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The personal blog of Duncan Double
Edware
Toronto
Watford/Rickmansworth
Cambridge
London
Lancaster
Preston
Sheffield
Norwich
Where next?
Critics of psychiatry, such as myself, still struggle to get our message across. As I said in my interview with Awais in my book chapter in his edited book, there's little evidence that critical/relational psychiatry has changed psychiatry. I struggled in my medical training, giving up in the middle for 8 years, because I couldn't make sense of the overmedicalisation of psychiatry (see eg. my Mad in America Radio interview and my talk given not long before I was first suspended - about which there is more information in a Times Higher Education article). Although there are critics of psychiatry that want to see psychiatry as non-medical, my position has always been that psychiatry is a branch of medicine and that it needs to move on from the reductionism of biomedicine (see eg. my article).
The problem is that there are powerful vested interests in mainstream psychiatry that do not want to fully take on board this need for change. Robin wants to inspire "thoughtful reflection and foster a spirit of collaboration and mutual respect, ultimately leading to better care for those that we serve". I couldn't agree more but it's difficult to see how psychiatry can or will change. Its current institutional crisis of fragmentation and dysfunction may bring the matter to a head (see eg. previous post on my Relational Psychiatry blog) but the likelihood is that psychiatry will continue with more of the same. How the power dynamics of psychiatry can change is uncertain.
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.
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.
‘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.
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.
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.
Visit to Cambridge University library embellished by excursion to Trinity College fellows’ garden (see website).
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.