Archive for the ‘NHS’ Tag

Drug service, anyone?

Thursday, October 2nd, 2014

I have been quiet for some time, but something momentous has happened, there are things that need to be said, and again the words have started whirring..

This week, our drug services have been privatised.

I need to make a few obvious political statements, but also want to pick through what this means.

The backdrop: in this area in the late 80s and the 90s, as a result of high unemployment and entire communities lacking self-worth, heroin became rife. Intravenous amphetamine use, which had long since died out in most parts of the country, was also a firm favourite amongst the socially forgotten, given its relative cheapness compared to the city folks’ crack. Drugs services were, it has to be said, sparse and extremely poor. Methadone was virtually unobtainable, the tightly-clenched fists of a few dangling it like an ever-retreating green carrot, and healthcare was an emergency commodity.

Unsurprisingly, people died. All over the place. Bodies dumped in wheelie bins and found in skips.

Political moves meant that something had to be done. Drugs had been the Number One Priority for local Police forces for some time, but the criminal justice angle had reaped few benefits. And so the other group saddled with the problem – the healthcare providers, who until now had primarily just responded to overdoses, deep vein thromboses, septicaemia and liver failure – stepped into the void. Drugs became a health problem. Ring-fenced funding direct from Central Government arrived, and substantial NHS drug services began functioning with vigour.

The deaths ground to a halt. In the first month, burglary reportedly decreased by 80%. Methods were crude, targets were basic. But it was an intervention of unrivalled success, not only for the drug users themselves but for the communities as a whole.

I’m not implying that things were perfect. In the years that followed, it has to be said, there was a period of relative affluence under Labour when services carried some dead wood. The overarching easiness meant that, in some corners, a lazy malaise developed. And the service users’ sense of entitlement, exploiting this new enhanced status, grew way beyond empowered independence.

Yet despite this imbalance, the interventions continued to work. The previously most excluded members of the community now had health opportunities, and with that came life choices.

Things have changed. The current Government have taken away the ring-fenced budget. They have separated financial decisions from the care providers, and moved public health money across to local councils. These councils are having their funds cut constantly. Services have been put out to tender, and decisions have been made not on quality of service provision or importance of outcome, but on finance alone. And the NHS cannot compete with private companies who pay less and offer less.

Concurrently, the Government’s smear campaign of the poor – portrayed as the cause of the financial crisis rather than the victims, a voiceless scapegoat for the mistakes of those few at the top – has made the vulnerable an easy target for funding cuts. The first service to go under council cuts in our area was rape crisis counselling. Drug services were never going to be far behind. If it’s not society’s problem when someone gets raped, it definitely isn’t when someone doesn’t have enough aspiration, self-esteem or identity to “just say no” to a drug problem. If I’m honest, I’m surprised the drug services have lasted so long.

So what does it mean to move service provision to private providers? On the plus side, in the private sector there is no room for dead wood. And there is no bureaucracy, so decisions will not take six months to make and a further six to implement.

However, no-one would want G4S running the police force. There is a reason why these services are so much cheaper to operate. Managed at arm’s length, lacking in local knowledge, paying less than an experienced, qualified professional is prepared to work for – my experience is that these organisations are inferior. And they are not healthcare providers. They are narrow, isolated ventures. So they do not have practice nurses on hand to dress wounds; they do not share a building with health visitors and school nurses to keep tabs on troubled families; they can’t run symptoms past a GP or psychiatrist to see if someone needs admitting; they have no way of providing integrated, holistic healthcare by sharing service provision with associated professionals for no extra cost.

They provide the required statistics and meet specific targets. And as anyone who has worked in healthcare knows, meeting targets is easy. Anyone can fiddle stats and ‘reinterpret criteria’ to appear splendid. Providing good care is much more complicated than that.

I worked for a similar organisation a while ago. They were never fully-staffed, because they employed inexperienced (cheap) staff who subsequently moved on as soon as they had good enough CVs to apply for other jobs. That won’t be an option for these guys – there is nowhere else for anyone to go now – but I am confident that the same attention to finance and not quality of care will rule supreme.

Recent investigations into private care homes has shown us what happens when we pay poorly and devalue care. When we treat staff like dispensable cattle, it will be those receiving the care that suffer the most. Especially when those receiving the care are once again the brunt of society and once again voiceless.

Given the bumper Afghani crop and the rate of novel psychoactives arriving, it doesn’t bode well. And whose problem will it be when drug services struggle to address the need? Not a Government organisation, that’s for sure.

