Tuesday, March 19, 2024

The meaning of gaslighting

Gaslighting is a form of psychological abuse where a person causes someone to question their sanity, memories, or perception of reality. Gas Light was a 1938 thriller play, set in 1880s London, written by the British novelist and playwright Patrick Hamilton (see Wikipedia entry). It is a story of a husband committed to driving his wife insane in order to steal from her.

Social media can be a toxic environment. People can argue their case vehemently. If people feel their reality and experience is being infringed they can accuse their opponent of gaslighting. I worry about the extension of this use of the word. 

Reality is socially constructed, but not totally socially constructed. Reality is constituted through active shifting of moving and multiple points of view reinforced by social perspective-taking (see eg. post on my Relational Psychiatry blog). The models of the world we create do not necessarily describe the real world (see eg. another post on my Relational Psychiatry blog). Just because people disagree and feel their reality is being questioned, does not mean they are right or gaslighted. Since the Enlightenment at least we have had to debate the nature of truth. 

Monday, February 12, 2024

Moving from bullshit to substance in NHS Foundation Trusts

I mentioned the Trust I used to work for in a previous post. It has been found inadequate four times by the CQC, although currently rated as requires improvement. As with Ofsted (see recent report from Education Committee) there are concerns about the way CQC is working, for example, because of single word ratings and the expertise of inspectors. I commonly find it difficult actually to understand what CQC reports are saying about services because of their lack of narrative. They can appear superficial and formulaic. There are concerns about their accuracy, completeness and depth of analysis. They don’t always make clear what services need to do to improve. 

Still, Norfolk and Suffolk Foundation Trust’s (NSFT) first inadequate rating was not surprising. CQC was probably looking for a Mental Health Trust to rate inadequate, as it had been created to give all Trusts a rating and hadn’t yet found a Mental Health Trust to rate inadequate. NSFT was the first and only inadequate Mental Health Trust in its first round of inspections. The Trust had been through a programme of radical redesign without proper consultation and chaotic implementation. I’m not convinced CQC really understood what was happening when they inspected but interviewed staff who were in turmoil. This led to the inadequate rating.

I was a governor at the time. In December 2012 I was observing the Trust Board meeting and spontaneously stood up and interrupted the meeting with a fellow governor because the non-executive directors (NEDs) bounced the CEO in the meeting into saying that the radical redesign would be implemented. The NEDs were unhappy about how long the Chief Operating Officer was taking to finalise the plan for the Trust to be in the lead of the charge to meet the Nicholson challenge, named after the then NHS CEO, for the NHS to make £20 billion efficiency savings. The Chair said the radical redesign was going ahead nonetheless and we had to sit down. This was before there had been the promised consultation, which never happened, about the plan.

Unfortunately the CEO resigned in June 2013. He was probably the only person who could have kept the radical design process together. Instead I witnessed the most chaotic implementation imaginable. I was, therefore, present as a governor, together with a roomful of concerned people, in November 2013 at the launch of the Campaign to Save Mental Health Services, which continues to this day in its campaign. Lurking in the background at the meeting was the interim CEO, who unfortunately that same month refuted that the Trust was in crisis.

Nonetheless the NEDs continued with their gung-ho attitude that the Trust had made major steps forward in forming NSFT by the merger of Norfolk and Waveney Mental Health NHS Foundation Trust and Suffolk Mental Health Partnership NHS Trust in January 2012. In fact they saw it as a takeover of Suffolk by Norfolk and Waveney, which technically it was. Nonetheless, I argued as a governor for the headquarters of NSFT to be in Ipswich, rather than Norwich, which of course did not happen.

The NEDs recruited a replacement CEO in March 2014. He was CEO at Norfolk Community Health and Care NHS Trust (NCH&C) and took up his post at NSFT later in the year. Personally I was not convinced he was the best candidate for the post, but it’s the NEDs that appoint a CEO not the governors, and clearly the governors had to ratify the appointment. I think he was probably sold a ‘pig in a poke’ by the NEDs that they were hoping to also take over NCH&C, which would be ideal for them because he had been CEO there. A few months after him starting in post, CQC gave the Trust its first inadequate rating in February 2015 following an inspection the previous October.

