What is Wrong with the Cass Report - and What is Right

 Dr Hillary Cass published her report into the way gender dysphoria services in the Uk have been mpoorly managed.  Much of what I read makes sense, but as appears typical to me, the passivity of NHS culture continues.

What do I mean?  The established culture I observe in mental health services is that there is little to no limit put on requests for services.  It is if the resource is, (or should be) limitless.  People make requests, and with very little screening, their requestings result in their names being placed on waiting lists.  The ides is that NHS services are good for you, so being on a waiting list is good.  Also there is the honourable idea that as citizens, all have a right to these services.  The waiting list is an inevitable and regrettable consequence.  There is also the unspoken belief that from a service perspective not having a long waiting list means that your service is vulnerable and possibly dispensable; next in line for cuts. 

Waiting lists occur when expenditure exceeds income (to use a financial metaphor).  Over the months, the debt grows steadily.  Eventually the overdraft limit is reached.  At this point the waiting list is at risk of dematerialising into a 'non-service'.  Even today I spoke to a mother who told me that her son was on a two year waiting list to be assessed for autism.  The letter she received states this as a matter of fact.  I have seen this methodology also used in the housing department when families are told that they are on a waiting list for a move to a council house in Cornwall.  What they have not been told is that this waiting list may be longer than the life they have left in them.  They are left with the belief that one day (not sure when) they will be moving away from this 'god forsaken place' to some wonderful existence elsewhere.  Consequently they never really put down roots or settle where they are.

In contrast I have worked for Social Services, where the answer is generally "NO" (oh, and by the way, what was the question?) This is an opposite philosophy when interventions are seen to have negative side effects, as well as positive ones.  Involvement is based on 'minimum necessary intervention', and very high demands on scarce resource is managed through this tough gatekeeping.  This system is also dishonest but in other ways.  Instead of being open about the scarcity of resources, the message is that the system is fine, it's just that you are not eligible. 

This is my view of the context of the Cass Report.

What was not said was that since the report 'Future in Mind' was published in 2015, there has been an emphasis on 'self referral' in Mental Health services.  This fits with the idea of freeing up barriers to accessing services, and emphasising people's rights to request NHS services.  Self referral was featured on the Tavistock Clinic Gender Identity Service (GIDS) website.  My understanding is that clinics were mainly based in London, but that there was another clinic in Leeds.  Future in mind also did away with the 'tiered' prioritisation model.  I guessed this was after hearing from articulate middle class parents distressed that they situations did not make them eligible to see a psychiatrist of psychologist.  The new idea was that all service could do a 'bit of this, and a bit of that.  It blurred the boundaries, and the flood gates were opened. 

The adult Gender Identity Service (GIS) based at the Tavistock has on its website an candid estimate of waiting time.  It says it has 15,086 people waiting, and that they see about 34 new people per month, with people waiting from Dec 2018 being next in the queue. They report receiving 406 referrals last month.  

This is the 'passivity' I am speaking of.  This message is 'it's not our fault, what can we do?  Give us more money and we can see more people.'

The Cass report rightly says that children referred to GIDS (the children's service) should have been directed to local mental health, and social services first, for more general care and assessments needed.  Often their gender dysphoria was a bit-part player in their overall distress, and local services saw the opportunity to 'off-load' work where they could, and especially if it was encouraged by the service itself.  Just like valium for depression, puberty blockers became the solution.  

Back at the ranch, local CAMHS services were playing the same game with long, unwieldy waiting list, and a their own culture of passivity, and disregard to the effects of long waiting times ("not my problem gov.")

In 1995, the New Labour government, in response to focus groups with patients and their representative, actually made significant changes to the status quo within the NHS.  At first they thought is was just money, but soon discovered that the money changed very little.  In child mental health, the Health Advisory Service published a report called  'Together We Stand' which addressed how the needs of the whole community could be mean wholistically.  They created the new mental health role called the  Primary Mental Health Team, which was designed to address the problem of waiting lists and inequality of access to services.  From the moment the Team came into existence it became subject to attacked from powerful professional groups within CAMHS itself.  The Primary Mental Health Team was designed to strengthen the interphase between universal services and the specialist CAMHS service.  This aim was  to ensure that only situations that merited specialist (and expensive) support was delt with by CAMHS.  Outsiders might assume that this would be what CAMHS might value, but no, CAMHS saw the limits placed by these boundaries as a threat to the status of the service in the wider community.  When the Primary Mental Health Team was allowed to work, with strong political backing, and with the strength provided by accountability to a multi-agency context, waiting time dropped to a maximum of 3 months (from 18 months to 2 years).  With the eyes of partner agencies on the work of the team, unacceptable practices became a taboo.  Indeed, the Primary Mental Health Team was able to do the same for other services, keeping us all focused on the only thing we shared- the children.  I am reminded that it is said that countries spend more money and time spying on their friends, rather than their enemies.  We kept each other in check.  As we worked together we could not wait say, 3 months for our partner agency to be getting its act together.  Generally all work was done within one month.

