over the lifetime of most people in this country, it is very easy to avoid thinking about vulnerability, including our own.

David Bell, president of the Institute of Psychoanalysis and a consultant psychiatrist, warns of the dangers:

Our relationship with awareness of our own vulnerability is far from comfortable – we have a natural tendency to locate it in other people – it is he, not me, who is in need, it is she, not me, who is vulnerable.

We maintain this attitude towards our future risks as well. Even if we’ve been fortunate enough to enjoy good health for most of our lives, we’ll all need medical attention in our latter years. On a few occasions this year I’ve spoken publicly about the incidence of disease and disability in old age, some of the uncomfortable statistics are as follows:

1 in 3 of you will spend your last years with some form of dementia

1 in 4 of you will experience mental health problems and 1 in 4 of you with 2 or more chronic diseases will also be depressed

1 in 10 of you will have cancer once you’re over the age of 60

Almost 1 in 4 men and 1 in 6 women over the age of 75 will have some form of heart disease.

About 1 in 7 men and 1 in 9 women over the age of 75 will have diabetes. If you are from a SE Asian background the chance will be up to 6 times higher.

1 in 5 men and 1 in 6 women will have some form of painful arthritis

Almost one in four men and one in five women aged 45 can expect to have a stroke if they live to 85.

Not only will you be diseased up to the earlobes you’ll also be drugged up to the eyeballs:

On average people over 60 received more than 42 prescription items in 2007. In 1997 they received on average only 21.

1 in 16 hospital admissions are due to adverse drug reactions and 2% of people admitted die as a result of these reactions

If any readers want to try reading these statistics out to their friends I expect you’ll have the same response that I had: people beg you to spare them the depressing details or they stick their fingers in their ears. When I debated with Civitas (the think-tank dedicated to seeking intellectual justification for the conversion of the NHS from a public service to a free market) one of the audience members said that GPs are no longer necessary because you can just put your symptoms into Google to get a diagnosis and then choose your specialist for treatment. What he means of course, is not that ‘people’ will have no need of a GP, but that he will not need a GP. His response is a real world example of what philosopher Slavoj Zizek describes as ‘a drive not to know’,

Another lesson of psychoanalysis is that, contrary to the notion that curiosity is innate, that there is deep inside each one of us a Wissenstrieb, a ‘drive to know’, there is, in fact, the opposite. Every advance in knowledge has to be earned by a painful struggle against our spontaneous propensity for ignorance. If there’s a history of Huntington’s chorea in my family, should I take the test which will tell me whether or not (and when) I will inexorably get it? If I can’t bear the prospect of knowing when I will die, the (not very realistic) solution may appear to be to authorise another person or institution whom I trust completely to test me and not tell me the result, but, if the result is positive, to kill me unexpectedly and painlessly in my sleep just before the disease’s onset. The problem with this solution is that I know that the Other knows the answer, and this ruins everything, exposing me to gnawing suspicion. Slavoj Zizek Bring me my Philips Mental Jacket

For David Bell, this ‘gnawing suspicion’ can be revealed in his patients who present with conditions such as schizophrenia and narcissistic disorders and also at the societal level where,

this projective system has a drive of its own: as it gathers momentum it acquires contempt, providing the psychological soil for destructive social processes such as racism or homophobia to germinate.

In a remarkably foresighted paper he wrote in 1999 in the journal of Psychoanalytic Psyochotherapy, titled Primative State of Mind, he explains the social implications:

But, Reich argued, [in his book The Mass Psychology of Fascism], fascism also reflects man’s deep aspirations and it cannot be fully understood without appreciation of the fascist mentality and its deep
roots in the unconscious. Reich explored how, through identification with a tyrannical (Nazi) figure, masses of the oppressed population were supported in their wish to project their own hated vulnerability elsewhere. The Nazi propaganda machine provided objects for this projection, namely Jews, gypsies, homosexuals and blacks. It is thus their own hated vulnerability and helplessness which they then sought to annihilate through extermination of these people. This is, of course, not meant to be a total explanation of fascism, but if it is not included in the broader social and political understanding of fascism, something essential is lost.

Like the ancient Greeks we have made a virtue of health and ability and infused them with moral status, so that when we ourselves are ill, disabled or vulnerable whether due to cancer, poverty or loneliness, our natural inclination is to ask, “why me? what did I do to deserve this? I never thought it would happen to me!” We project this perceived moral weakness on others in order to make ourselves feel better. I’ve explored this idea in a previous post: Is Socialised Medicine Evil? which discusses various right wing trends that link wealth and health with moral good, “We deserve to be wealthy and healthy because we are good, they deserve to suffer because they are bad.” Bell predicts our present state of affairs,

The cuts express an ideological assault on the concept of welfare – originating with Margaret Thatcher and now escalating violently. This ideological position can be characterised as follows: the welfare state does not provide people with the basic necessities of life as part of a duty of state but instead is a mechanism by which people are disempowered, creating in them a helpless state of invalidism. The “have-nots”, instead of “getting on their bikes” and competing in the marketplace, stay at home and whinge for the nanny state to do something for them. Namely, to have one’s basic needs met is to be treated as if suffering from a state of infantile dependence and to be dominated by a delusion of an inexhaustible supply of provision.

