Imperfect systems

During the run up to the election, I’ve been focussing on fighting off an existential huff.



The announcement that a Conservative government would employ 10,000 new mental health workers to deal with the crisis in services, and my honest reaction was how are you going to find enough 22 year old psychology interns to deliver all those mindfulness courses?


That something is really failing in public services is a given for those of us who rely on them. What is more painful during an election campaign is the dawning realisation that so is our belief in them.



The election campaigns that genuinely put care in centre place such as #voteNHS developed through the wonderful Health Campaigns Together are a tough gig. Although we may want to show support for public services, when they fail us its hard to maintain our belief in them. If you’re in any doubt about that statement read the cracking new book about the decline of the welfare state by Toynbee and Walker, Dismembered.


Working in healthcare can be really depressing. I mean that in its existential rather than clinical sense. Many of us working in healthcare spend periods feeling hopeless about whether what we do matters.


This is particularly true for those of us who work in health services who need those services ourselves. The therapist who needs therapy, the nurse forced to go to A&E, we’re all staring into the abyss. Every time I try to get compassionate care from my GP I have to write on my hand “For God’s sake don’t tell them you’ve written a book about this” because I can’t afford to annoy my doctor. Materially and emotionally, the more vulnerable our own situation becomes the harder it gets to care compassionately about  the systems we work within.


The decline of the institutions of healthcare has had a major downward effect on our public health. This isn’t just about NHS funding, its about the all the institutions that set the framework for good care, including professional bodies and trade unions.


The sorry state of healthcare professional bodies – although traditionally conservative and split between their various functions as representative and also regulators of professionals – has had an important negative impact on working conditions. In social care for example, the Social Care Association closed in 2012 and 2015 saw the closure of the College of Social Work set up after the case of Baby P. Both of these bodies provided the professional framework for their sectors, and both were closed due to pitifully small deficits in funding. If we had wanted to maintain these bodies we could have, easily.


This structural conflict within the professional bodies is crystal clear if we look at mental health. From the professional bodies negotiating with the DWP on providing IAPT services for the unemployed, to mental health charities such as Mind bidding for government contracts to get people off benefits, conscious or not the therapy industry is becoming complicit in the decline in quality services, forced to choose between their own survival over that of their memberships.


In healthcare its just a skip and a hop between having bad politics and betraying our principles, something that makes it increasingly hard for therapists to support their own professional tribe.


Last year I went to a mental health conference organised by the therapy industry to join a group developing a Wellbeing Charter for people working in psychological therapies. I normally last ten minutes in such environments before the existentials hit, but I took an occupational risk to show some willing over our professional survival.


This meant running the gauntlet of shiny young folk promoting Cognitive Behavioural Therapy Apps and online courses, wellbeing at work industry reps, private contractors delivering the Work Programme and welfare assessments, private employment agencies and clinical psychologists measuring the impact of self-guided resilience manuals. An MP on a podium delivers words, apparently unencumbered by actual facts about his own government’s inability to sign off the Universal Credit and unaware that being on welfare does not mean you are not in work, as 30% of NHS workers can testify.


As the discussions start about how we are going to build support for a Wellbeing Charter I realise that, for some, this is primarily a question of learning how to present the ‘business case’ and learn the creative accounting required to match targets and outputs with actually helping people. As someone who has spent most of their working life in industrial relations my experience is that whatever financial argument you present to protect psychological therapies actually doing it will require genuine political will on both sides. To simply adopt a business school logic creates just a fiction about ‘going forward’ in a context of profound institutional failure.



To actually defend public health services you actually have to believe in them.


To make matters worse I am sitting next to a rep from an online CBT provider talking about how the clinicians they employ value the flexibility of working on a zero hour contract. It appears she has not connected the growth of ‘flexible work’ with the growing number of people working in mental health services do not want to get out of bed in the morning because of the culture of fear they are forced to work in. Or the growth of online therapy because it offers an escape route for both patient and clinician from ever being in contact with other troublesome human beings ever again. And if you’re in doubt about that dismal statement read Gillian Proctor’s wonderful book The Dynamics of Power and Counselling and Psychotherapy.


This is definitely an appropriate moment to wheel out Public Enemy and remind you that if you don’t stand for something you fall for anything.


In Julian Lousada and Andrew Cooper’s important book Borderline Welfare they argue that when we lose the institutions of welfare we lose the general conditions that are necessary for care to take place. What we are left with is lots of activity that is done by increasingly vulnerable individuals trying to bridge a massive governance deficit. By not maintaining the institutions of welfare, the state fails in its duty of care to create the conditions under which health and social care work can responsibly be done.


In Surviving Work in Healthcare, I make the very uncool point that trade unions are the only show in town when it comes to defending healthcare. Having worked in trade unions for much of my working life there is not one romantic bone left in my body about unions as organisations. Regardless of how many committed and exceptional people work within them, they struggle like any institution to deliver on their principles and unsurprisingly in the current climate trade unions can be highly defensive making it even harder to defend them. But the fact remains that without unions there will literally be no collective bargaining. Ever. Whether its over wages or agency labour, none of us have the capacity to secure our rights on our own. It is a rare example of a workplace no-brainer that if you work in healthcare you just need to join a union.


Working in healthcare has always been a dual task of both defending and surviving the institutions of healthcare. Despite our experiences of healthcare organisations whether from a patient’s or employee’s perspective, we have to care for the institutions themselves. If the entire history of protecting public services is anything to go by this will only happen if we make the decision to defend our imperfect institutions by voting for a party that is not set on dismantling them. We will sorely miss them if they are gone.
Surviving Work in Healthcare: Helpful stuff for people on the frontline has been published by Routledge. Click here quoting code SUR230 to buy a copy for £17.50.


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