‘Agents of persuasion’? Just say no
GPs should defy government orders to 'reshape unhealthy behaviour'.
‘It may be wise to rely more heavily on GPs and other trusted health professionals as agents of persuasion. Currently these “strong” channels tend to get less focus than “weak” channels such as leaflets and factual information. The high respect (authority) and personal affiliation felt for medical professionals (liking and affiliation), together with their involvement at critical junctions of life (salience), means that they are uniquely well-placed to reshape unhealthy behaviour.’ (1)
A discussion paper produced by the Prime Minister’s Strategy Unit is valuable in making explicit some of the key themes of the government’s public health policy that are generally obscured by the rhetoric of choice and empowerment. Its title – ‘Personal responsibility and changing behaviour’ – is creepily intimate and subtly intimidating, reflecting the peculiar combination of the therapeutic and the authoritarian that is distinctively New Labour.
The prime minister’s advisers candidly acknowledge the problem that ‘the government cannot simply “deliver” key policy outcomes to a disengaged and passive public’. What is required is the ‘design and authorisation of more sophisticated methods of behavioural change, between state and citizen and between citizens themselves’. Implicitly recognising that politicians are too remote and unpopular to exert a direct influence on public behaviour, Blair’s policy wonks suggest that the government turn ‘trusted health professionals’ into instruments of government policy.
As a GP, by appointment to Tony Blair an ‘agent of persuasion’, entrusted with the task of regulating the behaviour of the public, I keep a bulging file of things that I am ‘uniquely well-placed’ to do. It extends from the familiar tasks of telling people not to smoke or drink or take illicit drugs, to telling them that they should take exercise and adopt a ‘healthy diet’, and observe the rituals of ‘safe sex’.
I am also ‘uniquely well placed’ to spot the signs of addiction to gambling or elder abuse, to interrogate pregnant women (indeed any woman) about their experience of domestic violence, and to discourage teenagers from sexual experimentation and pregnancy. I can see why expanding the role of the GP from medical practice to cover tasks of moral guidance and social surveillance appeals to government. But why should it appeal to GPs?
The drive to expand the role of the GP proceeds in parallel with the inflation of health. In the not-so-distant past, doctors worked in a society that made a clear distinction between health and illness. At the level of society as a whole, improving standards of health were regarded as the benefits of wider social progress; at the level of the individual, health was the precondition for the achievement of wider social or personal goals. Illness was a transient phase requiring the treatment of disease and the restoration of the capacity to participate actively in society. The biomedical model of medical practice assumed a doctor skilled in diagnosis and treatment according to the principles of scientific medicine and a patient who was a self-determining individual whose personal conduct was their own responsibility.
The ascendancy of the new public health reflects a fundamental shift in society (2). Health has become both the ultimate goal of individual existence (‘a state of complete physical, mental and social wellbeing’ in the notorious World Health Organisation formulation) and an unattainable ideal (as all those who worship in the gym can testify). Health is no longer regarded as a natural state, but one to be earnestly striven for and conscientiously maintained through a continual process of self-monitoring and self-denial (how many calories or portions of fruit and veg consumed, minutes of exercise endured, units of alcohol consumed, cigarettes smoked?) and through a willingness to seek medical advice (see a doctor, phone NHS Direct) and undergo regular check-ups and screening tests (blood pressure, blood sugar, cholesterol, smear tests, mammograms, etc).
By contrast, illness is no longer considered exceptional, but normal. We are all now potentially ill, as illness has become a protracted state that confers a new identity on the sufferer (‘cancer survivor’, ‘alcoholic in recovery’, ‘person in therapy’). As numerous autobiographical accounts in newspapers, magazines and books confirm, illness has become a positive experience, one that offers profound insights to the sufferer and confers social recognition and prestige.
The paradoxical effect of the widespread dissemination of the gospel of health promotion and the enhanced awareness of disease resulting from the relentless stream of healthy living propaganda is that everybody now feels ill. At a time when society is gripped by fears of future epidemics of flu (see Fearing flu) and non-existent epidemics (see Weighing the arguments), two current epidemics rage unnoticed. One is the epidemic of the ‘worried well’, people who have no disease but live in fear of developing one of the conditions selected for public awareness campaigns, such as cancer or heart disease. The other is the epidemic of the ‘worried ill’, those suffering from the wave of newly-defined conditions and syndromes of modern society – chronic fatigue, fibromyalgia, repetitive strain injury, attention deficit hyperactivity disorder, post-traumatic stress disorder. It is thus not surprising that the numbers on invalidity benefit have soared over the past decade, in parallel with the rising influence of the new paradigm.
Nor is it surprising that the Department of Health’s Expert Patient Programme should be offered to the ‘sixty per cent of adults who report some form of long-term or chronic health problem’ (some 36million people in the UK). As one advocate of this approach has argued, without a hint of irony, ‘the principles underlying the Expert Patient Programme could be extended to the whole population’ (3).
Another paradox of the new public health is that while it promotes the rhetoric of empowerment, it both presupposes and reinforces the powerlessness of the individual. The key targets of contemporary health promotion initiatives are those hapless individuals – the obese, smokers, those who appear incapable of adopting healthy lifestyles in terms of diet, exercise and other socially approved behaviours. These people – who make up at least one third of the population – are deemed powerless in the face of chemical dependencies and fast food advertising and judged incapable of defining their own interests. Hence they require ‘support’ to make healthy choices, and intensive therapeutic solutions supervised through Health Living Centres, Sure Start programmes and GP surgeries.
I fear that if doctors allow themselves to become instruments of the government’s social engineering agenda they will rapidly lose the respect of their patients. GPs are ‘uniquely well placed’ to refuse to surrender the doctor-patient relationship to the government’s cynical quest to recover its legitimacy.
Dr Michael Fitzpatrick is author of The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA), and is speaking at the spiked conference ‘Whose choice is it anyway? Questioning the new conformism’, in central London on Friday 11 March 2005. For information about the conference, see http://www.spiked-online.com/choice.
(1) Halpern D., Bates C., Beales G., Heathfield A., ‘Personal responsibility and changing behaviour: the state of knowledge and its implications for public policy’, London: Prime Minister’s Strategy Unit, 2004
(2) Health in a sick society, by Stephen Bowler
(3) Gupta, S. ‘Government programmes aim to improve engagement’, BMJ 2005; 330: 255
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