Plastic Words

I was reminded recently of the work of Uwe Poerksen the Professor of Language and Literature from Freiburg University. His book, “Plastic Words: The Tyranny of A Modular Language” is now out of print but, in a time when words are the very stuff of political and cultural battles, it seems overdue for a re-release. He wrote about words which are taken from the everyday vocabulary then transformed to become something quite different – words which become almost completely abstract and universal. These are words such as sexuality, development, resources, communication, and the like. They spread quickly and tend to replace their original sources. These vague, plastic, words are very valuable to those wishing to use language to cement their authority in an area and to alter how topics are discussed.

These are words that develop a lot of connotative power; that is they connote a great deal, they evoke emotions and feelings, but they have little power to denote; that is they do not really define or describe things. Their abstract nature makes them difficult, or impossible, to pin down. They are in essence there to set the emotional tone not to explain or inform. There was often a game played the hospital where I worked where we would take a selection of these words (Communication, Education, System. Resources) and show that we could use them in any order in any sentence without any change to the meaning of a sentence (“Communication resources are the basis of the education system”, “Systems of education require communication resources”, “The system resources are a basis for communication and education”, etc. etc). This game, along with management buzz word bingo, were favourite ways to pass the time in the interminable management meetings that were the fate of elderly clinicians.

These words are like “lego” to build a language which the speaker, or writer, feels shows their prowess and mastery of a topic whilst at the same time obscuring the actual facts of the matter. These plastic words tend to allow failings, or malevolent intentions, to be hidden – “divesting the system of excess resources” is much less upsetting than sacking workers and I think “enhanced interrogation” is felt to be a lot less unpleasant that torture. “Communication” is a much less precise word that the myriad of words that it tends to replace – talk, read, wrote, debate, listened, argued, published, shouted, entreated, pleaded, telephoned, email, and so on and on.

In my line of work, this misuse of language caused many problems and, as far as I can see, still does today. In particular, the use of words such as “depression” and “anxiety” as catchall words for emotional states created many difficulties. This was particularly so, given that these identical words were used as sloppy, vague descriptors of mental states as well as diagnostic categories. When you described someone as depressed or anxious you had already taken the first step in diagnosis and were a step closer to staring treatment.

I found that trainee doctors quickly lost their vocabulary skills on their psychiatric placement. All the words they knew to describe emotional experiences suddenly shrunk to a handful – depression, anxiety, apathy, and elated. They forgot about sadness, unhappiness, disappointment, grief, loss, pain, disgruntlement, sorrowful, dejected, downcast, broken hearted and so on. Everyone became simply “depressed”. This had major ramifications for medical practice. Consider the following hypothetical referrals :-

• A 36 year old lady wth anxiety and depression
• A 55 year old man with anxiety and depression
• A 70 year old woman with anxiety and depression.

These referral might refer to :-

A 36-year-old married woman who fears for her safety due to her abusive husband and is “sad” that her children witness the violence in the home. She spends nights in terror when he is in his rages and feels hopeless of finding a way out.

This 55-year-old man feels thwarted in his career progression and now has worries that he will be overlooks for promotions. He feels angry that others less talented than himself have been promoted above him and at times feels full of rage that life has turned out like this.

This 70year old elderly woman feels guilty that she is a failure in life. She falsely believes that she is a paedophile and is sure that she should be punished for her former sins. She us upset that the police ignore her statements and fob her off, she regrets the shame she has brought on her family and is so despairing that the only solution she sees is to end her life.

There is a tendency for all of these three scenarios to be described as a depressed-anxious patient but apart from this sloppy description this is all they have in common. Importantly, only one is likely to be mentally ill and in need of medical treatment, the other two may be more likely to benefit from the help of social services or the support of friends or colleagues. Unfortunately, in current times, all are likely to be considered candidates for medicinal treatment. In the case where it is indicated it will hopefully help but in the other two cases this approach is likely to worsen the situation. If you were previously the aggrieved wife, or disgruntled employee, then now you are also the patient taking medication. This makes you, and your concerns, easier to dismiss and ignore and has thus, by reducing your status, worsened your lot.

