Thread by @HZiauddeen

🧵 Scarcity, systems and people:

This was the 🧵I had planned for this weekend. It started out with mental health systems but then got a bit into COVID as well.

It's about how scarcity shapes, and is used to shape, systems and the people within them.
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I'm going to start with mental health services (MHS), partly because they will always be closer to heart, but also because it'll help illustrate the various levels this operates at. It'll take a bit of unpacking so please bear with me.
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A couple of points upfront:
1. Scarcity has to be thought about as both an in-the-moment & a long-term factor i.e. it shapes systems and people over the longer term and has accumulated effects that interact with the in-the-moment scarcity.
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For example, poverty shapes the lives and trajectories of communities over generations, taking them to very different positions than more affluent communities. The accumulated disadvantages worsen the impact of the ongoing poverty.
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2. Scarcity is not the only factor at play but it is a major one. Amongst the arguably more important factors are those that drive scarcity.
3. A lot of scarcity is created & this is largely done by forces outside the systems impacted.
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In MHS, scarcity is one of the major reasons we fail people (there are MANY other reasons, this 🧵is just about scarcity). In many countries, including the UK, MHS are very under-resourced and this is a long-term factor.
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The current state of MHS reflects the impact of decades of underfunding. Scarcity has to be thought of in terms of the need, not the absolute funding. Getting more money than you did last year (not sure when this last happened for MHS) may just mean being less worse off.
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There are several consequences of scarcity on health systems & the people in them. I'll start with the systems, sticking with what can reasonably fall in their remit e.g. poverty is a very important factor for MHS but tackling poverty is not something MHS can do.
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The consequences:
1. Preventative work (if any was happening) stops.
2. The whole system capacity will be reduced.
3. The focus will shift towards the more severely ill.
4. Acute care systems (e.g. hospital wards) will need to be prioritised (whilst still being reduced).
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5. Service thresholds will increase as only the most severe can be looked after. This means that there is little that can be done for the not so severely ill, even to prevent them from progressing to severe illness.
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As ridiculous as the latter seems, scarcity means that the limited available resources have to be allocated to those currently most severely ill.
6. The combination of 3, 4 and 5 will mean that most of the system will be focused on people who are more severely ill.
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7. However this will not be a symmetric effect i.e. it won't apply equally to all people or conditions because the reduced systems won't be able to cater to everyone and will end up focusing on those who are most suitable/can be most helped by the current system model.
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8. Groups that will miss out will be:
-Those who have chronic or longstanding illnesses and difficulties.
-Those who despite terrible suffering do not hit the risk threshold.
-Those who need to slower and longer-term support and treatment esp psychological treatment.
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-Those who have been historically underserved: e.g. children, victims of abuse and trauma, marginalised groups, people with ASD. When there was no/little provision previously, things will only get worse in times of scarcity.
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9. The system pressures & the frustration with not being able to provide adequate care, lead to problems with retention and recruitment, and further worsening of the scarcity. This also leads to a particular kind of selection pressure, who stays on in such systems?
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10. As a whole, the system shifts further away from 'what should be done?' to 'what can be done?'. Here it is important to bear in mind that if there's increased scarcity in MHS, there's almost certainly more scarcity in related systems (social care, welfare, housing).
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So what happens to people within these systems?
1. 'We know we can't do what we should so let's get on and do the best we can!' does not really work very well as a rallying cry to the workforce. So the system reconfigures itself and its narratives to try and be coherent.
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i.e. its structure and narrative all explain why it is the way it is. This can include creating new narratives about what it should be doing, e.g. promoting recovery and independence instead of being paternalistic and regressive (these do not have to be exclusive really).
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2. The system and the people who work within it have to come up with some internal narrative that explains why it/they cannot help a lot of people who come to them, and can only do so much for those who they can help.
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3. Sometimes this means that you just have to carry the sense of repeatedly failing people. This is difficult and some people manage this by emotional distancing, sometimes straying into callousness.
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(To be very clear, I don't condone this in any way. I'm very pro carrying-your-repeated-sense-of-failure & passing-it-up-the-chain but am mindful that I am very privileged).
4. But here is the more troubling aspect. Scarcity reinforces systemic prejudices and rivalries.
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It brings up the very unpleasant matter of deservedness. Who deserves to treated? Who deserves to get the resources available (be it patients or services)? These inevitably will reinforce existing beliefs about who is more deserving and what is more important.
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This is very common with scarcity, when you have only scraps, you fight over them, treating the fact that you have only scraps as an unavoidable bug in your system, rather than a feature of the systems above you.
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5. This gets really nasty when it comes to those you're meant to help. Because instead of telling people honestly you can't help them, you come up with reasons why they don't need help (the subtext often being they don't deserve it).
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Some people do this to protect themselves, some people actually believe this.
One particular systemic prejudice and stigma this exacerbates is that against people with the very problematic 'BPD' or just 'PD' diagnosis (whole other 🧵on this coming soon).
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This is a group that encompasses victims of trauma and abuse, and people needing longer-term support and psychological treatment. In truth, we have always had very limited provisions for these needs and I’ll come to this in a little while.
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6. Clinicians trying to help people in systems with scarcity, end up drawing excessively on the one resource that they do have control over, themselves. This means greatly stretching your own reserves and this is costly and unsustainable.
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For the individual patient, this may be very helpful but it does mean that your care becomes more dependent on whether you get such a clinician. Perversely, this is something that the systems above capitalise on and weaponise.
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So appeals to the nobility and caring nature of the professions, ‘this is what you go into it for’, ‘this is what you signed up for’, are all essentially telling those in the system to make up for the shortfall caused by scarcity, using themselves.
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7. For patients/carers in the system, it is extremely frustrating and often harrowing. From being told that you are not ill enough, that there is no provision for your needs, that you are too complex, that no one can take the time to figure out your difficulties.
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It is very understandable that patients get angry with us because we clinicians are the face of the system that they see. We cannot expect someone in distress, someone who is suffering greatly to understand that you really cannot do very much for them.
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Yet, it is far better you are honest and acknowledge this, rather than try and make it about them in some way. This happens far too often. In these helpless moments, all you can offer people is compassion and a listening ear.
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And in many of these encounters, as a clinician, you will fail. You may just need to carry this till you can take it to someone to help you.
All you can do a lot of the time is do the best you can so try and do at least that.
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Also see