From drugs work to the grave

Tuesday, December 18th, 2012

It’s a funny thing, contemplating a career change. We all spend years expressing internal groans at the sound of the morning alarm, hiding underneath the duvet, begging and praying that some natural disaster has occurred overnight that will suffice as an excuse not to go in today (death for a few people is surely a justifiable pay-off, no?), only to discover from a quick scan of available media that today is a day like any other. Shitbags. But the brief glimmer of hope that you might not have to deal with X,Y and Z today has meant, unavoidably, that you have now carved a brain-path directly to X, Y and Z – and so work starts straight away.

The simple joy of the morning shower is spent internally arguing with the nob-end that sits near you in the office, who you would never come into contact with socially and would subtly shuffle away from if you had the misfortune of a chance encounter in a public arena, but have to not only tolerate but attempt to be civil with, every miserable working day, leaving you resenting your pay-packet because it represents you whoring your soul to the devil. Then breakfast, surely intended as a pleasant and civil part of the day, is made somewhat less so as your bran flakes remind you of the dead, flakey skin around yesterday’s necrotic wound, and you find yourself wondering whether this would have the texture of a freshly-served crisp flake or a milk-soaked chewy one. And despite your attempts to gee yourself up with one of your favourite albums on the way to work, the sense of impending doom induced by the knowledge that today is going to entail battling the Safeguarding referral system (“Sorry, run that by me again – this is supposed to be a high-threshold, fast-response referral process, created to protect children from the most severe types of immediate harm, but you won’t take verbal information and no longer offer the facility for me to discuss the case with a social worker first – so I have to spend an hour completing paperwork, then face the traumatic, potentially damaging and counter-productive scenario of informing the family I have serious concerns about their parenting and so are breaching their confidentiality, in the knowledge that you will probably knock it back or do nothing about it anyway?”) means that you may as well be listening to someone shouting “You are mortal and one day, possibly soon, your time on earth will be over, more than likely following a period of extreme pain” in a broad South African accent, for all the relaxation the music provides. And that’s before you get to work to discover what shit has hit the fan overnight – who has been arrested, who has been admitted to hospital and, unfortunately, on occasions, who has died – and start getting paid.

But – for all its pains and strains and drains – not only does it pay the bills, it has seen you through some hard times. There is no better distraction from a failing relationship than a critical deep vein thrombosis with severe cellulitis; no quicker way to forget about personal tragedy than premature labour induced by persistent crack use.

However, without this job, would the relationship fail? And for everyone one case worthy of your emotional input at a time of personal heartache, how many needless metaphorical arse wipes must you perform? How many faces do you imagine smashing into desks with screams of “If you rip the copper out of your own boiler your landlord has every right to evict you, that doesn’t make you a victim – my own tragedies far surpass yours so I frankly couldn’t give a shit about the hole you have just dug yourself into!”? Imagine getting home each evening with something left to give other than anger and irritation at the world…

It’s a strange pay-off, and one which I am currently making attempts to unpick – is the emotional investment (or drain) offset by the distraction from one’s own problems? To what degree are these intense investments and distractions responsible for the lack of progress in one’s own life? And, fair enough, I might not want to be a drugs worker any more – but if not a drugs worker, then what? Do I have an identity at all? Or if I jack it all in, will I slip into a deep depression, brought on by a sudden lack of purpose, and find myself opening cans of baked beans with a screwdriver underneath a motorway bridge?

The only way I can resolve this internal dialogue is to remind myself that – if I stay in this job, I am likely to become ill(er) in the head, have very little or no chance of maintaining a healthy and drama-free relationship, and will probably, at some point, slip into a deep depression and find myself opening cans of baked beans with a screwdriver underneath a motorway bridge. I think I can make a fair, educated guess that, in this case, it is not better the devil I know. And so, career or no career, there is no healthy future for me as a drugs worker – and whatever the months and years ahead may hold, at least for now I have you lot to rant at, and have a sense of purpose in my attempts to inform and entertain. Thanks guys, you are keeping me (relatively / debatably) sane. And anyway, I like bar work.

To treat or not to treat (Part 2)

Wednesday, December 5th, 2012

Sorry I went off on one a bit yesterday. I was in a vile mood. And sorry to mental health nurses in Community Drug Teams, I do recognise there are some of you out there who are very committed to working with drug users and aren’t just in it for the supervised urine tests.