I used to joke that it would be impossible to see a psychiatrist twice without being given a prescription for an antidepressant, I am no longer sure that this isn’t true. When the doctor takes the step of thinking of the patient in terms of depression-anxiety they start to worry. There is a lot that they might lose if indeed the patient is unwell and they missed that fact. They could be blamed for the failure to recognise an ill individual and start appropriate treatment. In some regards it is an easier strategy for the doctor just to class all patients as unwell, certainly no chance of missing cases. However, if the patient was not ill then it is they that carry the negative consequences for this over diagnosis. The problems of overprescribing of medications, such as antidepressants or anxiolytics, is not a theoretical concern but a real risk for the patients unwittingly taking these medications.

These plastic words in psychiatry have allowed the edges of mental illness to be made invisible and the range of people who might be considered as needing treatment expanded (to almost everyone). Even the word “health” has been taken and fused into “mental health”. We no longer talk of illnesses and diseases but problems with our health. The stigma of mental illness has caused us to hide even the word itself. We don’t have departments of Physical Health, and nobody would be too impressed to receive a diagnosis of ‘physical health problem’ and the advice to take this generic tonic. But we seem content with ‘mental health services’ and ‘mental health problems’. This strategy is very effective in broadening the base of people who can become consumers of psychotropic medication or mental health services (without any proof that it helps them) and presumably this is why it is popular with treatment providers and manufacturers.

It is bad news for those who have social or personal problems that might be helped by non-medical interventions as these will probably not be forthcoming (The money having been spent of new expanded mental health services). It is also unwelcome news for the mentally ill as their needs, often complex and serious, often do not fit well in services designed for simpler problems. The stigma around mental illness, and our increasing ignoring of these conditions, mean that when their needs are not met and they suffer, society pays them little heed. After the annual tragedy, when another seriously ill patient dies through the consequences of their illness, or by their own hand, a statement will be written making it clear that “The resources of our mental health services are continually developing and improving, with better communication, education and outreach, to meet the needs of our diverse service users” – so no need to worry then! – although are you perhaps a bit anxious?

The Fix by Damian Thompson

I came across this book in a rather circuitous manner. I had accidentally downloaded a religious podcast from The Spectator magazine’s website and had this as my accompaniment to my morning walk. It was a surprisingly interesting look at the actions of the church in the midst of the coronavirus lockdown and painted a very pessimistic view of its future. I looked up the podcaster and found it was Damian Thompson and, having found his podcast interesting, decided to risk purchasing one of his books. This is how I ended up reading about the growing problems of addictions in our society.

This is a easily readable book which details the alarming rise in addictive behaviours of which we are all aware. There are many statistics here, many of which are quite frightening. It is not limited to the growth in recreational drug abuse but also details the rise in prescription drug abuse, the effect of sugar addition, alcoholism, computer gaming and addiction to pornography. The adverse effects of these problems are also described and enumerated. The numbers are made to come to life with anecdotes and real-life stories. This includes his own experience when he had major problems with alcohol and drug abuse and dependency.

As I read the book the scale of the problem we have became clear to me and also the amount of change that our society and culture has witnessed in a short space of time. Perhaps most arresting are the changes that have occurred in our eating and sexual habits. For many generations these have quite removed from their basic biological and natural functions and now function predominately in a cultural sense and are much more malleable. Unfortunately, there are those who will use this malleability against our better interests and who will promote consumption and behaviour which is damaging to us, both as individuals and as a society. There is interesting speculation that as individuals and as a society we are getting more satisfaction from objects and things than from people and relationships, and that our psychological attitude to things fuels this problem.

Thus far, this book is much like any other on the subject but he there is something rather different. He challenges the currently dominant disease model of addiction. Although there are many interesting biological differences which have been seen in those with addiction problems there is no evidence which supports the idea of a simple biological basis to addiction itself. We all have the same neural systems which could lead us to the same problems if the circumstances are right. We all have the same “desire” and “like” circuits in our brains. Recognising this helps explain the primary importance of the factor of “availability” in the genesis of addiction. Availability is not simply a matter of supply and price, though these are important, social and cultural attitudes (approval, tacit or explicit) also play their role in whether something is available.

