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Diagnosis: undervalued. A psychoanalytic exploration of doctor strikes in the British National Health Service, 2023–2024
Abstract
This work explores recent industrial action by doctors in the British National Health Service (NHS) through a psychoanalytic lens, exploring psychosocial context and the role of unconscious phantasy. Doctor strikes are conceptualised as a protest against devaluation. Expressed motivation for strike action, a real-term pay reduction, is symbolic of deeper societal devaluation of healthcare and those who provide it; pay restoration serves as a phantastic object through which amends can be made. Layers of holding and containment are identified, from the function of the health, or rather anti-death, service in containing deep-rooted anxiety around illness and death, to the holding, typically in limited supply, experienced by staff members working in health services, to the containing function individual staff provide for their patients.
Strike action shatters the NHS as a container, primitive anxieties emerge and primitive defences are activated. Anger expressed through protest causes an impact, expressing a demand to be recognised and valued. The time and space of the strike has generative potential; implications of breaking the ‘broken’ NHS give impetus to finding a way forward. Exploration of unconscious phantasy underpinning industrial action and public response may bring insight to negotiations, enabling grounded and coherent solutions to be derived.
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A theoretical paper which considers the previous multiple attempts by nursing to engage with and usefully apply the theories of psychoanalysis to varying aspects of the nursing role. References to psychoanalysis within the nursing literature of the last century are reviewed and the legitimacy of the use of psychoanalytic theory 'outside the clinic' explored with reference to general hospital nursing in the UK's National Health Service. Themes explored include unconscious motivation behind nursing as a career choice, with associated risks of stress and burnout when the unconscious drive to heal is thwarted. Psychoanalytic consideration of nurse-patient relationships provides insight into the patient experience on hospital wards, whilst exploration of other aspects of the nursing role was found to be limited. From a wider perspective, psychoanalysis offers nursing an insight into societal changes impacting the profession. The systems and processes of the healthcare institution have also been explored, particularly in relation to containment of anxiety, though limited practical impact has resulted from the psychoanalytic insight encountered in the literature. The limited engagement between psychoanalysis and general nursing is considered from both a psychoanalytic and nursing perspective; ongoing potentiality for enriching dialogue between the disciplines is established and potential barriers explored.
The English National Health Service (NHS) is one of the largest employers in the world with a global reputation of being at the forefront of medical research and high standards of treatment. Despite this, it is currently in a state of crisis with nurses going on strike for the first time in its history, paramedics also striking, and junior doctors experiencing burnout like never before. Working as a tutor, lecturer, and mentor on healthcare leadership programs in the UK, the author is hearing first-hand how exhausted so many of the English NHS workforce are and they have had enough of not being heard by the leaders of the organization. This critical review explores some of the serious considerations as to why this world-renowned health service is shattered – both in the metaphorical sense, but also physically.
Background:
Strike action carried out by healthcare workers raises a range of ethical issues. Most fundamentally, as a strike is designed to disrupt, it has the potential to impact patient outcomes and healthcare delivery. This paper synthesises and analyses the empirical literature that details the impact of strike action on healthcare delivery.
Methods:
A systematic scoping review was utilised to examine the extent, range and nature of research activity. Embase, Medline, CINAHL, Bioethicsline, EconLit and Web of Science were searched, yielding 5644 results. Papers were included if they examined the impact that strike action had on healthcare delivery (i.e., admissions, presentations, waiting time). After screening, 43 papers met inclusion criteria.
Results:
Nineteen studies explored presentations to emergency or admissions to hospital. Both dropped dramatically when comparing non-strike to strike periods. Ten studies examined length of stay in hospital and waiting times. No clear relationship was found with strike action, with some studies showing that wait times decreased. Nine studies examined the impact of strike action in facilities that were not on strike, but were impacted by nearby strike action along with the impact that strike action had on treatment seeking. Hospitals dealing with these upstream impacts often saw increase in presentations at hospitals, but results relates to treatment seeking during strike action were mixed.
Conclusion:
Strike action can have a substantial impact on the delivery of healthcare, but this impact is not felt uniformly across services. While many services are disrupted, a number are not, with several studies reporting increased efficiency.
