Note to NHS: stop treating the public with contempt
With nothing to say about the paternalism and authoritarianism of the UK health system, the Save Our NHS protests seem wilfully out of touch.
Dr Michael Fitzpatrick
A common theme links the government’s ‘obesity strategy’ and the latest exposure of neglect and ill-treatment of elderly hospital patients: a lack of respect for the individual. Yet this theme is conspicuously absent from the continuing debate about NHS reform.
According to chief medical officer Professor Sally Davies, launching the latest campaign to persuade the public to eat less and exercise more, individuals ‘need to be honest about what they are eating’ – but the trouble is that ‘people are not even honest with themselves’. The government has concluded that what people need is more hectoring and exhortation to live more virtuous and healthier lives. Health minister Andrew Lansley has taken time out from his laborious quest to reform the NHS to calculate that cutting the five billion calories off the national diet required to meet some arbitrary target is the equivalent of sacrificing 16.9million cheeseburgers (which would cover 20 football pitches) or 28.4million caffè lattes (which would fill four Olympic swimming pools). It is difficult to see how these bizarre calculations might encourage people to lose weight.
When Professor Philip James of the Association for the Study of Obesity dismisses the obesity strategy as ‘stupid’ and ‘pathetic’, it is difficult to disagree. Yet his alternative is even worse. Believing that the public is being ‘manipulated’ by the junkfood industry, he demands legislative measures to curb consumption. Celebrity chef Jamie Oliver feels ‘upset and let down’ by the new strategy, which he condemns as ‘worthless, regurgitated, patronising rubbish’ (a judgement which would serve as an accurate assessment of his crusades to change school meals and popular eating habits). But, what, after all the hot air, is Jamie’s alternative? His diatribe comes to the feeble conclusion that ‘education is the key’ and that ‘we need to give people the knowledge to be able to make better choices’ – a sentence that almost exactly replicates the line in the obesity strategy about ‘creating the right environment for the individual to make healthy choices’.
The conviction that unites both the advocates of the government’s obesity strategy and its critics is the presumption that people are incapable of making free and intelligent decisions. Indeed the belief that people are immature and suggestible and need to be supported and protected against both the malign influences of advertising and their own base instincts is even stronger among the coalition government’s radical opponents than among its traditional followers. Of course, conservative politicians have always taken a cynical view of the capacity of the masses to make rational decisions. But in recent years, this elitist prejudice has acquired a particular resonance in the sphere of health as substantial sections of the population are regarded as victims of diverse compulsions and addictions and as incapable of acting in their own interests.
The politics of behaviour – summed up in the notion that people need ‘support to make healthy choices’ – now governs public health. This reflects the transformation of the independent citizen into the fragile and vulnerable client of the health and welfare bureaucracy. The very existence of a government obesity strategy (which takes its place alongside similar strategies in relation to exercise, smoking, alcohol, drugs, sex, parenting, etc) presupposes the legitimacy of state intrusion into the conduct of personal life and intimate relationships. Such policies assume that individuals cannot conduct their own lives without expert official and professional intervention, ambivalently labelled ‘support’. By making personal experience subject to government regulation, the state inevitably undermines the autonomy of the individual: hence the irony that the obesity strategy ‘stresses the importance of individual responsibility’.
It is not surprising that when the same individuals who are the object of official sermons on their idleness, gluttony, drunkenness and all the rest – and of lying to themselves and their betters about their filthy habits – turn up in hospital, they are treated with something less than the respect due to a free and independent citizen. Yet another official inquiry last week revealed that half of all hospitals failed to meet basic standards of dignity and nutrition of elderly patients. This report merely confirmed the conclusion of several similar inquiries over the past decade – and of scandals, such as that at Stafford Hospital, where ‘appalling standards of care and chaotic systems for looking after patients’, were revealed in 2009. Other reports have revealed experiences of neglect and abuse of people with learning difficulties in the NHS as well as unsatisfactory levels of care for children. Another investigation, carried out by the Dispatches team on Channel 4 revealed poor standards in general practice and raised serious questions about the quality of regulation by the General Medical Council (1). While criticisms can be made of the reliability of some of these investigations, there can be little doubt that a lack of respect for the dignity of the individual, particularly the more vulnerable individual, is a widespread feature of the NHS.
Here we come to the debate over NHS reform, now proceeding through parliament, in a sort of parallel universe far removed from the day-to-day reality revealed by recent inquiries. On the one hand, the government is moving ahead with its ill-advised combination of a bureaucratic reshuffle and the extension of the corrosive commercialism imposed by New Labour. It is clear that the model of public-private partnership pioneered by New Labour did nothing to protect the vulnerable patients at Winterbourne View (the Bristol hospital for people with severe learning difficulties, now closed down) from grotesque abuse and ill-treatment. On the other hand, supporters of the ‘Keep it Public’ and ‘Save Our NHS’ campaigns go cap in hand to the House of Lords, apparently oblivious to the poor quality of care long endured by many patients under the NHS, of which the medical profession – and other professionals – have been the major beneficiaries.
The supreme irony of the last stages of the NHS reform debate was an open letter from more than 400 public-health doctors, asserting that the Health and Social Care Bill would ‘do irreparable harm to the NHS, individual patients, and to society as a whole’ (2). These same public-health doctors are among the leading promoters of more coercive and intrusive legislative measures to ‘nudge’, if not push, the public into healthier lifestyles.
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