The point I actually intended to make before I got side-tracked by my own negativity and social bitterness was – who should receive drug treatment, and who shouldn’t? The political back-drop I outlined yesterday does have an impact on this, as there are trends, depending on who is in power, how they feel about drug users, and how much money is available. However what I want to briefly consider here is a more clinical perspective.

When I first started as a treatment worker many years ago, prescribing methadone was perceived as an additional risk factor. The logic was that if someone was taking central nervous system (CNS) depressants, such as heroin, alcohol, benzodiazepines such as Valium, (all of which, may I add, are widely sought-after by engrained heroin users, and a combination of which is almost always present in cases of fatal overdose), and now the new wave of nerve painkillers such as pregablin and gabapentin, then adding another CNS depressant such as methadone would increase the risk of overdose.

Buprenorphine (Subutex) therefore became a popular choice – another opioid but which only works on two of the four opiate receptors in the brain, and so stops withdrawals without sedating. Subutex also blocks opiate receptors, making it difficult to get any effect at all from heroin when taking a regular, reasonably small dose of Subutex. It is brilliant stuff. However, in order for it to work, no heroin can be used for 12 hours before taking the first dose, and of course little effect can be gained from further heroin use – so needless to say, it is not a popular choice amongst the old hardcore. (Now in prisons, where it is crushed and snorted to get a buzz… that is a different matter.)

So, imagine that you are assessing someone for treatment – they come in and tell you that they are using heroin every 6 hours and their mental health isn’t great. Subutex might not be appropriate as they want the sedation provided by heroin to manage their mental state, so you decide together to opt for methadone. But this person has no intention of stopping heroin use at present because it is the only way they can block out the trauma they experienced as a child, which they do not feel ready to address until they have somewhere stable to live.

So the question is – do you offer them treatment?

In the olden days, the answer would have been “No”. People had to say they had no intention to continue using heroin once receiving a prescription, and this was monitored through regular drug tests. Any heroin-positive urine samples sent heads spinning, and would probably result in being given an ultimatum, and possibly no prescription (ouch). The logic behind this was that dual use would increase overdose risk.

The harm reduction movement changed that – once people had dared to continue to prescribing to those still using heroin, research showed that high doses of methadone not only ‘drowned’ opiate receptors and so also had a blocking effect, making it more difficult to experience the euphoric effects from taking heroin – but the surprise conclusion was that people were actually LESS likely to overdose when taking heroin on top of methadone. This was because people’s tolerance to opiates was so high that risk of overdose was greatly reduced, as long as they took their prescribed dosage daily to maintain their tolerance at this level. (If you imagine an alcoholic, who is used to supping a bottle of whisky a day, drinking half a Carling… if you want to try this experiment at home, get yourselves down Wetherspoon’s with a £1.40 in your pocket and talk to anyone sitting alone at the bar.) Plus, taking a decent dose of methadone meant no withdrawal symptoms; and so less frequent injecting, less dodgy, desperate injecting, and so less hepatitis C, HIV, deep vein thromboses and cellulitis. And so the answer back then would have been, “Yes, treat, and keep treating until they get bored with paying for something they aren’t getting an effect from”.

So how would the question be answered today? Well although methadone in itself is pretty cheap, and Subutex not unreasonable, the cost of these medications often lies in the level of monitoring that is required, because they are ‘controlled medications’. This often means paying the pharmacist to dispense it in single doses and supervising its ingestion each day. It also means more frequent monitoring by doctors and drug workers to ensure that prescribing is safe and to reduce extraneous risk factors such as mental health problems and homelessness.

The truth is, as the money dries up, doctors and mental health trusts are going to be significantly less interested in working with heroin users. Half of those still walking around have got bits dropping off them – open abscesses you could fit your fist in at the top of each thigh and swollen, purple legs, from injecting into the femoral vein and irreparably damaging the blood supply to the legs; terrible general health from years of poor diet and jabbing bacteria-laden substances directly into their blood vessels; and quite probably hepatitis C. To treat, they are expensive and time-consuming. And so, I fear, the answer to the question will increasingly be, again, “No”. And doctors can be extremely eloquent and creative when it comes to finding justifications for why someone is ‘not appropriate for treatment’.

Oh god, I’m having a go at doctors now, what is my problem?! I’d better go before I piss off the whole medical profession and start making wild claims like “All radiologists are gay”…

To treat or not to treat, that is the question

Monday, December 3rd, 2012

A recent paradigm shift within the drugs field has further complicated an already difficult and lively debate around what constitutes drug treatment and who should qualify for it. This movement has, weirdly, sprung from a combination of both grass-roots support groups and the Coalition’s austerity measures.

