How much do you have to prove? A tale of the modern NHS marketplace

I took a voluntary redundancy from the NHS in 2011. Since then I have run a small company providing clinical psychology services. I mainly do expert witness work for the family courts, which I have blogged about before, but we also offer therapy, consultancy, training, research and other services.

In 2012 we bid for a grant from The Health Foundation to offer brief psychological interventions into the diabetes service for people of all ages at the local hospital. We wanted the bid to be innovative, and so we were determined to think differently about how we structured the service and hoped for it to be commissioned. We decided we would use the grant to set up a Social Enterprise to deliver psychological services, and that we would aim to get commissioners to agree to fund the service in retrospect according to the outcomes we achieved. You read that right – we planned to deliver a service for no cost in return for an agreement to pay for the outcomes we achieved. No more “spend-to-save deadlock” in which the NHS can’t invest in the things that will save money; we were providing the service for no cost to the NHS during the project period and offering to continue to do so, based on retrospective returns dependent upon whether we improved people’s lives and saved costs for their medical treatment. We also agreed to survey the level of mental health need amongst the population using the diabetes service at the hospital, and look at whether this related to their blood test results (which are the best indicator of adherence to medication regimes and lifestyle advice, and of physical health prognosis).

Diabetes is a hot topic because it is predicted to “bankrupt the NHS” due to the rising incidence and cost of treatment. It already costs the NHS £10 billion to treat nearly 4 million people with diabetes in the UK, and this is set to rise to £17 billion by 2035 as the incidence increases to 6.25 million diabetics. Once the loss of working days, early death and informal care costs are factored in, these costs more than double. Even more shocking is the fact that 79% of this expenditure is preventable, if patients followed the lifestyle advice and medication regimes recommended. Studies consistently show that around 40% of people with diabetes have mental health problems, and around 14% of this cost is prevented if there are services to support the psychological health of patients. That is £2.4 billion pounds of avoidable NHS expenditure per year, and around £3.2 billion more in the wider economy. Yet psychological services for people with diabetes are far from universally available.

The Health Foundation loved our proposal and gave us a £75,000 Shine Award to deliver it.

We set up our Social Enterprise which we called Evolving Families. The name is designed to reflect the fact that people change in their thinking, behaviour, learning and roles over their lifespan (and a fair chunk of our work is with adults reflecting on childhood, with parents or with young people whose family circumstances have changed). A Social Enterprise is a business that is run for the benefit of a community, society or environment, and invests the majority of their profits towards that good cause. Our Social Enterprise was designed to invest in delivering psychological services that might not be otherwise funded, like doing research or subsidising people who could not afford to pay for therapy but were not eligible to get what they needed on the NHS.

We used our agility as a small company to employ staff very quickly, and we were up and running for the project to start on 1st Jan 2013. We accepted 65 referrals in the following year (52 adults and 13 children), and closed the project at the end of December 2013. Of those 48 (36 adults, 12 children) attended for psychological therapy and completed pre and post therapy measures, with an average of 6 therapy appointments each. We were able to see people at their homes, at schools, in the community and in our offices. We saw people in the evening if this was more convenient. We went to multi-agency meetings about some of the young people. And most importantly we didn’t have defensive service boundaries – if we felt we could improve psychological wellbeing then we offered services that didn’t directly relate to their diabetes or mental health, for example cognitive assessments, advice about employment, exploration of the impact of neuro-developmental difficulties or sensory impairments.

We screened 750 adults and 100 children who attended the clinics, using the PHQ-SADS (a measure of depression, anxiety and stress used in the IAPT scheme) and the Problem Areas in Diabetes questionnaire. This showed a highly significant relationship between all areas of mental health and HbA1c (the blood glucose score that is the best indicator of how well controlled the diabetes is). There was a very high rate of mental health problems, including a very worrying level of suicidal ideation in both age groups. There was also a very poor level of diabetes control; only 20% had an HbA1c score in the range considered to be optimal (<7) whilst 60% had dangerously elevated levels (>7.5), indicating that this hospital clinic serves a very complex and risky population group.