I came to the end of my terms of being a governor in 2015, although I continue to be a member of the Trust. A CQC report published in October 2016 following an inspection in July 2016 regraded the Trust to needs improvement. The following year the Trust was again regraded inadequate, with the CEO resigning just before the report was published. A warning notice under S29A of the Health and Social Care Act 2008 was issued following the inspection in July 2017. The Chair of the Trust left earlier than expected in November 2018 and was followed by the publication of a third inadequate CQC rating. 

The new Chair in January 2019 was already Chair at North East London NHS Foundation Trust (NELFT), which had an excellent CQC rating and she took on both roles. This was despite the governors having already appointed a replacement Chair. They were pressured to change their decision and the constitution of the Trust was changed to allow the new Chair to be appointed. The CEO she inherited was working towards splitting the Trust but he left, having been stopped in his tracks, when the new Chair insisted that the Trust remain a single organisation. She then appointed a new CEO, who had worked at NELFT in the past, although not as CEO. 

The CQC rating was changed to needs improvement in January 2020, following an inspection in October/November 2019. The CEO retired in March 2021. His replacement, who had also worked at NSFT and previously at NELFT, was appointed but withdrew his application when it emerged that parts of his CV were falsified. Although there was an interim CEO, the Chair, even though she was leaving, insisted on making a CEO appointment before she left and the COO was promoted to CEO in September 2021. I questioned whether this should happen, by asking in a public board meeting why an appointment could not wait until a new Chair was in post. The Chair told me that NHS East of England were supporting her in doing so.

I had retired from clinical work in July 2019. Nonetheless I continued my membership as a public rather than staff member. I continued to have some contact with colleagues with whom I used to work. The information I was receiving made me express my concern about the deterioration in services in Great Yarmouth and Waveney, where I used to work, in a Twitter thread in November 2021. I formally asked a question at the Council of Governors in December 2021 about why the Chair was stating that the Trust was one of the fastest improving Trusts in the country, when that clearly did not seem to be the case to me. I was so dissatisfied with her answer that I followed it up with a letter, which she eventually answered in January 2022 after she had left. I had also tried to engage with the lead governor on the telephone asking the Council of Governors to act but we ended up shouting at each other, for which I have subsequently apologised, but I don’t think it would have made any difference if I had kept my cool. As far as I was concerned the Chair did not properly engage with any of my concerns expressed in the letter. I had anticipated that the Trust would again be found inadequate in its next inspection and called for the resignation of the Chair, the two Vice Chairs, the Senior Independent Director and the lead governor in a tweet. As predicted, the Trust was again found inadequate in a report in February 2022 following inspections in November to December 2021. The CQC had already again initiated enforcement action before the Chair left at the end of 2021.

The new Chair duly came into post and managed to help the Trust obtain a CQC needs improvement rating in a report in February 2023 and the threat of enforcement was removed, following inspections in September and November 2022. I thought it was important to keep pressure on the Trust, even with a new Chair, and had been with the Campaign on their lobby of parliament in July 2022 (see EDP report and my Twitter thread). I called for the resignation of the CEO, and he eventually left in September 2023 (see EDP report). I do not think this was because of my campaigning, although MPs we met on our lobby of parliament questioned whether this was necessary. Personally I had no doubt and raised the matter in May 2022 with the two vice Chairs, as technically the appointment had been made before the Chair came into post. I was told the CEO had the full confidence of the Board and that they couldn’t help me any further. I suspect his performance at the Norfolk Health Overview and Scrutiny Board (HOSC) in September 2023 was a factor in his going. At the same meeting HOSC called for a public inquiry, as has the Campaign persistently and consistently for some time. An answer is still awaited from the Secretary of State although an inquiry is being resisted by the Trust and the two local Integrated Care Boards.

Personally I have become more confident that the Trust can turn itself round with its new CEO after the intervention of NHS England. Other campaigners remain more sceptical and they continue to think a public inquiry is necessary. This is not surprising considering the sorry saga I have related here. The Trust is also facing a criminal investigation (see EDP report).