https://twitter.com/DrChloeBeale/status/1438118282347880448?s=20

8. The thing with scarcity is, trying to do the best you can in the face of major systemic limitations, is not sustainable. There is only so far you can push yourself and people burn out and get jaded. But we ask people to do this again and again.
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9. Finally, scarcity forces people and systems into working very much in the short-term, not allowing space for reflection or for looking at the bigger picture. This is a thread about survival mode for people, some of it applies to systems as well
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https://twitter.com/HZiauddeen/status/1448650799148515333?s=20

Before I move on, I just want to be clear that while scarcity is an important factor and a good explanation, it is not an excuse for poor conduct and behaviour. This is not an apologist thread for treating people poorly in MHS.
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In the last bit, I want to focus a bit on the drivers of scarcity. Let’s consider why MHS are so underfunded. The first thing to note is that it is not about the availability of funding (follow the excellent @RichardJMurphy) as money can always be found to enrich folk.
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It is about what the political will (and its many drivers) thinks should be funded, or more precisely how much funding it thinks should be allocated to MHS and for what MHS specifically. This essentially boils down to who they think are important.
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The short answer here is not very much. The funding seems to be prioritised for keeping the system going as mainly a severe illness and urgent care service. It's certainly not about preventing severe illness or improving the general health of people with mental illnesses.
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One major area that the political system has never prioritised is the needs of children and women. This is a much wider systemic issue that affects MHS, education, social care, domestic and sexual violence services, support for victims of abuse and trauma.
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The long term scarcity in this area means that our wider services for these groups have always been scant e.g. longer term psychological treatment. Another group that has historically been severely neglected are disabled folk.
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This takes us into why these and other scarcities have been created & maintained by political systems that do have the ability to ameliorate them. And this takes us far back into history and into aspects of systems of power and the people in them.
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https://twitter.com/HZiauddeen/status/1319015839870427138?s=20

I won’t go into too much detail here but briefly, a huge part of scarcity is not due to lack of resources but to inequality of allocation and possession of resources. And scarcity also serves as a powerful tool to maintain this status quo.
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It keeps us fighting between each other for the scraps that are given to us, instead of asking why we only get scraps. It reinforces and even creates our prejudices about who is undeserving and who is responsible for our suffering.
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It fuels the ideas of ‘drain on the state’, ‘scroungers and benefit frauds’, ‘not really a person (deserving of care/equality)’. It makes scapegoats of immigrants, of teachers 'who are not satisfied with their cushy jobs', of doctors 'who are already paid so well'.
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It finds and makes the enemy within us, rather than those in power.
And scarcity has repeatedly been used to serve the interests of those in power e.g. defund services, run them into the ground, all to build the case for ultimate privatisation.
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And now with COVID and Brexit, there is a lot of scarcity. Some of this it was not about not having money (billions were found to help many of the rich deal with the scarcity of increasing wealth). But years of scarcity had the health service on its knees before COVID.
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What we see happening with the political and media attack on GPs at the moment is again a weaponization of the same. Scarcity within the system is being blamed on the people who are keeping the system running and the projected ends are only too clear.
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Austerity was the creation of more scarcity.
Scarcity is a powerful means of control of the majority and enrichment of the minority. It is presented to the majority as a fait accompli, now fight amongst yourselves about it.
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I have not made too much allusion to COVID here but I hope the ideas help make sense of the devastation that COVID has wrought and the way the govt and its backers have actually doubled down on what they were doing.
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Addendum (with thanks to @DrK_W1984)
About the point of 'deservedness' (should have been in quotes), this a common prejudice in societies, so easily triggered, weaponised, and turned towards hate. We should be thinking about people's needs, not 'deservedness',