The wrong battle

Much as I truly admire Lucy Johnstone and her work (September issue), I do sometimes wonder if she is fighting the wrong battle. When the anti-psychiatry debate kicked off in the sixties and seventies it was great fun and led to much creative thinking in the whole mental health field. One might speculate that the biological vs contextual debate reflects the age-old nature vs nurture dispute about the essence of human personality and behaviour. If so, it is likely to run for a good while yet.

However, since the Thatcher era another conflict has been going on in the NHS, largely unnoticed in the psychology literature, which is probably of far greater importance. Following the 1989 Working for Patients reforms a wave of managerialism was let loose on the NHS. Utilising a neo-liberal worldview, mandated not by argument but by electoral success, traditional caring values were replaced by efficiency, value-for-money, accountability and throughput. Although the rhetoric talked up the power of markets and competition, the overall effect was to empower the (non-clinical) managers and to de-professionalise those at the front line. Clinical staff now find their room for decision-making, even at the level of individual patient care, seriously curtailed by managerial commands. One common example from my career was the injunction to limit psychotherapy sessions. Further examples would be the (management) demand that clinicians spend hours of their valuable time filling in forms and attending pointless and redundant meetings.

It turned out that the alternative to the bio-medical model was a long, long way away from patient-centred care.

If I remember rightly, one of the promises of managerialism in its early days was that it would take power away from the small bunch of medical consultants who reputedly ran hospitals and distributed their merit awards in a secretive fashion. In its stead we were promised change, openness and freedom from stultifying medicalism. The new NHS would let a thousand flowers bloom. Many non-medical clinicians embraced managerialism, or at least went along with it, because of this. And so, the power of the medical establishment was shattered. Sadly, it turned out that the alternative to the bio-medical model was a long, long way away from patient-centred care. Maybe we should have been careful about what we wished for.

I would suggest that the triumph of managerialism in the NHS is a matter that we should all take seriously. Whilst the psychiatry vs anti-psychiatry debate has led to new ideas and changed some practices, the rise of managerialism has been accompanied by no debate, no resistance and no new creative ideas. It came along as government policy, and as that government was democratically elected, managerialism had a sense of inevitability about it. It was just the way things were going to be from now on. The results we can see around us. A demoralised workforce, mountains of paperwork, a deluge of trendy and often contradictory initiatives and, inevitably, a failing health service. Rising above it all we see a lordly class of managers – sometimes ex-clinicians, sometimes professional managers – whose working lives keep them insulated from contact with the stress and distress of face to face work with patients.

There is clearly a need for good management in the NHS, but in the limited role as supporter and enabler of those working at the clinical sharp end.

Paul Whitby,
Market Lavington