However, perhaps most importantly, the disease model has the risk or removing something that all addicts, and all addiction specialists, know to be the most important factor in breaking addictive behaviours; namely free will. There is a danger that the disease model portrays the addict as a hopeless victim at the mercy of their neurochemistry. No one will argue that there not serious problems with some compounds and the physical effects of their withdrawal which drive some people to continue their use in the face of great and increasing harm. However, an important factor in whether one starts to use something, continues to use, and most importantly manages to stop using is act of will. We need to bolster this rather than undermine it – we need to counter feelings of helplessness not engender them.

Although the book is rather old now (2012), much of what he has written has proven to be prescient rather than alarmist. It is now an even more important issue than before. At a societal level the war on drugs is destroying our communities, at the individual level our levels of obesity and diabetes are responsible for the untimely deaths of many, and in the area of relationships there is developing evidence of the damage being done by pornography on our sex lives. The effects of our addictions may, soon, “become a higher priority for the developing world than its ancient enemies, poverty and disease.“

‘The Great Pretender’ by Susanah Cahalan

Anyone who has an interest in mental illness, how it is diagnosed and treated, and especially an interest in society’s attitude to psychiatric practice will enjoy this book. It concerns the study published in Science in 1973 called “On being sane in insane places” by David Rosenhan, then professor of Psychology and Law at Stanford University. In summary this study purported to report on the fates of eight pseudo-patients who presented to psychiatric hospital. They reported hearing auditory hallucinations of a word such as “Thud” or a phrase such as “its hollow inside“. After this report, they behaved entirely normally without feigning any symptoms or exhibiting any unusual behaviour. The study reported that they were all admitted and diagnosed as mentally unwell (usually as having schizophrenia) and during weeks of admission given treatment for these conditions. The study suggested that psychiatrists could not distinguish between the sane and the insane, between health and mental illness.

This study shook psychiatry and mental health services to their core. At the time, following the work of the likes of Thomas Szasz (‘The Myth of Mental Illness’) and Erving Goffman (‘Asylums’), this seemed to give support and credence to the anti-psychiatry movement and provoked widespread, comprehensive and much needed change into the provision of in-patient psychiatric services. It was probably one of the prime drivers for the development of the DSM-III system of diagnosis which, at the time, helped address some of the major failings of psychiatric diagnosis.

I recall when I was a lecturer in psychological medicine referring to this study when lecturing to medical undergraduates, or psychiatric postgraduates, to try and inculcate a sense of shame that the profession was able to perform so poorly and fail our patients so badly.As a simple study with a blindingly obvious outcome it was very valuable.

However, it seems I may have been wrong. Without giving too much away this book looks into the study and checks the veracity of the reports. The author had a personal experience of psychiatric mis-diagnosis when she fell ill with autoimmune encephalitis and presented with psychotic symptoms. This kindled, in her, an interest in diagnostic accuracy and the interface between mental and physical illness and prompted her to look at this landmark study. Early in her research she noted significant defects in the study which she then started to explore. As the author follows clues, leading to the uncovering major flaws in the study, this book reads as easily as detective fiction. Although I suppose I should really class it as a true crime drama.

There is clear evidence that the ‘facts’ as reported are not the fact as they occurred. It is clear that some pseudo-patients actively feigned mental illness and threatened self-harm to capture the psychiatrists’ attention. The reports were also selectively reported so that positive or helpful experiences of psychiatric care were deliberately omitted from the published report. There is some, equivocal, evidence that Rosenhan was actively fraudulent in creating stories out of thin air to support his theories.

It is sad when our heroes turn out to have feet of clay. We feel duped when we discover the facts that were presented to us, and which we acted on, were misleading. However, many of the changes that followed this study were needed and one could argue that a “good lie” was more effective than many dry studies in forcing a change in the psychiatric services. I still hope that when people read the study they will think “how can we avoid problems like that ?“. However, a ‘good lie’ may prompt change but it is not a useful compass for what direction that change should take. We will all be glad to see that some of the bad practices are gone but this study did not help us see the positive aspects of “asylum” nor how we can preserve these. It lead us to throw the baby out with the bath water.

It is true that there are many less in-patient beds for patients with mental illness and that hospitals no longer degrade patients as they did. However, we now have many more psychiatric patients in prisons, nursing homes and general medical wards. Often the care here is poorer than that of the old institutions and I fear that the many mentally ill patients trapped in prisons are experiencing degrading and unpleasant treatment the equal of that in a seventies mental health hospital. In some senses we have just changed the nurse into a prison warder and the locked ward into a prison cell – the place and person may have changed but the crime hasn’t.

