This post will probably come across as the grumble of an old man. It is, but that doesn’t mean that it’s wrong. As we all learn eventually, some things bother older people more than younger people because the young, with their eyes on the future, do not yet understand what is being lost.
As I write, the Prime Minister’s political survival hangs by a thread due to the fairly unsurprising news that Downing Street ignored its own Covid-19 lockdown restrictions. This post isn’t really about the crisis, or even ‘Boris’. It is worth starting with him and the mess that he’s in, though. Both are emblematic of a corruption that has been spreading for a long time: hiding raw power behind friendly informality.
Both sides of the equation, the power and the informality, are particularly obvious with ‘Boris’. His raw ambition and his informality have both been analysed for decades now. This crisis has those same two features. The regulations in question are probably the furthest reaching and least scrutinised that have ever been produced in peacetime. At the same time, it is obvious that they weren’t taken very seriously within an inner circle that included senior civil servants as well as career politicians.
One particular way that ‘Boris’ masks power with chumminess is his name. Everyone just calls him ‘Boris’. Using first names to pretend closeness is widespread, and a good example of corrupting chumminess. It also occurs in hospitals.
I’m just old enough to remember the last of the old-school ward sisters who would always call patients by their pronoun and title: ‘Mr Clough’ or ‘Miss McClean’, not ‘Jimmy’ or ‘Chelsea’. These days, first name chumminess is almost universal. Nurses are called by their first name, other professionals are, and patients too. The only exceptions are the doctors, and increasingly only the senior ones. Even in a patient’s notes, if they have not been dehumanised entirely to ‘the patient’ or ‘pt’, they will be called by their first name: ‘Andrew has struggled with his swallowing today’.
At first, this seems well and good. After all, shouldn’t the NHS be friendly to patients? And, besides, why get worked up about something so minor? In reality, the practice is quietly but cumulatively corrupting. This took me a long time to understand. The old school sisters had retired by the time I actually learned their lesson and started referring to patients properly.
The thing that is wrong with first-name terms in the hospital is the same thing that is wrong with calling the Prime Minister ‘Boris’. The informality masks power. It does not reduce it. If you are a patient in hospital, staff have a huge amount of power over you. They can control almost every aspect of your experience, unless you are one of the tiny minority willing to raise a fuss even when unwell and scared. If you are confused, professionals can decide you lack mental capacity and start making any number of serious decisions on your behalf. There are legal controls on this; but, realistically, there is almost no oversight. One reason that first names are corrupting is that they let healthcare professionals think that their relationship with a patient is just like any other relationship. It is not.
I only spotted another reason why this chumminess corrupts when I started referring to patients properly. There was never any surprise from colleagues when I referred to, for instance, the retired teacher with the nice accent as ‘Mrs Hughes’. The surprise was when I referred to, for instance, the 18 year old with a psychiatric disorder and a drug problem as ‘Miss Jones’. On the whole, though, it isn’t the Mrs Hughes of the world that health care treats poorly. It is the Miss Jones of the world that get either ignored, treated against their wishes, or a bit of both.
Over time, I came to understand that this surprised reaction is nothing to do with how sympathetic the person is. Some people with learning disabilities are instantly liked by their nurses, yet the surprise was never more obvious than when I referred to someone with a profound learning disability properly. Instead of it being about the person’s likeability, the surprise reflected an assessment of their respectability. It was when I realised this that I became strict with myself. The easy chumminess of first names wouldn’t strip much respectability from the retired teacher, but a young person struggling with their first psychiatric event needs every scrap of respectability that they can get.
I won’t dwell too much on the effects of hiding power behind chumminess. Most people working in health and social care are trying to do the right thing. That is the main source of the danger. If you are motivated to help people and you think of the man facing a difficult situation as ‘Darren’, then it is easier to let your good intentions lead you over the line than if you think of him as ‘Mr Cooke’. Maybe you put a bit more pressure on him to ‘think’ about that nursing home than you really should; maybe you don’t take his worries as seriously as you should because you think you know what he really needs.
What the chumminess obscures is that the relationship nurses, doctors, and social workers have to patients is fundamentally transactional. A good professional will care within bounds, but at the end of the day they will change out of their uniform and go home. If you die, they might be upset, even sometimes very upset, but they will not mourn you. Patients are not family. They are not friends. Obscuring the nature of the relationship only makes it a little bit more comfortable for professionals to hold power without examining it.
And that is true about ‘Boris’ too, and about the wider way that informality is now wielded across society. The informality is never for the weaker party. It is there so that the stronger party need not confront the power that they nevertheless wield. It is a convenient lie, and that is why Mr Johnson is the perfect example of a person who relies on it.
I feel the same uncomfortableness when patients are referred to as clients or customers. This I believe creates an unhealthy relationship where like-ability and getting a 😀assessment is given too much attention. Rather than doing the right thing. I wonder if the informality you describe is a by-product of this drive to see patients as consumers. By the way thanks for taking the effort to write.
This is excellent. I always refer to people as Mr or Mrs when I am compiling, and writing, their assessments - I really don't like reading that a ninety-year-old lady is 'Nancy', it's never felt correct to do this. Somehow, if it's reduced to first names, it obliterates their long lives and infantilises them, and that has always felt wrong. Spot on analysis, and now I know why I do what I do!