De-stress Project: GP prescriptions and referrals for depression in low income communities

Providing effective treatment and support for mental distress is a stated government aim. Within low-income communities, use of antidepressant medications is relatively high, but current strategies frame mental distress as an individual psychological problem, masking the factors that are often the root causes of suffering e.g. social isolation, unemployment.

De-STRESS project research aims to:

examine why and how people’s ability to cope with poverty-related issues has become increasingly pathologised

understand how high levels of antidepressant prescribing and use are impacting on people’s health and wellbeing in low-income communities

The lead author of the report is Dr Felicity Thomas, Senior Research Fellow on the Cultural Contexts of Health, and a Senior Research Fellow in the Medical School at the University of Exeter.

Reflecting on the archives of waiting rooms

Whether in pop culture or academic work, time and space have often been inextricably linked. Though the Waiting Times team has been thinking about temporality in ways that breaks – or at least complicates – this connection, one space that I have been thinking about recently has been the general practice waiting room.

The waiting room as an historical space

As work by the Cultural Histories of the NHS project suggests, contemporary experiences and associations of NHS waiting are often shaped by its material elements, not least the chairs and signs that populate its waiting rooms.

The work I have been doing has been to consider how such spaces and associations came to be. Much like the medical appointment, the waiting room is an historical construction. It is a space which only began to receive sustained public attention in Britain with the collectivisation of healthcare funding under National Health Insurancein 1913, and which practitioners only began to think about substantively following the creation of the health service after 1948.

The creation of the NHS was particularly important, with the removal of insurance principles or payment barriers increasing the demand on premises that had not been designed to hold large numbers of patients: many practices in 1948 were in small converted shop premises or in a GP’s house. The latter might have the dining room as a waiting area, but patients waiting outside either type of premises was not uncommon.

The NHS also made criticisms of health services a problem for central government – leading politicians to apply pressure for reform – as well as drawing much firmer lines between general practice and hospital practice, forcing GPs to think about how to distinguish themselves professionally.

The post-war settlement and the waiting room

The way that the NHS brought attention to the waiting room often meant that discussions were framed in relation to the promises of – and discontents with – what some historians refer to as the post-war settlement.

With regards to healthcare, elite practitioners and organised professional bodies like the British Medical Association had opposed the NHS as conceived by the Labour government in 1948. Among other things, they feared that state employment would result in a loss of income, professional freedom, and unmediated professional-patient relationships.

GPs in particular continued to criticise the new service into the early 1950s.

Some complained about a loss of class deference and professional status, of being treated by patients as servants or ‘suppliers of medicines’ rather than as a medical advisers or even as friends.

They also argued that, by removing financial barriers to care, the NHS created demanding and entitled patients. Patients would allegedly enter the consulting room ‘‘to tell us what is wrong and what [they] want for it’.

Manchester Guardian, 18 October 1949.

These anxieties about status and the shifting relations of medicine were played out in discussions of waiting rooms.

Reports were sent to central government departments about patients who would ‘tear out pages of periodicals in the waiting room, grind sticky sweets into the carpet, take cushions, and even carve their initials on the furniture’. One GP appealed to the Ministry of Health to make ‘it quite clear to the general public that a doctor’s waiting-room is not a place of public entertainment, but rather a place where people are expected to behave with a certain amount of respect and decorum’.

The focus on patient behaviour and deference was indicative of the class-bound anxieties of some GPs, many of whom would have previously had separate entrances and waiting spaces for private patients and those receiving publicly-funded care. No longer able to segregate their patients, some doctors were still so concerned about working class patients bringing dirt into waiting rooms that they even used interior design to prevent ‘greasy heads’ marking walls, and praised the durability of flooring to stand up to workmen’s boots.

The domestic and middle-class ideals of GP waiting rooms
Supplement to the British Medical Journal, 6 November 1954

The challenges of writing histories of the waiting room

There is still much to explore about how waiting rooms were thought about and redeveloped over the twentieth century. However, researching the subject so far has not proven straightforward.

Methodologically, I have faced problems familiar to many social and cultural historians. The “archives” of general practice waiting rooms are hardly substantial, and have been largely created or curated by medical professionals, civil servants, and media editors. Equally, their materials are predominantly composed of digressions about waiting rooms made in discussions about other topics, or are made up of complaints that reveal expectations and social norms only by their absence or negation.

