At Your Service #7, 5 Giants and Mortality
At Your Service - text by Heather Ditch from Go-Native, September 2018
Our National Health Service employs over 1.7million people, making it the fifth largest employer in the world. It is a service unique to the UK that over 70 years has evolved into a potent symbol of Britishness; an institution, a national treasure, a source of great national pride, as well as something we take utterly for granted. Perhaps that’s because it’s felt to ‘belong’ to us – we see access to healthcare as our right, and assume that the NHS’s experts and facilities will diagnose, treat, mend, sustain and watch over us, unconditionally.
And that’s really the intention of it – the first line of the NHS Constitution is ‘The NHS belongs to the people.’ It’s the theme of belonging that sits at the heart of Mir Jansen’s work. She brings two key perspectives to bear on this subject – firstly from her work as an artist and an arts in health co-ordinator working in the NHS. Secondly, as a Dutch national living in Sheffield for over 30 years, facing the uncertainty created by the vote to leave the European Union.
In At Your Service, Mir celebrates the NHS and pays tribute to the 160,000 European staff who make it what it is. She explores the idea of belonging – to the NHS workforce, on a local and national scale, to the European Union, to our home nations, to Sheffield. By virtue of that she explores ownership too, the things or concepts that we possess – the rights bestowed on us by the NHS Constitution, the idea of ‘nationhood’ or citizenship, the stories that we gather and own.
In three pieces of work, At Your Service explores ‘belonging’ on a series of scales. We start with I Have The Right – five panels that describe the most common causes of death in the five stages of human life, from infancy to old age. And while congenital conditions, accidental poisoning, suicide, cancer and neurological disease might end lives on a vast scale, Mir uses just five individual portraits to tell the tale of life and death. It’s the impossibly huge made meaningful, each portrait an individual ambassador for their age group. That same shift, from mass to individual, has occurred across the NHS’s 70 years.
Today, as we live longer, our ailments grow in complexity. Instead of the mass immunisation programmes of the NHS’s formative years, which would have saved thousands of lives at a time from polio, whooping cough or TB, now the service must cater to those complicated, unique needs.
The second piece of work – We Have The Right – sees a series of 60 hand-painted panels create a collective portrait of 11 European employees working for Sheffield Teaching Hospitals. Mir interviewed these people in detail, prompting conversations with a series of questions: What was your reaction to Brexit? What do you miss about the country you were born in? What do you love about Sheffield? What do you admire about the NHS? What are your concerns for the NHS? And a question she says non-UK residents are asked persistently – What do you contribute to life in the UK and Sheffield? The interviewees who are not full UK citizens, do not know if they will qualify, after Brexit, to the rights and entitlements set out in the NHS Constitution. What else will they lose, what will no longer belong to them, when this country no longer belongs to the EU? We Have The Right paints a portrait of 11 individuals, fragmented yet combined and the indelible marks left by ‘belonging’ to place, people and culture.
The final piece is You Have The Right, and it presents ten of the thirty-five our entitlements, as set out in the NHS Constitution, cut into plywood and backed with transparent acrylic to allow the light through. They project our rights onto a wall behind that’s marked with fragments of the Union Jack – another symbol of Britishness. In pieces, as isolated graphic shapes, it’s impossible to tell if the flag is disassembling, or re-gathering. Is this about the breaking of our union with Europe, or the potential split with our bordering nations as Scotland considers another vote on independence, or does it reflect the divisions across the country following the Brexit vote? Or is it illustrative of re-building? Will ambitious new trade plans see a sort of new empire emerge? Is there something intrinsically ‘British’ building in strength as we sever links with the EU?
Famously, the UK has no written constitution. In this sense, the NHS is more of a consolidation of British entitlements than anything else. It shines a bright light on the mysterious ‘British values’ our government often references but doesn’t detail. The principles at the heart of the NHS are admirable – democracy, fairness and equality. Aren’t those what we want at the heart of this nation too? By omitting reference to ‘care’ and ‘treatment’ in this setting out of our rights, Mir takes this a step further, creating ten statements that could well be the bones of national constitution. Take just a few of these - you have the right to be involved in making decisions; the right to be treated with dignity and respect; the right to be given information – and imagine these statements as the pledges of our government, in the context of the Brexit vote. The NHS’s Constitution makes radical promises to the people it belongs to – brave, bold promises that its staff work so hard to honour, in spite of all the forces that deplete the service.
At Your Service crosses from the individual to the collective to the notional. Brexit might be no more than a cut-and-shut term that even 27 months after the referendum remains so meaningless it translates only into itself – Brexit still only really means ‘Brexit’. It’s individual stories that bring meaning to both the idea of leaving and the notion of belonging, to anything. And by talking about these things in the context of the NHS, that too emerges with a significance beyond the obvious: it assumes the role of a sort of nation in its own right. The NHS is a place and set of principles that brings together 1.7million people, 160,000 of them from mainland Europe and the rest from the UK and all other corners of the world. A place made of principalities, like Sheffield Teaching Hospitals where this work originated: almost 16,000 people governed by their own ‘localised’ set of values. The NHS bestows on staff and the millions of people they serve, a range of rights that goes further and deeper than the promises made by our own governments, past and present. And inside that nation, which is both cherished and taken for granted; loved and unloved; united and disintegrating through privatisation, the population is bound by a principle so human, it could never really belong to our government – the devoted giving of care without prejudice.
How often do we read about the NHS as blighted and struggling, but its staff as angels and miracle workers? What inspires this dedication in the face of underfunding and adversity? What will inspire the ongoing support of 160,000 European staff after we have left the European Union? Belonging. To teams, to solemn pledges, to vocations, ambitions and beliefs, to humanity…staff and patients are one nation, plucked from across the globe, united in the NHS, home to a hundred or more languages, millions of human stories, and an unwavering promise to belong to its people.
