Is there a psychic epidemic in the NHS?

C.G. Jung not only provided therapy for individuals, but also for religions, cultures and societies. From his analysis of two world wars and the emerging cold war, he identified the psychic epidemic as one of civilisation’s ills.

On 26/27 April 2016, NHS Junior Doctors will be on all-out strike.  This will include the withdrawal of support for emergency care and sick children. The dispute is complex and has been going on for several years. In this article, I’m not going to focus on the nature or complexities of the dispute itself, but on how each side has dealt with the conflict. The ongoing failure to resolve the dispute is not due to disagreements over particular points.  It is the result of a psychic epidemic, which is something that is much deeper and more difficult to resolve.

Background

The term “junior doctors” is a bit of a misnomer. They are fully qualified doctors who are the backbone of one of the most important services – perhaps the most important – in the UK: the National Health Service (NHS).  They often work incredibly long hours, and make life-and-death decisions on a regular basis.  To get to that position, they have worked hard from a very young age.  The entry requirements for medical training are high.  It is only open to the brightest students who have worked their way through school to achieve perfect, or near-perfect, qualifications.  The medical training is longer and harder than most – typically 5 years of intense academic study.  Thereafter there is a much higher level of on-the-job training than in most other occupations.  The vast majority of doctors are motivated by altruism.  Their job is one of the most challenging of all occupations.  And more than half of them suffer from stress as a result.

On the other side of the dispute are the employers and the government.  Their responsibilities are to provide the planning, infrastructure, funding, and resources that enable the doctors to do their job.  Although they do not have same challenges and stress as the doctors, they nevertheless do have challenges and difficult decisions to make.  The pressure on the NHS is increasing due to an aging population.  This is a double whammy because it not only increases the demand for health services, but also reduces the money available to spend on it.  Furthermore, the UK’s current financial position is far worse than it should be, due to decisions taken by the labour government in 2000/2001.  In what he later admitted was a mistake, the chancellor Gordon Brown claimed he had ended boom-and-bust – i.e. the economic cycle.  This left him free to increase public spending rather than reduce debt. The graph below compares the UK’s actual public spending (red line) and what it would have been if spending plans had taken account of the 10 to 15 year economic cycle.

Some of this increased spending was productive – e.g. refurbishing school buildings.  However, much of it was wasted – e.g. simply paying more for the same services.  This was through higher salaries or employing more people than is necessary for the same level of output.  They also expanded tax credits which, in effect, subsidised private employers.  This had the long term effect of suppressing the contribution of the private sector.  It also made the UK economy more dependent on the government.  This was unsustainable in the long term, even without the banking collapse in 2008, because the private sector is the origin of most of the government’s money.  Despite the attempts to bring public spending under control, we still have:

• the second highest external debt in the world (£45,000 for every man, woman, and child),
• the 20th highest government debt (as a percentage of GDP).
• approximately £1.7 trillion of public debt (£27k per citizen, £47k per taxpayer)
• we are still adding to that public debt at the rate of £1.3 billion per week.

Although there are many other aspects to the junior doctors dispute, the summary above identifies one of the big issues.  Both sides are under significant pressure – though, different types of pressure.  The doctors are having to work longer hours to meet increasing demand, but the employers and government are having to provide increasing support to the health service when – as the outgoing labour treasury secretary noted in 2010 – there is no money left.

Is there a solution?

In analytical psychology, as in many other approaches to conflict resolution, the primary focus is on finding a win-win – a solution that meets the needs of both sides.  The government have ring-fenced health spending, and are actually increasing it whilst other departments are being cut.  Nevertheless, a slightly bigger health budget is insufficient to meet the rate of increase of demand.  Even if spending were to be increased further, it doesn’t relieve much of the pressure on the NHS because there is a significant and increasing shortage of doctors.

The government’s solution to this is the “7-day NHS” – something that the medical profession have themselves been working towards since at least 2011.  At present, routine operations are carried out mainly on weekdays, with other services such as intensive or emergency care continuing through the weekend.  To illustrate how a 7-day NHS could relieve the pressure on both doctors and the government, consider this simplified scenario:

• There are 4 hospitals providing routine operations for 5 days a week, therefore providing a total of 20 ‘hospital days’ per week (4 hospitals x 5 days).
• Demand is going to increase by 25%, to 25 hospital days
• Therefore, another hospital is needed, with 25% more doctors who will work the same long hours as the original doctors.