Typical responses to a confrontation with failures in authority, or what Lacanians term ‘the lack in the Other’, involve attempts to shore it up. A patient undergoing psychoanalysis eventually faces the impossibility of doing this successfully; the Other will always be lacking. This creates a space through which she can reimagine how she might intervene in her suffering. Similarly, when coronavirus forces us to confront the brute fact of the lack in the Other at the socio-political level, we have the opportunity to discover a space for acting rather than continuing symptomatic behaviour that increasingly fails to work.
The crisis of physician burnout has been widely and repeatedly reported across the mainstream press and medical journals around the world, in the closing years of the second decade of the 21st century. Despite multiple systematic reviews and commentary on the scale of this ‘global epidemic’, understandings of both the phenomenon and the most effective interventions remain limited. Practice-based medical humanities represents the collaborative sharing of conceptual tools for understanding illness and clinical practice and the shouldering of responsibility for mapping the shape of care, in all its local, national and global contexts, thinking-with rather than critique on the profession and its practices. In keeping with this approach, this article offers a new perspective on the contemporary crisis of physician burnout by exploring the objectification of the clinician’s body within the systems and practice of healthcare. Within the context of medical humanities’ scholarship, discussions of objectification usually navigate towards a discussion about patient identity and its potentially reductive objectification within the frameworks of biomedical science. However, this article crosses the cultural divide between clinician and patient, and comes to focus on the objectification of the clinician herself, using object relations theory from the field of psychoanalysis to excavate the psychodynamics of care and their impact on clinicians, and the systems of healthcare in which care is delivered.
Objective: To analyse the characteristics, frequency, drivers, outcomes and stakeholders of health workers’ strikes in low-income countries.
Methods: We reviewed the published and grey literature from online sources for the years 2009 to 2018. We used four search strategies:
(i) exploration of main health and social sciences databases; (ii) use of specialized websites on human resources for health and development;
(iii) customized Google search; and (iv) consultation with experts to validate findings. To analyse individual strike episodes, pre-existing
conditions and influencing actors, we developed a conceptual framework from the literature.
Results: We identified 116 records reporting on 70 unique health workers’ strikes in 23 low-income countries during the period, accounting
for 875 days of strike. Year 2018 had the highest number of events (17), corresponding to 170 work days lost. Strikes involving more than one
professional category was the frequent strike modality (32 events), followed by strikes by physicians only (22 events). The most commonly
reported cause was complaints about remuneration (63 events), followed by protest against the sector’s governance or policies (25 events)
and safety of working conditions (10 events). Positive resolution was achieved more often when collective bargaining institutions and higher
levels of government were involved in the negotiations.
Conclusion: In low-income countries, some common features appear to exist in health sector strikes’ occurrence and actors involved in
such events. Future research should focus on both individual events and regional patterns, to form an evidence base for mechanisms to
prevent and resolve strikes.
Modern medicine is confronted with cultural crossings in various forms. In facing these challenges, it is not enough to simply increase our insight into the cultural dimensions of health and well-being. We must, more radically, question the conventional distinction between the ‘objectivity of science’ and the ‘subjectivity of culture’. This obligation creates an urgent call for the medical humanities but also for a fundamental rethinking of their grounding assumptions.
Julia Kristeva (JK) has problematised the biomedical concept of health through her reading of the anthropogony of Cura (Care), who according to the Roman myth created man out of a piece of clay. JK uses this fable as an allegory for the cultural distinction between health construed as a ‘definitive state’, which belongs to biological life (bios), and healing as a durative ‘process with twists and turns in time’ that characterises human living (zoe). A consequence of this demarcation is that biomedicine is in constant need of ‘repairing’ and bridging the gap between bios and zoe, nature and culture. Even in radical versions, the medical humanities are mostly reduced to such an instrument of repairment, seeing them as what we refer to as a soft, ‘subjective’ and cultural supplement to a stable body of ‘objective’, biomedical and scientific knowledge. In this article, we present a prolegomenon to a more radical programme for the medical humanities, which calls the conventional distinctions between the humanities and the natural sciences into question, acknowledges the pathological and healing powers of culture, and sees the body as a complex biocultural fact. A key element in such a project is the rethinking of the concept of ‘evidence’ in healthcare.