In years gone by (and still in some regions today), Community Drug Teams were primarily made up of mental health nurses who, from what I could see, had got fed up with shift work on acute wards (having to work nights with full-blown nut jobs) and decided that community work was probably a cushy number (9-5 weekdays and 44p a mile). On the whole, these services met very nicely the needs of the nurses – and the prescribing psychiatrists – who admittedly had to endure sitting in grubby rooms in run-down buildings (god forbid drug users be seen in health centres and mix with the public), escorting their patients to the toilet for weekly supervised drug tests in return for a methadone prescription. Services were there to treat, almost exclusively, heroin users; a social group who, at the time, were massively excluded and disempowered, and who were very much at the services’ mercy. The power dynamic was engrained and aggressively maintained – CDT consultation rooms were reminiscent of Dickensian orphanages, and for those of us new to the field and not (at that point) full of cynicism, it was uncomfortable to witness. The approach was not holistic, nor did it address the psychological or social needs of the individual, and only those prepared to dip their caps, express their subordinate gratitude, reduce their drug use as instructed, attend regular appointments, and grovel for several weeks, if not months, ever made it past the waiting list for a prescription.

For those who did make it as far as an appointment with the prescriber, the only treatment available was low-dose, short-term methadone. The standard treatment plan was: enter treatment, stop using all drugs immediately, then reduce methadone dosage rapidly until opiate-free. Unsurprisingly, this method was rarely successful, as not only did it leave service users in a state of opiate withdrawal from treatment start until several weeks after treatment end, it also failed to take into account the person’s reasons for starting to take heroin in the first place – so as the opioids reduced, past trauma resurfaced, mental health problems were unmasked and exacerbated, and the reality of life hit right between the eyes. And should Mr Druguser share his concerns with Mrs Nurse, possibly disclosing self-prescribed codeine or Valium use to manage the symptoms produced by fast detoxification from methadone, he ran the risk of being labelled ‘not ready for treatment’ and being plonked back onto the waiting list. People could sit on these for up to a year in some areas, and the nurses seemed to miss the fact that heroin – well, it’s quite moreish. Needless to say, what became known as ‘The Revolving Door of Treatment’ only helped anyone whose motivation was extremely high, support networks were excellent, and mental health was completely stable. Everyone else spent their time trying to get onto a script, only to be either kicked off mid-treatment, or detoxed so fast that relapse onto heroin to manage withdrawal symptoms from methadone became almost unavoidable.

Then people started dying. Or at least, the public started to notice people dying. Bodies were being dumped in wheelie bins and skips because the Police automatically attended overdoses with ambulances. Families of the dead started to campaign, drug services came under fire, and at the same time, the links between Class A drug use and acquisitive crime were being formally logged, making these problems not just for those at the bottom of the social strata, but for the whole community.

And so came the 10-Year Drug Strategy, the new Labour Government’s attempt to tackle the problem. Money came flooding in to fund new services, and the focus of treatment shifted from purely medical to consider social and psychological aspects, meaning that there were opportunities for non-medical staff within the field (sometimes even within the mystical and superior world of prescribing). Services even started to employ ex-service users who had furthered themselves in education and experience. The power dynamic between service provider and service user started to dissolve, drug users were listened to – and, in many cases, preferred and pampered, with complementary therapies, immediate access to specialist education provision, and vulnerability tags when applying for housing.

The philosophy became – treat everybody. The research providing the evidence-base told us that a heroin user is less likely to die in treatment than when not in treatment; lessons from the 80s told us that legal and public denial of injecting practices led to steep increases in HIV and hepatitis C infection as a result of needle-sharing; the costs of treating health problems associated with long-term IV use and policing drug-fuelled acquisitive crime became clearer; and so thresholds for access to treatment were reduced. Harm Reduction was the phrase of the era, and this was extended to the harm caused to communities as well as to drug users themselves. Year by year, the money kept on coming and, to be honest, drug users and drug workers alike became a bit spoilt.

And so we move into a recession and a right-wing government. New presentations into opiate treatment are few and far between because heroin is so passé, and those with the will have made use of the plethora of services and reintegrated into mainstream society. The group that are left are not happy – no more free gym passes or massages, no more sick pay for providing sick notes stating ‘substance misuse issues’, but instead an expectation to attend medicals and Jobcentre courses.