If the hospitals move to a 7-day week for routine operations, it changes the statistics quite dramatically:

• There are 4 hospitals providing routine services for 7 days a week.  With the current number of doctors, they are still providing 20 ‘hospital days’, but spread more throughout the week.
• When demand increases by 25%, to 25 hospital days, this can be met within the current buildings, for which the maximum capacity is now 28 hospital days (4 hospitals x 7 days).
• To meet the extra demand, therefore, they don’t need to build another hospital.  All they need to do is recruit 25% more doctors.
• With the money saved on the building that is no longer needed, they can now recruit doctors above that 25%.  This means that all doctors (both existing and new recruits) can work fewer hours.

NB: this financial argument only works if, when the existing working hours are redistributed throughout the week, the overall bill for junior doctors remains the same for that same amount of work.  Otherwise, the additional ‘unsociable hours’ payments would wipe out a lot of the financial saving and prevent the recruitment of more doctors.  That is, suppose (in the above simplistic example) unsociable payments are double-time.  This means:

• When that same amount of work is distributed over 7 days, the bill goes up by 2/7ths  for the same 20 hospital days (as two days are paid double time).
• This is roughly a 29% increase in the wage bill, for the same 20 hospital days of work.
• This wipes out the 25% efficiency savings on the buildings, which could otherwise have been spent on more doctors.

As a result, fewer doctors would be recruited, so the existing doctors would work longer hours.  The doctors would also earn a lot more, but very few want this. 90% would rather forego some salary to achieve a better work-life balance.

The 7-day NHS is a radical but effective solution to several problems.  It enables more doctors to be recruited.  It reduces the working hours of existing doctors.  It relieves the financial stress on the NHS.  It is something that the government want.  It is something the electorate want (having been part of the Conservative election manifesto).  And for several years it has been something the medical profession have themselves wanted.

So how has it all gone so wrong?  Why are altruistic doctors going on strike and withdrawing all forms of care, including from emergency services and sick children?

A psychic epidemic

The Observer have identified some of the mistakes made by the government in these negotiations, but they also point to mistakes made by the GMA (the junior doctors’ union).  They note that the two sides are not very far apart, yet agreement cannot be reached.  Sarah Wollaston – who has been a GP and is now an MP – argues that both sides have lost sight of the patient.

From the perspective of analytical psychology, we have reached the point where conscious reasoning has been overwhelmed by collective unconscious forces – i.e. there is a psychic epidemic.  This is one of Jung’s terms that hasn’t caught the public imagination as much as others – such as complexes, archetypes, extraversion, introversion, etc. Nevertheless, it represents an important theme that runs throughout much of his critique of the relations between groups and societies.  The term ‘psychic epidemic’ describes the behaviour of a group or society that is driven more by shared psychological factors (i.e. unconscious archetypes) than real problems.

If the term is applied to the NHS junior doctors’ dispute, it does not mean there are no real problems.  On the contrary, there is widespread recognition of the major challenges faced by the NHS.  But a psychic epidemic is an emotionally-driven and dysfunctional response to those problems.  Rather than searching for the best solution, “the driving forces of a psychological mass movement are essentially archetypal” (Civilisation in Transition, §474).  In simple terms, they are shared, powerful, and infectious emotions that cause one to lose sight of the realities in the situation:

Archetypes attract energy and influence a person’s functioning… Archetypes carry a strong, potentially overpowering charge of energy which it is difficult to resist…  Archetypes arouse [emotions], blind one to realities and take possession of will. (A Critical Dictionary of Jungian Analysis, p. 26)

Symptoms

In a psychic epidemic, people in the group think they are being rational. But what is actually happening is that they are responding emotionally and unconsciously to the archetypal image rather than the external reality.  The sides involved in a psychic epidemic may exhibit some or all of the following characteristics:

1. Polarised or split between seemingly unreconcilable differences.
2. Emotional judgments and distorted reasoning.
3. Very selective and one-sided presentation of facts (if presented at all).
4. Focused intensely on particular individuals.
5. Expressed in extremes, associating good with one person/group and evil with another.
6. Is unable to listen to and summarise the valid aspects of the other side’s argument.
7. Similar behaviours or emotions are expressed spontaneously by large groups of people.
8. There is a lack of awareness that they are being swept along by collective emotion.

