Prof Dame Clare Gerada, one time chair of the Royal College of General Practitioners, now co-chair of the NHS Assembly, has been touring the BBC radio studios, trying to introduce some nuance into the debate about the huge rise in work absenteeism due to mental health conditions. Mel Stride, Work and Pensions Secretary, has made the point that many such conditions are being overdiagnosed, and that the normal vicissitudes, the ups-and-downs of daily life, are being mistaken for pathology. One can see how a discussion like this tends quickly to become polarised. On the one hand, we have the stiff upper lip party. Don’t be a snowflake. Pull yourself together, pull your socks up, and just get on with it. On the other hand, we have the “It’s okay not to be okay” party. If you are struggling, seek help. There is no stigma. It’s good to talk.
Clare Gerada had some sympathy with Mel Stride’s point of view. She felt that overdiagnosis was to some extent an import from the USA. She quoted “conditions” like loneliness, homesickness, and shyness. But in any case, whether you are just lonely, or whether you are clinically depressed, in most cases you are much better going to work. The worst thing you can possibly do for a twenty-year old with a mental health problem, is to sign him, or her, off long term. In other words, at least from the point of view of the capacity to work, the diagnostic issue is merely a question of semantics.
Yes, said Jeremy Vine (BBC Radio 2), but was the massive increase in numbers of people affected, particularly among the young, actually real? After all, he said, the suicide rate overall is if anything slightly lower than it was 20 years ago. “Burnout” is on the rise. But Clare Gerada pointed out that burnout has been around for over 100 years, first appearing in the medical literature about 1910. Yet in some cases, an epidemic of mental illness appears to be real. Brian Dow, chair of the charity Mental Health UK, pointed to the extraordinary rise in eating disorders amongst young women. That is real.
So the debate has developed this narrative. Why are so many people off work? Are they really sick, or are they “throwing a sickie”?
But there’s another way of looking at this, which doesn’t generally seem to have been picked up on. Maybe the problem isn’t with the workforce at all; maybe the problem is with the work. Maybe people are exhibiting “work refusal” because the work place has become such a toxic environment. The deterioration in the workplace certainly drove me, at long last, to refuse to go to work. Not that I got a sick note, or a “fit note”; I just retired. But then I was lucky to have that option. Roughly from the start of the new millennium, I could see the way that the purveyors of, and traffickers in, information technology, had infiltrated my profession and taken over its governance. Within a remarkably short timeframe, all business taking place within the general practice consulting room was conducted through the prism of the computer screen. We became paper-light, then paperless. The patient record, the laboratory investigations, appointments, and GP-consultant correspondence, all became virtual. This took place during the noughties around the time of the new GP contract. This defined a Quality and Outcomes Framework (QOF) that dictated the hurdles a GP needed to leap, or the hoops she needed to pass through, in order to satisfy the criteria for remuneration. A series of pop-up menus dominated the computer screen, reminding GPs of the tasks required to be undertaken. They might include documentation of smoking status, fulfilment of targets, say, with respect to cholesterol or BP control, and frequency of medication review. Initially, the targets were pretty easy to attain and optimal remuneration pretty easy to achieve. Then things got more complex. Gradually, the third person in the consultation room, the computer, took over the consultation, which became dominated, not by the patient’s agenda, not even by the GP’s agenda, but by the computer’s agenda. Who devised this agenda? Down at the coal-face, we never really knew. But if the overseers were medical, they had bought into the IT model of patient care.
Next up, “Whole Systems Working”, a series of table-top exercises generally concealing a hidden agenda, such as the perceived need to cut down GP-hospital referral rates.
Within a decade, the entire modus operandi within general practice had shifted from the traditional model of the medical consultation – history, examination, targeted investigation, diagnosis, formulation, and management, to the imposition of a series of algorithms which rarely bore any resemblance to any real clinical presenting complaint, and the way it might be approached in a caring and compassionate way. I hated it. I fashioned a sign and stuck it up on my office wall: The QOF must be destroyed. Then I got out.
I’m a little out of touch now, but from talking to ex-colleagues I don’t think the situation, either in general practice or in hospital is any better. The “junior doctors” in England are perpetually on strike, or about to strike, and apparently the dispute is all about money. But I suspect the discontent goes much deeper than that. It is a humane and natural response to the dystopian work environment we have created in the twinkling of an eye.
I don’t know, but I suspect something similar is happening in many other walks of life where IT has established itself, like a cancer, deep within our systems and has dehumanised the workers by making them stare at a computer screen all day, not allowing them to interact with fellow human beings in a normal and compassionate way.
At work, I was never so happy as when the computers crashed. For a brief interlude, we were allowed to establish eye contact with our patient, and get on with our job. You need very little technology to conduct an effective medical consultation. Okay, the MRI scanner needs a computer, but keep it in the back shop. Out front, all you need is a quiet room, a handful of simple devices such as a stethoscope, BP cuff, tendon hammer, and ophthalmoscope; some knowledge, skill, and wisdom, and an abundance of tender loving care.
jamescalumcampbell 