By the way, I’m not being rude when I use the term ‘bullshit’. The technical definition is explained in another previous post

Tuesday, December 12, 2023

The exhibition on ‘Spitting Image’ is worth seeing at the Cambridge University Library. It makes links with the origin of satire in Georgian England (see book by Alice Loxton Uproar: Satire, scandal and printmakers in Georgian England).

Hogarth, of course, used satire to expose social ills and encourage reform.
Maybe our modern age no longer worries about the ridiculing of its follies and vices but instead exploits them.

Saturday, September 23, 2023

From spin to bullshit

That’s now two blog post headings with the word ‘bullshit’ in them (see other one)! I’m meaning the technical definition of bullshit which means a corporate rhetoric that creates a positive image regardless of the organisational reality. I think the point to emphasise is that the organisation doesn’t care about the real situation. Instead it has become more concerned with words and rituals which are actually empty. Management speak is supposed to give the impression of expertise, but actually avoids dealing with the real issues. Producing, distributing and consuming bullshit becomes a goal in itself. Rampant bureaucracy creates forms to be filled in, procedures to be followed and standards to be complied with. Managers feel compelled to deal with a problem by bullshitting.

Truthful, accurate and transparent communications are crucial to keeping people properly informed. How an organisation presents and promotes itself can be packaged, which has potentially problematic implications in a democracy. Communication has become a formidable industry in politics and business. Spin has always existed where there are people to be influenced. Something new developed, though, in British politics in the 1990s. "The media, industry, politics, the establishment and the arts conspired to bring us not their constituent parts, but a presentation of what they would like us to think they were" (see Demos article). Presentation seemed to become all and form overcame content. A lack of substance in what was being said and interpretation parading as facts meant that 'spin' eventually became a pejorative term. 

Even though there may have been signs that the spin culture had run its course as people disapproved of spin because it was lacking substance, I'm not convinced we have moved on to a culture in which there is an open and honest debate. Instead there is still too much bullshitting, which is actually worse than mere spin because it is an indication that the organisation doing the bullshitting does not care. I may well post further once I have read André Spicer's Business Bullshit.

Wednesday, September 13, 2023

Münchausen by proxy infanticide

I’ve mentioned David Southall three times previously (see firstsecond and third posts). He was a professor of paediatrics and a child protection specialist with a worldwide reputation. He spent 14 years under investigation (including being struck off and reinstated) by the General Medical Council.

As a specialist at the Royal Brompton in babies’ breathing problems, he set up a system with the cooperation of police and social services of covert video suveillance, which showed that some parents were suffocating their children. He became a leading expert on Münchausen syndrome by proxy, first named by Sir Roy Meadow in 1977. Meadow too was struck off by the GMC, but appeal to the Court of Appeal was found in his favour by a majority. What got him into trouble was his so-called law that “one sudden infant death is a tragedy, two is suspicious and three is murder, until proved otherwise“. This was because Sally Clark’s conviction for the murder of her two baby sons, primarily on the basis of Meadow’s law, was overturned by the Court of Appeal (see BBC news report).. 

People do kill defenceless infants. This even includes health care staff, such as Beverley Allitt (see Wikipedia entry) and Lucy Letby. I doubt the Lucy Letby statutory inquiry, which will include looking at the Trust’s response to the consultants who expressed their suspicions of infanticide (see SOS statement), will take us forward much in the understanding of Munchausen by proxy infanticide, about which the consultants will have had some knowledge. However, the inquiry should improve working relationships between managers and consultants in the NHS. The primary problem is that, because of increased accountability over recent years, managers have usurped clinical responsibility. Instead they need to be held to account for creating the right environment in which clinicians can exert that clinical responsibility. Clinicians shouldn’t necessarily be accused of bullying, or some other disciplinary offence, because they express dissent (see eg. my BMJ letter). Managers must not misuse their disciplinary power (see previous post). If they hadn’t in the Letby case, her serial killing might have been detected earlier.

