Policed Industrialisation of Healthcare
Author: David Zigmond
David Zigmond ran a small, successful and popular GP surgery in inner London. Following a disagreement with the Care Quality Commission (CQC) in 2016 his practice was forced into closure. Since this traumatic event David has written a number of articles reflecting on what this event means in the wider context of a society that is replacing trust, relationship and common-sense with mechanistic control. Here we bring together some of Davids' thoughts and his imagined dialogue with the system.
Some may recall the sudden and draconian closure of my small, long-established and very popular inner London General Practice by NHS England and the Care Quality Commission (CQC) in 2016. Realising that this drama was but one episode amidst much wider troubles throughout welfare services, I have, in the period since, thought, talked and investigated widely around our health service. In this process I have attempted to engage these authorities in a dialogue which gets beyond the procedural, the managerial and the legalistic. Unfortunately I have failed to get any response, and so the following imaginary dialogue constitutes a kind of valedictory history of this complexity, both personal and organisational.
2016-17 - The conflict with CQC
The practice closure was followed by a brief flurry of public interest carried by the media and on the internet. The CQC maintained that my documented compliance to regulations was so egregiously bad that my practice must be immediately closed, for public protection, by exceptional legal order, obstructing my request for legal representation and thus postponement. I maintained that this charge of extreme hazard was specious: that this small practice was, rather, a clear example of how the rolling-out of ever-more rigid regulation often rolled over and crushed much of greater value, often heedless of what is crushed.
Our regulation is then more harmful than helpful. In my own particular case, I argued from another, and more vernacular, kind of evidence: that of an excellent long record – of patient and close-collegial relationships, accompanied by the remarkable absence of complaints and critical incidents – notably these were clearly recognised in a previous and positively glowing CQC report just two years earlier (with only improvements in the meantime). All these offered, I believed, far more realistic indicators of competence, safety, compassion and probity than this incumbent regime: a mandate of box-ticking for all ‘performers’, to demonstrate documented compliance to prophylactic regulation. Perhaps significantly, I had been writing about the destructive aspects of such formulaic ‘solutions’ for several years prior to the CQC’s existence.
I have never argued that such CQC measures are always wrong, rather that they are certainly not always right, and that evasion of this complexity can be very damaging. It is like any medical screening, diagnosis or treatment: real harm can be done to exceptions, anomalies or outliers. As in medical practice it is important to know when this is happening. So all such activities need our intelligent restraint and humility – and sometimes eccentric objection – as much as assertion: we need to know when to desist, deflect or stop.
At the time of my practice’s closure I was increasingly troubled by authorities’ heedlessness of this first Hippocratic principle: First, do no harm. I had witnessed how widespread and serial reforms – our ‘treatment’ of the NHS itself – was often actually making our NHS sicker, both personally and organisationally. This seemed to me particularly true of ever-more extensive and ratcheted appraisal and inspection regimes: these were – overall – wearying, stressing and burning-out many otherwise good-enough (or significantly better) professionals. Increasingly we are flogging a dying horse.
In my last years of practice, I had written and published these views to stimulate thought and raise alarms. I attempted the equivalent in professional meetings, often to be stymied by management’s prescribed and blocking agendas. Attempts to engage managing authorities in courteous, thoughtful dialogue seemed doomed to circumvention After nearly 40 years in General Practice I now considered many of the burgeoning regulations were often unsustainable, contextually nonsensical and even – most crucially – destructive to more important tasks. This experience seemed true across the generations of practitioners.
What to do? I hoped that a kind of well-mannered Ghandist ‘non-cooperation’ might galvanise management’s broader and better sense. My belief that this was possible drew equally, probably, from hubris and naivety.
Events then quickly demonstrated how my mission may be correct, but clearly my method was bound to fail.
I am aware of an interesting and instructive parallel here: the divergence of mission and method – isn’t that central to my analysis of what has gone so seriously wrong with our ratcheting reforms? Clearly this is easier to critique than avoid.
Exploring the meaning
So, many months on, what do we find in the profession and patient population I left with such mixed sorrow, regret and relief?
