Understanding Healthcare Systems

Surviving Work in Healthcare



Marianna “By systemic change I mean that the discourses and meanings have changed that are associated with health and care. They are concretised by financial arrangements but actually they are based on political ideologies in my view.”


Julian “It seems to me that the financial structure that we’re now struggling with could never have taken place if the idea of the welfare settlement hadn’t been so seriously challenged. The welfare state became renamed ‘The Nanny” without asking where the money had gone and why. There’s also been the relentless denigration of professionals. So you had an attack on the instruments of welfare – undermining its value as a humane social function – it becomes this endless debate about the destructiveness of dependency. Then you attack the workers – calling them charlatans – and attack them so comprehensively whether they’re care workers or social workers. Currently the current junior doctors’ contract is a disgrace. I speak with some feeling about it because my daughter is one. Its the relentless substitution of the professional class by the consuming class. The ideological context is just as important as privatisation.”


Marianna “Vulnerability has been associated with failure. For example if you are sacked from your job you must be doing something wrong. If you are ill it is your personal failure. This is underpinned by attacking anything that is to do with collective values, collective action and just relationality like communities, even families. Your metaphor of the mother and the nanny – a person we normally pay, a person we contract out to provide care and that shift is so fundamental. It has such a deeper meaning and consequences. On the one hand vulnerability is just exiled, its a personal failure and on the other hand those individuals are also consumers. No more citizens or people in need. The concept of being human is just collapsed into a concept of being a consumer.”


Julian “Its penetrated so much of the training now. The training I had as a social worker – the psychosocial underpinning of it – moving more and more into an instrumental competency based training in which the relational has taken a very poor second.”


Marianna “Actually the patient doesn’t know why his or her care is the last consideration in the whole system. You have different people who design care, different people who report on financial targets, different people who are on the front line. Nurses versus doctors are endlessly pitted against each other and the patients’ interests are often going out of the window. That splitting is by design – introduced to break down this collective logic that underpins the collective values that in turn underpin the NHS. Universalistic values, this is what’s been attacked.”



To hear the full conversation between Julian Lousada, Marianna Fotaki and Elizabeth Cotton go HERE.


To listen to these podcasts taken from the conversation click on the links below

1. What happened to the healthcare system?

2. When vulnerability becomes personal failure

3. Why are we so convinced by patient choice?

4. We’re not just victims in the NHS

5. Fear is a powerful tool for control

6. How can people protect health services?

7. Who has a duty of care to whom?

8. How do we cope with death and despair?

9. Why wellbeing policies don’t work

10. How to blame the workers

11. How could we change the system?

12. Taking responsibility for relationality 


Surviving Work in Healthcare is a free online resource Surviving Work in Healthcare designed for people working on the frontline. The website is a joint project by Surviving Work and the Tavistock & Portman NHS Foundation Trust offering podcasts, videos and survival guides that take a jargon free, de-stigmatizing and practical approach to addressing the real problems of working in healthcare.


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