To improve the treatment of the mentally ill we need not only to understand mental illness better but also to understand better our own attitudes towards it. Although I will miss using this study in a ‘fire and brimstone’ talk about diagnostic accuracy I would (were I still teaching) have to be very cautious referring to it now. When we think we understand, but don’t, we are at the greatest risk of making mistakes. As this book reveals, even with good intentions, a prejudiced and dishonest look at the facts helps no-one in the long run.

Drug Deaths in Scotland

Deaths due to drug abuse in Scotland have hit an all-time high. In 2018 1,187 people died in Scotland as a consequence of drug abuse a rise of 27% on the already frightening figures of 2017. This places Scotland in a class of its own in Europe with a level of drug-related deaths twice that of the next nearest country (Estonia). It would be difficult to underplay the size of the problem. The drug-related death rate in Scotland is now three times the size of that in the U.K. as a whole and last year more people died in Scotland from drug misuse than from the direct effects of alcohol!

The figures did unnerve me but unfortunately they did not come as a surprise. In the decade before I moved to Wales, I worked as a consultant psychiatrist in a deprived area of Scotland and had witnessed first hand the growing problem. More importantly, I had also seen the developing drug strategy which was being pursued. This policy seemed doomed to failure and almost guaranteed to increase the amount of death and injury due to recreational drug use.

The main reason for this was that the strategy in Scotland had only one string to its bow and that string was Harm Reduction. This took a number of forms including needle exchanges, methadone prescribing, safe spaces and the like. While harm reduction can be valuable it is not enough on its own unless you can reduce the harm to negligible levels (which is not going to be the case with something like drug use). The simple logic is that if you reduce the rate of harm to half of what is was before then this will look impressive, but if at the same time you triple the number of people taking the risk then you will have increased, not reduced, the total amount of harm done. The evidence is that Scotland has many, many more people abusing drugs than previously and thus as a consequence many more deaths. It is important to note that about half of these deaths involve methadone which is the prescribed opiate which was intended to reduce the harm.

More people taking these drugs leads to more deaths and a false sense of security by harm reduction strategies may compound the problem. The need is to reduce the harm, but more importantly, to reduce the usage of drugs. It is unlikely that laws against usage will make any great headway, there is little evidence that laws deter people from drug use. Indeed, there is a little evidence that illegality enhances the cachet of drugs in some groups and promotes their use. This cachet is further enhanced by our culture’s tendency to glamourize drug use; watch any late evening chat show or read any interview with a modern media star and see the use of drugs being used as a badge to garner respect. In the recent race to become the Tory party leader, and hence Prime Minister of the UK, had the unedifying spectacle of all the candidates competitively ‘confessing‘ their drug misuse in an attempt to win the youth vote.

In addition to this cultural acceptance of drug use there is the further problem that, now, drug misuse is an access route into welfare benefits. In a country, such as Scotland, with high levels of unemployment and poverty there will be some pressures to look at the problem of addictions differently – when being on the sick role as an addict could mean being prescribed opiates (methadone) by the state and receiving money in the form of Personal Independence Payments. (Addictions UK for example have a service to help secure payments when you have an addiction). The biggest problem facing those with addiction problems is securing autonomy and independence again, compounding a drug dependency with a welfare dependency will simply amplify the problem.

In an ideal society people would be free to decide on their use of drugs but also responsible for the consequences of taking them. There is little to suggest that the state will be able to make this aspect of our behaviour disappear but there is good reason to think that it has the capacity to make problems worse. Prescribed opiates are now killing as many people as illicit ones, and we have developed a large industry which lives on the backs of those trapped in cycles of dependency. The last decades have seen Scotland move to a much more authoritarian and controlling nation state. This change has important social and cultural effects and these figures showing a dreadful loss of life, and hinting at even worse disability and hurt, should act as a wake up call to the risks involved.

Resource

Drug-related Deaths in Scotland 2018. National Records of Scotland Download

Closeup of young girl in heroine overdose holding syringe and lying on pavement. Copy space

The shame of Britain’s jewel.