In this period I have attempted to assemble and understand the prevailing bigger picture, realising that my own experience is just a small, if dramatic, part. To do this I needed to conduct a kind of informal field-research: hundreds of personal conversations with practitioners, patients and managers, together with material in the public domain.
The more parochial picture from my own erstwhile patients and close colleagues is grim. Patients report the replacement services offering poor access to ever-changing doctors who seem stressed, rushed and thus officious: personal continuity of care seems to have almost disappeared. Practitioners glumly report their complementary role and respondent frustration.
The larger picture that emerges seems unmistakably one that I was long warning about and campaigning against. Any satisfaction I could savour about being correctly foresighted is short-lived and massively eclipsed by the consequences: what pleasure is there in seeing my erstwhile much-loved, yet (inevitably) flawed, profession become so craven, fragmented, stressed, dispirited and mistrustful… thus compromising even further a difficult and demanding job? The damage done to patient-doctor access, relationships and quality of care is then inevitable.
As you will see in my imagined dialogue below, how this happens, and then what it leads to, takes many forms.
An underlying and anchoring principle is this: our healthiest welfare services grow and survive best from matrices of trust, encouragement, human connection and meaning. Conversely, attempts to manage or engineer such services – predominantly by forensically-spirited checks and punishments, grounded in command-and-control human systems – will manage, mostly, only short-term compliance. Healthy growth becomes increasingly impossible.
The longer-term penalties of failing to heed this are the perverse consequences we now struggle with.
Exceptions? Yes, of course. But what are the hazards of disregarding this seminal truth?
Destruction is a dangerous therapy
We have a tragedy of errors here. A historical similarity – far more massive and shocking – may nevertheless serve as a kind of explanation.
In the 1960s the USA government believed they could win the Vietnam War – both militarily and hearts-and-minds – by eliminating the ‘bad’ Vietcong. The USA then guided their campaign by assumed metrics and algorithms: if they could kill ten Vietcong to every one of the Allied (USA and South Vietnam) Forces, then they would surely win the war.
What followed is, retrospectively, horrifically stupid. The USA adopted the strategy of killing as many Vietcong as possible. But Vietcong were often hard to identify definitely, so then anyone who was possibly a Vietcong was killed: that way the figures would be assured and the war would be won.
But the war did not go well for the USA, despite their vaunting very successful death-yields: Vietcong fresh recruitment kept exceeding the deaths, and with that recruitment came hearts and minds. The indiscriminate slaughter – to ensure a predominance of Vietcong deaths – almost certainly resolved the surviving lives to opposition. The greater the American ‘success’, the more they were bound to fail.
Eventually, in the 1970s, the USA realised it had become a victim to its own misassumptions: taking out ‘bad’ people could not have made anyone ‘good’, or any better. Stumbling towards peace would require much more understanding of what makes for our better trust, cohesion and any kind of peaceful, viable cooperation. The next decades would unearth and demonstrate just how counterproductive their coerced ‘solution’ had been.
Of course, it is important to distinguish between napalmed villages and, say, the closure of small, popular general practices. But there are instructive parallels.
The hubris of control
The common central folly is the hubris of control without the kind of engagement that brings understanding. Such regimes – predicated on design-command-control mindsets – have a natural history: they initially seem to have decisive clarity and resolve which launches into early success. But then, like a motor engine without adequate coolant or lubricant, they will eventually slow and then seize through increasing internal friction. Such a situation is hardly likely to be helped by trying to drive the motor harder. Yet this is the equivalent of what we are now doing in our welfare services: ‘We must have more rules, regulations, goals, checks and punishments, whatever the cost’. This – as we are witnessing – becomes doomed to a kind of institutional self-damage.
So, curiously, this is the common fate not just of the most terrible dictatorships of the last century, but also our more benignly intended attempts at current welfare reform – those whose rapidity and rhetoric leaves behind our more subtle engagements and understanding.
True-spirited democracy is slower, more cumbersome and messy, initially at least. But it has enough coolant and lubricant to keep its engine running.