At the same time, the Recovery Movement becomes popular. Now the phrase, ‘Recovery’, does not sit comfortably with me. It is a phrase that comes from the mental health domain and conjures in my mind images of the sick – all very 12-Step Model, where substance use is not a choice but a disease for which there is no cure, where the victim must struggle through and put faith in a ‘higher power’ to help them manage this terrible affliction. Dodgy. I personally find it disempowering, patronising and lacking in the notion of personal responsibility – it’s not a disease, it’s a lifestyle choice, you haven’t got cancer for christ’s sake – but I appreciate that it is a phrase that was chosen and adopted by a group of service users, and so who am I to criticise. If it works and people relate to it, that’s fine by me.

The Recovery Model also promotes working towards abstinence. Now abstinence became somewhat of a taboo phrase during the Harm Reduction Years, as the focus was on engagement and retainment in treatment, to reduce the damage drug use did to individuals’ health and the overall damage done to communities (admittedly for financial reasons, not the sympathetic reasons Tony might have had us believe). And so what the Coalition has done, somewhat cleverly it has to be said, it to take a service user-led movement which focuses on moving people away from substance use by moving them towards ‘recovery’, and twisted this into “You know that expensive drug treatment you’ve all been getting for years? Well, much like your benefits, you’re not going to be getting it for much longer. Get your head round it. Oh and – it’s for your own good you know”. Handy – and cheap.

Now I’m not one for enabling drug users to remain unquestioningly stationary – and anyone who has read my other posts will know that I am also sick to death of the ‘dependency culture’ that has developed in this country. But taking a group of people who have been socially vilified then pitied, who have been consistently encouraged to get in treatment, stay in treatment, and routinely drink the green nectar as their contribution to society for the last ten years – and then giving them six months to fully detox from methadone and get a job – that is just too much to ask and too great a challenge to the belief system of someone who thinks that going to the chemist every day is a vocation.

Some services, fearing decommissioning, have done exactly that – employed a ‘six months and you’re out’ policy. Others have decided that if someone drops out of treatment, that ‘probably means’ they don’t need treatment any more and so must be classed statistically as a ‘successful discharge’. This lack of any real health-focused philosophy within drug services is driven by the Government’s new system of Payment By Results – and the results they want are drug users out of treatment and into work (hence the targets around successful discharges). As well as the questionable morality of removing what has been sold for many years as a medical intervention (without a change in the research-base about its effectiveness, may I add), it chooses to turn a blind eye to the lack of skill, experience or motivation of most of the people left within this (pretty hopeless) group. Most importantly, it fails to acknowledge the level of psychological dependence on the medication that has enabled the opiate-dependent to function as normal human beings, given that methadone and buprenorphine (Subutex) both have long half-lives where heroin’s is very short, and so users take their medication once a day and then can go about their business (probably watching Jeremy Kyle, training their Staffies to fight, and seeing who picks up benzodiazepines at the chemist today if I’m honest – but many also work, parent successfully, and lead more stable lives than I). The fear of opiate withdrawals is significantly worse and longer-lasting than the physical withdrawals themselves, and politicians encouraging, promoting and feeding that dependency for TEN YEARS, then withdrawing it, is, in my mind, nothing short of abusive.

And where will it take us, I wonder, when in a few months’ time this group are poorer, more desperate and without the crutch that for so long has reduced their risk of dying? Is that a revolving door I see…?

Eclipsed by the Murk

Friday, November 30th, 2012

Our the budding writer continues on her journey, and though she hath faced adversity in her flee from Lord Bureaucracy, and had to ally herself with the lazy and meaningless Baron Twitter, the path ahead is becoming more clear and more easily trod. The band of merry travellers who accompany her on her journey have lightened her load, and their occasional shouts of ‘G’won my son!’ have propelled her when the track became treacherous. Even iPad, her trusty tool, is becoming easier to wield, which can be seen by all as it now doth sport sticky fingerprints, and these make her feel somewhat bilious and induce regular, unconscious finger-sniffing.

And yet, as she walks, she can feel a shadow encroaching, and though she turns quickly to face this dark force, she can see it not. She feels its presence at night when she sleeps, it awakens her and taunts her with its blackness, filling her head with death and destruction. She catches glimpses of it in her periphery as she walks, and it makes her quicken her step. She can feel it when she eats, squeezing her stomach as though it were a lemon, which, although not a pleasant feeling, does help her lose a few pounds around the waist, which is no bad thing.