Background:
Strikes are means to influence policies related to working conditions, yet raise ethical dilemmas for healthcare workers. Nurse strikes have become more prominent around the world.
Objective:
To assess the change in Israeli nurses' attitudes towards strikes in light of two physician strikes that have preceded a nursing strike.
Methods:
An anonymous survey was administered once in 2000 (N = 106) and again in 2011 (n = 175) following 110 days of a physician strike, to assess nurses' attitudes towards the strike and resulting ethical issues.
Results:
A statistically significant change (p < 0.05) between administrations revealed that in 2011 more nurses identified striking as a legitimate mechanism, would strike under the same circumstances, and felt that collaboration with physicians persisted despite the strike. Additionally, an increasing number of nurses said that the suffering of patients due to the strike is somewhat or entirely justified, although they were faced with a difficult dilemma of loyalty to physician colleagues vs.
Patients:
Nurses reported finding ways to mitigate the suffering of patients resulting from the strike.
Conclusions:
While patient-centered care remains nurses' first and foremost priority, findings indicate an increasing support of collective bargaining and strike to promote working conditions related to professional and public health agendas.
In this article, we explore how the application of organizational psychodynamic theories might improve the understanding of unconscious forces influencing apparently rational and evidence-based processes such as the generation and implementation of health policy. There is a growing body of literature using psychodynamic theories to explore discontinuities in policy-making and the containment of anxiety in organizations. In this article, we focus on the dyadic relationship between policy formation and the media/public response, in particular knee-jerk reactions that can cause ‘U’ turns in policy implementation, and the role of organizational leaders in containing public anxiety. We illustrate this using three contrasting instrumental case examples. Drawing on the seminal work of Isabel Menzies and the psychodynamic literature, we explore how anxiety is manifested in organizations and the role of public institutions as receptacles of public anxiety. We suggest that policy has a latent function of controlling objects into which public anxiety is projected and that we need to understand the sources of this anxiety if more rational policy responses are to ensue. We also explore the implications this has for policy development generally and for the role of senior managers.
Doctor and healthcare worker (HCW) strikes are a global phenomenon with the potential to negatively impact on the quality of healthcare services and the doctor-patient relationship. Strikes are a legitimate deadlock breaking mechanism employed when labour negotiations have reached an impasse during collective bargaining. Striking doctors usually have a moral dilemma between adherence to the Hippocratic tenets of the medical profession and fiduciary obligation to patients. In such circumstances the ethical principles of respect for autonomy, justice and beneficence all come into conflict, whereby doctors struggle with their role as ordinary employees who are rightfully entitled to a just wage for just work versus their moral obligations to patients and society.
It has been argued that to deny any group of workers, including "essential workers" the right to strike is akin to enslavement which is ethically and morally indefensible. While HCW strikes occur globally, the impact appears more severe in developing countries challenged by poorer socio-economic circumstances, embedded infrastructural deficiencies, and lack of viable alternative means of obtaining healthcare. These communities appear to satisfy the criteria for vulnerability and may be deserving of special ethical consideration when doctor and HCW strikes are contemplated.
The right to strike is considered a fundamental right whose derogation would be inimical to the proper functioning of employer/employee collective bargaining in democratic societies. Motivations for HCW strikes include the natural pressure to fulfil human needs and the paradigm shift in modern medical practice, from self-employment and benevolent paternalism, to managed healthcare and consumer rights. Minimizing the incidence and impact of HCW strikes will require an ethical approach from all stakeholders, and recognition that all parties have an equal moral obligation to serve the best interests of society. Employers should implement legitimate collective bargaining agreements in a timely manner and high-handed actions such as mass-firing of striking HCWs, or unjustifiable disciplinary action by regulators should be avoided. Minimum service level agreements should be implemented to mitigate the impact of HCW strikes on indigent populations. Striking employees including HCWs should also desist from making unrealistic wage demands which could bankrupt governments/employers or hamper provision of other equally important social services to the general population.