After the year was complete, we had clear evidence that our service was helpful and cost effective. We made a significant change to participants lives – not bad for 48 people getting  an average of 6 sessions of psychological therapy. Their mental health improved markedly. Fifteen people who were having frequent suicidal thoughts were no longer suicidal, 19 A&E visits in the months before therapy were reduced to 1 in the same number of months after therapy, 30 ward admissions in the same period were down to 5. The cost saved by this reduction in physical treatments was greater than the project cost to deliver. All in all we had pretty impressive results for providing psychological interventions at a cost per head that was lower than IAPT. We were Highly Commended in the HSJ Efficiency Awards.

But did commissioners bite our hand off to take up the offer of paying for the service based on the results it achieved? No. We couldn’t even get to talk to commissioners in person. The hospital told us to talk to the CCG, the CCG told us to talk to the hospital. They told us they need fixed cost contracts to put in their budget, not this outcome based stuff. The contract value is too small to be separately commissioned, and we are outside providers. The service closed to referrals a year ago, and although our service users are passionate about the need for the project and the impact it made on their lives, nobody seems to be listening. So we’ve written a business case and given it to the various service managers at the hospital, and we’ve presented our results locally and we wait, with dwindling hope that it will be picked up at some point in the future. Maybe in the next financial year. Maybe when they reconfigure the diabetes provision.

So I ask: how much do you have to prove in the modern NHS marketplace? If we can deliver a highly effective, life-changing service, and save the NHS more than it costs within the financial year, and we are prepared to accept payment in arrears based on the outcomes we achieve, what more can we do?

Video flash of powerpoint showing outcome data for the project is here: https://www.youtube.com/watch?v=sdyVfGOkdD0

Service user comments about the project are here: https://www.youtube.com/watch?v=KsQDgs-yDq4

Slow burn: Reflecting on the emotional impact of working with chronic trauma*

*This post contains vignettes of harrowing material which may upset some readers. Case examples are all anonymised.

When I decided to do work in child protection, people warned me it was the fast road to burnout. Twenty years later I think they are right about the direction, if not about the speed.

Burnout is an insidious thing. It sneaks up on you as a chronic accumulation of many tiny things, rather than having an obvious trigger, like a single life threatening event that causes PTSD. A thousand small examples of vicarious traumatisation. Experiences that I shouldn’t complain about as I’ve chosen a career that inevitably brings exposure to distress and tragedy. It feels like I’ve chosen to wade through the grottiest parts of life, until I’m normed on that 1% of stories that cause the most concern. It saturates me. Pollutes my perceptions of life. It has been building up for a long time.

Fifteen years ago my two specialist placements included post abuse work with survivors of sexual abuse, a group for non-abusing parents of children who had been sexually abused and work with “complex” children and families, such as those on the child protection register. I knew it was emotionally harrowing work then. I talked about it with a good friend, and concluded that my drive was to go where I was most needed, to grapple with the most complex cases, and that I’d worry about burnout when I got there. I graduated onto a clinic for children who were “failing to thrive” and most of my clinical time being with Looked After Children and therapeutic work with those who had experienced trauma or maltreatment. Right from the start, it was an induction of fire, salved only by the fact that it was important work that needed to be done.

It started with individual stories.

The sad silent child who ate 7 digestive biscuits and carefully stowed extras in his pockets during clinic, but whose parents claimed he had a digestive disorder that meant he wasn’t gaining weight despite eating plenty.

The young woman with learning disabilities who repeatedly played out how the daddy bear lay on top of the baby bear and thrust, but said baby bear was a liar and nobody believed her when she told.

The adult relatives who revealed at the last moment the sadistic physical and sexual abuse that their step-father inflicted, after he had charmed the professionals enough to get residence of his grand children, when their mother was unable to cope and had reverted to chronic drug use.