How will things change?  For me the only way is for citizens to take control again.  They must move away from 'poor NHS, covid heros, there is nothing you can do since covid came.'  The solutions are various, but one of them is to put the 'service' back into NHS, and see the patient's calling more of the shots.  And this is not through 'self-referral'.

Heaven is a Place on Earth

Flammarion Engraving

What is Heaven? 

Before I was conceived, I existed only as a cell in my mother's ovary, and then as an egg.  These were formed when my mother was herself a fetus in her own mother's womb. She began as a ball of dividing cells and one cell was assigned to be a possible 'me'.  A physical part of me was also being 'born' at the same time that she was. 

When did I come into existence?  

When I die do I return to this pre-birth state?  A state of nothingness; no memory?  Is this the circle of life: returning to whence I came? And does it matter? 

There are a number of challenges to this for me.  The first is to note that I can actually contemplate, and wonder about existence.  Am I entirely dependent on my physical being?  Are people being kept alive in a vegetative state for years 'living'?  When the flame of life is extinguished, is that the end? Complete finality?  

I note that during my lifetime I have developed a relationship with a 'Creator'.  I share this with many others.  Much the same as it is with any relationship this is based on undenyable experience. It will not 'go away'. The relationship speaks to me that there is more.  I am more than just a physical entity.

It is also undeniable that from the beginning of human existence, there has always been a concept that life on earth is not 'it'.  The Ancient Egyptians made this clear to us.  Even today, the jury is still out on the existence of more.., also here in the West.   

In our contemporary western world, the prevailing view appears to be that life on this earth is final.  This is it, so it is worth not dying just yet, (unless you are really not having a good time where assisted suicide seems to be an option).  For the rich West, we channel vast resources into simply staying alive.  

There is also a growing belief that the world will not survive much longer in its present state. Humanity will die out, or return to some primitive form, with the main bulk of the population being wiped out through war or disaster.

Reading the Wikipedia entry on Heaven helps present a diverse history of different understandings of  Heaven across the world, and across time.  

The english word 'Heaven', like the word for 'God', comes from norse mythology.  What are the important distinctions and concepts?  Words from different cultures do not translate well, and require an understanding of the philosophical milieu from which they emanate.

This is my attempt at explaining Heaven.

1) Heaven is the place where the Creator is.  (Is there anywhere where the Creator isn't? What about Hell?)

2) Heaven is a place where people go when they die.  (This throws up other questions.  All people? What about animals?  Vegetables and Trees? Again, what about Hell?)

My take from reading around this subject is that there are three main concepts of heaven.

The first and oldest is that heaven is a spiritual soup where the 'life force' is held and redistributed into all living things.  A final state of harmony exists after a long journey, but this will be similar to nothingness. (A pleasant nothingness however.) In this model, God is the creator.  God is 'good', but health/wellbeing and disfunction/harm and pain are striving to find balance, or harmony.  God is good, but bad is included as a subsection of good.  

The second is that this life is Part I of our experience of life.  Those who survive and to go on to Part II can be understood as on a continuum from 'all people' (universalism) to a select group, either self-selected (God doesn't send anyone to Hell, but sometimes we choose to go ourselves), to the 'chosen', who fit a defined prescription (with different combinations in between).  This can depend on my actions and decisions taken in this life, including 'repentactance', and living for, or submitting my will to, 'the Creator'.  This model includes the possibility of a 'bad' Part II - or 'Hell' (being separated from the Creator). 

The Third is one which has always had some traction across time (including with the famous 'Sadducees', or Jewish philosophers who did not believe in Heaven).  This is that we live one life.  As the flame is extinguished, so are we, and that is it.  Here Heaven can only be what we create here on earth, and the alternative, a living Hell. 