This article argues that public organizations are inherently more complex than private ones. Their complexity derives from two sources. The public sphere is the site for the continuous contestation of public purposes and this means that questions regarding values and policies saturate all public organizations, particularly at the point of delivery. Second, because government partly acts as the receptacle for the alienated subjectivity of citizens, public organizations have to contain much of what is disowned by the society in which they are situated. It follows that the fate of the public official, sometimes referred to as the ‘street-level bureaucrat’, is to have to contain the unresolved (and often partially suppressed) value conflicts and moral ambivalence of society. Such a perspective has implications for all of those who, in their different roles, seek to bring about change or development in public organizations. Psychoanalytic approaches to organizational consultation have not adequately understood the contested nature of public organizations and some key aspects of this approach, such as the concept of the organization's primary task, need to be reconsidered.
Patient choice is at the forefront of the debate about the future of healthcare provision in many industrialized countries. It is argued that understanding the complexities and the multiple consequences involved in implementing individual patient choice in public health systems calls for an analytic framework extending beyond economic determinism and positivist social science paradigms. This study applies psychoanalytic concepts to illuminate policy dynamics and limitations, using the example of patient choice in the English NHS. It separates declared from unexpressed policy goals theorizing on the role of imaginary institutions and their defensive and less obvious functions in society, and reflects on the implications of policies that are formulated at a distance from operational reality on healthcare organizations. By focusing on the deeper primitive anxieties that are evoked and enacted in patient–doctor interactions, this article examines opportunities and limitations involved in developing individual patient choice.
This paper describes the nature of today's corporatized health care system in the United States, offering examples of the psychological toll it takes on clinicians at all levels. It details corporate practices that disenfranchise practitioners from exercising their clinical judgment and from offering input to system administrators about problematic patient care experiences. It discusses the sense of frustration, resignation and moral injury that can permeate their work lives and disrupt their sense of effectiveness and well‐being in this context. Following this background is a psychoanalytic analysis of narratives from two physicians about their corporate health care experiences. Two case studies follow, in which a nurse and a physician entered psychoanalytic psychotherapy to process the destructive psychological impact of their work environments. A third case illustrates the negative impact of automatized insurance practices on one psychologist and her patient.
Objective
To evaluate the impact of an adapted psychoanalytic work discussion group for mental health nurses working in adolescent PICU.
Background
There is no prior research investigating interventions that effectively support and enable adolescent PICU nursing teams to sustain the therapeutic tasks of their work and their own sense of wellbeing.
Methods
A bespoke psychoanalytic work discussion group was implemented within an adolescent PICU. Data was collected using in-depth semi-structured interviews with participants, about the impact of the group upon their practice. Data analysis used thematic analysis.
Results
The group positively impacted upon participant knowledge and understanding, emotion management, personal efficacy, therapeutic relationship building, managing challenging behaviour, leadership, professional identity and team cohesion.
Conclusion
Mechanisms by which these outcomes were achieved are elaborated utilising the concepts of projective identification, emotional containment and ‘temporary outsider-ship’. There is a need to account for the interplay between adolescent defense mechanisms, nursing anxieties and setting-specific organisational dynamics, in the design of effective support interventions for adolescent mental health nurses.
Inside Lives belongs to the heart of the thinking and working of the Tavistock Clinic. Its aim is to bring psychoanalytic theory to life, to make it accessible to a much wider range of readers, both lay and professional, than would normally be familiar with this kind of approach. In the simplest of terms it tells the most complex of stories: the story of the internal development of a person from infancy to old age. In so doing, it reflects and encompasses the generational structure of the clinic as a whole, tracing the interacting influences - between infant, child, adolescent and adult - on the nature and quality of emotional growth and development. This book provides a perspective on the relationship between psychoanalytic theory and the nature of human development, which is not currently available in written form. Following the major developmental phases from infancy to old age, the author lucidly explores those vital aspects of experience, which promote mental and emotional growth and those which impede it.