5 Giants - Text by Dr. John Rawlinson
Whilst the five figures seen in the I Have the Right piece reflect the ‘Cradle to Grave’ care provided by the NHS, they also contain strong echoes of the ‘Five Giants’ identified by William Beveridge in his influential and radical 1942 report as the great evils afflicting society at that time: Want, Disease, Ignorance, Idleness and Squalor. These were the obstacles that would need to be tackled on the road to post war reconstruction in order to create a richer, healthier, informed and more productive society.
In Beveridge’s view, a great opportunity for societal reform and improvement had been squandered by the Lloyd George administration in the aftermath of WW1. Charged by the wartime coalition government with drawing up plans to reform social security, Beveridge was determined that the moment should be seized this time. ‘A revolutionary moment in the world’s history is a time for revolutions, not patching’ he said. The report he produced is now considered to be the cornerstone of the modern welfare state.
Beveridge knew that ill health was often a cause of poverty as well as the result of it, and that the twin Giants of want and disease would need to be tackled together. Reform of ‘social security’ alone with its disparate and fragmented patchwork of pensions, unemployment and sickness insurances was, in his view, an inadequate aim. He envisioned a system of universal healthcare available to all and free of charge and made this one of the fundamental assumptions in his report. Weekly national insurance contributions were to help fund the new service along with the new system of sickness and unemployment benefits. The Beveridge report was received with enthusiasm by the public and achieved a broad consensus amongst politicians.
In 1945 a Labour government was returned with the largest parliamentary majority ever seen. With its huge mandate, the new administration set about constructing the five great programmes of reform that would form the backbone of the new welfare state. Social security, health, education, housing and full employment were the weapons to be deployed against the Giants. The man charged with creating the new health service was Aneurin Bevan, a charismatic ex miner from the Welsh valleys with a reputation for fiery rhetoric and a radical socialist outlook. He faced his own giant obstacles in the form of resistance from a myriad of organisations and vested interests, not least of which were the British Medical Association and GPs. With a masterful combination of dogged persistence, browbeating, cajoling, coercion, diplomacy and negotiation, Bevan overcame all the obstructions. The National Health Service was launched in July 1948.
It is striking to think that in the darkest days of the war, the greatest crisis the country had ever faced, plans of such magnitude and ambition for the betterment of society were being made. With Brexit looming, Britain now stands at another critical moment and much is made of the divisions the referendum vote has exposed in our society. Perhaps now is the time for national reflection and self-examination. What giants do we face on the post Brexit road and how do we go about healing the divisions and achieving future national consensus?
Summary Report on Causes of Death
by the Office For National Statistics 2017
Age Standardised Mortality Rates (ASMR) for cancers, respiratory diseases and circulatory diseases continued to decrease in 2017, whilst rates for mental and behavioural disorders, and diseases of the nervous system increased by 3.6% and 7.0% respectively.
“Mortality rates for cancers, respiratory diseases and circulatory diseases have also decreased. However, rates increased for mental and behavioural disorders, such as dementia, and diseases of the nervous system, such as Parkinson’s and Alzheimer’s. This could be partly linked to a better understanding of these conditions, which may have led to better identification and diagnoses.” (Office for National Statistics – 2017).
Cancer accounted for 28.1% of all deaths registered in 2017 and has remained the most common broad cause of death since 2011. Cancer accounted for 30.5% of all male deaths and 25.7% of all female deaths registered in 2017.
The ASMR for mental and behavioural disorders, such as dementia, has more than doubled over the last decade, increasing by 3.6% in 2017. A similar pattern is apparent for diseases of the nervous system, such as Alzheimer disease, for which the rate increased by 7.0% in 2017, a 70.8% increase compared with 10 years ago. Increases in these rates are likely due to improvements in recognition, identification and diagnosis of such disorders.
2016 specific data (figures for 2017 will be published in October 2017)
For boys and girls aged 1 to 4 years, congenital malformations, deformations and chromosomal abnormalities remained the leading cause of death. This cause accounted for 14.9% of male and female deaths in this age group, an increase from 10.9% in 2015.
For both boys and girls aged 5 to 19 years the leading cause of death remained suicide and injury or poisoning of undetermined intent, accounting for 15.2% and 9.6% of deaths respectively, a decrease from 2015. (The National Statistics definition of suicide, used here, includes all deaths from intentional self-harm for persons aged 10 and over, and deaths where the intent was undetermined for those aged 15 and over). In England and Wales, a conclusion of suicide cannot be returned for children under the age of 10 years.
There was a 4.2% decrease in the proportion of deaths to suicide and injury or poisoning of undetermined intent at ages 20 to 34 years, but it remained the leading cause of death for both males and females in this age group with 20.5% of all deaths. This trend was similar for males aged 35 to 49 years, where suicide and injury or poisoning of undetermined intent remained the leading cause, accounting for 11.3% of male deaths. For females at this age, breast cancer remained the leading cause, accounting for 13.4% of female deaths, a slight decrease from 13.5% in 2015.
The leading causes of death for both males and females aged 50 to 79 years in 2016 were due to long-term diseases and conditions. For females aged 50 to 79 years, lung cancer remained the leading cause of death, responsible for 10.5% of female deaths at this age group. Ischaemic heart diseases remained the leading cause for males aged 50 to 79 years, accounting for 15.7% of male deaths, followed by lung cancers, accounting for 9.5% of male deaths.
Dementia and Alzheimer disease remained the leading cause of death for both men and women aged 80 and over in 2016, accounting for 14.3% of male deaths and 22.2% of female deaths at this age. For those aged 80 and over, 18.9% deaths in 2016 were caused by dementia and Alzheimer disease, up from 18.1% in 2015.