The maps of children’s bodies in medical notes, used for annotating injuries, including one for babies. The paediatricians sharing photographs of torn orifices, injuries, malnourishment and legs with rickets. “This one has burns on their hands up to a straight line on their arms, showing they were held in boiling water as a punishment”. No, I don’t want to see, thanks.

The little girl in a religious cult who couldn’t disclose her abuser as she had been taught it was as bad to think or speak badly of others as what they had done, and shown pictures of people rotting in the ground or burning in hell for their sins.

The boy who was conceived through rape, whose mother couldn’t look at him, and whose grandmother thought any challenging behaviour showed he was “living up to his genes”.

A girl asking how she got the zigzag scar on her stomach. The family didn’t want to tell her about how her mother tried to cut her open to let the devil out during a puerperal psychosis. They don’t want to spoil the relationship as she goes to Mum for alternate weekends. When I meet Mum she talked incoherently about spirits and auras, telling me she likes climbing on the roof to be nearer to God. She has no need of adult mental health services, thanks.

The young woman who always claims to be pregnant. Partners are less likely to harm her that way. She is couch surfing at the moment, which is the new name for homeless. Her only possession is a photograph of her son who was removed at birth and adopted. After physical and sexual abuse at home, and attempts to stay with numerous relatives, she grew up in care. She had a sexual relationship with her male carer at 14 which she views as consensual.

Since 2000 I have done expert witness work for the family courts. That means reading bundles of documents about trauma, child abuse, neglect, loss, violence, family breakdowns and mental health problems. It means speaking to parents who have been maltreated in their own lives, lack coping resources and instead of being able to create healthy relationships and flourish have limped from one bad experience to another. It involves speaking to children who have seen too much, had to cope with awful things and missed out on the love and nurture that you’d want every child to take for granted. I read about and sometimes see the state of the home, with rubbish heaped up and rotting, flies circling, dirty nappies on the floor, no clean clothing, nowhere to store possessions and no space that isn’t filled with clutter. I hear about broken bones, bruises, burns, rapes and assaults. Sometimes there are x-rays, photographs or medical records. I see sadness and anger accumulated over many years of getting a raw deal. I measure problems with learning, attention, behaviour, life skills, self-esteem and mental health. I observe who denies the problems, who spills over with them, and who recognises themselves doing as they were done by despite all their best intentions otherwise.

I read, and I listen. I measure and observe. I pull the pieces together to see what fits and what conflicts. It is an active process, trying to understand what happened, how and why. Evaluating insight and future risks. A computer couldn’t be programmed to do this. It takes empathy, curiosity, critical thinking and detective skills. I am the barometer of relationships, of what would feel okay, of what is causing harm. If I felt nothing, I couldn’t do the job. But there is so much pain to feel. So many sad stories.

A little girl with curly dark blond hair who the foster carer told me “shook with excitement to get her own dolly for the first time and promised to keep it pristine so that when mummy gives it to her little sister she will still think it is new”. I nod politely. Take verbatim notes. I have to stop the car on the way home for a cry.

A teenage boy tells me how his father often pinned him up against the wall by his neck or beat him with a belt. He wonders why he dissociates when he perceives threat or criticism now and worries that he is going mad. I try to explain his brain learnt to protect him when nothing else could.

I observe the baby that was rescued from the fire. Her scars are healing slowly, and the medical treatments are painful. She can’t bear to be touched. There is too much pain for someone so young.

A mother tells me how it hurts her watching the foster carer do a better job than she was able to at caring for her children. “I always swore I’d be different to my mum, make better choices of partner than she did, keep my kids safe from harm. I look at where we are now and see it has happened all over again and I can’t bear it”. And neither can I.

A teenage girl tells me she took the overdose because her step-dad broke the door down and overturned the bed to reach where she and her mother were hiding, and hit her mother repeatedly with the broken bed leg. She shrugs and smiles, and says “its just how it is, you know”. I don’t know. But trying to imagine it makes my guts curl and my eyes leak involuntarily.