The dominance of complaints from “establishment” groups, however, has also posed other challenges, causing me to reflect on my own subjectivity and affective responses to sources.

As a social historian, I share my field’s political and intellectual sympathies to histories of marginalised groups, as well as its critical disposition to power and professional self-interest. Likewise, as someone who has grown up with – and been a long-term beneficiary of – the NHS, I have been interpellated by its core ideals (if not lived practice) of universal healthcare, free at the point of use.

As a result, GPs’ grievances initially struck me as exaggerated, underpinned by a sense of superiority to patients, and indicative of an opposition to any form of egalitarianism from professionals with considerable class privilege.

Indeed, surveys conducted at the time provided some support for this reading, with one prominent medical observer noting that ‘some general practitioners are so easily irritated by such an attitude [of entitlement and lack of respect among patients] that they are apt to think it more widespread than it actually is’.

My first engagement with these materials, therefore, was to read criticisms primarily for the way they provided insight to the reception of the post-war welfare state, and for the strategic purpose the played inprofessional and political projects.

Nonetheless, further exploration and consideration has brought home the importance of maintaining critical reflection on my own subjectivity and affective responses.

Historically, it was not just doctors who were sceptical or anxious about the NHS. State provision had not been welcomed by everyone.[1] For instance, though many were quickly convinced of the NHS’s advantages, a significant proportion of the British public were initially concerned about the potential loss of ‘the personal touch’ in state-funded medicine.

Moreover, though there is a clear element of performativity in GPs’ complaints, in reading them differently I have also begun to tease out insights into the culture of the early health service – the way its proposed radicalism was filtered through inherited buildings and beliefs, the presumptive middle-class norms behind ideas of universality, and the ways that attitudes towards patients were slowly built into the very fabric of the service.

Even more varied readings are possible, ones that might reveal more about the everyday life of post-war Britain. Complaints about demanding patients, for example, could provide insight into the complexities of the psychological life of traditional middle-class groups in a period of rising affluence but concern about relative decline. Similarly, reading discussions about nailed boots and greasy heads for indicators of patient behaviour might generate insight into the changing nature of work and housing, or shifting social norms about self-presentation in public spaces, if read over time.

However, changing the way I engage with sources and the questions I ask has required more than a change in methodology or conceptualisation.

I have had to maintain an awareness of my own position in academic and political fields. I have had to reflect on how my work has been informed by my own psychological investments in the NHS and its proposed values, as well as by my attachment or critical disposition towards certain professional groups.

Of course, undertaking practices of self-reflection is not the same as striving for “objectivity”, or somehow overcoming my position as an historically-formed subject. Instead, it is to realise that a critical disposition towards the historian’s subjectivity can open up new questions and new avenues for research.

Who would have thought that even just thinking about waiting rooms (rather than being forced to wait within one) could encourage such existential questions? (Bergson, put your hand down – no-one likes a show-off.)

Henri Bergson – Philosopher, Smart-Ass, Terrible Queuing Partner

Dr Martin Moore is the historian on the Waiting Times project.

Notes

[1]For more in depth analyses, see work by Nick Hayes: https://academic.oup.com/ehr/article/CXXVII/526/625/438109. And Andrew Seaton: https://academic.oup.com/tcbh/article/26/3/424/2451908.

 

What the Papers Said – starting a public conversation about NHS waiting times

What the Papers Said: The NHS at 70 – Promises and Discontents

Earlier this year, the Waiting Times team collaborated with the Centre of Medical History and the Centre for Cultures and Environments of Health at the University of Exeter to run a public workshop to mark the 70 years of the NHS.

The aim was to use the intense interest in the service generated by the 70thanniversary to bring historical reflection on present day concerns.

The day encouraged discussion among the diverse participants, with exchange structured by three academic papers and provocations. The first, by Jonathan Barry (University of Exeter), provided insight into how the major broadsheet press treated the creation of the health service, whilst the second by Andrew Seaton (New York University), reflected on the everyday experiences of life on the wards of NHS hospitals. Among other things, these papers raised important points about the way that support from the press and middle-class users in particular was essential to securing the political future of the nascent service.

My own paper looked at the different ways that the politics of welfare and values attached to the NHS influenced patient perceptions of waiting for referrals and appointments in surgery and outpatient departments.