Although she attempts to turn away from this tenebrous phenomenon, she knows its source, for she hath felt it before and she knows what brings it. For this gloomy suspension is Stress, sent by the abhorrent Lord Bureaucracy to impede her quest, and with it comes the breath of those that drink Special Brew and the stench of those that washeth not their putrid feet for they are without a home, which have been dragged from the land from which Stress came, where amphetamine is ingested like bread and at once the houses are cleaned. And though she tries to escape Stress’ odour and out-run its oppression, the smog surrounds her, and it ages her and gives her spots and bags under her eyes, and she increasingly struggles to resist the temptation of the many public inns that are scattered enticingly along her way and the luscious golden elixir contained within. And the macabre mist begins to engulf her and cripple her, and she struggles to find the strength to battle against her internal desires to stab and slice all those that present even the slightest challenge to her on her journey and say things like “Just chill ouuuuuuuut”. And all of her ration and her tolerance is gone.

And yet, even as she suffocates, and writhes on the path awaiting Stress’ final crushing blow, through the foul fog a group appear; within them a medic, who has long known of her plight and advised whence afore Stress enveloped her; and her father, loyal and true, who picks her up, dusts her down and sticks a much-needed beer in her hand. And then, through the ashen haze, she hears the sound of horses hooves, and on a three-legged steed arrives a union rep, who, though late and almost impossible to contact by phone, knows Stress well and is adept at challenging those who send it. And she gives our heroine the Mask of Advocacy, and wraps her in the Blanket of Legal Terminology, and pledges to protect the aspiring author from the evils that Lord Bureaucracy may send.

And wrapped in her blanket, and softened by the ale, the traveller may sleep, and dream of what lays ahead, and in sleeping she becomes refreshed and rejuvenated, and no longer does she look like a decrepit ascetic with herpes, but awakes fresh-faced and ready to face whatever tribulations may lie ahead.

Help! I think I’m turning into Margaret Thatcher!

Saturday, November 24th, 2012

Writing ‘I heart NHS’ left me pondering on why the wonderful, socialist systems of which our country can be so proud are nowadays so readily and shamelessly exploited, and questioning my own political standpoint. While I consider myself a big old soft romantic leftie to the core, my journeys into human nature have singed me and turned purity of belief, naivity of youth, and blissful idealist indulgence, into pragmatic cynicism.

There is no part of me that feels the welfare state is a bad idea – I am glad to contribute to keeping those unable to work in a decent of standing of living. But then, in the words of someone wise, the welfare state was meant to be a trampoline but has become a net – and I scare myself sometimes these days when I sympathise with the Daily Mail, or nod when I hear Cameron speaking of welfare reforms. I mean, really scare myself.

It is an internal clash I face daily as a drugs worker. No, dear client, you are not unfit for work because you are taking methadone, lots of people hold down jobs whilst on medication. Yes, dear client, you will almost certainly be less depressed and feel better about yourself if you get off your arse and do something constructive with your time to evoke a sense of satisfaction and purpose. No, dear client, the benefits you choose to live off are probably not yours morally, even if you are entitled to them legally. Yes, dear client, you might start sleeping at night without Valium if you do something with your body and brain other than watching Jeremy Kyle.

Once, as I attempted to convince a client that losing his disability benefits might be a blessing in disguise, an opportunity to be grasped, a chance to evolve and progress, I was asked, “What mug would go to work when he can get paid to stay at home?”. I managed to hold myself back from flying-kicking him across the consultation room (I’m a professional, you know), or from screaming my true feelings of “One with a sense of morality / work ethic / conscience / anything other than HIMSELF, you egocentric sponger!”, or from leaping over the desk, ragging off his Nikes and touch-screen mobile phone (why do you think it was so cheap – because it’s STOLEN!), shoving them up my jumper, and running out, howling “They’re mine! I paid for them with my taxes!”. Like I said, I’m a professional – I just reduced his methadone by 10mls and booked him in for some unnecessary and painful capillary blood tests.

It’s a poignant question though. The father of the welfare state, William Beveridge, would have answered that it was each person’s aspirations “to provide more than that minimum for himself and his family”. I suggest he somewhat over-estimated a significant proportion of the present British public’s aspirations. Possibly a few days in my job, working with the third-generation unemployed, would have made him question his basic premise.

