Issue 213 of SOCIALIST REVIEW Published November 1997 Copyright Socialist Review

Feature article: Stress fractures

Jonathan Neale speaks to a mental health nurse about the pressures of working in the NHS

Ian works nights in a mental hospital. One night some patients were watching the BBC and it announced mental patients were being sterilised in China. The patients were very upset. One young man was really anxious, so Ian did what any good nurse would do and took him aside for a chat. During the chat Ian and the patient drew up a petition to John Major he was prime minister then asking him to publicly condemn the Chinese government action and to reassure them he wouldn't do it here.

The patient took the petition around the other patients and all but one signed. Ian took it round the staff. That was a different matter. There were some he really had to argue with.

Ian knew the problem was the 'medical model' which pervades mental care. This model says that major mental illness is caused by faulty genes. You can't cure it, so the best you can probably do is give people drugs to take the edge off the pain and fear.

But, of course, if major mental illness is caused by faulty genes, then sterilisation makes a lot of sense. That's what was going through the minds of the staff who didn't want to sign the petition.

Ian doesn't think it's genes. He thinks it's capitalism. He's not dealing with mad axemen, he says. He's dealing with the consequences of a mad axeman. His job is to put sticking plasters on axe wounds, but nobody's taking the axe away.

After all, there are no millionaires on Ian's ward, and very few middle class people. Even though the ward draws from a very 'nice' part of Oxfordshire most of the patients are low paid or on benefits.

Sometimes it's harder for the middle class patients, though. They have farther to fall. There was one man Ian really felt for. He had a high flying job, part of a dog eat dog world, and he was the dog that got ate. He lost his job and then his relationship. He put a brave face on it in hospital. But when he got out, facing a lifetime on benefits, he killed himself.

It's extraordinary how working class people usually just endure all the shit life throws at them.

You can see at admission that 'madness' is not an individual thing. Very often it is people's families or relatives who bring patients in because they can't cope. That whole family needs help, not the one person.

There are therapists around who agree with Ian, and some doctors. He worked with a consultant once who practised 'family systems' therapy. Working with her, they still used the drugs trolley a bit to help people over the hairy bits. But mainly they talked to the patients.

Talking takes time. And time is money. Money the government doesn't want to spend on workers in fear and pain. On Ian's ward they have three nurses on a shift for 24 patients. One of the main ways you get into hospital is when you might kill yourself. So if you have one patient at high risk and three at medium risk, there's two nurses just watching people. If you're the one left and a patient is getting really anxious, you can sit down with her for an hour and start to unravel the complex history and web of pain that's brought her to this moment. If you do, after 20 minutes, just when she's finally opening up, just when she's at her most vulnerable, somebody's going to call you to sort out some other mess.

So you give her a pill.

There are family therapists in the adolescent unit, and sometimes in the hospital. But not many it's really labour intensive. And none once you get a diagnosis of major mental illness such as schizophrenia or depression. Because that's caused by your genes.

A lot of families and some patients are relieved by the diagnosis. It's only a word, but at least it's some kind of handle, some kind of understanding. For others it's crushing. The consultant tells them, calmly, with kindness and authority, that they are schizophrenic, it's in their genes and it's for life. Some people despair.

And if Ian asks the consultant, 'What's the problem?' and the consultant says, 'He's schizophrenic,' Ian's none the wiser. But if Ian asks the mum and she says, 'He stays up all night, he never cleans his room and he keeps trying to strangle the cat,' then Ian knows what he's dealing with.

A lot of Ian's work is dealing with anti-social behaviour. The people who get kept in hospital the longest are the ones who don't think they're ill and don't want to be cared for. They also create the most anxiety in the staff and other patients. The people who want to be in hospital keep getting hustled out.

That's because of the pressure on beds. Oxford used to send people out of the county or to private hospitals. Now that's being cut. But it seems to Ian the main problem is that the stress 'outside' is getting worse, so more people can't cope. So there's more and more pressure on the beds. You don't make people well. You look around the ward and pick the least sick people and send them home.