Bullshit in NHS Foundation Trusts

As Dave Pilgrim writes in British psychology in crisis:-

‘Management speak’ with confident terminology and phrases abound, and many employees now simply expect their managers to talk bullshit. Clichés are offered, as and when required, to mollify the public. When the latter are assured about probity, transparency, or safety in a press release, then there are often good grounds for healthy suspicion from the ordinary citizen.

In the NHS, for example, this means that managers can spend their time bullshitting to protect the organisation rather than improving patient care. Non-executive directors in Foundation Trusts, who are supposed to ensure that patient care is improving, fail to challenge executives, leaving sceptical members of the Trust and the public in general without confidence, even in their elected Council of Governors.

Norfolk and Suffolk NHS Foundation Trust, where I used to work and was a governor for 7 years, has been found inadequate four times by the Care Quality Commission. I could see the fourth inadequate coming and publicly called for the resignation of the Chair (who was going anyway), the two vice Chairs, the Senior Independent Director (SID) and the lead governor. This wasn’t because of personal antagonism to the people in post, all of whom I knew through working as a governor and keeping in touch subsequently as a member.

Of course this did not happen! The Chair designate came into post and has helped to get the CQC rating improved to ‘Needs improvement’ rather than ‘Inadequate’. The SID has moved on and one of the vice-Chairs is also due to come to the end of his term soon. Still, I thought the better way for the Trust to manage its difficulties was to accept accountability by these public resignations. 

The Trust still, therefore, lurches from scandal to crisis and back, most recently with a BBC Newsnight investigation (see BBC report). This was partly about the Trust’s handling of its mortality data, but also about the need for an open and honest debate about the state of mental health services in Norfolk and Suffolk. I still don’t fully understand what the Trust is saying about how it has handled, is handling and will handle its mortality data. The concern about the state and quality of services is due to the fact that the Trust has still not properly recovered from its first CQC inadequate rating due to the disastrous implementation of its radical redesign before that first inadequate rating. 

There are of course national issues also about the state of mental health services in this country. NHS England seems to be leaving Trusts to sort out their own messes, so there still needs to be an open and honest discussion about the state of mental health services in Norfolk and Suffolk. If non-executive directors are not willing to facilitate this discussion, they should resign and be held to account by the Trust Governors.

Being a University student

Still revelling in having spent more than 7 years of my life (3 years BA, 2 years and a term clinical studies and two years part-time PhD) as a student at Trinity College Cambridge.

Wednesday, July 05, 2023

Solving the problem of the NHS

It doesn’t go down well to say that we have too much medicine (eg. see previous post) when we have so many people on NHS waiting lists. Although it is true that the NHS is currently unsustainable, particularly when care has become so fragmented and dysfunctional, the answer is not just more money. Hopefully the recently announced NHS Long Term Workforce Plan will help, but more fundamentally the NHS does need to prioritise responding to need rather than demand. 

Ironically, it is the NHS itself that has often inflated demand. The overmedicalisation of society must be reversed in the interests of the country’s health.

Saturday, May 06, 2023

Prince Charles’ room in New Court, Cambridge was a bit grander than the average freshman’s. A bath was even installed on the staircase. He left Trinity in the academic year before I started, and the bath in the next staircase saved me having to go across the court in my second year. I remember going to the Wren library and presumably there is a similar photo of me in the admissions book from 1970, although I can’t remember it being taken.

Monday, May 01, 2023

Human thinking and ChatGPT

An interesting paper by Durt et al discusses why ChatGPT and other large language models may seem so good at modelling human thinking. Generative artificial intelligence uses structures and patterns of human language to produce outputs that can be strikingly like human beings. The so-called neural network architecture of ChatGPT, although it can't act independently or make decisions, generates responses based on the patterns and associations found in the vast amount of inputted text. Meaning really has no existence outside of language use and rather results from it, so perhaps we shouldn't be so surprised by the extent to which thinking is guided by patterns. Thinking can be intuitive, even creative, but most of the time we're just pinching ideas from other people. 

Wednesday, February 08, 2023

Visit to Cambridge University library embellished by excursion to Trinity College fellows’ garden (see website).