A mother tells me about the culture she grew up in, and how grateful she is to be here, even though the whole family live in a single room in slum conditions, and it is hard to find work as an illegal immigrant. If her son is hungry, developmentally delayed, and being beaten for misbehaviour at least he is safe. I think that isn’t safe. It is all relative.

A father tells me that his uncle sexually abused him as a young boy, but there was too much stigma to tell anyone and he was afraid to lose this special relationship. He still spends time with his uncle now, and trusts him implicitly with his own children. A few sentences later he says he is baffled why the children are showing sexualised behaviour. I am baffled that other people can’t see how obviously the pieces fit together.

I assess a couple that smell so bad I struggle not to gag. I open the windows but it is not enough. I go out for air every hour. A social worker sprays perfume on my sleeve so I can raise it to my face to mask the smell. I learn the phrase “body odour to an extent causing discomfort to anyone in the proximity”. They don’t own toothbrushes and show me teeth rotting in swollen gums.

A woman tells me she has put on 9 stone as she needs to have fat deeper than the knife blade is long, since she was stabbed by her ex-partner. She wheezes for a long time after climbing the stairs at the contact centre, and she struggles to get down on the floor to play with the baby. I worry when she is slower than expected to return from the toilet, do I need to check if she is okay?

The child was born with HIV. His mother died of it. He lives with his grandmother. She doubts the diagnosis. “He doesn’t look ill, the English doctors don’t know about us”, she says when I ask why his prescriptions have not been collected.

A lady tells me that she must have had post natal depression. If she wasn’t ill she would keep the house clean, but when she is ill she can hardly get out of bed, and gets ideas that the world is very unsafe. That is why she kept the children in her bed with her, rather than sending them to school, until they were no longer able to walk. She’s on antidepressants now, and saw a counsellor for six sessions, so everything will be fine. The social workers are making a fuss about nothing.

A man tells me he has exercised to pass the time whilst in prison. He is proud that he is bigger and tougher than his father now. He says the robbery was the fault of the friends who bought him the beer and suggested the idea, and much exaggerated by the victim. I am glad I brought with a student to observe, as the room is quite isolated and his body language makes me tense.

This couple have managed to sustain the acrimony of their separation for five years. She says he was controlling, violent and obsessive about having every last penny accounted for. She tolerated his promiscuity for far too long. He says she was moody and manipulative, and it is probably her mental health that’s the problem, and her jealousy that he moved onto another relationship. It makes me cross that both of them seem to have forgotten the kids in the middle of their conflict.

A little boy tells me what it felt like to be buggered. I try not to think about it that night in bed. I play tetris on my phone until I fall asleep at 4am.

A woman tells me that all of her relationships have been with men who present a sexual risk with children. They are all so different, she says, that whenever she learns what to avoid the next one is nothing like it. And why wouldn’t you move in with someone you’ve just met? How else do you get somewhere to live after the last relationship has turned sour?

The story stems of a girl of eight show the family repeatedly pushing the girl off a cliff and laughing at her. For variation they poison her and laugh as she vomits. She repeats the loop for 90 minutes, then returns to lying foetal under the table as I leave, just as she was when I arrived.

“I had a cold, mum caught it, and it made her sick so she fell down the stairs” says the boy with autism. “That is why she had to go to hospital”. It wasn’t the head injuries her partner caused, it was his fault. But later in the conversation “Daddy gets out of prison soon. When he finds us he will kill us this time”. It is deadpan. An emotionless fact of life.

The girl in the children’s ward tells me “I didn’t want to go home. I jumped off the bridge because it would be better to be dead. They say I will need to be in hospital at least six weeks whilst my leg heals”. She smiles showing me the metal cage and all the pins reassembling her bones, and counts the pieces in the x-ray. She won’t say what is wrong at home.