Of course, frustrations with waiting were often underpinned by agonising uncertainty, physical pain, and a more general anxiety about wasting time that might have been better used elsewhere.

Nonetheless, the promises of – and discontents with – the values of the welfare state and universal health care structured interpretations of waiting. For instance, for some of the newly enfranchised, queuing for spectacles was seen as the result of the egalitarian return of the repressed. By contrast, for others, waiting in outpatients for hours was seen as a failure to fulfil promises to “universalise the best”, and forced people into the arms of private medicine.

Manchester Guardian, 13 January 1953

The promise of speed in alternatives to the NHS (which is itself built on the exclusion of large-scale demand) is still an ever present in marketing campaigns for providers.

BUPA Website, c. September 2018

One issue I wanted to give particular emphasis in my discussion, however, was how the early NHS had failed to incorporate patient perspectives within its structures. The NHS was essentially created as a way to bring doctors and healthcare staff into state services and thus expand access to a comprehensive and equitable health service to all.

Official government pamphlet promoting launch of the NHS, c. 1948

Yet, although grounded in socialist and social democratic traditions (among other influences), the creators of the service paid little attention to democratic input other than through the selection of governments over election cycles.

Patients and their families rarely had direct input into the design of services in the early years of the NHS, and there were no formal mechanisms for raising complaints or providing patient perspectives until after scandals in long stay hospitals in the late 1960s and early 1970s.

Prior to then, if patients were lucky complaints about waiting might be considered institutionally, but the few internal investigations I have seen all found “no case to answer”. In such circumstances, we can see patients’ letters to the press as arising out of frustrations having no alternative route for expression.

I wanted to outline this history at the event to raise questions around accountability and inclusion that exist outside the usual managerial frames of audits and surveys. I also wanted to ask participants on the day about how we might build the local components of the NHS as democratic institutions, incorporating patient expectations into services in a way that might escape the traps of “rights and responsibilities” discourses.

Asking these questions, I believe, might have some import for our contemporary understanding of waiting. If, as my paper suggested, our experience of waiting is intertwined, at least in part, with historically-specific ideas of what is owed, then perhaps our waiting might take on a different set of meanings if those who are waiting are a part of the promise-making process.

These themes, along with many others raised by the workshop participants, will form part of an ongoing discussion that we hope to have over the coming few years.

Dr Martin Moore is the historian working on the Waiting Times project.

Patiently Waiting in the Early NHS? – a blog by our historian Martin

Whilst “wasting time”/“productively searching for historic pop culture representations of waiting” this week [delete as appropriate], I happened upon an episode of the sketch show, A Bit of Fry and Laurie from the early 1990s. In one of their “talking head” parodies, Hugh Laurie’s character comments:

“Well, we had our first child on the NHS. And had to wait nine months…

…Can you believe it?”

 

At the risk of proving E. B. White correct (and ‘killing the frog’), on the surface the joke played upon well-known durations of pregnancy, and invites us to laugh at the commentator’s ignorance.[i] The skit, however, also lampooned a certain type of caricatured middle class NHS user: one who approached health care with consumerist expectations, and who was prone to making (in this case, unreasonable) complaints about public service inefficiency.

The sketch, in other words, was a response to changing popular and parliamentary approaches to health care.[ii] As Sally Sheard and Alex Mold (respectively) have demonstrated, political and managerial attention to health service waiting undoubtedly intensified during the 1980s and early 1990s, and the period witnessed an individualisation of patient consumerism more generally.[iii]

Yet, as early Waiting Times research is showing (and as suggested by the ageing Laurie’s character), patient dissatisfaction with delays and waiting had been a feature of the NHS since its beginning.

During the late 1940s and early 1950s, for instance, Britain’s newspapers carried numerous letters from patients discussing their experiences of waiting for consultations in general practice and hospital outpatients, as well as deploring the waiting lists for hospital appointments, admission, and treatments.

Patients attending for consultations described waiting as ‘irksome’, ‘inconvenien[t], and ‘endless’.

Most did not explain why they were displeased at this wasted, interminable time, perhaps assuming the reasons to be obvious. However, we can find glimpses.

Some correspondents hinted that frustration arose from misaligned public and private schedules. They had multiple personal and social responsibilities, and time became an economic resource: time spent waiting was time taken away from other tasks.[iv]

There were, however, more symbolic concerns. The prioritisation of medical time over the patient’s own was a source of irritation, especially when subsequent encounters were depersonalised.

