“Find some time in your day to relax”, and other useless advice.
For four years I was in the Cabinet in Redcar and Cleveland Council as Lead Member for Children’s Social Services and Education. On the various boards and committees I sat on there were many presentations of data about children’s health and well-being. One day we were looking at a large number of data categories for children from across the Tees area; for example obesity, breast-feeding rates, missed hospital appointments, missed vaccinations, school attendance, etc. It occurred to me that, though these were all presented as separate issues, they all affected the same significant minority of families across Teesside. The highest priority was surely not how to break down their problems into categories and rates, but how to help them. I began to wonder if there is an inherent inertia and even political bias in the injunction to “keep staring at the data” as one speaker advised us to do. Whose interest was served by constantly presenting numbers rather than people. Why so many boxes and so few case studies?
. This was also around the time I first read the work of Professor Michael Marmot on the health inequalities caused by social inequality and poverty, and I also attended a lecture by Professor Ted Schrecker at Durham University, entitled “Lifestyle Drift”. This refers to the tendency of official government and government-commissioned reports on health to begin broadly, describing how the health of the population is affected by deprivation, but then, often only a few ppages later, the focus shifts entirely to individual life-style choices. Prof. Schrecker gave us an example of why focusing on individual choice does not work. He said, “If you are a single mother holding down two or even three part-time jobs, you are much more likely to smoke than someone with an easier life because nicotine has psycho-active properties which help you keep going when you are exhausted.” This being the case, printing a leaflet about stress and putting it in a GP surgery, exhorting patients to “find some time in your day to relax” is worse than useless.
. This policy coincided with changes in the NHS (when are there not changes in the NHS?). The new buzz-phrase was “self-care”, which meant in summary that healthy people would keep themselves healthy and those with long-term health conditions would manage their own illnesses. This approach purported to be better for the health of the nation and would mean less money need be spent on the NHS. One document we were presented with had a section on “how to move on from your long-term illness”. This way of putting it really helped to show that the intention behind self-care was to make health and illness a personal, moral issue. To have a long-term illness which refuses to behave itself then becomes a moral failing. Not only is this idea immoral in itself; it is also based on a very shallow understanding of human beings. Any government policy which is designed to throw citizens into the maelstrom of guilt is bound to fail, as it is only a matter of time before the failure to meet unrealistic demands dooms the project.
. A few years ago I accompanied a friend to one of her chemotherapy sessions. She was a former nurse herself, and during our conversation as she was receiving treatment she asked, rhetorically, “When did we start blaming people for their own illnesses?”. It was an emotional statement; she was incredulous. No doubt this partly reflected what she was going through at the time, but it is also a very good question. Though its answer, or answers, are too large for this essay, in began to gain ground in the second half of the 1980s and was part of the viral brutality which has infected everything from government and corporate business to schools and colleges, the BBC (Birtism), party politics and even NHS management practices.
. Yet most members of the South Tees Health and Wellbeing Board, when I was on it, saw no problem with “self-care” when it was presented to us. Even the GPs present thought it was a good idea. Their reaction reminded me of what Prof. Schrecker told us: how for some reason doctors and other medical professionals (though not nurses) tend to resist the truths of health inequalities in society. He related how he was once invited to lecture at a medical school, but after his talk on health inequalities he was never invited back. His view was that medical doctors tend to reject the social sciences as being not scientific enough.
. Surely it is not hard to see how disastrous a policy based on “self-care” would be for the health of the population and therefore for the NHS budget. For example, there are an estimated twenty thousand people with undiagnosed raised blood-pressure just in Teesside. Under “self-care” these people are still assumed to be healthy, as their raised bp would only be diagnosed if they were already being treated for a condition. Their task would therefore be to remain healthy by making the right lifestyle choices. Yet, as we still do not fully understand the relationship between blood-pressure and lifestyle, (especially the extent to which factors such as genetics and stress play a role), there is great risk in this laissez-faire approach. The moral failure of individuals to make the right choices still results in huge costs for the NHS, and therefore for taxpayers, if the raised bp leads to many heart attacks and strokes. When we factor-in the difficulty for many of making the approved lifestyle choices in a time of increasing inequality (“make some time in your day to relax”), it would seem that we are courting social and financial disaster for the sake of being able to divide people into the deserving and undeserving sick.
. I think the inability of many of my fellow board members to agree with me on this is thanks to the general lifestyle drift. There is a settled view amongst many intelligent people that health is mainly about individual choice. It did not matter how much evidence I cited, I was seen as eccentric, or worse; Political. This is the answer to how we came to blame people for their own illnesses; if the Book of Job were written today, Job’s comforters would blame his boils on his lifestyle choices.
. Without in any way questioning our need for a really effective ambulance service, there enough evidence to show that some people who phone 999 for an ambulance do not need, physically, an emergency response. There is no doubt, however, that they are in a terrible state. A typical example would be an elderly person living alone who feels ill, and whose loneliness and anxiety has elevated their symptoms into panic and mortal dread. This should not be surprising; we are social and psychological beings after all.
. Possible responses to this issue require some investment, of course, though a general reduction of inequality is not relevant in this particular case, as it is in many others. As an example of what can be done, there was an experimental project in Teesside entitled “Cohort 32” which placed a number of social services key workers in the emergency services call centre, so that they were immediately available to respond to callers who were in distress but did not need a blue-light service.
. When I was briefed on this project by the excellent Public Health Director, Edward Kayunga, I chased more information about it but could never find out why the arrangement was never made permanent. After all, here was a practical arrangement which addressed a particular social problem with some success, and which could also save public money.
. It sometimes feels as if this country has become a place where good ideas go to die. Addressing our social problems, including health issues like loneliness, as well as physical issues like smoking and obesity, is much less expensive in the long run than dismissing them.