And the moment of discharge is very tricky. The patient is frightened of what's out there, of not being able to cope. The staff have to push, just when they should be most gentle. Somebody more desperate needs the bed.

And one of the saddest things, for Ian, is that so many people want to stay in a mental hospital amid all that unhappiness rather than go back to what they face in this society.

Right after the election in May things went very quiet and the pressure for new beds eased. Now the pressure is rising again. The pressure gets to the staff. There seems to be more and more sickness. Everybody knows it's because staff can't cope, can't face the day.

Staff can't see any alternative. Years ago, when they opened the doors of the institutions and emptied the big old mental hospitals, there was hope. You could think that the asylums were the problem and care in the community was the solution. Now everybody knows that didn't work. They don't know what will. And staff are frightened. They're frightened of losing their jobs. It's not a very realistic fear because of the shortage of nurses. But it's there. The institution makes staff frightened and conservative. The instinct is to avoid trouble, risks, disaster. So staff worry if patients have sexual relationships. They worry if they think patients are taking drugs. They cover their backs because the consultants and hospital management are conservative.

There are younger medical staff who don't agree with the usual way of doing things. But the consultants control their promotion prospects pretty tightly. All in all, the surprising thing is how much people keep trying, how much kindness staff manage. But the way to fight fear isn't really to argue about mental illness. The way to fight fear is to unite the staff against the management who frighten them.

Ian's the senior Unison steward and a socialist in the hospital. They've got a number of really good stewards now. He's proud of what they've achieved. Five years ago if management said, 'Jump', staff asked, 'How high?' Now if management says, 'Jump', they say, 'I'll find my representative and ask if I have to jump.'

It's not a revolution. But it is a habit of looking for help from other people.

Collections and petitions have been crucial to this: for the Hillingdon Hospital strikers, for the Liverpool dockers, for Essex firefighters, for all sorts. The collections and petitions tell people that solidarity is not out of date. They give people a feeling that there are some people standing up for an alternative. And every nurse who puts a quid in the collection feels a part of a struggle.

When Ian started in the hospital everybody talked of the union as if it was something outside themselves. Sometimes they thought the union was the branch secretary in another hospital. But with each dispute things get better. Of course after the dispute people fall back, but not as far back as they were. And each time somebody comes with a problem Ian tries to say, 'Who else is in this with you?' And then get a meeting of all those people together.

For instance, a group of housekeepers lodged their own grievance. Three housekeepers had left and management was trying to get nine women to do the work of 12. Management split them by setting new rotas which offered some people preferential treatment, so half were happy. The other half were bloody raging. The losers had always worked weekends, which fitted with their child care and gave them weekend enhancements. Now they lost their weekends.

The union called a meeting and the unhappy ones turned up. Some were seeing the doctors themselves, getting medication for the stress. If the union had gone in to see management for those workers they would have remained split. Instead Ian and another steward took all nine workers in to argue with management. Doing it that way united the staff, and made management agree to fill the vacancies.

Again, almost three years ago management was trying to force the night shift nurses to rotate days and nights. This would have cut wages by between 150 and 300 a month. The union called a meeting. Twenty four nurses came. They took all 24 to see management. The manager talked about the new rotas for 20 minutes, until Ian broke in and said, 'I'm sorry. There seems to be some confusion here. We called this meeting, and we called it so you could listen to what all of us had to say.'

Then they all told her, shouting fucking this and fucking that and yelling about their mortgages and their pension entitlements and their financial commitments for 40 minutes.

Over two years later nobody who wants to stay on nights has been moved off.

I asked Ian what he'd say to any new steward in a weakly organised hospital. He looked at the floor in embarrassment and said, 'I learnt everything through error.' Then he thought and said, 'The most important thing is being prepared to fight. But you have to know the way you can fight depends on how many people you've got. And you have to get them together and get them to fight for themselves.'

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