Who’s afraid of whom?

The health service is beset by fear at every level, and yet fear damages health, setting up a destructive vicious cycle that adds to the costs, both human and monetary.

It cannot be easy being a politician in government while capitalism, unopposed, is rampant and seems to be spiralling out of control. The spectre of Greece, bankrupt and burning, must haunt the nightmares of those charged with the financial solvency of our nation. The fear of this sort of meltdown must surely be driving the quest to ensure profit in parts of society traditionally exempt from this sort of imperative. The current government is proposing opening up the transactions of healthcare and of education, previously regarded as public services to be provided from general taxation, to the full power of the market in the hope, presumably, of stabilising the economy. It seems a measure of desperation that it is prepared to invoke the forces of global competition, which have over the preceding five decades laid waste to the nation’s manufacturing industry. Politicians are afraid of the unbridled dominance of global companies whose patronage they must court, and they are also afraid of the citizens who form the electorate, the sometimes influential professionals who oppose their ideas, and the patients whose stories have the potential to precipitate scandals, all or any of which might bring down governments.

NHS patients have quite different fears: of illness, disease, and death; pain, disability, and incontinence; loss of dignity, coherence, and sanity. And this is to mention only a few of the many profound existential fears that linger at the margins of every consultation. And there are also fears of the machinations of medicine itself: of misdiagnosis, too much and too little, and of the harms and side effects of investigations and treatments. Patients are most afraid of the betrayal of their own bodies and minds, but they are also afraid of doctors and other healthcare staff at whose mercy they find themselves. They are frightened and disconcerted by seeing a succession of different members of staff and of getting lost in the system. And they are afraid of politicians who have the power to close hospitals and cut budgets, so that patients fear for the future of the staff, treatments, and facilities that they might need.

Healthcare professionals are sometimes afraid of patients, of failing to cope with overwhelming need or unremitting suffering, even of being threatened with violence. They are afraid of making mistakes, and they are sometimes paralysed by the array of regulations, instructions, and protocols to which they are told to adhere. They are afraid of politicians and policy makers because they can make challenging working conditions even more difficult through financial cuts or by imposing disruptive restructuring that puts working relationships and job security at risk.

Citizens are afraid of politicians because, despite a too often less than robust democratic mandate, it is politicians who set the framework of values and priorities within which society at large and the health service within it are obliged to operate, and these values and priorities may be alien to many citizens. They may also be fearful because of the power of politicians to impose taxes and to restrict benefits and so threaten the viability of families and communities. Citizens are also afraid of health professionals and of becoming patients, and they worry about the implications of the insistent rhetoric of preventive healthcare that subjects them to the deliberate and instrumental use of fear to coerce compliance: if you do not do this or that, or stop doing this or that, be afraid because your health will suffer.

Everyone is afraid of death or of dying. In the margin of his 1563 edition of Lucretius’ great poem On the Nature of Things, Michel de Montaigne wrote: “Death is the cause of all our vices.” And this certainly seems to hold true for many of the vices of contemporary healthcare, with its insistence on longevity as a measure of achievement and its exponentially expanding technology for eking out a few more days and weeks even in the already very old. In the rich countries of the world there is a greed for life that feeds fear and disquiet.

The balance between fear and trust has tipped too far towards fear. People begin to fear rather than trust their own bodies; and the whole catalogue of mutual fears reverberates within a distrustful society. Yet, remarkably, trust endures between professional and patient, more often than not, because healthcare cannot function without it, and that trust is built on a willingness to listen, to be honest, and to be open to the other person’s point of view—on deliberate positive regard. There is an increasingly urgent need for these commitments to be modelled at every level of the health service. And perhaps this should start with those politicians who are tasked with leadership. Sadly, any optimism in this regard is not helped by the repetitive mantra from on high that “our modernisation plans are essential if we are to put the NHS on a sustainable footing, hand power to doctors and nurses, give patients more choice, and reduce needless bureaucracy.” This is profoundly dishonest. All the stated aims could have been achieved without any change in the legislative framework of the NHS. The real intentions lie poorly concealed in the voluminous and increasingly confusing text of the bill. No wonder we have problems with fear and trust.