Paganism reduced to its essentials is the worship of idols. It is usually talked of as primitive religion. The concrete idol acts as intermediary between the mere human and the divine. These idols can be anything from naturally occurring items in the physical environment such as trees, rocks, the sun or moon or the items can be fashioned artefacts such as masks, dolls, or what the French refer to as fétiche. So, the idea goes that the primitive person cannot grasp the divine without intercession, without a concrete image. And, the major religions did away with this. That is, at least, the theory but it is very far from the truth. All you have to do is enter a Catholic church and the images of Christ on the crucifix or of Mary the mother of God will dismiss the idea that paganism is flourishing only in those places far from the epicentre, from the metropolis, in some backwater somewhere. These are pure idols.
I want to argue that paganism, fetishism flourishes in the most unexpected places. That taking the token for the thing itself, that valorising the token (for that is what idolatry and paganism is) is everywhere in the modern world and that it is at its most rampant in healthcare, particularly in the NHS. Our fetishistic attachment to bureaucratic forms, to meaningless certificates and awards, to grades and audits, to numbers as purveyors and icons of excellence, all these in my view are part of the new paganism.
The new idolatry has evolved out of the desire to have accountability systems in place within the public services. But, these systems have been perilous for the NHS as for other public services. Onora O’Neill in her Reith lectures wrote
‘Perhaps the culture of accountability that we are relentlessly building for ourselves actually damages trust rather than supporting it’. And, ‘The new accountability takes the form of detailed control. An unending stream of new legislation and regulation, memoranda and instructions, guidance and advice floods into public sector institutions. For example, a look into the vast database of documents on the DOH website arouses a mixture of despair and disbelief’.
She goes on
‘I think that many public sector professionals find that the new demands damage their real work. Teachers aim to teach their pupils; nurses to care for their patients….Each profession has its proper aim, and this aim is not reducible to meeting set targets following prescribed procedures and requirements’.
Furthermore, she says
‘Much of the mistrust and criticism now directed at professionals and public institutions complains about their diligence in responding to incentives to which they have been required to respond rather than pursuing the intrinsic requirements of being good nurses and teachers, good doctors and police officers..’
And Onora O’Neill understood the pernicious influence of the accountability systems on trust. She quotes Samuel Johnson
‘It is better to be cheated than not to trust’
My topic is ‘trust’. How what Michael Power has termed the ‘Audit Society’ actually damages trust and in turn damages the basis of society, the compact we form one with another. There are innumerable systems of verification, pathological rituals of verification that have come to cripple the smooth running of public services and have more or less dealt a fatal blow to the healthcare system. Many people are not alive to the lethality of the wounds sustained by the healthcare system.
‘The Labor government’s new Commission for Health Improvement (aka CQC in present incarnation) perfectly illustrates my concept of ‘control of control’, whereby high-level organizations are created to check on lower-level checking processes’.
It is obvious that these arrangements are not designed to identify error but merely to produce comfort and reassurance as the events in Stafford show and the Francis report accurately demonstrate and as the current investigations in the North West also underline. The point that Power is making is that ‘Accounts only become objects of explicit checking in situations of doubt, conflict, mistrust and danger’. In ordinary times, accounts seem to serve an assurance role only, so that even when there is substantive poor performance as there was in Stafford, audit systems can give the all clear. Power goes on ‘Trust releases us from the need for checking’ and ‘The more one thinks about it, the more apparent it is that the imperative ‘never trust, always check’ could not be a universalizable principle of social order’.
‘The audit society is a society that endangers itself because it invests too heavily in shallow rituals of verification at the expense of other forms of organizational intelligence’. Yet this conclusion is yet to be understood by those in authority. The actual seeing of patients in the NHS is accompanied by elaborate form filling whose central purpose is part of a verification system that is at most tangentially related to clinical care. Indeed these administrative/bureaucratic systems which started of as a token of the clinical care of patients have metamorphosed into the thing itself, this despite being only tangentially reflective of the actual clinical care. In short the token has come to be taken for the thing itself. And there is a whole army of people whose purpose in life is to serve these systems, to worship, as it were, these idols. Without much notice we have the new idolatry, the new paganism with all the accoutrement of religion: temples, acolytes, priests, liturgy, rituals and sanctions. In the event of breach of sacred rites there is always the risk of excommunication!
At the heart of all of this is low trust and regulatory overkill. And, yet we cannot do without trust. Every time we drive down the road we have to trust that all other road users know what they are doing, that they are licensed to drive, that the authorities have designed the roads with safety in mind, and that the car and all its component parts is safe. The kind of regulatory overkill that we have instituted in healthcare would totally kill off traffic: imagine having to fill a 25 paged form in every time you got in a car, and having a troop stop everyone every mile to confirm that the car is as it ought to be and so on. Well that is the system that we have created in healthcare. But, if only that was the sole damage being caused. But, alas it is not.
Francis Fukuyama in his book on Trust wrote
‘Trust is the expectation that arises within a community of regular, honest, and co-operative behaviour, based on commonly shared norms…That is, we trust a doctor not to do us deliberate injury because we expect him or her to live by the Hippocratic oath and the standards of the medical profession’.
He continues quoting Kenneth Arrow
‘Now trust has a very important pragmatic value, if nothing else. Trust is an important lubricant of a social system. It is extremely efficient; it saves a lot of trouble to have a fair degree of reliance on other people’s word. Unfortunately this is not a commodity which can be bought very easily’.
And he concludes
‘There is usually an inverse relationship between rules and trust: the more people depend on rules to regulate their interactions, the less they trust each other, and vice versa’
The upshot of all of this is that the society we have created, this one that we now have, with its new paganism, it bureaucratic fetishism, is decidedly unhealthy, is at variance with the desire for a compassionate workforce, is definitely noxious in effect if not in intent. This week we have had the Secretary of State for Health make pronouncements about nurse training, about compassion, and about a legal duty of candour. But the fundamental desire for clinicians who hold the imperative of responsibility as their beacon is not likely to occur without an analysis that recognises what it is that has gone wrong. Not that the diagnosis has not been made several times over and communicated.
Finally, Hans Jonas in The Imperative of Responsibility wrote
‘The first and most general condition of responsibility is causal power, that is, that acting makes an impact on the world; the second, that such acting is under the agent’s control; and third, that he can foresee its consequences to some extent’. In this model, Hans Jonas is describing how responsibility and accountability connect. In healthcare, the clinicians no longer have causal power and their authority for the integrity of the work environment has been markedly constrained. Hence the correspondence between responsibility and accountability has become tenuous if not fractured.
In conclusion, Jonas says
‘The well-being, the interest, the fate of others has, by circumstance or agreement, come under my care, which means that my control over it involves at the same time my obligation for it. The exercise of the power with disregard of the obligation is, then, “irresponsible”, that is, a breach of the trust-relation of responsibility. A distinct disparity of power or competence belongs to this relationship. The captain is master of the ship and its passengers, and bears responsibility for them’. In our case, the captain is not master of the ship or of its passengers.