In this kind of thinking, or more properly non-thinking, the world collapses into simple binary categories – “us and them” – and all complexity is lost.

Those on welfare become just “scroungers”. Worst of all, many who are legitimately entitled to benefit identify with this propaganda and collapse into despair. The nanny state slogan expresses this perverse logic and hatred of vulnerability.

The propaganda is most effective when it is internalised, sentiments echoed by the Archbishop of Canterbury last month, talking about government plans to force pople on welfare to do voluntary work,

people who start feeling vulnerable feel even more vulnerable as time goes on, that’s the kind of unfairness that I feel. People often are in this starting place, not because they’re wicked or stupid or lazy, but because circumstances have been against them, they’ve failed to break through into something and to drive that spiral deeper, as I say, does seem a great problem.

I see this in my patients every day, they really are driven to despair, believing that others see and treat them as a burden on society, they internalise this as guilt and shame which leads to misery and anxiety and in the worse cases, suicide. Returning to the BBC survey of attitudes to disablity,

People in lower income groups were found to be less compassionate on the issue of disability than skilled people, with older people sometimes more intolerant than the young.

The shocking conclusion is that the ideological assault on the welfare state, including the NHS is made likely to succeed because in doing away with the institutions designed to protect us when we are most vulnerable we are both denying and symbolically doing away with our own vulnerablity.

What’s needed is a renewed compassion for others and ourselves.

See also

Today’s Britain: where the poor are forced to steal or beg from food banks. Guardian 27/10/2014

Language is a weapon used to make ‘others’ of people in poverty. Joseph Rowntree Foundation. April 2013

The ‘scounger’ myth is causing real suffering to many in society. LSE blog. April 2013

Owen Jones, Independent 13.12.2011:

We don’t even really talk about the unemployed anymore; they’re more likely to be “people on benefits” defining them not by lack of work, but by reliance on taxpayers’ money.

John Harris, Guardian 01.04.2013 :

We have to talk about why some people agree with benefit cuts

Truth and Lies about Poverty. Pocket Guide

Scroungers, Scumbags and Soaring Welfare Costs: excellent analysis about where the money is going by FlipchartFairytales

Benefits in Britain. Separating the Facts from the Fiction. Guardian

17 responses to “Who is the NHS for? Not me!

  1. I came across your blog rather unexpectedly and I really respect this post. As someone in my early 30’s with a Mental Health Problem, namely ‘Borderline Personality Disorder’ I use to often think of myself as a burden on society especially when I first had to give up work. However just over three years on I still claim benefits but have studied part time and also work in a voluntary organisation that looks after the welfare of patients with Mental Health Issues so I no longer feel like a burden or someone who is incapable of working because they are ill. Actually today I submitted my first job application in three years, fingers crossed I am successful!

  2. found it! hello!
    What a relief to find a rationale that pulls the rug out from under the social Darwinists. Has triggered more thoughts and questions than I can try to cram in here… …
    Troubled though by the difficultly in unravelling motivation from outcomes. If we assume for a moment that the vulnerability-deniers are in fact not deluded, but rational utilitarians, doesn’t that leave the boundlessly compassionate quickly out of cash?
    Got any recommendations for some reading matter that would help quash that idea?

    • Hi,
      You could look at the other related posts, Is socialised healthcare evil? and What is the point of the NHS? Which give some background to my thinking.
      David Bell’s original article said that narcissistic patients in particular were vulnerability deniers. Narcissism is a trait I suspect is over-represented in politicians, right wing ones in particular.
      If one rejects the hypothesis, you still have to make a case for what to do for those who cannot cope. Tony Judt gives a good defence of the argument that it is more effective and efficient to extend services such as health to all without trying to determine who is most vulnerable. Additionally the social solidarity aspect is of great value. Tudor Hart argues that healthcare has to be distributed to the most vulnerable and markets do the opposite. Does this help?

  3. polyglot who can't spell

    Thanks, yes, like that post, also the Midgley article you link to v interesting.
    Not suggesting it is so, re possible utilitarians (no one wants to be a narcissistic denier!), rather hoping that everyone’s motivation might be good – and worrying that perhaps even those with best motivations can cause harm. Will take a look at Tony Judt and Tudor Hart.
    Don’t know if you ever watch TV(!) but the socialised healthcare post made me think again about BBC4 Art of Germany series – Graham-Dixon talked about the overwhelmingly bleak spiritual outcomes of the rise of individualism as a result of Protestantism in Germany: how, during the Romantic movement, as religious inspiration was sought in nature, individuals struggled to redefine their relationship with God – and in doing so their goals, role and purpose in life – daily, over and again, with no givens, only the brutality of nature as their guide. Romantics were facing a raging sea of fear; specifically, G-D was talking about Caspar David Friedrich, who painted this:
    http://en.wikipedia.org/wiki/The_Monk_by_the_Sea

  4. A splendid read. Thanks for taking the time to write what I have known but not put into communication. Question: I wonder if it would be ok to link to this aricle please? I ask because my website is somewhat controversial. Naturally I would put in a small para along the lines of ‘abbetternhs is completely independent of our website, we have linked to the blog because we very much like reading what abetternhs writes. There is much sense common and uncommon in the insights given’.