The Learning Disability Mortality Review was published this week and it has largely gone unnoticed in the press and news. While we flaunt the successes of our health service, and describe it as the “the envy of the world“, we have ignored the fact that there is a serious problem with how the NHS treats one of the most vulnerable groups in our society. The report looked at those with learning Disability dying in NHS care and found that in about one in eight of those deaths neglect, abuse or incompetence had “adversely affected” the care that the individual had received.

The report makes harrowing and upsetting reading. It is clear that this group of people are being sold short by our health service, that they are often felt to have lives not worth saving. There are reports of staff failing to recognise the worth of the individual and thus they are discriminated against. This utilitarian view of life is very dangerous and particularly dangerous, in a system such as the NHS, where the client is not the patient but the state itself. The state will have the tendency to value some lives are more productive than others, more valuable than others, and thus worthy of more attention. This group of people find themselves at the bottom of the pile when priorities are being drawn up. When the calculus of how much someone is worth is reckoned their values – the pleasure they bring to their families, the love they express, the friendships they make – don’t weight well in the scales and they loose out.

Staff recognise this and start to behave accordingly; they care less for the patients and come to view them as obstacles in the path to giving better care to more deserving patients, and, in extreme cases, unworthy of using the resources which could be better used by someone more valuable. All of this has echoes of the film “Dasein Ohne Leben ” (“Existence without Life”), the 1942 Nazi propaganda film which was intended to soften the public’s opposition to the euthanasia, or murder, of the physically and mentally handicapped.

Although this group of people almost certainly suffer the most from this neglect they are unfortunately not alone. When I was working I was repeatedly shocked by the contempt that medical and nursing staff could express for patients with dementia seeing them as nothing more than “bed blockers” who were misusing scarce resources. Recent scandals about breast screening errors again show that ageism is still prevalent. Older women have higher risks of breast cancer but screening is avoided because it is “not worth it” in this group. Were the NHS an insurance system, as it was initially intended, then people who had been in the scheme longer, and contributed more, would expect better dividends not a scheme which rewards their involvement by reducing their entitlements.

But advanced age is not necessary to be a victim of this type of calculation. The high profile cases of severely disabled children being removed from their parent’s control causes further concern. In these awful cases, the parents asked for nothing extra from the NHS other than to get out of the way and to let them try what they could for their babies. Their hopes for their offspring were almost certainly futile but it may have helped the parents to know that they had done all that was humanly possible for their sons. But the system felt is was important, having assessed the importance of these infants lives, to stop the parents and other systems doing what the might lest they squandered resources.

When systems become too large they often become inhumane. When the patient and their family is not the focus then the system operates on economic principles of value for money. It stops being an insurance scheme to protect us form the high costs of health care, by aggregating risks, and becomes a system to ration care. In a rationing system the vulnerable groups of the disabled and elderly always loose out particularly in times of scarcity. As the NHS becomes increasingly unable to meet the demands put upon it it will start to ration ever more strictly. Then it matters not a fig, whether you paid your taxes diligently, or worked productively, or are a valued member of your family and community, if you are deemed too expensive and too unproductive then your services are going to be poor. You will get the minimum that can be offered if a callous system allow even that to happen.

Our sons and daughters, and brothers and sisters, with learning disabilities are not lesser people than us. They have every right to care and we should feel ashamed that a system what we hoped would provide universal healthcare  is failing to do so for the weakest and most vulnerable of our fellow citizens.

 

Getting out while I still could.

I recall that about half-way through my medical career I had a premonition of the problems with patient dissatisfaction  that we are now see. It was therefore with dismay, but no real surprise, that I read the results of the British Social Attitudes Survey on patient satisfaction with the NHS and social care. This has shown that growing dissatisfaction continues; now only 57% of people were satisfied with their healthcare while nearly a third (29%) were dissatisfied. These were significant changes, and deterioration, from previous reports and there was a particular drop in satisfaction with General Practice services. Primary Care had previously been the jewel in the crown of the NHS but now was viewed little better than other areas of the NHS. Some areas barely managed a majority of the population feeling satisfied (A&E for example at 52%) and these are generally worrisome figures.

These rates of satisfaction should alarm us. We often hold up the NHS as the “envy of the world” despite its relatively lacklustre outcome measures. We are now watching it slip to the bottom of league tables, of developed European countries, in public satisfaction as well as in performance. Why is this ? It does not seem that it is due to sudden increases in public satisfaction with other European services (though they have generally modestly improved their scores on this matter). It is because of an increase in dissatisfaction with the NHS’s provision and people cite unhappiness with inadequate staffing, delays in being seen, and poor quality of care. They tend to view this as a consequence of inadequate funding and government interference.