Our increasingly troubled REmote Management Inspection and Compliance regime (REMIC) finds another and more contemporary instructive parallel with our civilian policing. Stop-and-search is sometimes truly necessary, but its inordinate use will surely add to our problems. So the balance is always difficult, and directive formulae from HQ have often made matters worse. To cause least damage to the wider interests of our community we must constantly relearn the values and skills that come from contextual knowledge and intelligent discrimination.
Isn’t this capricious – fallible and risky? Yes, but less so than our overzealous yet doomed initiatives to eliminate all such risk with universal formulae.
In my first decades in practice I had many conversations with colleagues and managers about these matters. Questions of individual, group and governmental responsibility were much discussed, but little dictated or controlled by officialdom. So the profession was trusted with much more judgement and responsibility, and so accountability. Curiously, I found that old fashioned world to be much less hierarchical and authoritarian than now – as a young junior I often talked with people at many different levels in ways that have since perished from loss of time, autonomy, trust, language and culture. Through these previous, less formal and formulaic times, much more seemed to get done without the kind of authoritarian mistrust that has now taken hold. Of course there were faults and imperfections, but few veteran practitioners perceive that their working life is now safer or more efficient. Almost all would say it is less pleasurable.
As I became an older practitioner the culture utterly changed. Certainly, we are now replete with all the correct words and phrases that seem to empower, encourage and democratise: patient-choice and transparency, coordination, consultation, three hundred and sixty degree feedback, integration, dialogue, compassion, dignity, open-consultation, advocacy, going forward, … Yet these words were rarely heard three decades ago despite, or because of, the fact that such experiences then emerged more readily, implicitly and naturally: we did not need to constantly talk about these things, or manage them. It seems that as we have driven out the natural growth of these qualities with our industrialised welfare, so we have vainly attempted to compensate for their loss by a kind of sanctifying, then propagandising, language.
It is no coincidence that the term NHS Trust was introduced at the time when the actual and natural trust of our services was being destroyed by marketisation. We are left with many legal Trusts, but little human trust.
These are the kind of topics I tried to talk with my latter-day managers and administrators about. Almost always I was met with avoidance, obfuscation and obstruction.
After my retirement I thought this pattern might change as I would no longer be an organisational anomaly or operational threat to executive officers or organisations. This has not happened. For example, my very carefully phrased missives inviting exploration and debate have usually drawn no reply. The two replies I did receive were epitomes of procedurally-anchored and defensive justification, steering well clear of my invitations to a different kind of dialogue.
So why do I persist? Well, my motivation extends far beyond my obstinacy or vanity: it is about my reluctance to relinquish an ethos that I learned, practised, cherished and taught over five decades. It is about the kind of world I continue to want to live in, and the kind I do not, and the one I am leaving behind.
Ghandi said ‘Be the change in the world you wish to see.’ Well, my preferences have always tended to philosophy rather than procedure, to understanding more than data, and to dialogue exceeding declaration. So if I want such dialogue I must build bridges and then keep them open.
In view of the effective lack of response from the relevant authorities I have created a ‘virtual’ dialogue with NHS England and the CQC: what I believe a candid and courteous initial ten-minute conversation would sound like – were we to risk such an unprocedural interchange.
If any wish to join in a real life (before death) dialogue I will certainly respond.
The more laws the less justice
A posthumous dispute
The end of contractual employment usually terminates our legal responsibility. But what about our moral responsibility toward unattended compromises we know we are leaving? How well can ghosts speak for, and to, the living?
What follows is a virtual dialogue with healthcare’s governing authorities, whom I call REMIC (Remote Management Inspection and Compliance).
* * *
REMIC: Why are you still contacting us, after all this time?
DZ: Well, I’ve long wanted a broader conversation… Not just about my own case, but what it represents throughout Welfare services… Many people continue to contact me about it.
REMIC: Look, we’re not here for such ‘broader conversations’. We’re getting on with an important job to help the public. We do that using established and transparent procedures. If you think we haven’t followed those procedures correctly, then you have every right to an Appeal: that, again is a correct procedure. We note you haven’t followed it.
