Anonymous, 2012. A letter to the NHS.... Reformulation, Winter, pp.20-21.
I have known you for many years as a family friend, at times as an interloper, as an employer and as a provider of care for me, my family and my children. You were around in my life for as long as I can remember. You were never particularly visible, but you were a constant presence in my life and that of my family, like a backdrop in the theatre of our family life, a permanent guest at our dinner table. Sometimes you were more like a demanding rival for the attentions of our parents, their absence marked by your needs rather than ours. You'd given my mother a career in nursing which she doggedly held on to despite young children. You trained her and gave her a valued career. Her commitment to you was strong and she'd spend long hours with you, her patients, and her staff. My father worked with you in a non-clinical position, but both his relationship and hours with you were no less intense.
Your role in life and death, and all shades of health in between, has been huge. I do not have a memory of life without you, but my father does. He tells me of how it was to have grown up in a family before you existed, where 2 siblings had already died as a result of common health problems which would be treated easily and quickly today. My grandparents’ commitment to ensuring the survival of their next 2 children was strong, but he can still recall the additional anxieties within the household, associated with any sort of illness, where 'the doctor's bill' and how it would be met, had to be considered before making any request for medical help.
At the other end of this lense I witnessed and experienced at first hand your largely compassionate and attentive end-of-life care in a close relative's final week of life. I am struck by how the intense anxiety and distress of that experience were not amplified further by concerns about the cost of this intensive episode of care. A friend commented afterwards on what the implications may have been had we lived in a country where the NHS did not exist. Choices about relief of my relative's significant pain and intense anxiety may then have had to be made on the basis of cost, his realisable assets and those of his family. As it was, the human and emotional costs for him, and those of us bearing witness to his passing were significant enough. I shudder to think of how it may have been without you.
As a child when I thought about what I wanted to be when I grew up, there were few careers I could imagine that didn't involve you in some way. I was lucky that you were able to offer me opportunities to develop my interest in clinical psychology. Before joining you as an employee, I spent some time working in a US university psychology department, where I was surprised and perturbed by the routes people there had to take to access psychological treatment. I would sit on a phone taking calls from people who had seen treatment advertised in the local papers, offered on the basis that they would consent to taking part in drug trials. My job was to screen people over the phone and, if they matched criteria set by the study, to invite them to be recruits. Most of my efforts had to go into excluding the many callers who did not meet criteria but were highly distressed and desperate for some sort of help as they didn't have the means to pay for it otherwise. On returning to the UK and taking up my first job with you in psychology services, I was struck by the contrast between this glimpse of the US experience and the easier and more familiar routes people could take to make use of what you offered them here in the UK.
Not that you have been perfect by any means, and not that everyone could make use of you equally. Through my career I have seen and understood better how you have been less available and more withholding to some groups. At times, within mental health care in particular, you seem to favour some more than others. Some communities have not understood you or have found what you offer less than helpful and been wary of engaging with you. You've not always understood the communities around you well and not always done a good job of reaching out. You've acted harshly towards some and provided care which has inadvertently harmed or stigmatised further. And despite your repeated observations of how both physical and mental health is influenced by economic and social advantages and disadvantages, you have been more silent about this than you might. But you've had some capacity, in places, at times, to support those working within you to reflect on such issues, leading to action to improve your understanding, your reach, your voice, and to behave more fairly to those you've neglected or harmed.
You have been such a constant presence in my world, part of my embedded culture, that for many years I just assumed you would be here, for me, for those I love, and for the communities with whom I work . In recent years your continued survival has been in question and I've fought for you when you've been threatened. Latterly I have seen how your health has suffered following repeated reorganisation, 'modernisation' and the legislation pushed through earlier this year despite massive collective opposition. I hear that you have had more and more resources invested in you, however I see your health deteriorating, your workforce struggling, and your capacity to provide those around you with healthcare being depleted in many ways. The more you are fragmented and locally commissioned, the less I can see you as able to respond to a range of needs, particularly in relation to those who will need high intensity, high cost interventions. The more that cost improvement programmes diminish your staff in both number and spirit, the less human resource will be available to provide care. The official line is that you are not being destroyed; however from where I stand I cannot see how you can survive in any robust way. Your brand may survive but what lies beneath the logo will in time bear little resemblance to your constitution and founding principles.
In the present climate it's hard to know how to stand up for you effectively, as so many previous efforts have gone unheeded. It certainly feels as though singular efforts are now irrelevant, and indeed quite dangerous for those who are prepared to speak up and challenge in an identifiable way. (The act of writing this letter presses me to feel careful about what I reveal, whether I could be identified and what penalties there might be if I was.) The willingness of some to push ahead or go along with reforms that weaken you further makes me think that there must be many whose life experiences have somehow bypassed you, who don't have a memory of how you have underpinned their own and the UK population's wellbeing for so many years. I can't imagine there are many who haven't benefitted from what you've offered. I think what is more likely is that, as the historian Eric Hobsbawm suggests of young people at the end of the 20th century, those of us who are not historians 'grow up in a sort of permanent present lacking any organic relation to the public past of the times [we] live in' (Hobsbawm 1994, p 3). If this remains the case, a decade or two further on, it may be that as a population, we will not consider or imagine how it was before you existed, we may indeed take you for granted, fail to act sufficiently when we see you being harmed, and therefore let you down at your time of most need. And once you have gone, there will be no bringing you back. The reality of a UK without you will be stark and grim.
If you were my client and I could see those who claim to be your custodians acting with such disregard for your welfare and future, and paying no heed to those who express concerns about you, I would be expressing strong concerns to those responsible for your care, and instigating some form of safeguarding. But you are not my client, I seemingly have no powers to protect you, and I am quite exhausted in any case. Hence a letter to you, but one which is open to a larger group who may be able to offer some thoughts, some skills, and some collective actions which may help to keep you safe. Failing that, as a group we may at least help to document the human stories which define your contributions to health and wellbeing over the last 60 years.
Hobsbawm, E. (1994), Age of Extremes: The Short Twentieth Century 1914-1991. Abacus
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