These two factors will, without any doubt, foster and magnify dissatisfaction but I am unsure that these factors are as important as they might initially seem. European healthcare funding has been squeezed in all countries but other countries have not witnessed the deteriorations in satisfaction we have observed, indeed, some have even seen slight ongoing increases. It is difficult to quantify government interference but it is a safe bet that this has not been absent in any of our comparator countries. But could there be another factor underpinning this dissatisfaction ? I thought I felt the start of this change many years ago, and this premonition, lead me to leave the practice of medicine earlier than I might otherwise have done.

When I finished University and started working as a practicing doctor I was full of enthusiasm and keen to learn and use new skills. I saw myself as a medical technician; the better I could be at various techniques then the better my patients would fare and the more satisfied I would feel. This was a useful approach, it spurred my education and learning. When a young doctor I had little time for the “professional” hokum that my seniors espoused. It seemed to me to be a way of holding onto power in the face of technological change and advancement they seemed to be using calls to “professional standards” as ways to obstruct needed change. I was certain that I would never become an old reactionary like them.

But time progressed and I learnt my craft and I started to realise that technological skill was only one aspect of healthcare. There was also a large number of other skills that were necessary, political ability for example, to effect change. I also learnt through my successes and, more importantly, failures that there was an art to the practice of medicine which was as important as my knowledge or technical ability. I know that the times that I failed patients it was rarely through ignorance or ineptitude but rather because of a failure to relate to the patient equally and fairly. I recognised that when I failed; it was the times I rushed, did the job but little extra, and paid inadequate heed to the opinions of the patient or their wishes. I started to recognise that I needed more in order to be a decent doctor and began to discover the importance of professionalism.

I grew to learn that professionalism was an asset for both me and the patients I worked with. The NHS was changing around me, a culture of target setting and central planning was reducing the autonomy of clinicians and reducing the choice for patients. It is often said that patients have difficulty in making healthcare decisions due to the knowledge deficit and that they are almost wholly reliant on their medical attendants in order to make these decisions. This is not the case. I grew to be very aware that one skill that patients have is the ability to distinguish between good and bad doctors. They are much better at it than fellow professionals, they know who is good at the job and who is not. But unfortunately they do not get to make that most basic choice – the choice of whom to see, whose advice to seek and with whom they will work to improve their health. In the NHS these decisions are removed; you see the GP that covers your area and the specialist contracted for your area, the patient has little or no say in the matter. If they are lucky they will be paired with the best, on average they will receive average care, and if they are unlucky they may be stuck with the underperforming. You could be referred to the best doctor for people with Parkinsons  disease but if your problem is diabetes then this might be less than wonderful. Patients would rarely make this kind of mistake, systems often do.

This lack of patient choice was worsened by another aspect. The patient didn’t chose the doctor and the doctor increasingly didn’t feel that they worked for them as an individual. The central planning and target setting meant clinicians felt that their employer was the NHS, in its various bodies, not the patient per se. Targets were set at Health Board meetings not by patient-doctor discussion. Many times targets could be thought of as useful but a target which pays doctors to increase the number of people on statins might mean that the elderly man who went to see his GP because of loneliness and poor mobility might find himself on the bus back home with a prescription for a statin he had never thought he wanted. It may be beneficial for him, and it might reduce the cardiovascular morbidity of the group, but that had not been his issue and it is possible that the time taken to discuss the statin left less time to talk about the poor mobility and their fears about this. Taking a professional approach meant that, while we would try and meet the targets put forward by my employer, my first loyalty was to my patient and we had to address their concerns first, agree a plan of action with them, and only secondly try and mesh this with the central dictats which were aimed at improving the group.