This paper looks back to one of the founding strands in the psychoanalytic study of organisations: a tradition of innovative and action focused practice that came out of the wartime experiments initiated by Wilfred Bion and a multi-disciplinary group of colleagues, often later referred to as the "Tavistock group", between 1940 and 1945. It is argued that this tradition was rooted in a unique bringing together of psychoanalytic insight and an "ethical imagination", applied to the social and organisational challenges of war and post-war reconstruction: that is, the capacity actively to imagine new forms of group and organisational life in the service of human resilience and flourishing. This imaginative capacity was to inform the creation and early work of the Tavistock Institute of Human Relations, set up as a "sister" enterprise of the Tavistock Clinic in 1947. Within this emerging tradition, notably in its early days, the "ethical imagination" was as much found as made, captured in, and generated through the collective experience of an ordinary work group, responding creatively to changing social and technological conditions. In turn, from the outset, it was subject to powerful resistances, societal, organisational, and personal. Over time, it is argued, the combination of resistance and an increasingly dependent culture was to function as a regressive pull, foreclosing potential development at the interface of theory and practice and leading to an imaginative loss, in which the more radical origins of the tradition tended to be replaced by more neutral and adaptive modes of enquiry. Given the challenges of a radically changing social and organisational environment, the paper argues a need for the rediscovery of this tradition and its implications for the ways in which, as practitioners, we think and work, our modes of engagement.
The application of psychoanalytic knowledge to the care of the patient in hospital is considered in relation to two patients, one an acute surgical admission, the other psychotic. The psychological parallel is examined and defined before proceeding to where they diverge. The psychotic patient's use of splitting and projective identification, in order to avoid psychic pain felt to be incompatible with survival, is described along with the hospital staff's unconscious and empirical collusion with it. The patient's need to be ill, which is his right to be ill in hospital, is considered in relation to the psychotic's denial of his need. The inseparability of the care of the patient's body and mind, in these circumstances, is also illustrated, and argued to be equally germane to psychoanalytic thinking in this setting. It is submitted that the application of psychoanalytic knowledge catalyses and sustains relationship with these patients. The use of interpretation is briefly noted.
The paper is an attempt to stimulate thought and other publications in this field, one of lasting relevance to psychoanalytic psychotherapists working in the National Health Service.
Over the past 2 years, the UK government and the medical profession’s trade union, the British Medical Association (BMA), have been locked in dispute over new contracts for both junior doctors—the UK equivalents of residents, interns, and fellows—and for consultants—hospital-based physicians who have completed specialist training. The junior doctor contract has proven particularly difficult to negotiate, and unpopular proposed contracts have resulted in strikes by junior doctors including the first ever all-out strikes in the history of the National Health Service (NHS). How did it get to this impasse and what can be learned?
In 1929, Wilhelm Reich lectured on “Psychoanalysis as a natural science” before the Communist Academy in Moscow; he was the only Freudian-trained Central European psychoanalyst to do so. That same year, his article “Dialectical materialism and psychoanalysis” was published in the Academy's journal, Under the Banner of Marxism, in both Moscow and Berlin. By this time, Reich's involvement with political activism aligned with the Austrian Communist Party was increasing, while simultaneously psychoanalysis in the Soviet Union was in decline. Our paper places these events in their proper historical context and includes a discussion of the various attempts to determine the compatibility of psychoanalysis and Marxism. We offer analyses of both the article, “Dialectical materialism and psychoanalysis,” and the lecture, “Psychoanalysis as a natural science,” and the reactions to both by Reich's Russian critics. We show the ways in which responses to his lecture foreshadow what becomes the standard Soviet assessment of psychoanalysis. As an appendix to this paper, we provide the first English translation of the Russian account of his lecture, as published in the Herald of the Communist Academy.
The first aim of this article is to offer a framework for constructive and rigorous discussions of the ethics of doctors' strikes, beginning with an in-principle distinction between the questions of how one should conduct oneself while working as a doctor and when and how one can suspend that work. The second is to explore how that framework applies to the contemporary British case of strikes by English junior doctors, with my suggestion being that those strikes do meet all of the criteria proposed. In closing, I gesture towards a further ethical dimension to strikes which is too often overlooked: namely, the responsibilities of employers and others not to misrepresent or demonise those doctors who are engaged in or considering taking industrial action.