The three things that stand against a nihilist future heaven are 'Faith, Hope and Trust'.  I have faith that my relationship with the Creator, and 'our' relationship with the Creator, is real and enduring.  I am created for a purpose, and this is the reason for existence.  I have hope that life is worth it, even through pain and injustice, because the presence of a 'Good' Creator which makes all things bearable.  I trust that the message put in our hearts in true, and that through whatever happens, we are not alone.

Like life itself, this is a flame that burns despite everything else going on roundabout.

 

On Etiquette

James Gillray 1805.  Overbearing male suiters,
shocked when a wealthy widow
gets up to ring the bell! (Wikipedia)

These are my thoughts stimulated by listening to the BBC World Service programme called 'The Forum'.

Etiquette- largely arbitrary and slowly evolving rules 'of engagement between people'.  Or how to 'get along'.  This is particularly important for people who live crammed together in cities.  We talk about people being 'Urbaine'; those who know how to live 'cheek by jowl' with their neighbour.

The word comes from the french for 'labels', 'signs' or 'notices'.  It is most likely that modern european etiquette was defined first the Spanish court, adopting the french word, as if it was aping the wonders of the French court. 

In every age there is evidence that the popular view is that things 'ain't what they used to be', in other words there is always perceived to be a drop downwards in standards, which in actual fact cannot be true, because otherwise we would by now be in the basement. 

A lot of the way we do things will be subconscious, and absorbed from the adult world as we grow up.  Some of it will make sense, some not.  Etiquette has also been laiden with the stuff of power and inequality.  Across the world there is etiquette for women, and for men, for children and for adults, for the workers, and for the rich.  Some might be perceived as harmless, such as bowing or curtsying to the King. (when will I ever need to do this?) Others reinforce the status quo.  "This is your position and you stay in it."

Much etiquette is of course trivial.  In a french restaurant you are supposed not to eat the bread brought before the meal.  You need to be patient.  The bread is not for filling up, and will not be replaced.  No one tells you this because it's so trivial, but if you want to see a waiter's disapproval, stuff your face as soon as the bread arrives.

Etiquette as we grow old is interesting.  As a child you know that one day you will be in that position of power where you can eat chocolate bars for breakfast. When the time arrives, sadly so does the inclination.  However as we grow much older, our status may reduce, and etiquette moves more into patronising platitudes, and concern and worry.

Etiquette is most visible in other cultures, were the contrast offered  to the 'outsider' provided acuity to the definition.  However, an interpreter is likely to be needed, because initial assumptions are often wrong.   Apparently in China there are few platitudinous greetings, such as Hello, or Good Morning.  To the European, an encounter with their Chinese colleague may feel abrupt.  But the chinese may instead ask, how is your family? This is the greeting, just as we ask 'How are you?' and do not expect a long explanation.  Some cultures distain please and thank you, as unnecessary insecurities. 

American are often foxed by the 'how are you?' question, until they realise we don't really mean it.

Is etiquette only a challenge in cross-cultural situations?  I remember seeing a car crash outside my student house in Bristol.  An  African-Caribbean man's car was smashed into by a white women at a junction.  They both got out.  The Caribbean man remonstrated 'what has you done?' The white woman look terrified.  The Caribbean man burst out laughing.  There was no malice or threat in his approach. It was a cross cultural encounter.  

So are cross-cultural encounters to be avoided?  At our peril.  This is where the 'cutting edge' of culture exists; where culture is challenged, reflected on and refined.  Without it we risk continuing to adopt illogical and counterproductive ways of living.  

I recall meeting a Christian social worker from a Caribbean heritage and we discussed all the aspects of western christianity that are 'cultural' and perhaps not core to the faith.  It was very refreshing. We were able to focus on what is essential, and what is etiquette, tradition and ritual.

We joke in our house when we have meals with people from different cultures that there is only one rule, and that is that there are no rules (relating to table manners).  I guess my meaning is similar to Augustines (misquoted) saying 'Love God and do as you please.'  I am assuming that our friends actually care about us.  Indeed on the programme we heard about teinei (丁寧).  This roughly translates to 'Politeness'.  You could call it 'after you' etiquette, where you think about the needs of others constantly.  All cultures require this, and, in the UK and US this is can be seen as similar to the concept of 'random acts of kindness', where strangers notice the needs of others, and take proactive steps to help their situations to be 'blessed'.  We could call this 'micro-philanthropy'.