  5. Here is my page on which I have linked to this article: http://www.nhsjusticegroup.co.uk/nhsculture.html – I hope that I have not been too fulsome for you 🙂

  6. This is an excellent analysis, however I think it needs more input about the disabling ‘prime of life’ conditions which are more pertinent to the welfare/benefits and nazi-loaded ‘scrounger’ argument, rather than the post 65 conditions which are highlighted at the top of the piece. It would be helpful to link up to the planned changes in the management of long term conditions in the Health & Social Care Bill which simply lumps a myriad of complex conditions together in non specific fashion rather than emphasising nuances of both patient need and medical skill. This is clearly going to undermine even more the chances of specialist treatments being perpetuated – or introduced. Fudge is the new ‘solution’. For excellent illustration of the impact this will make, I recommend the neurologies debate in the Lords last Thursday introduced by Lord Alf Dubs.http://bit.ly/sqHz2O Indeed, their Lordships also make clear that with these conditions the UK is already sadly lagging far behind European counterparts, so heaven knows what the future will bring for sufferers of these conditions in the future if the bi-partite legislation of health and welfare culling goes through.

    For those of you who doubt the worth of the Lords, their detailed and informative debates on these matters perhaps tell us otherwise..as Lord Dubs said to me ‘watch this space’.

  7. Excellent article, I do not know what drives the ideological hatred of the useless eaters, but I am appalle at the hate crime the scrounger campaign has generated in the gutter press , fed by lies by the government, the sleeping giant will not accept this anymore, yes people with disabilities should be given the chance to work but the obstacles are huge,they do not understand nor care about the differences between illhealth and disability.

  8. Wonderful blog – I know about how people do not want to see that they too or their children might one day become ill and disabled. Over the years we saw people walking away from us as Dani became more ill, more things happened to her, one crisis after another. Even her partner turned round and told her she was a shirker, at the time she was recovering from open heart surgery after undiagnosed heart infection while on dialysis, . Even some of the nurses thought that she should be working – who was going to employ some one in pain, at the hospital three times a week (the total time out of the house each session was about 6 hours) and who was on large doses of opiate pain relieve. Dani wanted to work, she was not able to. She was trying to do little things like learn to make jewellery. Shy so many people thought that renal failure, transplantation, followed by cancer, followed by the inevitable osteoporosis etc and then the destruction of her heart were catching still amazes me. Sadly Dani died last year.

    • Dear Helga i am so sorry, Dani was treated terribly, the comments appalling. i have comments from my own family and know it hurts. I send condolences from the bottom of my heart and wish you and all Dani`s family the peace you need . God Bless

    • Helga Warzecha | September 8, 2012 at 8:04 am | Reply

      Wonderful blog – I know about how people do not want to see that they too or their children might one day become ill and disabled. Over the years we saw people walking away from us as Dani became more ill, more things happened to her, one crisis after another. Even her partner turned round and told her she was a shirker, at the time she was recovering from open heart surgery after undiagnosed heart infection while on dialysis, . Even some of the nurses thought that she should be working – who was going to employ some one in pain, at the hospital three times a week (the total time out of the house each session was about 6 hours) and who was on large doses of opiate pain relieve. Dani wanted to work, she was not able to. She was trying to do little things like learn to make jewellery. Shy so many people thought that renal failure, transplantation, followed by cancer, followed by the inevitable osteoporosis etc and then the destruction of her heart were catching still amazes me. Sadly Dani died last year.

      Leave a Reply Cancel reply

      Enter your comment here…

      Fill in your details below or click an icon to log in:

      Website

      Notify me of follow-up comments via email.

      kate thomson | September 10, 2012 at 2:54 pm | Reply

      Dear Helga i am so sorry, Dani was treated terribly, the comments appalling. i have comments from my own family and know it hurts. I send condolences from the bottom of my heart and wish you and all Dani`s family the peace you need . God Bless

  9. simply thank you . i wish for a GP with this level of compassion and empathy.

  10. brianbuchbinder

    I know this is not news, but responses to NHS/welfare seem to be driven by divergent personality types. Most people don’t like feeling cheated, and most people want to help others in need. Both helping and cheating are effects of public welfare. My conservative friends emphasize the former, my liberal ones, the latter.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s