Without this professional approach there was a great danger of starting to practice a little like a veterinarian. When you take your hamster to the vet, the vet assesses the hamster and discusses with you how you would like to proceed. If the vet informs you that you will have to sell your car to pay for the hamster’s surgery, or forgo a holiday, it is quite likely that the hamster’s days are numbered. We will all grieve for the hamster and agree that it was for the best. Increasingly I found that patients came to me for advice, for example with Alzheimer’s Disease, and I would consider whether we should start a cognitive enhancer. But I would not discuss this with the patient, who is now in the role of the hamster, but with the NHS prescribing group who was in the role of the hamster’s owner. They (Hamster owner/ Prescribing Group) often decided that economically it was for the best that we didn’t prescribe and while this was true at a group level (in health economic terms) it may not have been at the individual level.

These are always difficult decisions but they are difficult decisions that should be taken openly, after discussion, with the patient. The patient should be able to trust that the advice they are being given is the best advice for them as an individual not simply the best decision for the community. When patients choose their doctors they are seeking the best source of advice, advice they can trust because it is not skewed to meet a third parties interest.

In the NHS patients lack the ability to choose who they see. Doctors and nurses are  becoming increasingly micromanaged and their professionalism, and thus their independence, undermined. Together this leads to patients unable to work well with their medical attendants and unable to be certain that the advice given is the best available. It sets up distrust and discontent, they see that other European countries, with similar healthcare budgets to ours, do better by patients with common serious medical conditions. Patients read that survival rates for breast cancer in Britain are poorer than elsewhere and that we have more infant deaths than the European average. No matter how many politicians tell them that there are more doctors or nurses, or the NHS is doing more than ever before (which is quite possibly true), will counteract their experience of impersonal healthcare and poor quality outcomes. They will become dissatisfied and this dissatisfaction will continue to grow until the primary problems are addressed.

Until individual patients are again at the centre of how healthcare is delivered it is likely that even if we throw much more money at the system (which will probably be the electoral strategy) this discontent will grow. When we look back, we see the Tredegar Workmen’s Medical Aid Society made a great influence on Aneurin Bevan and influenced the development of the NHS. Unfortunately we seem to forget that the workmen in the Medical Aid Society chose and employed their doctors – they voted on who would be employed and sacked those that were felt inadequate to the job. I am sure this choice greatly enhanced the likelihood of patient satisfaction and is something that we need to rediscover.

Before my career had arrived at its natural end, I had premonitions that dissatisfaction by patients would be inescapable and lead to dissatisfaction in  clinical staff also. I could see the first changes in morale and attitude and felt I had to leave. I hope that I will be proved to be wrong in this prediction, as I have been on many others, but recent news has not given me cause for optimism.

 

 

It’s a big fat lie.

I read today [OECD] that Britain has the highest rates of obesity, and fatness, in Europe and is the 6th most obese country in the world. There is also  the terrifying statistic that the rate of obesity has doubled since the 1990’s and we face the serious prospect of this bankrupting the NHS. Obesity is a major risk factor, as we all know, for diabetes, cancer, hypertension, heart disease, stroke and dementia – this rate of change should alarm us – but it won’t.

For many years, most of my working life, I ignored a growing problem. This problem was the growing size of my belly and my increasing size. By the time I changed my lifestyle 6 years ago I had managed to create quite a respectable problem for myself. My waist was 35 inches, my weight was 14 stones and unfortunately not being a tall man my BMI was 31.6. I was quite clearly obese. This had crept up on me, I knew as I aged I was becoming less fit but I didn’t look that different to many other middle-aged men and nobody passed any adverse comments. As a doctor, I knew I was building up risks for myself but I was able to  minimise these in my head. Nothing bad had happened, I don’t look that unusual, my blood pressure is OK, I still stay active – it really was easy to convince myself that this was no great deal.

Then came the rude awakening. Five years ago I was diagnosed with Type II diabetes mellitus with blood sugars so high I had the full range of symptoms and was started on metformin instantly, at a pretty high dose. I then went through the NHS’s education package. This told me to take my medicines, eat regularly and sensibly, and take a bit of exercise. With this, I was assured, the thing was manageable and I’d be fine. No-one took a blind bit of notice of the large, and obvious, wobbly bundle of fat I had around my middle even though this was the most conspicuous thing of my appearance. (If you want to imagine me then – not recommended – then imagine a potato with four cocktail sticks as limbs, that was me to a “T”). I sat on classes with other similarly shaped people and we all pretended that there was nothing amiss, nothing that eating a stick of celery couldn’t sort out. I went to the gym, where the rhythmical bouncing of my and my new friends’ bellies, while we tried to jog on the treadmills, was almost hypnotic to watch. Through it all no doctor, no nurse, no dietician, no-one said – for goodness sake get rid of that belly ! They were all too polite to mention it.