Back in his day, though, the working class sat cross-legged on the floor of the social stratosphere. Nowadays, although standards of living are higher for everyone and we all have chairs to sit on, I suppose the working class are the middle classes in that they are the ones who go to work, and an under-class has developed of people who are out of work. (I was tempted to put ‘an under-class of people who don’t want to work’ but freaked myself out that the Daily Mail within was starting to ooze out – but, in all honesty, many of the jobs that have been created locally are currently filled by Polish people because the local, English-speaking unemployed for whom they were created do not want them.) It could be labelled ‘dependency culture’, but ‘dependency’ for me conjures up images of vulnerability and need, which are the people who the welfare state should exist for – for me, it’s more an entitlement culture, represented by the right to choose not to work.

So, I find myself over-worked, though not under-paid, feeling down-trodden, and somewhat resentful (and jealous?) of the people who do get paid to sit at home all day, make a few extra quid from selling bent cigarettes (and therefore by-passing paying tax which would otherwise contribute towards their and their customers’ impending heart failure / lung cancer treatment), laughing at mugs like me running around like a blue-arsed fly trying to reduce their health inequities – which, largely, they create, and I / we / definitely not they, pay for. So, the question I ask myself, and put to you, oh readers who have pledged to be honest and true – am I a bigot?! Are my frustrations with the current systems justified and rational – or will I soon find myself agreeing with headlines that fail to differentiate between refugees and illegal immigrants facilitating sex trafficking? Will I next find my hand, on Election Day, quivering with pent-up anger and resentment, unconsciously drawn towards the box marked ‘BNP’? And if so, what next – all drug users are scum? All Muslims are suicide bombers? Premiership footballers are rightly the role models of future generations? Tits on Page 3 and Babestation are examples of equality in employment and, as such, good for women? I just don’t know anymore, readers, I am so confused and feel so compromised, having already strayed so far from my pure, true, clean socialist belief system and resenting the unemployed!

I heart NHS

Saturday, November 10th, 2012

After reading I realise I should make something clear, and explicitly express my adoration for the NHS. It may not be fast, it may not be flawless, but the notion of free health care for all still swells my British heart. Seeing the work firsthand that goes into reducing health inequities is genuinely awe-inspiring, and although it may have gone a bit diabetic in its old age, it still does a cracking job of training, recruiting and retaining some of the most committed individuals our communities have to offer. I’m not implying it’s altruism – I know others may disagree but I think most of us are paid quite reasonably since public sector pay increases under Labour – but I’m going to hazard a guess there’s a higher concentration of generally decent and morally sound people working for the NHS than in, say, the banking sector or estate agencies.

Unfortunately, the employment rights and decent pay do also attract and subsequently retain some entirely soulless arseholes. There are loads of them, and whether they seem to end up in management positions as a result of their Machiavellian pursuit for an easy life or the rolls of red tape that protect them and enable them to weave their way up the ladder, there are some seriously lazy people working in the NHS and there is nothing, it seems, that anyone can do about it. Luckily there are just enough self-sacrificing grafters to keep the boat afloat, but their workloads are even greater because of the shameless free-loaders that drink lattes and ‘work from home’ without ever really producing anything in return for their public pay-packet. And if they ever do get formally challenged, they can just go off sick and wait for the whole thing to blow over, sitting at home drinking lattes and getting paid for it, just like the old days.

It’s a frighteningly delicate balance, it seems, between worker rights and worker piss-taking-opportunities. Much as with the reduction of health inequities for drug users, as per my first post, the NHS can be a victim of its own success and tip the balance slightly too far. As with so many of my favourite things about this country, systems which are free for all become a free-for-all, and probably my least favourite thing about human nature is that there is always someone eager to find a generous system to exploit.

All said, I’ve fulfilled a life ambition in working for the old boy, and whilst emotionally I cannot serve him much longer, I am sure in years to come, when he is dead, I will think of my time with him with tenderness and pride.

Public servant craves freedom

Tuesday, November 6th, 2012

So, my first attempt at a blog, where to start..

We all come to crossroads in our lives as part of the privileged world of choices we exist in, and yes, I fully accept that choosing one’s career path is a luxury which the majority of the world’s population do not enjoy, and so I don’t want to get too whimsical or self-pitying here. However, it has to be said, my choice of career was one which left my school teachers and lecturers scratching their heads and asking ‘why?’ and telling me ‘there isn’t much money in it, you know’, both of which, at the time, as a fresh-faced, political, optimistic young woman, meant nothing to me. I thought I could change the world – not the whole world, but the individual worlds of people who were struggling, which is all one ever really wants as a psychologist. Maybe it was a desire to make a difference, maybe it was the result of teenage years spent unwittingly wrangling with low mood, maybe it was the values of a socialist, fierce but compassionate mother, maybe, as a boyfriend put it, my need to take on a caring role was a form of self-validation, or maybe it was just middle-class guilt. Whatever the reason, I launched myself into drugs work like a dwarfed Wonder Woman out of a cannon. And I loved it.