An impasse in negotiations between the Department of Health (DoH) and the British Medical Association in November this year led to an overwhelming vote for industrial action (IA) by junior doctors. At the time of writing, a last minute concession by DoH led to a deferment of IA to allow further negotiations mediated by the Advisory, Conciliation and Arbitration Service. However, IA by junior doctors remains a possibility if these negotiations stall again. Would the proposed action be ethically justifiable? Furthermore, is IA by doctors ever ethically defendable? Building on previous work, we explore important ethical considerations for doctors considering IA. The primary moral objection to doctors striking is often claimed to be risk of harm to patients. Other common arguments against IA by doctors include breaching their vocational responsibilities and possible damage to their relationship with patients and the public in general. These positions are in turn countered by claims of a greater long-term good and the legal and moral rights of employees to strike. Absolute restrictions appear to be hard to justify in the modern context, as does an unrestricted right to IA. We review these arguments, find that some common moral objections to doctors striking may be less relevant to the current situation, that a stronger contemporary objection to IA might be from a position of social justice and suggest criteria for ethically permissible doctor IA.
This article explores how the Italian filmmaker and novelist Lorenza Mazzetti (1928-) has appropriated psychoanalysis. By looking at her novels and basically at her column of personal advice within the Communist weekly Vie Nuove during the 1960s, the article shows her increasing use of psychoanalytic insights as a form of defending a secular sexual morality and changes in gender relations as well as way of analysing the relationship between youth and politics. The article highlights Mazzetti's initial distrust towards psychoanalysis, and contrasts it with her increasing enthusiasm for psychoanalysis as a necessary companion of revolutionary activism. It takes Mazzetti's case as evidence of the receptivity towards psychoanalysis among Italian Communists.
Why do workers decide to go on strike or change their mind during a strike? This field study aims to determine to what extent employees' perceptions of justice formed during the collective bargaining process influence their strike vote. Data were collected from a North American university faculty that went on strike 21 months after the expiration of its collective agreement. The results show that perceived justice about collective bargaining is a determinant of the strike vote. The role played by the employer and the union as a source of (in)justice and the importance of the four types of justice perceptions (procedural, distributive, interpersonal, and informational) vary depending on the context of ballots (initiate, continue, or end the strike). This suggests that the reduction of uncertainty leads to the activation of three different mechanisms: judgmental heuristics (salience), social comparison, and cognitive dissonance. The results also suggest that employees attempt to be as rational as possible when they decide to go on strike. Nevertheless, the decision to join strikers and to continue the strike is partly based on an emotional process: employees use the strike to punish the employer. Copyright © 2012 John Wiley & Sons, Ltd.
In response to a strike action by some doctors at the Safdarjung Hospital, the Delhi Medical Council issued a statement, in December 2010, that it was "...of the view that under no circumstances doctors should resort to strike as the same puts patient care in serious jeopardy and such actions are also in violation of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002". Statements such as this are common responses of medical councils across the world whenever they are confronted with the increasingly difficult issue of striking doctors. Evidently, these statements are not effective in stopping doctors from repeatedly engaging in strike action. In India, the statement by the medical council was, for instance, followed by many strikes, amongst which was the well-publicised nationwide strike initiated by the Indian Medical Association in June 2012.
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I argue that on both the small-scale level of the interpersonal relationship, and the large-scale level of society, the manic defense makes it difficult to care about others, and so militates against a sense of social responsibility. I address four basic questions: what is the nature of social responsibility? What is the nature of the manic defense? How does the manic defense interfere with the potential for social responsibility? And, on a more general level, what are the issues with respect to methodology for efforts such as this one to link psychoanalysis and social theory?
In this paper, the nature of the psychotherapeutic function of the general nurse is considered in the light of current and future changes in nursing. Important ways in which general nurses can be psychotherapeutic in the course of their everyday work are highlighted and linked with the maternal function. The main thesis is that many apparently progressive changes in nursing occur in such a way that there is no real change in the organisational defences which are used to prevent therapeutic closeness with patients. Possible reasons for this are suggested, in particular that the defences serve to prevent distressing projections from patients spreading up through the organisational hierarchy. This in turn leaves the nurses ‘at the bedside’ without the containment they need in order to tolerate these projections. The denigration by nurses of the maternal function is also considered and it is suggested that this not only plays a part in the defence but also, paradoxically, gives nurses less status and recognition rather than the greater status they seek.