When I received the diagnosis a cold shiver went down my spine. I’d worked in an area where I’d seen the consequences of diabetes. I’d spoken to men about to have their feet amputated, I’d given rehab advise to folk after their stroke, I’d completed forms confirming that a diabetic man was now blind, and I’d consoled widows after their spouse’s fatal heart attack. I knew my mortality risk was now considerably increased and I knew some of the problems I might face. I also knew, from very cursory information gathering, that my poor diet and obesity were the main factor in this.

I decided to change, I was so scared and shocked, I knew I had to change. I went on a low carb diet and lost 3 stones, I kept on the diet and took regular exercise. I saw my waistline shrink, my belly disappear and my blood return to near normal. After a few months I came off medication and have remained medication free, and with relatively normal bloods, for the past years. A couple of my diabetic pals, who were equally shocked, did the same thing with similarly good results.  But I meet my other pals, who were never troubled by the thought of their weight; still obese, still taking medication and now starting to experience the adverse consequences of this illness.

So I have a personal interest in this report of growing obesity in the UK even though I am a relative neophyte to the world of diets and healthy eating. What are we to do to try and stop this growing trend. It is clear that there are some things we can’t do.

We can’t reduce the availability of food. This is a non-starter, there is no way we can limit what people eat – they must do this themselves. If you don’t sell the double pack of Mars bars I’m smart enough to get around this by buying two packs as is everybody else. Attempt to limit things by smaller packaging could only work if we were happy to accept central rationing of our food, otherwise we just buy more of the smaller packets.

I don’t think that we will get around this by education. I don’t think that there is anyone left that thinks a Big Mac and fries becomes a healthy option because it has a gherkin in it. We all know that a salad is healthier than a bar of chocolate – education is the answer when ignorance is the problem. That is not the issue here.

I doubt we will have much success tackling our increasingly sedentary lifestyles. Anyone suggesting we get rid of the automobile, or suggesting we dig roads by hand or get rid of any other  labour saving machinery, is unlikely to have a successful career in politics. We can suggest that people exercise and find ways to make it easier but, unless we are going to have forced marches then we need to find ways to make people want to do this.

The key in the affluent west is that we need people to want to be normal sized, to fear being obese. This is what we have lost. As I walked around I saw other people the same shape as me, it normalised my obesity. Chairs, cars, everything has been slightly adapted to suit the larger body, each step making it easier to be obese and, more importantly, making it easier to ignore your own obesity. I needed somebody to tell me – “Whoa ! You’ve got far too big there. That doesn’t look right” but even when I had fallen ill people were too afraid to mention it. They were happier to let me die earlier or loose my sight, or foot,  than to be accused of “fat shaming”

We would prefer people to be comfortable in their obesity, than in any way upset – but this is precisely what we do not need.  Discomfort might prompt thought and redirection and improvement to their health and life. I wish someone had spoken honestly to me, when I asked “How do I look ?” I wish they had said “you are getting fat” rather than lied with “Fine”. There is no need to be unpleasant about this we just need to be honest. We also need to be careful about attempts to actively normalise obesity. I noted, when in the supermarket today, this is not as strange and impossible idea as I had thought –  three of the covers of magazines (directed to young women) were using obese models. It may be dangerous to promote anorexic stick insect ideals of beauty but it is equally dangerous to promote obesity as a good choice.

The problem of obesity  has unfortunately got bound up in the gender issues of objectification of womenWe  but obesity doesn’t affect only one gender. All of us are at risk when we treat our health and future in a cavalier way like this. There are many vested interests who would prefer us not to think about it; the food and pharmaceutical industries would be much happier we consumed more of their products and dealt with the consequences. The media and beauty industry can sell us their products either way, fat or thin models, it is of no concern to them simply which model sells more copy.

People are free to live as they wish, they are free to be fat or thin as they choose, but they must choose with adequate knowledge. We should not influence these decisions because of our political biases and we should net let people die early because we were too afraid to tell the truth.

 

Cosmopolitan – This photo series shows that “fat” can be as beautiful as any other body type