“He spat right in my face and pushed me over. I was so angry then. I hit him with the lamp until it broke, then I whipped him with the cable. I could see the shape of the switch in the bruises when I was done. They might have seen it, but that’s not the same. I’d never hurt the children.”

A boy tells me what is different in foster care. “It was the best day ever. We went to the garden centre. I got to look at the fish, and we had a drink and a slice of cake at the cafe. We eat at the table with the grown ups here. I got my own coat too, nobody wore it before me! And my skin is better”. The carers tell me that they had to wash the grime off the bath after he arrived, replace all his clothes and do twice daily treatments of his infected eczema. They had to get a court order to shave off his matted hair as his parents would not give consent.

A five year old girl tells me about the day she came into care. “I could hear they had fish and chips in the front room. I could smell it. I tried to walk there, but my legs weren’t working and I kept falling over”. The medical records show that a visitor called an ambulance when they saw her unconscious. Her blood test results are marked with blue biro. Haemoglobin is captioned “how is she alive?”. She dances when she shows me the foster carers have a rabbit run in the garden.

In each family I hear many of these stories from each individual, and I see several families each month for assessment. I’ve been doing this for over a decade now. I have banked hundreds of such narratives, maybe a thousand. All involve a child or children being harmed. The stories are each unique, but the themes recur. James blurs into Joshua and Jared and Jacob. Samira merges with Samantha and Saskia and Sasha. Depression and anxiety, broken bones and bruises, filth and mayhem, conflict and violence, cancer, obesity and sensory impairment, neglect and abuse heap up in my repertoire of human experience and leak out into my life. I see those stories lurking at the edge of my vision, in the arguments partially overheard in the shops, or behind the headlines in the news. I see their echoes amongst people that I know; my neighbours and colleagues and friends.

I set myself impossible standards. I worry if my child has messy hair when she gets back from school, or I notice mud under his fingernails. Will people think we aren’t taking proper care of them? Are we not taking proper care of them? We go to A&E after my daughter burns her hand. I ask her to tell the story before I speak and she says “it was your fault mummy, it was your drink I tipped over”. I feel like a failure and a hypocrite. My cat has a jaw infection and needs teeth removed and antibiotics. I should have known. He smells like the couple I assessed at the social work centre last year.

I say we need to leave the restaurant. I can hear a mother saying “ungrateful brat, I should never have had you” to her son. Outside the school a mother pushing a baby in a pram says to her friend “look at him giving me evils, he’s going to be just like his father”. I move away. The couple outside the pub argue incoherently and their voices get louder and shriller as we walk back to our car after a night out. The child in the park approaches me and asks me to push him on the swings. People on the internet disclose abuse. In the supermarket I hear a slap and the child is crying. The woman walks past on the street with a fading black eye. They are anonymous and legion. The scale of the problem is overwhelming. I can do nothing.

Friends of friends ask for advice as they have heard I am a psychologist. Its important to try to point people in the right direction, but I am depleted. Another 2 lever arch files arrive at work. Its an incest case and mother is terminally ill. Surely there can be no more stories this bad, but there is a queue awaiting my attention. The next one has police transcripts of the interviews of all of Dad’s victims. He might be a paedophile but his daughter wants to see him anyway. The one after that they want me to see Dad whilst he is in prison for abducting the children to a different country. He believes it is his right; fathers own children in his culture. Then back to the bread and butter of court work, another family where neglect and maltreatment has been the norm through many generations. One of the children is the same age and gender as one of mine. Don’t make comparisons. Don’t go there. Change the subject.