‘Outpatients at hospital’, Manchester Guardian, 3rd January 1953

Complainants often criticised the self-interestedness of doctors for appointment system failures and expressed dismay at clinicians for arriving late.

Yet, even when the doctors were considered courteous and blameless (with administrators were positioned as the villains of the piece), correspondents suggested that the squalor of public environments of waiting compounded their physical and psychological distress, and made their experiences almost unbearable.

 

‘Outpatients at hospital’, Manchester Guardian, 3rd January 1953

Of course, early patient responses to waiting also varied.

As with newspapers and political parties, some letters linked their quotidian experiences to broader political points.[v]Letter writers and Mass Observation respondents both echoed public narratives that queues were either the inevitable result of iniquitous, incompetent socialism, or temporary, and signs of egalitarian health care extending to persons previously priced-out of access. Others were tentatively resigned to waiting simply being a part of mass medical practice.

Yet, whether incensed or accepting (or simply mildly irritated), the vast majority of correspondents to publications and surveillance machinery, offered possible solutions.

Commentators suggested disaggregating appointments (rather than block booking everyone for the start of the clinic) and providing better information on the order of patients to be seen, as well as suggesting that waiting patients ‘equip themselves with a book or piece of knitting’ (‘it seems only common prudence’).[vi]

Like the Doctor looking for a fez, one correspondent seemingly got a little carried away in their endeavour, suggesting: ‘the waiting period should be made more pleasant by decorating the walls more attractively, better use of light, plenty of up-to-date magazines, books etc., flowers and pot plants, even an aquarium or small aviary, but most of all an air of cheerfulness and efficiency about the place.’[vii]

Although likely containing only the viewpoints of a very specific subset of the general population, these letters and survey responses thus offer considerable insight into waiting in the early NHS.

They shed light into the power dynamics at play in British medicine (for instance, whose time was prioritised). They highlight how modernist drives to “synchronise” individual, public, and institutional time had ordered the lives of mid-century patients and practitioners, but caused psychological distress when disturbed.[viii]

They also offer a glimpse into the longer history of quotidian experiences of waiting as slow and endless, and demonstrate the importance of comportment and environment to such perceptions.

Crucially for our appreciation of ‘80s and ‘90s sketch shows available on popular streaming services, however, they also underscore how political opposition to public services, and complaints about waiting in them, are as old as the services themselves.

Dr Martin Moore is the historian working on the Waiting Times project.

Notes

[i]White reportedly said: “humor can be dissected, as a frog can, but the thing dies in the process and the innards are discouraging to any but the pure scientific mind”. Those innards would likely be purchased by high-end restaurants and served on a bed of puréed dreams, now, however…

[ii]The show itself was well-known for lampooning older traditions of conservative morality, as well as what were then termed “Thatcherite” views of business and national services. It once suggested that Mrs Thatcher herself could be easily replaced by a coat hanger (to the nation’s benefit), and satirically created its own “Comedy Charter”, ‘a basket of top proposals’ to enable the viewer to complain and thus maintain the show’s quality and standards. The latter was a conscious play on the spate of such documents that followed John Major’s “Citizen’s Charter”, one of which was a “Patient’s Charter” that included minimum waiting times for patients.

[iii]S. Sheard, ‘Space, place and (waiting) time: reflections on health policy and politics’, Health Economics, Policy, and Law, (Early Access Online); A. Mold Making the Patient Consumer: Patient Organisations and Health Consumerism in Britain, (Manchester: Manchester University Press, 2015).

[iv]G. Horobin and J. McIntosh, ‘Time, risk and routine in general practice’, Sociology of Health and Illness, 5:3, (1983), 312-31.

[v]J. Moran, ‘Queuing up in Post-War Britain’, Twentieth Century British History, 16:3, (2005), 283-305.

[vi]B. M. Fleming, ‘Hospital out-patients’, Manchester Guardian, 13thJanuary1953, p. 2.

[vii]H. Sumerfield, ‘Out-patients at hospital’, Manchester Guardian, 8thJanuary1953, p. 4.

[viii]B. Adam, Timewatch: The Social Analysis of Time, (Cambridge: Polity Press, 1995); Jacques Le Goff [translated by Arthur Goldhammer], Time, Work and Culture in the Middle Ages, (Chicago: University of Chicago Press, 1980).