Perverse dynamics

The health service sits within a broader society that shapes its rules, agreements and unconscious social pacts. In the Introduction, we noted the spirit of cooperation that was around in the immediate aftermath of the Second World War and how this provided the value base and a fertile ground for implementing the welfare state. There is little doubt, though, that such communalism has been steadily encroached upon by individualism, consumerism, acquisition and exploitation, even greed, since then. What sort of organisations do these values nurture?

Susan Long attempts to answer this in her book The Perverse Organisation and Its Deadly Sins. A basic premise of her book is that there has been a move in society generally from a culture of narcissism (Lasch, 1979) to elements of a culture of perversion (Long, 2008, p. 1). Perversion flourishes where instrumental relations have dominance – in other words, where people are used as a means to an end, as tools and commodities rather than respected citizens. It is these relations that Long sees predominating increasingly. Her book considers large private corporations rather than the public sector. However, the fashion to idealise large private sector corporations and the subsequent corporatisation of the public sector means much of the thinking in her book is relevant to the modern NHS.

Perversion is not simply a deviation from normative morality, or occasional failures in the healthy struggle with mixed feelings described in earlier chapters. Perversion is about seeking individual gain and pleasure at the expense of the common good, often to the extent of not recognising the existence of others or their rights. For many people, the word conjures up extreme examples, such as the sadistic murderer Harold Shipman, or the appalling stories of physically and sexually abusive teachers and priests that hit the headlines regularly: a world everyone would prefer to distance themselves from.