Back then, drug users were a genuinely socially excluded group. They didn’t access healthcare because doctor’s surgeries wouldn’t accept them as patients, and if they did make it through the door, they would cope with health complications rather than go back to be treated like sub-humans. Only people with an address could register with health centres, and people presenting with a bedraggled or unkempt appearance were considered unfit to be seated in waiting rooms with ‘normal’ patients. Women especially did not present asking for help or treatment because the party line was that drug users were not fit to be parents, the substance use instead of the parenting was assessed, the failings instead of the need recorded, and so people struggled on alone, quietly, rather than put themselves up to be judged, criticised, and risk losing their families.

It was a great job, back then, being a drugs worker. You had battles with GPs about the definition of the word ‘healthcare’, you compiled evidence-based arguments to challenge psychiatry’s refusal to treat drug-users, quoting research about the co-morbidity of substance use and mental health issues, you waved the flag of the vulnerable and battered down doors until people listened to the plight (or just got sick of hearing you banging on) and agreed to let you in. It was hard, but god was it rewarding, and the clients were just grateful that for once someone was listening to them and was on their side.

Flash forward eleven years… A Labour Government has been in place, social equality has been a priority, times have been affluent, public sector wages are brought into line with the private sector, and drug users have been given recognition as a vulnerable group – no longer perceived as waster layabouts, some have addressed their issues and gone on to successful careers, breaking down prejudices and presuppositions about substance users, while the others are acknowledged as probably having had experienced childhood abuse and have therefore developed poor coping strategies, needing intensive rehabilitation if they are to address their issues, and so are sympathetically cradled by the system.

But hang on, there’s a global recession, funds are being cut, and the luxurious ten years of the Drug Strategy seem long behind us. So now drugs services start pitching themselves against each other for funding, long-existing relationships become strained, GPs start to wonder if it’s really worth having this type of patient in their surgeries if the money is drying up..

But worst, by far the worst, change to the landscape of the role of a drugs worker comes from the client group themselves, the very people you went into this role to help. They too have had a few comfortable years – now not only able to access healthcare, training opportunities, support with parenting, housing and finances, but with an ever-growing, burning sense of entitlement. They’ve had their legal aid, they know their rights, they’ve learned to exploit every loophole in every system, and they are used to being fast-tracked to the front of every queue because they are IN NEED. And they see ME, their drugs worker, their advocate, their bodyguard against inequity, as their root to a happy life, their guarantee that never again will they be poor, homeless, badly-treated or in need.

Now the twenty year old me might have been willing to attempt to fulfil that impossible role – but by now I have faced my own fair share of adversity, been on my arse a few times as we all are as humans, and learned to pick myself up, dust myself down, and get on with what needs to be done. And so regular attempts at emotional black-mail to the cry of ‘if you don’t get me some benzos so I can sleep / sort out my rent arrears so I don’t get evicted / tell Social Services I’ve stopped using so I don’t lose my kids / have me a new prescription at the pharmacy by 12 with an increase to my methadone dose, it’s YOUR fault I’m going to use’ wore thin and, frankly, I started to find the lack of personal responsibility and dependence of the State tedious, irritating and, at times, downright infuriating.

And so here I am, stuck in a miserable, unrewarding, emotionally-exhausting job, wondering where the last eleven years have gone, unsure if I have the skills to transfer to another profession which, likely as not, will also be subject to cut-backs and job losses, and really much preferring the idea of disappearing up a mountain alone, never again to address humankind. You don’t see the best in life, working as a drugs worker, and I don’t want to keep seeing the world like the big pile of shit I have been for so many years. I used to be an optimist, for god’s sake! Now it seems I am unshockable, unscarable, and have the emotional range of Oscar the Grouch.

The English language was always my first love, sadly neglected over the years of personal austerity, and life events and puzzles started taking me back to it during periods of lone reflection. And I thought to myself – I’ve paid my dues, I’ve done my time, and I’ve got enough material to start writing now and never stop.. And so here begineth the attempted transformation from drugs worker to writer…

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