A letter from a solicitor tells me that my invoice has been reduced by the Legal Aid Agency on appraisal. I will get £400 less than the total billed, despite not billing for 6 hours work already because of the fee caps. The hours were “not proportionate”. Do I explain again that it takes longer to do assessments via a translator? I don’t have the energy. Another one is querying the hourly rate. I should work for £7 less if I only see the adults as I won’t be a child psychologist. I ask if a psychiatrist gets paid the rate for a psychotherapist if they don’t diagnose or prescribe. The solicitor is sympathetic but there is nothing they can do. A father doesn’t attend an appointment. I have driven 2 hours to get here, and I wait for an hour whilst phone calls are made, then drive 2 hours home, exhausted. I can do nothing else with my day. Legal Aid say a psychologist can fill their time productively with other activities and refuse to pay anything over travel costs, even though the contract says that they will pay for any appointment cancelled with less than 72 hours notice. I can’t bill for materials, venues or typing. The questionnaires cost an average of £5.31 each. I used 6 per child and there were 7 children in the family. Does it add enough to my report to justify £220 of lost income? The LAA ask what ‘capacity’ is and why it took me 4 hours to assess it. Is it not embarrassing to work for the family court system and not to know this or to have the sense to Google? The self-funding father wants to pay in monthly instalments, but my staff get paid next week. The wealthy mother from abroad hasn’t paid her share of the bill from 4 months ago, but the court wants me to do more work for her case. Why do I do this again?

Tomorrow is the appointment to assess the teenage mother in the mother and baby unit. Yesterday her boyfriend told me about how they met online, and gave me their usernames. Google shows me his dating site entries seeking single mothers, Facebook posts about the violence in their relationship and a video of baby’s “sexy dance”. A solicitor phones. Can I squeeze in one extra case this month? Mother has been evicted. She doesn’t want to see her child and is too anxious to talk to her lawyers. Could I fit the capacity assessment in this week? I get an email. Craig is feeling suicidal. I have reached compassion fatigue. I reply with the phone numbers for the Samaritans and the local crisis service. I turn off my phone and computer and go back to bed.

I am empty. My emotional resources have run out. Is this constant aching tiredness what they call burnout? I run on clockwork. I am a robot Mum and a robot wife. I fall asleep on the sofa. I am exhausted. At night when I finally fall to sleep I dream about children with their eyes sewn shut. I can’t save them all. When I wake I go to work and do it all over again. I’m good at this. It is important. It is needed. It is never ending.

Then I pause and take a few weeks off. The bubble of numbness bursts. I cry watching a video on Youtube. It segues into crying for all the children I’ve met, and all the children someone like me never met or didn’t reach in time, including the parents I speak to so often. I cry with frustration at my own limited reach. I cry for the selfishness of politicians, the broken systems and missing safety nets. I despair at how you increasingly need money to buy justice, and how hopeless and disengaged wide tranches of society are becoming. I click to sign petitions. I donate to campaigns. I counsel compassion in online debates. But I am tired. Achingly tired. Tired in my bones and my guts and my heart. I know how much this needs to be done. And I don’t know what else I can do. But I can’t do this any more.

A shallow look at fat

In her usual abrasive style, Katie Hopkins’ latest click-bait project is ‘to fat and back’ – she is putting on 3.5 stone in weight and will then lose it again, to show us how easy weight loss is and how there is no excuse for being fat. Some journalists appear to think there is something in it whilst others are a little more sceptical.

To me it seems obesity isn’t a simple matter of will power. You can’t will yourself thin any more than you can will yourself out of depression or addiction. Your ability to change the pattern will depend on how long it has been around, your biology and what caused it to start in the first place, as well as your commitment to change, support network and what else is going on in your life. In Clinical Psychology we look at the biological, psychological and social contributors to particular behaviours or symptoms and make a formulation of how these interplay, so it is frustrating when people with no expertise pronounce easy solutions which ignore these factors.

If a thin person with very negative ideas about obesity puts on weight for three months, they will find it unpleasant, find losing weight rewarding, and have all the previous factors that made them thin before to revert to. If she is being filmed and paid then she has financial and performance pressures to succeed also, her reputation and career to maintain, as well as a wardrobe to return to. She has the metabolism, muscle tone, neurochemistry and lifestyle of a slimmer person. Will three months change that? She has people around her who expect her to be active and slim, and will support her returning to that familiar mould. And when losing weight she has the money for personal trainers, gym memberships and healthy food (if not diet systems and products).