DZ: Well, the reasons are pretty substantial…
DZ: I was seventy years old at the time of my decommissioning. My practice income from real work was falling, while my regulatory and compliance expenses kept rising. Like many small practices I was doomed to extinction. Most important, though, was that the way I was closed down made it almost impossible for me to ever reopen…
REMIC: Why is that?
DZ: Well, I was immediately stopped from working. So my patients had to be cared for elsewhere, and a final ‘closure payment’ was made to my practice. But my trusty reception staff etc would need solid security of future payments and jobs and I couldn’t vouchsafe these during a lengthy appeal process… I couldn’t continue to pay them for an indeterminate period for an unsure future. Being realistic, they would have to find other jobs. And, being equally realistic, I would never be able to replace them with people of equal calibre. Who would give up a good job to join a battling septuagenarian? I knew I was finished by this strike: I couldn’t get back onto my feet again. I think REMIC calculated that…
REMIC: No, those are not our considerations. But, again, you could have appealed.
DZ: Well I could, but without hope of success, yet incurring much expense and stress. REMIC is a large corporation which simultaneously is the executive, the judiciary and the jury and has funds and lawyers aplenty. I am an outlying septuagenarian with no ready funds or lawyers, who has been very selectively non-compliant with – and therefore in breach of – REMIC-managed contractual regulations. How could an Appeal possibly succeed? So I decided to continue to argue my cause, but to cut my losses before martyrdom.
REMIC: Beyond your own hurt and losses why do you think your cause is so important?
DZ: Well, I see the incremental effect that the machinery of REMIC has had on our healthcare culture. Look at us! We are a sickened and demoralised profession. If you want statistics there are many to show the extent of our dispirited trouble: poor recruitment, career abandonment, earliest retirement, retreat into ‘portfolio careers’, widely varied physical and mental illness, intra-institutional litigation, drug and alcohol abuse, marriage and family breakdown… and…
REMIC: OK, OK. And your point is?
DZ: That if we’re not very careful REMIC overuse increasingly generates more problems than it can solve. In my working lifetime I’ve seen the collapse of my profession’s heart, art, spirit, soul, intellect and wit. And other welfare services, with their own kinds of REMIC, report much the same…
REMIC: That’s quite a list! We can’t be held responsible for all that, surely?
DZ: Well not personally, and not completely. But it’s like any partially-sighted yet overdeveloped public system. It becomes dysfunctional because it becomes both hermetic and then difficult to change or steer. And then all participants are forced into one of three roles: perpetrator, victim or bystander. There is, however, a fourth position: opponent, but that has its own problems, as you can see. So direct opposition from employed practitioners is frightened into retreat and hiding.
REMIC: We’ve heard this from you before and think it’s unfair. It’s certainly not our intent…
DZ: OK, probably not to begin with. But all sorts of social and political campaigns have a horrible tendency to turn into something quite different. And then avowed intention becomes very different from consequences. Shall I give you some historical examples?
REMIC: No! We don’t need all that from you. What we’re trying to do is quite straightforward. We’re assuring for the public the quality of their health service: its compassion, competence, comfort, efficiency and safety. What can be wrong with that?
DZ: Only that you’re conflating your mission with your method.
REMIC: What does that mean?
DZ: Well, few people are going to dispute your mission. Who would? But almost all experienced practitioners who are not defending a governing position have much more doubt about REMIC’s methods. How can we possibly fulfil a mission if our method can’t even get people to do, or stay in, the job? What kind of care can we offer others if we, ourselves, are dispirited, insecure, harried and harassed?
A year ago I wrote an essayed letter to NHS England titled General Practice used to be the Art of the Possible, but we have turned it into a Tyranny of the Unworkable. They never replied.
REMIC: One of our concerns about you is that you seem to be against all organisational rules, regulations, checks and disciplines. You don’t seem to see the necessity for any of it… In our view that makes you look very risky.