Thursday, February 02, 2023

Being unacceptable

I have been looking at the website for the research project on the work of Don Cupitt (listen to eg. Radio 4 programme about Cupitt’s 1980s TV series Sea of faith). He was one of my supervisors when I switched to Religious Studies for my Part II at Cambridge (see eg. previous post). Interestingly, he had an exhibition to Trinity Hall for Part I of his degree in Natural Sciences before switching to theology. I had an exhibition to Trinity eighteen years later to study Medical Sciences before changing to Religious Studies. Maybe I’ve been as much as a provocateur for psychiatry as he has been for religion. 

Having flirted with death of God theology (see previous post), I gave up my involvement with the church a few years after Cambridge. Actually I’ve never wanted to be a heretic within psychiatry. As I’ve said throughout my Relational Psychiatry blog, psychiatry does need to change. I’m not wanting to abolish it.

Tuesday, January 17, 2023

I came across two portraits online (see link and another) painted by my great uncle, Alfred H. Page, who I never knew.

Thursday, January 05, 2023

Just to prove it, I’ve come across my certificate from August 1979 showing I am an Associate of the Institute of Bankers. I did not like working for Lloyds bank for four years, but was grateful they lent me money cheaply to buy our house when mortgage rates were even higher than now.

Saturday, December 10, 2022

Chance and necessity revisited

Jacques Monod viewed molecular biology as justification for a mechanistic and deterministic view of life, which he elucidated in his best seller Chance and necessity. The book influenced me when I was an undergraduate at Cambridge University doing Part I Medical Sciences in 1970-2. It was only when I switched to Religious Studies for my Part II that I realised that a reductionist and positivistic view of science was at least open to question.

Monod argued that living beings are chemical and self-constructing machines. He acknowledged that “our understanding of the mechanisms of development is still very imperfect” (p. 52). Nonetheless he was clear that the “process of spontaneous and autonomous morphogenetic is based on stereospecific recognition properties of proteins”. I’m sure it is, but the question is whether proteins “animate and build living systems (p.52)”? Contra Monod,  I’ve come to accept Kant’s view that life cannot be explained in mechanical terms (eg. see post on my Relational Psychiatry blog).

Even though the scientific and professional establishment tend to agree with Monod, it’s not just the human sciences, but also biology, that need to be anti-reductionist (see eg. another post from my Relational Psychiatry blog). The implication for psychiatry (see my Relational Psychiatry blog passim) and for medicine in general, is that it is not person-centred enough.

Thursday, June 30, 2022

Sustaining the NHS

Sajid Javid in the introduction to his keynote speech to Policy Exchange on 'Digital transformation in health and social care' said "The truth is that our health and social care system is following an unsustainable path that is too often not delivering for patients". He went on, "At the start of this century health service spending represented some 27% of day-to-day public service spending. By 2024 it is set to account for 44%. ... But can we really say we've seen an equivalent improvement in outcomes?"

Obviously this rhetorical question was meant to be answered in the negative and I would agree. I've said before (eg. see previous post) that overmedicalisation of society has created too much medicine. This situation is ironic as the currently fragmented and dysfunctional NHS has also inflated demand so that it cannot cope. The NHS needs to relearn to concentrate on priorities. There needs to be a shift back towards meeting need rather than demand.

The BMJ has recently called for a reset in its campaign against too much medicine (see editorial). A rushed article of mine 'The limits of psychiatry' was published (with several fairly minor errors eg. picture of Alfred rather than Adolf Meyer) in a BMJ theme issue in 2002 highlighting the dangers of too much medicine. As the recent editorial says. "Evidence for the damaging effect of overdiagnosis and overtreatment continues to grow". And as it concludes, there needs to be a move from "rhetoric and scattered evidence to actionable evidence and measurable impact".

Sunday, May 29, 2022

Peter the Great was no saint

Commentary in Politico suggest Vladimir Putin is no Peter the Great because he has failed to stop murder and rape in Ukraine. But this tapestry of Peter shows him looking pretty pleased with the carnage of the Battle of Poltava in Ukraine in the background.

Battle was raging between Russian forces and the army of Charles XII of Sweden, marking the beginning of Russian hegemony in Northern Europe.