It’s a million miles away from being a chronically obese person and trying to lose the same amount of weight. To pretend this is a serious experiment that will tell us something about how to lose weight is playing at a serious issue. It reminds me of Pulp’s Common People.

A real obese person may have put on weight after a trauma or loss, during a pregnancy, or to insulate themselves from the world, or because food is the only pleasure in their life. They might comfort eat because feeding is tied in to their experiences of nurture. They might be ignorant about healthy eating, or have other lifestyle constraints that make healthy eating harder, like poverty or chronic sleep deprivation, or a family/peer group that consume huge amounts of calories (whether the 20 pint weekend, the endless cake in the office, massive portions or regular takeaways being delivered). They might have health conditions or disabilities that make exercise or even activity difficult. They may have developed psychological and neurochemical reward pathways for their eating pattern. They may feel shamed by the societal pressures to conform to what is considered attractive in the airbrushed models on glossy magazines and find thinking about losing weight a painful and ever-present topic (see this paper by Ratcliffe and Ellison last year). On the other hand, they may be ambivalent about weight loss. Their partners, parents, friends or kids may be used to their shape and habits. They may have had many experiences of previous attempts at weightloss that have been unsuccessful or were quickly regained. Change in many circumstances is really hard to make, and harder to sustain.

Every story is different. I know people who feel they need to be heavier than a past abuser or dominating partner, so they can’t be pushed around again. I know people who want a layer of protection against a dangerous world. I know people who want fat deeper than a knife blade is long, in case they are attacked again. I know people who want to deter any sexual attention. I know people too anxious to leave their house to shop or exercise, or too poor to afford fruit and veg or to pay for fuel to cook with. I know serotonin junkies where food is their drug of choice. I know exhausted people who fend off tiredness with sugar. I know of people who want to be taken seriously in the workplace and not have their success attributed to using their appearance. I know a lot of unhappy people who don’t think they deserve better, or could ever be attractive or physically fit. I know people who are hopeless about ever losing weight (often within a wider sense of hopelessness about their lives). I know people who have spent their whole lives being fat and living a lifestyle constrained by that fat – tired, big, heavy and excluded from physical activities. Mocked at every turn. Excluded from aspects of society. Disempowered. Weight loss is categorically different from that starting point, and it is not just naive but wilfully ignorant to pretend otherwise.

Of course, I also know people who like being fat or who see their weight as a very low priority in life. There are women who enjoy defying what they see as body fascism or sexist expectations about women’s appearance, or who simply see their curves as sexy. I can see the appeal in filtering away the shallow people who care about how people look more than who they are and what they do. And I’m aware that BMI is a blunt tool for measuring obesity, as it ignores body composition and scores people with high levels of muscle as equivalently “unhealthy” to those with little muscle, despite the positive differences in health that resistance exercise is known to make.

Katie won’t be happy being fat, and maybe it will give her some perspective about how judged and self conscious people feel when they are overweight. Maybe she’ll show some hitherto hidden empathy or concern for others apart from herself, but I doubt it. The promotional spots so far suggest the usual dose of hubris and ignorance, carefully engineered to provide publicity. I see this program as part of our obsession with celebrity and appearance, and the tendency to discuss serious issues (especially those affecting women primarily) with no depth. Hopkins has become the mouthpiece of internalized sexism; the pervasive belief that women need to be decorative rather than functional to be off value, and therefore shouldn’t think about issues beyond their own appearance and judging the appearance of others.

Finally, I am reminded of a line that is helpful to think to yourself when experiencing playground bullies: I’d rather have my weight than your attitude. For all the challenges involved in losing weight, it’s still easier than changing personality or gaining empathy after years as a callous, judgemental, self-serving, attention seeking provocateur.