DZ: Hm! I’m in the same boat as you, then: that’s not my intent, but those are the consequences. I apologise for you misunderstanding me. Look, I’m not that kind of nihilistic anarchist. I believe all structures, strictures and penalties have their place and value, but that such placement and value are complex matters needing endless thought, editing and navigation. We have to understand how something good in one context can be very harmful in another. Our structures must often be tempered by flexibility. We have to understand how some grand schemes spawn even larger, however unintended, problems…
REMIC: So how much institutional direction do you believe in? Will you submit to?
DZ: Well, I’m certainly not going to give you a figure! Let me answer with a metaphor. The health service used to mostly resemble a well-functioning family, which depended on appropriate trust, commonality, personal understanding, overlapping and interchangeable responsibilities and flexible judgements about these. But our reforms have attempted to disband the family and replace it with a network of factories, where all these ‘family’ qualities are replaced by rigid command-and-control procedures, protocols and instructions.
Sometimes parents will attempt to bring up their children in this way – they are over-structured, overstrict, intrusive and controlling. They say: ‘we are only doing what is best for them, for the family.’ The long-term results, though, are usually very different to what they say they intend…
REMIC: But all our procedures and disciplines are there for good reason. Overall they are there for everyone’s safety and protection. Abandoning those responsibilities would lead to much greater problems, dangers and harm. Do you not see that?
DZ: OK. I agree that REMIC is not the same as, say, a military dictatorship! What I am saying is that, if we are not careful, there are similarities in process and outcome.
REMIC: But what about our public responsibilities?
DZ: Look, let me repeat an important point: I agree with your concern and your mission, though clearly and often, not your method.
Perhaps it will help my mission to make these distinctions:
- Creative dissent is different from destructive anarchy.
- Outliers to systems are not necessarily bad; they may be outstandingly good.
- In history, conscientious objectors have brought us Gandhi, Martin Luther King, Galileo. In contrast, the millions who automatically obeyed governing authorities brought us … what? I’m sure you can fill in the gap.
REMIC: Yes, yes. History, the herd, the compromised individual, the corrupted mission. But what about our question about public responsibility?
DZ: Of course, but I think we’ve become paralysed with anxious confusion and lost sight of this: in Welfare most workers want to do good work with good care. Generally, this is what they will do as long as they get good human contact, encouragement and satisfaction from their work milieu. But the inverse is also true: If welfare workers are frustrated in their human and vocational satisfactions, no amount of regulations, rules, trainings and inspections will remedy a failing service. That is what we have now: a tendency to draconian and forensic management attempting to control – yet actually further damaging – an ailing service. Flogging a dying horse.
And this brings me back to your first question: ‘why am I still trying to discuss all this with REMIC authorities?’
In a way I am trying to heal my own grief, of both private and public kinds. Let me differentiate.
There is my private grief for the ending of my much-loved role, my practice, familiar and dear people and daily time-structures, my reciprocated significance for others… If we live long enough we all have to face such losses, so they are universal and inevitable as well as private. You may be sympathetic, but you cannot otherwise help me with this.
My other kind of grief may be publicly generated but must be privately borne. It is about the cultural loss of certain kinds of relationships and shared values. For the first half of my long career I was blessed by welfare work that – for the most part – could grow healthily in a wholesome and trusting (yet inevitably flawed) ‘family’. The second half of this working life has seemed like an accelerating and enforced march to work in a series of mistrustful and depersonalised, REMIC-controlled ‘factories’.
What I learned, how I practised, and how I taught were all anchored in this earlier vocational, fraternal ethos. My grief is about the systematic deracination and destruction of all this: it exceeds what I personally have lost; it is more about what I am leaving behind, in the public sphere, for others. So it is a transcendent and transpersonal grief.
This you can, certainly, help me with.
REMIC: So we’re not just the bad dictators, then?
DZ: Not so long as you invite discussion and debate. There’s more hope for all of us then.
* * *
And, reader, what would you wish to add to this debate?
Background information plus further articles are available via David Zigmond’s blog here.
David would be pleased to receive your feedback.
The publisher is the Centre for Welfare Reform.
The Policed Industrialisation of Healthcare © David Zigmond 2019.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.