Psychic epidemics are not rare.  Jung was of the opinion that “the political mass movements of our time are psychic epidemics” (Civilisation in Transition, §465).  He saw one common source as being “politicians and journalists [who can] unwittingly let loose psychic epidemics on the world” (Alchemical Studies, §54).

Evidence

We can see most of the above characteristics in the current junior doctors’ dispute:

1. Some observers suggest that neither side wants to settle the dispute, they would rather fight it out. The BMA, for example, are using the dispute to combat the wider economic austerity programme.  They have called for support from other unions (which is illegal in UK trade relations law) to help doctors achieve “the first real crack in the entire edifice of austerity in the UK”.
2. As one example amongst several of distorted reasoning, the junior doctors used the slogan “not fair, not safe” during the last strike. However, the government also have safety as a priority.  The GMA and employers reached agreement on safety during the ACAS talks, and the junior doctors were told about it in a letter.
3. The presentation of facts has become a central battleground in this dispute – particularly concerning the mortality rates associated with the weekend effect.  The facts are not driving the debate, they have become pawns in the battle – each side using the same facts to defeat the opponent.
4. There has been an intense focus on the character of Jeremy Hunt (UK Secretary of State for Health) even though, for example, the argument about mortality at weekends had its origins elsewhere.  (See the recommendation, particular para 6 on p. 4, to move to a 7-day NHS made by medical and patient representatives to Jeremy Hunt in 2013.) Hunt has been accused of lying, manipulation, incompetence, and more.  He is reported to be the most hated politician in the UK.   An online petition calling for his resignation or removal acquired over 125,000 signatures (more than twice the number of junior doctors!).
5. The extremes of language are illustrated by the BMA deputy chair’s comparison of the Conservatives with the Nazis.
6. This criterion – of being unable to summarise the other side’s argument – is difficult to assess.  There is evidence that some some junior doctors understand what the government is trying to do, but their voices do not seem to be prominent in the debate.  On the other side, the government have misjudged the feelings and views of junior doctors. For example, at the same time as announcing the imposition of contracts, they also announced a review of junior doctor morale. Predictably, this has not gone down well.
7. The ‘collective’ emotion and behaviour has been in evidence in some of the strike picket lines.  It is an example of participation mystique which creates a feeling of unity that causes careful, conscious reflection to be suspended.
8. The final criterion – of awareness of the collective emotion – is also difficult to assess.

Treatment

C.G. Jung saw the causes of psychic epidemics as being the “complete breakdown of all conscious hopes and expectations” (Civilization in Transition, §468).  It produces “mass-suggestions against which the individual is defenceless” (§469).  As a result, “the group… has no freedom of choice, and so psychic activity runs on in it like an uncontrolled force of nature.” (§471).

It is easy to see how the hopes and expectations of the junior doctors have been destroyed.  Their motives are the most noble – the well-being not only of their patients but also society at large – but it seems that the government is preventing them from fulfilling that goal.  Yet the government are on the same side, seeking to support the NHS without bankrupting the country.  They are each dealing with the same problem, but from two very different sides.

To resolves difficult situations such as this requires good teamwork – constructive, creative, and collaborative problem solving on all sides.  However, the psychic epidemic has resulted in the opposite – a polarisation between them and a breakdown of relationships.  One of the key failings of the government has been their inability to explain how moving to a 7-day NHS increases the funding available to spend on doctors, which will then mean that doctors can work fewer hours.  They have based their primary argument on a different reason – mortality rates – which has fuelled the debate rather than winning the doctors over.

The treatment of a psychic epidemic, in Jung’s view, was to find someone in a position of significant influence “who can emancipate himself from the grip of the collective… extricating himself from that fatal identity with the group psyche” (Civilization in Translation, §471).  That person then needs to take responsibility for the process of communication, removing the heat from the exchanges, and providing enough information so that the misunderstandings, speculations, and distortions that fuel the epidemic are also removed:

“The officials in possession of authoritative information should not hesitate to enlighten the public as speedily and thoroughly as possible [rather than allow] a lot of fantastic and mendacious publicity to run riot – the best possible preparation for panic and psychic epidemics” (The Symbolic Life, §1440).

Is there a psychic epidemic doctor in the house?  Sadly, there doesn’t seem to be anyone in a position of influence who is either able or willing to answer that call.  As a result, it seems that the government and the doctors are going to carry on trying to beat the living daylights out of each other.  And, in the process, it is the patient who is going to suffer.